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M HEALTH FAIRVIEW LAKES MEDICAL CENTER

5200 FAIRVIEW BOULEVARD

WYOMING, MN 55092

PATIENT RIGHTS: INFORMED DECISION

Tag No.: A0132

Based on interview and document review, the hospital failed to ensure a system for informing patients of their right to formulate an advanced directive 5 of 10 patients (P2, P4, P5, P6, and P7) reviewed for advanced directives.

Findings include:

P2's Admission Default Flowsheet Data dated 12/29/24, indicated P2 did not have an advanced directive. P2's flowsheet lacked evidence advance directive information was provided.

P4's Admission Default Flowsheet Data dated 12/29/24, indicated P4 did not have an advanced directive. P4's flowsheet lacked evidence advance directive information was provided.

P5's Admission Default Flowsheet Data dated 12/30/24, indicated P5 did not have an advanced directive. P5's flowsheet lacked evidence advance directive information was provided.

P6's Admission Default Flowsheet Data dated 12/29/24, indicated P6 did not have an advanced directive. P6's flowsheet lacked evidence advance directive information was provided.

P7's Admission Default Flowsheet Data dated 5/14/25, indicated P7 did not have an advanced directive. P7's flowsheet lacked evidence advance directive information was provided.

On 5/14/25 at 2:35 p.m. a registered nurse (RN)-A stated admission nurses provided the advance directive notice to the patients during an admission, and documented in the admission navigator.

On 5/15/25 at 4:05 p.m., RN-B (emergency department [ED] manager) stated she was unable to verify whether P2, P4, P5, P6 and/or P7 had received the required advanced directive information at the time of admission. Admission nurses should have offered those patients advanced directive information at the time of admission, and it should be documented in the admission navigator by the admission nurse.

The hospital Advance Care Planning (ACP) and Advance Directives policy dated 1/20/22 and reviewed on 11/05/24, directed admission nurses to review the medical record and document the presence of an Advance Directives in the admission navigator. The policy further directed nurses to provide a health care directive information at the time of any patient's admission and documented in the admission navigator.