HospitalInspections.org

Based on record review and interview the hospital failed to ensure the patient/patients representative had the right to participate in the development/implementation of the plan of care and/or refuse treatment for 1 of 30 sampled patients (#17) as evidenced by having no hospital policy which identified the process for obtaining information regarding Code Status/Power of Attorney in an incompetent patient. This resulted in the patient (#17) not being listed as "Do Not Resuscitate" (DNR) for 25 days while in the hospital. The attending physician (S8MD) for the inpatient days (25) was also the physician for patient #17 at the sending nursing home and was aware of the daughter's Power of Attorney and DNR status. Findings:

Review of the medical record of patient #17 revealed he was admitted to St. Martin Hospital acute care on 01/14/12 with a diagnosis of CHF (congestive heart failure), and Acute Bronchitis. Review of all physician orders revealed no order regarding the Code Status of patient #17 for his acute stay from 01/14/12 through 01/24/12.

On 01/24/12 patient #17 was discharged from acute care and admitted to a swing bed. Review of the physician orders for the swing admission on 01/24/12 through 02/05/12 revealed no orders regarding the Code Status of patient #17.

In an interview on 02/07/12 at 3:00 p.m. with S6RN, Nurse Manager, she stated that on 01/24/12 the hospital was preparing to "go live" with Electronic Medical Records (EMR) on 01/25/12 at 0001. S6RN further stated that as part of this process she was entering orders from the paper records into the EMR. S6RN stated she reviewed the medical record of patient #17, found no DNR order, and entered a "Full Resuscitation" status on patient #17 in his EMR.

(On 01/25/12 at 0001 St. Martin Hospital implemented an Electronic Medical Record (EMR) system).

Review of the EMR record for patient #17 revealed an order, documented as a written order from S8MD by S6RN, on a page titled "Resuscitation Status (Code Status)" that read as follows: "Order 01/24/2012 (at) 5:15 p.m. Entered by (S6RN) on 01/24/2012 at 5:13 PM CST (central standard time). Written order by (S8MD)...Details. Requested Start Date/Time: 01/24/2012 5:13 PM CST. Resuscitation Status: Full Resuscitation. Constant Order: Yes."

Review of the EMR revealed a page titled "MD to Nurse (resuscitation status is incorrect)" revealed the following: "Order 02/05/2012 7:37 PM CST. Entered by (S8MD) on 2/5/2012 at 7:36 PM CST...Details: Requested Start Time 2/5/2012 7:36 PM CST. Constant Order: Yes. Enter verbatim order: resuscitation status is incorrect..."

Further review of the EMR revealed documentation by S7LPN on the "Resuscitation Status (Code Status)" page, dated 2/7/2012 at 7:58 AM CST, that discontinued the "Full Resuscitation" status on patient #17. The documentation further indicated this was a written order from S8MD.

Review of the document in the EMR further revealed that an entry was made by S7LPN dated 2/7/2012 at 8:00 AM CST that discontinued the "resuscitation status is incorrect" note on the "MD to Nurse" communication page.

Further review of the medical record of patient #17 revealed an entry into the EMR dated 2/7/2012 at 7:58 AM CST by S7LPN that read in part: "Written Order by (S8MD)...Details. Requested Start Date/Time: 2/7/2012 7:58 AM CST. Resuscitation Status: Do Not Resuscitate. Constant Order:Yes..."

In an interview on 02/07/12 at 10:07 a.m. with S7LPN she stated that on 02/07/12 she came on duty at 7:00 a.m. She further stated that patient #17 was a "Full Resuscitation" at that time. S7LPN confirmed she reviewed the 02/05/12 note from the attending physician (S8MD) that indicated the "resuscitation status is incorrect". (which was now approximately 36 hours since being written) S7LPN stated that she obtained the Advance Directive and Power of Attorney paperwork from a binder in Admissions. S7LPN stated she further reviewed a previous admit chart of patient #17 and found there was a DNR order in the record. S7LPN stated she took the physician's note (that the resuscitation status was incorrect) "as an order to write a DNR order". S7LPN stated she had no verbal or face to face communication with S8MD on 02/07/12 from the time she came on duty and the time she entered an order, documented as a written order by S8MD, making patient #17 a DNR.

Review of a document presented by S6RN which she stated was contained in a binder in the hospital revealed a legal document titled "Medical Power of Attorney" designating a daughter of patient #17 "as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. This medical power of attorney takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician..." The document is signed by patient #17 (with an X - his mark) and two witnesses dated May 21, 2009.

