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Based on expert medical record review, the medical staff was not accountable to the governing body for the quality of the medical care provided to Patient #1 relative to his capacity to make decisions, the administration of narcotic analgesics and the management of chronic CO2 retention and muscular dystrophy.

Findings Include:

- Review of the IPRO Summary of Professional Analysis of Care revealed the patient was described as pale with a pulse of 133, respiratory rate of 20-30's with breath shallow and poorly moving air associated with marked CO2 retention and acidosis when the patient was asked if he wanted to be intubated. Just because he was considered alert, under the physiological, stressful status described above, it is not at all certain he had capacity to reverse his prior wishes as documented several times in the chart as NOT DNR.The patient's brother was described as surprised that the patient refused life-saving measures.


-Review of Physician Orders dated 9/18/10 revealed a postoperative order for Dilaudid 2mg by mouth every four hours.

-Review of the Medication Administration Record dated 9/19/10 revealed Dilaudid 2 mg by mouth was administered at 3:02am, 5:32am, 10:23am and 1:39pm

-Review of Patient Rounds Log dated 9/19/10 revealed a pain level of "0" was documented every two hours from 12:00am through 6:00pm.

-Review of the IPRO Summary of Professional Analysis of Care revealed the need for around the clock narcotic analgesic was not warranted in this patient given the risk of respiratory depression and CO2 retention in this patient with muscular dystrophy.

-Blood chemistries dated 9/15/10 indicated Patient #1 had an elevated serum bicarb of 37 implying chronic CO2 retention. Yet a blood gas was not obtained to ascertain his chronic degree of hypoventilation and to determine if there was a need for CPAP ventilation prior to or after surgery to assist ventilation. Following the patient's refusal of intubation on 9/19/10, there is no evidence CPAP was considered to assist his breathing.

Based on medical record review, the nursing staff did not administer narcotic medication to Patient #1 in accordance with physician orders.

Findings include:

-Review of Physician Orders dated 9/18/10 revealed a postoperative order for Dilaudid 2mg by mouth every 4 hours.

-Review of the Medication Administration Record revealed Dilaudid 2mg by mouth was administered to the patient as follows:
-9/18/10- 9:28pm.
-9/19/10- 3:02am, 5:32am, 10:23am and 1:39pm.

-Dilaudid 2mg by mouth was administered to Patient #1 on two occasions at less than the four hour ordered interval. Specifically, the patient received Dilaudid on 9/19/10 at 3:02am and then again at 5:32am, at an interval of 2.5 hours and at 10:23am and 1:39pm, at an interval of 3 hours and 16 minutes.

-This finding was verified with Staff #1 on 1/3/11.