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Based on findings from document review and interviews, in 8 of 9 medical records (MRs) reviewed during the Department of Health's initial onsite visit in this complaint investigation on 7-19-10, the hospital's process for determining and complying with patients' advance directives was not effective. Specifically, in the 8 MRs, discrepancies in recorded advance directives were noted between the facility's electronic Registration Face Sheet, the ECU (Emergency Care Unit) Admission Sheet, the Nursing Admission Assessment Form and/or the physician orders. Also, "Do Not Resuscitate (DNR)" orders were provided in the absence of necessary completed paperwork (per internal hospital policy) - this was found in 3 of 9 records reviewed. In 1 of the 9 MRs reviewed, a DNR order was issued despite discrepancy between what the patient told the attending physician she wanted and what she told a nurse. Additionally, in 7 of the 9 Emergency Care Unit (ECU) Admission Sheets reviewed, ECU staff did not document whether the patients had advance directives. Further, the hospital policy and procedure (P & P) addressing advance directives was incomplete, lacking all information necessary to guide staff in determining and complying with patients' advance directives.

Findings include:

--- Per review of a hospital Patient Complaint Investigation Report dated 4-05-10 regarding a complaint about the care provided to Patient A, the complainant explained the following to the hospital: When Patient A was admitted to the hospital on 4-03-10, a nurse (Nurse #1) in the emergency department told the complainant that hospital records (the electronic Registration Face Sheet ) indicated the patient's advance directive was "Do Not Resuscitate." This was not true so staff took the complainant to the reception desk to have this changed. The Patient Complaint Investigation Report also indicated this problem was due to a computer system issue and described the following corrective action: "Staff are to ask every time patient presents to register ... (about) HCP, DNR, POA & Living Will, rather than state 'Is everything the same as last time'."

However, per review of Patient A's MR for a return visit to the hospital ED on 5-13-10, it lacks any indication the patient was asked about her advance directives. The Registration Face Sheet contains documentation indicating the patient's advance directives were "Unknown."

The initial error in the advance directives information during Patient A's 4-03-10 admission was confirmed by the Director of Risk and Quality Management (DRQM) on 7-19-10 at 3:00 p.m. She explained that the problem with the electronic Registration Face Sheets was that occasionally the form was being pre-populated with information about patients' advance directives, from prior hospitalizations. When Phase 1 of a new electronic MR system was implemented and interfaced with the existing electronic MR system, inaccurate advance directive information was sometimes transferred to the current registration face sheet. The DRQM informed the registration clerks to verbally ask each patient about his/her advance directives no matter what came up on the computer screen, correct it and notify her or a nursing supervisor in her absence. During monitoring the DRQM was notified of this problem (automatic population of the Advance Directives section of the electronic Registration Face Sheet with inaccurate information) occurring for 3 other patients. Due to these infrequent occurrences, the DRQM did not feel the electronic MR system needed to be changed. (During interview, the DRQM did not indicate that this problem with the inaccurate Registration Face Sheets was specifically addressed with the information technology staff in the hospital.)

---Per review of the MR for Patient B on 7-19-10, documentation on the Registration Face Sheet form indicated the patient's advance directive was "Do Not Resuscitate," while the Nursing Admission Assessment Form only indicated the patient had a Health Care Proxy (HCP). (A DNR order was not documented in the MR.)

During interview with Patient B (verified to be alert and oriented by the MR documentation) on 7-19-10 at 1:00 p.m., he indicated that he would want to be fully resuscitated in the event of cardiopulmonary arrest.

--- Per review of Patient C's MR on 7-19-10, the Registration Face Sheet contained documentation stating the patient's advance directive was "Do Not Resuscitate." The Nursing Admission Assessment Form completed by Nurse #2 also indicated the patient desired to not be resuscitated (DNR) and that she had a HCP. However, the History and Physical Examination (H&P) completed by Physician #1 indicated the patient was a "Full Code" (i.e., full resuscitation). Regardless, 3 hours after the H&P was dictated, Physician #1 provided a telephone order for "DNR."

During interview with Patient C on 7-19-10 at 11:50 a.m., she stated that she had a HCP who will make her DNR decision when she is not able to make that decision. She noted she had not made a decision regarding resuscitation at this time.

However, when these findings were discussed with Nurse #2 at 12:00 p.m., she indicated that when she had talked with the patient, the patient expressed a desire for DNR status; so she (Nurse #2) communicated this to Physician #1 and obtained the telephone order for the DNR.

Given the discrepant information provided by Patient C to the nurse and the physician, it was inappropriate for Physician #1 to provide a DNR order before further interacting with the patient.

Also, per review of the hospital P & P entitled "Do Not Resuscitate Orders," last revised 8-05, it requires "The DNR order must be written on the order sheet in addition to completing the Documentation Sheet in order to meet criteria for a valid appropriate order." That was not done in this case.

