HospitalInspections.org

Based on staff interview and document review, it was determined the hospital failed to ensure that each patient had the right to make informed decisions regarding his or her care to include the right to refuse treatment, specifically Cardiopulmonary Resuscitation (CPR), for one (1) of twelve (12) records reviewed in the survey sample. Medical record #1.

Findings:
Twelve (12) medical records were reviewed in the hospital 08/11-19/2020. The Licensing and Accreditation Registered Nurse (RN) (staff member #7) assisted in the navigation of the electronic medical record (EMR) for patient #1.

The medical record for patient #1 contained documentation that the patient was brought to the Emergency Department (ED) by ambulance on 10/08/2019 at 09:56 AM. The patient advised hospital staff of his/her DNR (Do Not Resuscitate) code status.

The medical record for patient #1 contained documentation of a DNR order entered by the physician on 10/08/2019 at 7:52 PM. The EMR contained documentation that the order was acknowledged the patient's assigned and admitting Registered Nurse (RN) on 10/08/2019 at 8:11 PM.

The record contained documentation that the patient was transferred from the medical floor to the interventional radiology (IR) department for a midline (type of intravenous line) placement on 10/09/2019. The record failed to contain any documentation that a handoff report regarding the patient to include the patient's code status was completed between the patient's floor nurse and the patient transporter or the radiology department. The IR nursing progress note on 10/09/2019 partially reads as follows, "the patient did not have any identification bracelets, DNR bracelets, or allergy bracelets on. "

The medical record contained documented evidence that a code blue (code for cardiac arrest, loss of breathing and heart function) was called for the patient while in IR. The IR RN consulted with the rapid response team RN and determined the patient, "did not have a DNR on file" and began CPR. CPR was performed on the patient on 10/09/2019 from 10:50 AM-11:01 AM " until the patient's code status was confirmed."

The record contained documentation in a nursing progress note on 10/09/2019 at 11:01 AM that the physician, "came back to bedside and after discussion with family it was stated patient supposed to be a DNR and all resuscitation efforts should be stopped. Time of death 11:01 AM. "

The hospital's policy, DNR (Do Not Resuscitate) was reviewed in the hospital and partially reads as follows, "After the patients with a DNR/DDNR (Durable Do Not Resuscitate) status has been identified: 1. The Health Unit Coordinator (HUC) will notify the RN responsible for the patient of the DNR order. The RN will have a second nurse independently verify the patient's identity and will then place the purple wristband on the same arm as the patient's identification wristband. Application of the purple wristband should be noted in the Nurses' Notes with both nurses' names."

Four (4) medical records of patients with DNR orders were entered into the survey sample and reviewed. Four (4) of four (4) of the medical records reviewed (medical record #'s 1, 2 7, and 10) failed to contain documentation that two (2) nurses placed purple DNR wristbands on the patients as indicated in the hospital's policy.

The hospital's policy, Transporting Patients partially reads as follows, "Communication in the form of a written/verbal report between department personnel to ensure that the continuation of prescribed treatments will occur. Transfer of responsibility of care either temporary or permanent requires this communication and documentation thereof. A Ticket to Ride is completed for all patients transport off of the patient care area to the care of another provider (i.e. for diagnostic/interventional procedures, dialysis, etc)."

An interview was conducted on 08/13/2020 at 2:00 PM with the RN (staff member #11) caring for the patient on the morning of 08/09/2019. The RN stated that he/she was aware the patient had a DNR order. The RN stated that he/she was busy with another patient the morning of 08/09/2019 and he/she was not aware the patient left the floor to be transported to radiology. The RN acknowledged a handoff report in the form of a "ticket to ride" should have been completed for the patient. The RN stated he/she did not complete this document or give report to the receiving unit. The RN documented the following on 08/09/2019 "IR called saying that patient is in acute distress, went down to check patient but she already coded and nurses doing CPR. Unfortunately,patient passed away, family at bedside. "

An interview was conducted with the Chief Nursing Officer (staff member #1) and the Senior Medical Director (staff member #8) on 08/13/2020. Staff member #8 stated that education had been given to the radiology department regarding where to locate information in the patient's record regarding the patient's code status. Staff member #8 stated that the hospital was in the process of making changes to its EMR to allow the code status of the patient to be more readily seen between departments and visits. Documentation of meeting minutes and/or evidence of planning for these changes was requested. Staff member #12, Regulatory Affairs and Risk Manager, confirmed that no meeting minutes or documented evidence of the process change were available. Documentation of education materials provided to interventional radiology staff was provided and reviewed by the MFI on 08/12/2020.

The Chief Nursing Officer acknowledged the above noted deficiency during the exit conference on 08/20/2020.

