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Based on record review and interview, the facility failed to ensure that compliance with policy and procedure for Advance Directives in regard to documented witnesses in 1 of 1 patient chart reviewed. (ID#10)

Findings include:

Record Review of facility policy titled "Advance Directives, Life Sustaining Treatment Decisions, Do Not Resuscitate (DNR) and Comfort Care," dated 12/09/2021 showed the following information:

POLICY PURPOSE
The purpose of this policy is to comply with the Advanced Directives Act and establish procedures for use at Memorial Hermann Katy hospital.

DEFINITIONS

F. "Witness"- In any circumstance in which the Advance Directives Act requires the execution of an advanced directive or the issuance of a non-written advance directive to be witnessed, each witness must be a competent adult and at least one of the witnesses must be a person who is not:

2.) a person related to the declarant by blood or marriage;

B. Verbal Directive or Non-Written Directive

A competent qualified patient who is an adult may issue a directive by a non- written means of communication. The declarant must issue the directive in the presence of the attending physician and two witnesses who possess the same qualifications as are required for witnesses. The physician shall document the existence of the verbal director in the progress note section of the declarant's medical record and the witnesses cell sign the entry. Obtain a written confirmation of the directive from the declarant if and/or when possible.

Interview with Director of ICU (ID# 56) on 4/11/2023 at 10:15 AM, he stated what generally happens in regard to DNR is that the physician has a documented conversation with patient and family and then an order is written for DNR.

Interview with Clinical Director of acute care (ID #55) on 4/11/2023 at 12:08 PM, she confirmed that a physician having the conversation with a patient and family regarding end-of-life decision including DNR would be considered a Verbal or Non- Written Directive. She stated that in here experience there is not two witnesses documented.

Review of medical record for patient (ID# 10) showed the following information:
Advance Care Planning: 4/9/2023 21:20
Discussion Participant/Witness: Daughter
Advance Care Planning Discussion Time Spent: 20 minutes
Goals of Care: Be comfortable
Advance care planning discussion details: discussed with wife and daughter by the bedside regarding resuscitation if the patient's heart suddenly stops. Wife and daughter deliberated and agreed that if for any reason the patient's heart stops, they would not want the patient to be resuscitated or intubated. Patient is DNI/DNR.
Resuscitation Attestation: advance care planning decisions were discussed with the health care decision maker and healthcare deserve maker agrees and apps plan of care.

Physician Order: 4/9/2023 21:45, No CPR/ No intubation

Based on record review and interview, the facility failed to ensure nursing had a provider order for placement of a rectal tube, prior to insertion, in Patient ID #3.

Findings Included:

Record review of HHSC Intake #TX00446948 which was received by telephone intake on 1/18/2023. The complainant stated "a rectal tube was introduced ..."

Record review of medical record for Patient ID #3 performed with Information Specialist Staff ID #78 on 4/11/23 at 1:15 pm. She confirmed that she could not locate an order for rectal tube placement. She confirmed rectal tube was inserted by RN Staff ID #76 on 12/21/22 at 11:00 am.

Record review of State of the Texas Nurse Practice Act (Occupations Code: Health Professions, Regulation of Nursing), Chapter 301. The practice act stated "professional nursing involves: ... (C) the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist."

Interview 4/11/23 at 1:20 pm with Director of Acute Care ID #55 was completed. She confirmed that registered nurses need to have a physician or provider order prior to insertion of rectal tube. She confirmed there was no order for rectal tube placement located in medical record for Patient ID#3.

Based on record review and interview, the facility failed to ensure nursing interventions were documented in 1 of 4 patients (ID #10).

Findings included:

Review of facility policy titled "Assessment, Reassessment and Documentation" dated 9/25/2020 showed the following information:

PARAMETERS
1. All components of the patient care process, plan of care, evaluation and outcomes will be documented in the patient's medical record. The documentation will address the patient's biopsychosocial needs, capabilities, and limitations.
2. The nursing process is used in the delivery of patient care and is evidenced by:

c. Documented nursing interventions, which are related to the patient problems identified in the plan of care.

d. documented aspects of nursing care provided to the patient or significant other(s). The effectiveness or outcomes of nursing interventions and the patient's response.

Interview with nursing educator (ID# 74) on 4/11/2023, she stated that all nursing interventions, including failed attempts should be documented in the medical record.

Review of medical record for patient (ID#10) showed physician order for Gastric tube placement on 4/10/23.

Physician communication was noted as multiple failed attempts of NG tube placement including charge nurse.

When asked to see documentation of failed attempts, times, tube type and size and by whom, Charge nurse (ID #73) stated that she did not get to document it yesterday. She was not able to locate any documentation of nursing attempts of gastric tube placement.