In an interview on 02/08/12 at 9:30 a.m. with S6RN, Nurse Manager, she stated that she had reviewed the hospital's policy and procedure's. She further confirmed that there was no policy to designate who is responsible to obtain the name of the patient's representative if the patient is not a competent major and/or Power of Attorney and copy of document upon admission. S6RN further stated that if patient #17 would have gone into Cardiac and/or Pulmonary arrest between 01/14/12 and 02/07/12 (25 days) he would have had been a "Full Resuscitation". S6RN stated that "Code Status" is not a Nursing function, it is the responsibility of the Physician." S6RN further stated that nursing staff should have questioned the physician and gotten clarification on the physician documentation dated 02/05/12 that the "resuscitation status is incorrect." S6RN further stated that S7LPN entered the DNR status on patient #17 based on information from previous records and not a written order from S8MD. S6RN further stated that patient #17's representative/POA was at the hospital nearly every day patient #17 was in the hospital.

In an interview on 02/08/12 at 9:50 a.m. with S8MD she stated that she was aware since 01/14/12 (date of admission as an acute patient) that patient #17 was a DNR (at the nursing home where she was his physician). S8MD stated that "he (patient #17) was not in bad shape so I was not concerned about his Code Status." S8MD further stated that on 02/05/12 when she sent the note to Nursing that the "resuscitation status is incorrect" she knew patient #17 was a DNR. S8MD stated this was the first day she realized the medical record indicated patient #17's Code Status was "Full Resuscitation." S8MD stated she "was unsure of where to document DNR status in the new computer system." S8MD further stated that she did not write or give a verbal order on 02/07/12 to make patient #17 a DNR. S8MD stated she knew patient #17's daughter had Healthcare Power of Attorney and named the daughter.

In an interview on 02/08/12 at 11:30 with S2DON she stated the Power of Attorney/Code Status information should have been addressed upon admission. S2DON further confirmed that there was no hospital policy concerning obtaining this information. S2DON confirmed there was no Code Status from 01/14/12 to 01/24/12, failure to include the patient's representative/POA in the development/implementation of the care plan, entry of DNR order's by an LPN and the lack of documentation in the physician's progress notes as to how the DNR was obtained.

Review of a hospital policy titled "St. Martin Hospital Admission Process/Procedures to Inpatient Services" revealed no documentation to indicate which staff member or at which part of the admission process should information regarding the presence/absence of the wishes of the patient/patient representative regarding Code Status and/or refusal of services in the event of Cardiopulmonary arrest.

Review of a hospital policy titled "Patient Rights to Refuse Treatment and Formulate Advance Directives", initiated 04-2011, no date of review of revision, presented as current hospital policy, reads in part: "Statement of Purpose: It is the desire and intent of St. Martin Hospital to ensure that the patient's rights to refuse treatment and formulate advanced directives are honored...Policy Interpretation and Implementation: The patient has the right to refuse treatment...and to formulate an advanced directive..."Advanced Directive" means a written instruction, such as living will or durable power of attorney for healthcare, recognized under state law, relating to the provisions of health care when the individual is incapacitated. "Participates in planning care and treatment" means that the patient is afforded the opportunity to select from alternative treatments...The patient has the right to participate in care planning and to refuse treatment...Advanced directives will be secured utilizing current hospital forms and procedures."

Review of a hospital policy titled "Writing DNR/No Code Orders", no policy number, no effective date, last revised 04-07, presented as current hospital policy, reads in part: "Subject: Resuscitation of patients. All patients with cardiac or respiratory arrest Will be resuscitated unless there is a physician's order that specifies "DO NOT RESUSCITATE" (DNR Order). Purpose: 1. To inform all personnel when a patient is to not receive Cardiopulmonary Resuscitation (CPR). 2. To indicate on the medical record why this decision is appropriate. Scope: Nursing Staff, Medical Staff. Principle. 1. Under most circumstances, competent adults (18 or over) have the right to refuse any treatment, and should be informed of their condition, in order to make appropriate choices to serve their own goals. 2. Incompetent patients may have proxy decisions made by their legal guardians (often the next of kin) in consultation with the attending physician...Procedure:...If the patient has not been consulted, Section a AND/OR b, as outlined below must be followed: a. An additional note must be written, stating: 1. The family concurs (or no family is immediately available). 2. The patient is incapable of understanding and evaluating such an order. 3. Then the DNR order may be written. AND/OR b. 1. The family concurs (or no family is immediately available). 2. The family agrees discussion with the patient is not in the best interest of the patient. 3. Then the DNR order may be written....6. CPR will be undertaken in the absence of orders not to resuscitate. RESPONSIBLE PERSONS: All Nursing personnel, attending physicians."