HospitalInspections.org

Based on reocord review and interview, the faiility failed to ensure staff and practitioners comply with the patients' advance directives in 1 out 10 Sample Patients (SP).
(SP#1).

The findings include:

Record review for sample patient (SP#1) conducted from August 08, 2012 to August 09, 2012 revealed SP#1 was admitted to facility on April 30, 2012 through the Emergency Department (E.D.) accompanied by caretaker after sustaining a fall at the Group home where SP#1 resides. Review of the Conditions of Admission forms dated April 30, 2012 showed the forms were witnessed by 2 staff members of the facility ' s Registration department due to " medical condition " . The section " I have not executed an Advance Directive and do not wish to execute one at this time " was checked off. There was no Health Care Surrogate form completed in clinical record at time of record review. Further record review of the clinical record showed that on May 1, 2012 at 18:57 P.M., the Registered Nurse taking care of the patient wrote that she had spoken to the Director of Nursing from the patient ' s group home and was informed that patient had a surrogate and to call the surrogate to see if the surrogate will allow placement of the Nasogastric tube (N.G.T.). On May 1, 2012 at 18:59 P.M., the R.N. documented that patient ' s surrogate was called and plan of care was discussed and surrogate was in agreement with N.G.T. insertion as long as sedation is running. Further record review of the forms " Consent for Colonoscopy and Anesthesia Consent " dated May 2, 2012 witnessed by 2 Registered Nurses at 17:55 P.M. stated SP#1 ' s surrogate (sister) had agreed to colonoscopy. The form " An Important Message from Medicare About Your Rights " completed on May 8, 2012 at 2:00 P.M. by facility under the section " Signature of Patient or Representative " states " verbal consent yes " but does not show who gave verbal consent on this form.

Interview with SE#11, Assistant Director of Case Manager was interviewed on August 9, 2012 from 11:47 A.M. to 12:13 P.M. in the presence of the Director of Risk Management and A.C.N.O. and SE#10 (Case Manager). SE#11 stated that SP#1 belonged to a group home but was not going back due to Insulin management. SP#1 was discharged to a Skilled Nursing Facility. Confirmation that no health care surrogate forms were documented in clinical record at time of review was done at this time.