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Based on records reviewed and interview, the Hospital failed to comply with its policy for activating the Health Care Proxy (HCP) for two of two patients (Patient # 7 and #8) deemed unable to make an informed decision.

According to the Hospital policy titled "Advance Directives and Health Care Proxy", dated 1/9/18, the Health Care Agent does not have the authority to make healthcare decisions for the patient until the responsible provider makes the determination that the patient lacks capacity and the provider must document the patient's lack of capacity in the patient's medical record.

Patient #7 had a complex medical history that required mechanical ventilation and sedation. Patient #7's advanced directives (code status) were determined by Patient #7's Health Care Agent without documentation of activation of the Health Care Proxy by Patient #7's physician as required.

Patient #8 had several comorbid conditions resulting in his/her requiring mechanical ventilation and sedation. Patient #8's Health Care Agent signed an informed consent for an invasive procedure on Patient #8 without documentation of activation of the Health Care Proxy by Patient #8's physician as required.

The Surveyor interviewed the Risk Manager at 4:00 P.M. on 11/5/2020. The Risk Manager said the Hospital had a process for activating the Health Care Proxy but it was not found in either Patient #7 or Patient #8's medical record.