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 10 medical records reviewed (MR1).

Findings include:

Review of facility policy, "Advanced Health Care Directives" last reviewed May 2016 revealed "...C. Implementing An Advanced Health Care Directive. 1. Implementation of patient self-determination continues during the hospitalization of the patient...facilitating communication with and among the healthcare team and the patient and the family..."

A review of MR1 on September 26, 2017 at approximately 1:30PM revealed a Durable Health Care Power Of Attorney signed on 2/28/2017 by the patient and two witnesses. Noted in the section "GUIDANCE FOR HEALTH CARE AGENT (OPTIONAL)" was handwritten "Do not recessitate" {sic}. Further review of the section "LIVING WILL" revealed ..."3. I specifically do not want any of the following as life prolonging procedures: ...Heart-lung resuscitation (CPR)...."

Further review of MR1 revealed the patient went into cardiac arrest on March 19, 2017 at 10:00AM and underwent 31 minutes of resuscitation with CPR.

Further review of MR1 revealed the patients Level Of Care was a "level I (For all patients unless otherwise ordered levels of care order set is used to change status. Begin CPR if brain viability is possible or if no legal or medically reason to withhold. Call CASE ONE if cardiac/respiratory arrest)." Further review of MR1 revealed a Level II is "all resources available will be applied to preserve life except CPR and intubation. The nursing staff will notify the appropriate physician if a cardiac and/or respiratory arrest occurs."

An interview conducted on September 26, 2017, at approximately 1:45PM with EMP1 confirmed an advanced directive signed by the patient was on the patient's chart and that the advanced directive indicated the patient did not want CPR. Further interview with EMP1 confirmed the patient was coded for 31 minutes and that the Level Of Care should have been changed from a I to a II.