HospitalInspections.org

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to comply with the patient's advance directives for one of 22 medical records reviewed (MR1).

Findings include:

Review of facility policy, Medical Advance Directive, Physician Orders for Life Sustaining Treatment (POLST), Mental Health Declaration, and Mental Health Power of Attorney Policy, dated January 28, 2017, revealed, "Consistent with federal and/or state legislation, it is the policy of St Clair Hospital to accept and honor patients' wishes regarding medical and/or mental health treatment whenever possible and to encourage and assist patients in determining and expressing their preferences regarding treatment decisions, ... II. Procedure. A. Emergency Department physician may honor a valid (signed, dated, witnessed) medical advance directive and/or POLST, and issue appropriate code status for implementation. ... B. Admitted Patients. 1. If a Medical Advance Directive exists and the patient presents a copy, the registrar will: 1) Incorporate that information into the Hospital's computer system and scan the document into the Hospital's computer system if not already done."
1. Review of MR1 revealed, "Durable Health Care Power of Attorney with Living Will. 1. Health Care declaration I, [wife of MR1], (Principal) of the Commonwealth of Pennsylvania, appoint the person named below to be my Health Care Agent ... Health Care Agent: [MR1], my husband ... 8. Severe Brain Damage or Brain Disease ... I agree. Keep me comfortable and allow natural death to occur. ... End-Stage Medical Condition or Permanent Unconsciousness ... I do not want aggressive medical care, and give the following instructions ... I do not consent to donate my organs or tissues at the time of my death. "
2. Interview with EMP1 on August 14, 2017 at approximately 11:00 am, revealed, "The Advanced Directives that the personal care home sent over belonged to his wife, not the patient."
3. Interview with EMP6 on August 14, 2017, at approximately 1:00 pm, revealed, "Yes, I confirmed that he was on hospice at the peronal care home."