HospitalInspections.org

Based on policy review, medical record review, and interview, the hospital failed to ensure a patient had the right to participate in the development and implementation of the plan of care and ensure a patient's treatment preferences were honored for 1 of 4 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's policy, "Patient Rights and Responsibilities," revealed, "...Patient Rights...You or your personal representative has the right to participate in the development and implementation of your plan of care...You have the right to have your treatment preferences honored..."

2. Medical record review for Patient #1 revealed an admission date of 8/16/2021 with diagnoses which included Obesity, Diabetes Insipidus, Gastroesophageal Reflux Disease, Shortness of Breath, possible Pneumonia, and possible Pulmonary Embolism.

The History and Physical dated 8/16/2021 revealed, "...[Patient #1]...presenting with about 4 weeks of cough and shortness of breath. Cough is nonproductive...She went to an ER [emergency room] 1 ½ weeks ago, where she tested negative for COVID-19. She was prescribed antibiotics and steroids. There was no benefit, leading to her presentation to the ER at [Hospital #2] overnight...At the outside ER...She had a CTA [computed tomography angiography] of the chest that showed a possible tiny distal pulmonary embolism near the lingula, and right middle lobe atelectasis versus consolidation. To treat for possible pneumonia, she was given ceftriaxone [antibiotic] and azithromycin [antibiotic]. She also was given albuterol [bronchodilator] nebulized treatment and Lovenox [anticoagulant] 1 mg [milligram]/kg [kilogram] subcutaneous. She subsequently was transferred here for admission..."

A Consultation Note dated 8/16/2021 revealed, "...History of Present Illness...she [Patient #1] continues to report cough, severe at times and occasionally productive of white or yellow sputum...her cta chest reviewed by me [Physician #1] reveals bronchiectasis in bilateral lower lobes along with atx [atelectasis]/mucus plugging bilaterally...Physical Exam...General...coughing..."

A physician's order dated 8/16/2021 at 7:59 PM revealed, "...codeine-guaifenesin (Cheratussin AC 10 mg-100 mg/5 ml oral syrup...10 ml..." The medication was administered on 8/16/2021 at 8:08 PM.

3. In a phone interview on 8/18/2021 at 9:00 AM, Physician #2 stated he saw Patient #1 on 8/16/2021 at 4:48 PM (time of Physician #2's progress note). Physician #2 stated Patient #1 complained about a cough and requested cough medicine. Physician #2 stated he did not think much about Patient #1's request for cough medicine, because he was interested in the big picture (Physician #2 referred to Patient #1 possibly having a pulmonary embolism). After mentioning the cough medicine during the interview, Physician #2 stated, "...if that's what this (this complaint investigation) is about, that doesn't bother me at all..."

In a phone interview on 8/19/2021 at 9:49 AM, Registered Nurse (RN) #1 stated Patient #1 began asking for cough medicine on 8/16/2021 around 3:30 PM. RN #1 stated he attempted to message the physician, but the message did not send. RN #1 stated Patient #1 became angry around the change of shift (7:00 PM), because she had not received any cough medication. RN #1 stated he then called the physician on call and got an order for cough medicine (8/16/2021 at 7:59 PM, 4 hours 29 minutes after RN #1 stated Patient #1 first started asking for the medication).

In a phone interview on 8/19/2021 at 10:25 AM, Patient #1 stated she began asking for cough medicine on 8/16/2021 at approximately 3:00 PM. Patient #1 stated she asked RN #1 for cough medicine several times, but he kept telling her there was no order for cough medicine. Patient #1 stated she did not get any cough medicine on 8/16/2021 until sometime after 8:00 PM.