At 12:30 p.m. on 7-19-10, the DRQM indicated the DNR order would be placed on hold and this situation would be immediately brought to the attention of Physician #1. A DNR Documentation Sheet #1 was later completed by Patient C and Physician #1on 7-19-10.

--- Per review of Patient D's MR, the Registration Face Sheet, the ECU Admission Sheet, and the Nursing Admission Assessment Form, all contained documentation indicating the patient's advanced directive was "DNR." However, the corresponding DNR paperwork (i.e., named Documentation Sheet #4 at this hospital) in Patient D's MR lacked appropriate physician signatures and was not current, i.e., it was dated 2-22-10, 5 months prior to this 7-18-10 admission.

--- Per review of Patient E's MR, he was admitted from a skilled nursing facility on 7-14-10. Patient E was identified as a DNR on the Registration Face Sheet and the Nursing Admission Assessment Form. However, on 7-19-10, Patient E's MR contained only a one page Nonhospital Do Not Resuscitate (DNR Order) form, signed and dated on 10-05-09. A completed facility DNR Documentation Sheet and a physician order for DNR (as required by hospital policy) was lacking in Patient E's MR.

--- Per review of Patients F's MR, the Registration Face Sheet indicated the patient "has advance directives" but the section regarding advance directives in the Nursing Admission Assessment Form was not completed. There was no other information on advance directives in the MR.

--- Per review of Patient G's MR, it does not contain information obtained in the hospital about her advance directives. However, there was a copy of her skilled nursing facility's DNR form. While there was a physician order for DNR/Do Not Intubate, the corresponding hospital DNR Documentation Sheet (as required by hospital policy) was lacking.

--- Per review of Patient H's MR, the Registration Face Sheet indicated the patient's advance directives were "Unknown," the advance directives section of the ECU Admission Sheet was was not completed, and the Nursing Admission Assessment indicated the patient had a HCP.

--- Per review of the ECU Admission Sheets, on 7-19-10, in 7 of 9 MRs, the patient's advance directives section was not completed.

--- During interactions with the DRQM at multiple times throughout the day on 7-19-10, she confirmed the findings noted above. When the continuation of discrepancies were discussed with her, she acknowledged systemic problems and noted they would be addressed that day. During followup with the hospital on 7-23-10, the administrator informed the DOH that "the facilty is screening all current patients admitted to the hospital to verify accurate advanced directives status. If there are discrepancies, they are being corrected at the time, including notification of physicians. Over the weekend all admissions will be reviewed by nursing supervisors to ensure accuracy of patient wishes regarding advanced directives. If there are discrepancies, the nursing supervisor will correct at that time as well."

--- During onsite followup at the hospital on 7-27-10:

- A review of 44 MRs (concluded at 4:45 p.m.) revealed that each patients' advanced directive status (i.e., DNR or full resuscitation) was accurate, but also that some occurrences of inconsistent documentation remained. (Administrative staff, including the Chief Executive Officer, affirmed that all MR documentation inconsistencies would be resolved in the MRs by the end of 7-28-10, if not sooner.)

- During interview of 5 Nurse Managers (NMs #1 - #5), they indicated they were aware of the recent problems with advance directives MR documentation. However, only 2 of the 5 nurse managers were aware that audits of patients' advance directives had been completed over the past 4 days.

- During interview of 17 of 17 staff nurses (Nurses #3 - #19), they did not indicate they were aware of the hospital's current corrective action plan to verify accurate recording and implementation of advance directives, that any identified discrepancies in advance directives information were to be resolved, and that the attending physician would be notified of discrepancies.

--- Per review of the hospital P & P entitled "Patient Self-Determination Act Compliance at Auburn Memorial Hospital: Advance-Directives -Adult Patients," last revised June 2008, this policy lacked the following:

1) a definition of advance directives,
2) acknowledgement of the patient's right to formulate written and oral instructions on health care, including an advance directive, and to have those wishes recognized,
3) correct description of the types of patients that should be informed of their rights and provided advance directive information,
4) description of a procedure for determining a patient's advance directive decision(s), and
5) description of the procedure used to immediately identify if a patient has an advance directive regarding resuscitation, in the event of cardiopulmonary arrest.

Based on findings from document review and interviews, the hospital did not implement effective corrective actions to address problems identified during its investigation of a complaint concerning inaccurate medical record (MR) documentation of a patient's advance directives.

Findings include:

--- Per review of the hospital's Patient Complaint Investigation Report dated 4-05-10 regarding a complaint about inaccurate documentation of a patient's (Patient A) advance directives, the hospital investigation identified that a new electronic medical record system issue was resulting in sporadic pre-population of the electronic Registration Face Sheet with information about a patient's advance directives that was not current and/or accurate. Corrective action included directing the registration staff to verbally verify the accuracy of each patient's advance directives upon admission. There is no documentation that the hospital's information technology staff were consulted in this matter.

--- Survey findings from the Department of Health's 7-19-10 onsite revealed continuing problems with accurate documentation of patients' advance directives, as well as with compliance with patients' directives. See the findings in Tag A0115.