HospitalInspections.org

Based on staff interviews, medical record reviews, facility document review, and review of policy and procedure, it was determined that the facility failed to ensure the protection and the promotion of patient's rights.

Findings include:

1. The facility failed to ensure that the physician order was in accordance with a patient's decision regarding a DNR status. (Refer to Tag 0131)

2. The facility failed to ensure a determination of competency in a patient with dementia. (Refer to Tag 0144)

3. The facility failed to ensure that each restraint order for violent behavior was renewed by a physician within the maximum time period. (Refer to Tag 0171)

Based on staff interview, medical record review of patients with a current Do Not Resuscitate (DNR) order, and review of facility policy and procedure, it was determined that the facility failed to ensure that the physician order is in accordance with facility policy and a patient's decision regarding a DNR status in one (1) out of five (5) medical records (#4).

Findings include:

Reference: Facility policy titled: "Do Not Resuscitate (DNR)" states, " ...D. A DNR order can be written when requested by a patient with decision making capacity ..... *Decision making capacity is defined as an individual's ability to understand the benefits and risks of a proposed medical treatment and its alternatives and to reach an informed decision ..... PROCEDURE RESPONSIBILITY ACTION ... Physician/Nurse ... 3. Consent to a DNR order shall be obtained from the patient ... ".

1. The medical record of Patient #4 was reviewed on 10/20/2020 in the presence of Staff #23. The following was identified:

a. A written DNR order on 10/19/2020 at 2:16 PM by Staff #24, a physician.

b. The medical record lacked documentation that the risks, benefits, and alternatives were discussed by Staff #24 with the patient in order to reach the decision of DNR.

2. An interview on 10/20/2020 at 3:30 PM with Staff #1 and Staff #23 confirmed that Patient #4 was aware of the DNR order and current status.

3. On 10/21/2020 at 9:28 AM, medical record entries, written by Staff #24, were provided by Staff #1 that identified the following:

a. A physician progress note dated 10/20/2020 and timed 3:39 PM that stated: "Patient had a dnr [sic] that was placed. This was placed by error without the patient's knowledge."

b. A discontinued DNR order written by Staff #24 on 10/20/2020 at 3:39 PM.

4. Staff #1 confirmed the above findings on 10/21/2020 at 9:28 AM.

Based on staff interview, medical record review of a patient with a history dementia, and review of facility policy and procedure, it was determined that the facility failed to ensure a determination of competency in one (1) out of (1) medical records (#1).

Findings include:

Reference #1: Facility policy titled: "Care of the Older Adult" states, " ...acute care facilities recognize the older adult has unique health care needs due to the expected physiologic and psychological influences of aging .... Nursing ... develops an individualized plan of care with appropriate interventions to mitigate signs and symptoms of health concerns in older adults ..... 6. Dementia -Use valid screening questions to identify those with cognitive impairment who need further assessment. -Obtain pertinent history to identify signs of cognitive impairment. -Uses effective communication strategies with cognitively impaired older adults. -Identify and provide safety measures to older adults with dementia. -Be aware of how the environment can affect an older adult with dementia ....."

1. On 10/20/20, a review of the medical record of Patient #1 was conducted in the presence of Staff #2. The following was identified:

a. The patient presented to the facility Emergency Department (ED) on 8/22/2020 at 2:51 PM with complaints of Chest Pain. Patient #1 had a documented history of dementia.

b. Nursing documentation by Staff #25 on 8/23/2020 at 2:20 PM revealed that the patient "...signed out of the hospital against medical advice..... Pt [patient] was offered a (paid car service) and refused....." The medical record lacked documentation of a screening to determine the degree of cognitive impairment prior to the patient leaving against medical advice.

2. The above findings were confirmed with Staff #2 on 10/20/2020 at 12:45 PM.

Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure that each restraint order for violent behavior is renewed within the maximum time period of four (4) hours.

Findings include:

Reference: Facility policy titled, "Restraints" states, " ... Orders for restraints/seclusion ...The maximum time frame of the order for Violent Behavior or Seclusion is four (4) hours for patients 18 and over ..."

1. On 10/21/2020 at 9:32 AM, a review of Medical Record #8 revealed the following:

a. On 10/19/20 at 8:41 AM, Staff #20, a physician, placed an order for "Restraints for Violent/Self Destructive Behavior; Adult (18 years and older). "

(i) At 8:49 AM, Staff #21, a Registered Nurse (RN), documented in the "Violent Restraints" Flowsheet the start of the following restraints: "Locked Leather/Synthetic R (right) Wrist; Locked Leather/Synthetic L (left) Wrist; Locked Leather/Synthetic R (right) Ankle; Locked Leather/Synthetic L (Left) Ankle."

(ii) Staff #21 documented in the "Violent Restraint" Flowsheet that Locked Leather/Synthetic R (right) Wrist; Locked Leather/Synthetic L (left) Wrist; Locked Leather/Synthetic R (right) Ankle; Locked Leather/Synthetic L (Left) Ankle were continued at 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM.

