HospitalInspections.org

Based on surveyor review of records and interview with staff, the facility failed to follow its Advance Directive policy by failing to inform patient #1's representative of The Ethics Committee determination in writing and failed to document The Ethics Committee decision in patient #1's medical record. The findings include:

1. The Advance Directive policy reads [in part]:

~ The person responsible for the treatment decision shall receive a written explanation of the recommendation reached during the review process. Such written explanation must be included in the patient's health record.

~ . . . If the "person making a treatment decision is requesting life-sustaining treatment that the attending physician has decided is inappropriate treatment and the Clinical Ethics Committee concurs with the physician's decision, the patient shall be given available life-sustaining treatment pending transfer. . . The attending physician and [facility] are not obligated to provide life-sustaining treatment after the tenth day after the written recommendation of the Ethics Committee is provided" to the patient's representative.

2. During an interview in the facility's conference room on 1/6/21 at approximately 1400, staff #4 stated, "I didn't have to consult the Ethics Committee because we weren't withdrawing care. I probably used the wrong wording in his [patient #1's] chart. This was not a withdrawal; this was just removing him from the ventilator. He [patient #1] was already legally dead when I discontinued the orders for the fluids on 12/30/21 and medications on 1/3/22. I was within my legal rights. I consulted the Ethics Committee because of the family's difficulty with the death."

~ On 12/28/21 1738, staff #4 documented in patient #1's medical record, "He is declared to be brain dead [on 12/25/21]; however, the family does not want to withdraw care and wants the patient to remain full code and continue aggressive therapy. Meeting with the family has been scheduled for tomorrow . . . We intend to politely discuss options."

3. The Ethics Committee meeting was held on 1/31/21. Patient #1's medical record lacks documentation of meeting decisions and recommendations. Patient #1's representative denies receiving Ethics Committee's decision letter or being informed of rights to transfer and/or find an attending physician that would accept transfer of patient #1's care.


On 1/6/22 at 1530, staff #3 confirmed findings, stating, "Even if not needed, once the Ethics Committee process was started by staff, we should have followed the steps in the policy. We did not send a letter to his [patient #1's] representative."