HospitalInspections.org

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure patients were given an advance directive notice and the right to formulate an advance directive, and ensure copy's of advance directives were included in the medical record for 2 of 20 inpatients (P2 & P5) whose medical records were reviewed.

Findings include:

Review of P2's medical record, indicated the patient was admitted on 7/8/18, for cellulitis of the left hand. The admission notes did not include an advance directive nor did it indicate it had been offered.

Review of P5's medical record, indicated the patient was admitted on 4/26/18, for nausea and vomiting. The admission notes did not include an advance directive nor did it indicate it had been offered.

Interview with the facility's regional nurse administrator (RNA) on 1/17/19, at 3:00 p.m., confirmed P2 and P5 did not receive the required advance directive information upon admission.