(iii) Staff #22, an RN, documented in the "Violent Restraint" Flowsheet that Locked Leather/Synthetic R (right) Wrist; Locked Leather/Synthetic L (left) Wrist; Locked Leather/Synthetic R (right) Ankle; Locked Leather/Synthetic L (Left) Ankle were continued at 8:00 PM.

(iv) The next order for "Restraints for Violent/Self Destructive Behavior; Adult (18 years and older)" was not written until 9:32 PM, 8 hours and 51 minutes after the last order expired.

(v) The patient remained in restraints without an order from 12:41 PM until 9:32 PM.

2. The above findings were confirmed by Staff #10 and Staff #12 at 9:45 AM.

Based on staff interview, medical record review, and review of the rules and regulations of the medical staff, it was determined that the facility failed to coordinate the course of treatment between physicians in two (2) out of twenty-three (23) medical records reviewed (#10, #11).

Findings include:

Reference: Facility Rules and Regulations of the Medical/Dental Staff state, "... C. Discharge of Patients 1. Patients shall be discharged only on order of the Attending Practitioner..... H. Medical Records 1. Responsibilities of Preparation and Content: a. A patient's Attending Practioner shall be responsible for the preparation of the patient's medical records and completion of it prior to his/her discharge. The medical record shall include, but not be limited to the following: i. ...The H&P (history and physical) must be performed within 30 days prior to hospital admission or within 24 hours after admission to any in-patient service... vii. Clinical/Progress notes: A clinical progress notes [sic] shall be entered by a Practitioner each time that a patient is visited and shall be written at the time of the observation..... The notes shall provide a full and accurate description of the care provided to the patient. The notes shall also provide a description and an evaluation of the patient's responses to treatment. If issues have been raised in the medical record by other disciplines, the note shall respond ... ."

1. On 10/21/2020, a review of the medical record of Patient #10 was conducted in the presence of Staff #23. The following was identified:

a. A physician order written on 8/8/2020 at 7:02 AM that stated: "Consult to Neurology ONE TIME" for a syncopal episode. The status noted that the order was completed.

b. The medical record of Patient #10 lacked evidence of a Neurology consultation having been performed.

2. On 10/21/2020, a review of the medical record of Patient #11 was conducted in the presence of Staff #23. The following was identified:

a. A "Code Stroke" was initiated at 9:00 PM on 8/14/2020. Staff #27, an emergency department (ED) physician, wrote a note recommending observation status and a consult was placed for Cardiology and Internal Medicine to assist with treating the patient.

b. On 8/15/2020 at 1:15 PM, a progress note written by Staff #28, an internal medicine physician, recommended admitting the patient with telemetry.

c. On 8/15/2020 at 5:00 PM, a discharge order was written by Staff #29, a critical care advanced practice nurse. There was no corresponding note by this practitioner that discussed the change in treatment, or addressed the treatment recommendations by Staff #28.

3. Staff #23 confirmed the above findings at the time of the medical record reviews.

A. Based on staff interview, medical record review of a patient leaving against medical advice (AMA), and review of facility policy and procedure, it was determined that the facility failed to ensure that the protocol for a patient leaving AMA was followed for one (1) of one (1) patient (#1).

Findings include:

Reference: Facility policy titled, "AMA: Patient Leaving the Hospital Against Medical Advice" states, " ...1. Whenever an individual with decision making capacity wants to leave the hospital against medical advice, the staff member will contact the attending MD/Physician to discuss the desire to leave AMA ... 3. The physician (or licensed professional staff member in consult with the physician) will provide the patient the patient [sic] with the following information: -Nature of recommended treatment -Risks and consequences for refusing care and treatment -Benefits of the treatments -Alternatives (if any) 4. The staff member will complete Release Form: Leaving Against Medical Advice ... The staff member will document the information provided to the patient and obtain the patient's signature on the form. 5. If the patient refuses to sign the release form, the staff member shall document the refusal, time, and date on the form and place it on the medical record ... ."

1. On 10/20/2020, a review of the medical record of Patient #1 was conducted in the presence of Staff #2. The following was identified:

a. The patient presented to the Emergency Department (ED) on 8/22/2020 at 2:51 PM with a complaint of Chest Pain. Patient #1 had a documented history of dementia. Patient #1 was admitted to the facility for observation status on 8/22/2020 at 3:48 PM.

b. Nursing documentation by Staff #25 on 8/23/2020 at 2:20 PM revealed that the patient "...signed out of the hospital against medical advice..... Pt [patient] was offered a (paid care service) and refused....."

c. The medical record lacked evidence of the document: "Release Form: Leaving Against Medical Advice."

d. The medical record lacked documentation of the information provided to the patient regarding leaving AMA.

2. An interview with Staff #1 and Staff #3 on 10/20/2020 at 11:48 AM confirmed the above findings and that there should have been a release form in the medical record.