Based on medical record reviews and staff interview, it was determined that facility staff failed to initiate and reassess a nursing care plan for one (1) of three (3) patients (Patient #10).

The findings include:

The surveyor reviewed Patient #10's medical record for evidence of the initiation and ongoing assessment of a nursing care plan. The surveyor was unable to locate the evidence. On 8/18/2020, the surveyor asked Staff Member #23 (Regulatory Affairs Coordinator) for assistance locating a nursing care plan in Patient #10's medical record. Staff Member #23 replied, "We are unable to locate the nursing care plan in Patient #10's chart."

Review of the facility policy and procedure titled, "Nursing Process - Delivery of Patient Care", documented in part ..."Diagnosis/Planning. .....2. The plan of care should be initiated by the [Registered Nurse] RN within 8 hours of admission to an inpatient unit or within 4 hours of admission to a critical care unit, and addresses the immediate acute needs of the patient (to include physical, psychosocial, educational, as well as environmental/self-care/discharge planning needs). 3. The plan of care will be based on evidence based standards that provide a systematic method to achieve patient goals/outcomes. 4. The plan of care is reviewed in consultation with appropriate members of the health care team and the patient/family. a. The RN revises the plan of care as appropriate to the patient's condition and the ongoing assessment process in collaboration with the healthcare team. b. The RN is accountable for changes to the plan of care; therefore, the [Licensed Practical Nurse] LPN will notify the RN of any change in assessment findings at the time the change in patient condition occurs. c. The plan of care is reviewed and patient's progress toward established goals/outcomes is documented at least every shift. 5. The responsibility and accountability for analyzing the reassessment data and for the modification of a patient specific plan of care remains with the RN ...."

The survey team discussed the concerns regarding the missing plan of care with the facility administration at the exit conference on 8/20/2020.

Based on staff interview and document review, it was determined that facility staff failed to ensure its discharge planning process identified at an early state of hospitalization patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning; specifically, the hospital failed to identify a patient with home oxygen needs and ensure portable oxygen was available for the patient for the transfer home and at discharge in one (1) of twelve (12) medical records reviewed in the survey sample. Medical record # 5.

Findings

Twelve (12) medical records were reviewed in the hospital 08/11-19/2020 with the following findings:

The medical record for patient #5 contained documentation of oxygen orders for the patient per the hospital oxygen protocol ordered on the date of admission, 06/04/2020. Multiple nurses notes in the medical record contained documentation of the patient requiring supplemental oxygen use in the hospital. The medical record failed to contain any documentation that the need for oxygen at discharge was addressed to include the need for home oxygen and/or the availability of supplemental oxygen at home on discharge.

The record contained documentation that the patient was discharged on 6/6/2020 at 1:15 pm with no orders for oxygen therapy and no evidence of a discharge planning assessment to include the need for oxygen. Patient #5 was escorted by RN, Staff Member #13 to the outside front of the hospital and transferred to a bench to await transportation home.

The hospital's Policy "Interdisciplinary Care Coordination and Discharge Planning" was reviewed and stated in part,

a) "Discharge planning begins on admission...".
b) "The intent of discharge planning is to ensure that all patients in need of post-hospital services have a safe and planned program for continuing care... and involves assessment of the patient's post-hospital needs and suitable arrangements for the post-hospital environment."

The hospital's Policy "Patient Discharge" states in part,
"a) The RN will: Discuss discharge arrangements with the patient/family
1. Who will pick up the patient
2. When the family member will be present to pick up patient
3. Any assistance/special considerations needed to safely get patient home (i.e. portable oxygen, etc)."

The medical record failed to contain evidence that an RN discussed when a family member would be present to pick up the patient or provided the patient with portable oxygen as required in the hospital policy.

The Surveyor conducted an interview on 8/17/2020 at 10:30 am with an RN, Staff Member # 13. Staff Member #13 stated he/she did not speak with the family regarding the discharge, rather inquired of the patient, "do you want me to call someone to pick you up?" The Patient responded, "no, I'm calling someone right now". Staff Member #13 observed the Patient talking on a cell phone and overheard him/her say, " I'm getting discharged, come and get me." Staff Member #13 then prepared and escorted the Patient outside, assisted to the bench to wait for [transportation]. Staff Member #13 recalled the Patient often feeling cold and "requested to sit outside even though it was hot that day". Staff Member #13 stated that the Patient "was alert and oriented and capable of making decisions, and I double checked if [the Patient] wanted to come back inside and [the Patient] said no". In regards to the use of oxygen, Staff Member #13 stated, the Patient, " takes the oxygen off sometimes and does not always use it. I can't force [him/her] to keep it on."

The above noted discharge planning deficiency was acknowledged by hospital administration during the exit conference on 08/20/2020.