HospitalInspections.org

Based on review of the clinical records, policies and procedures and staff interviews the Hospital failed to comply with their policy and procedure titled Advance Directives/Health Care Proxy in two (2) of two (2) incapacitated patients (Patient #3 and #6) requiring activation of their Health Care Proxy.

According to the Hospital policy titled Advance Directives/Health Care Proxy, the attending physician makes the determination that a patient lacks the capacity to make healthcare decisions. The medical record must contain a.) the physician's determination of incapacity, b.) the physician's opinion about the cause and duration, if possible, of the incapacity c.) notice of the determination of incapacity to the agent.

For Patient #3, living in a group home with a major psychiatric diagnosis. Patient #3 suffered respiratory failure, was ventilator dependant, sedated, and required medications to maintain his/her blood pressure. The physician approached Patient #3's Health Care Proxy to sign informed consent for two invasive procedures and to declare a code status (Comfort Measures Only). Review of the clinical record indicated there was no documentation of the Health Care Proxy being activated by the physician due to the patient's incapacitation, as required by Hospital policy.

For Patient #6, with dementia and advanced age. Patient #6 suffered from abdominal pain and required placement of a PICC line(a peripherally inserted central catheter is long, flexible intravenous tube that is inserted into a peripheral vein and terminates in a large vein in the chest). Review of the clinical record indicated the physician had Patient #6's Health Care Proxy sign an informed consent for this invasive procedure. Review of the clinical record indicated there was no documentation of the Health Care Proxy being activated by the physician due to the patient's incapacitation, as required by Hospital policy.