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Based on record review ad interview, the hospital failed to ensure documentation of written notification of advance directive policy for one (Patient #8) of three patients.

This failed practice has the likelihood to result in patients having a knowledge deficit of their right to formulate an advance directive to direct medical care decisions.

Finding:

Patient #8

Review of a flowsheet dated 01/04/21 at 3:17 PM in the medical record showed an entry of "No Advance Directive" and an entry of "NA" (not applicable) to the query of giving the patient advance directive information.

On 04/15/21 at 11:15 AM, Staff C reviewed the medical record for Patient #8 and stated the following:
1. The patient did not have an advance directive.
2. The patient did not receive any advance directive information.

On 04/16/21 at 10:32 AM, Staff E the following:
1. There was no inpatient advance directive policy.
2. There was no documentation of nursing education related to advance directives and it was something they need to do.
3. The risk to patients was performing life support measures on someone who did not want it.