HospitalInspections.org

Based on review of 8 open medical records and 5 closed medical records, it was determined the hospital failed to present evidence the (Medicare recipients/ beneficiaries) patient or the patient's (recipient's/ beneficiary's) representative was provided "An Important Message from Medicare" (IM) notice of rights. Specifically, the hospital did not provide the initial IM for 3 of 13 patient records and did not provide the secondary IM for 2 of 13 patient records reviewed.
Review of medical records for Patient (Pt) # 1, Pt# 2, and Pt# 10 revealed no initial IM was provided. Additionally, Pt# 9 and Pt# 10
records were missing the secondary IM as required.

Based on review of 5 closed medical records and 8 open records it was determined the hospital failed to honor the rights of patient #2 regarding end of life care.

Patient #1 was a 70+ year old patient with a complicated medical history who presented to the hospital in respiratory distress. Patient was admitted to the Intermediate Care Unit (IMC) for exacerbation of chronic lung disease. Per nursing "Admission History-Part II" on the day of admission, patient #2 responded "No" when asked if they had an advance directive. Per provider progress note on the same day, the patient was made a full code. The note stated, "pt is unsure about (his/her) decision but at this time is full code with plan to intubate for short time (3 days) if needed."

Three days into patient #1's admission, the patient's condition worsened. Per Intensive Care Unit (ICU) progress note on that date at 0226, the provider documented patient "insists that (he/she) "would rather die" than undergo trial of intubation, is very clear." Provider documented patient was awake and oriented x 3 under the physical exam. Per same note under "Assessment/Plan" the provider documented "absolutely refusing intubation." Per same note under "Other:" "Will change code status to NO INTUBATION /NO CPR at patient request."

An addendum was added to the same note mentioned above at 0526 stating patient's condition continued to worsen. The provider mentioned they left messages with the patient's spouse and offspring to update them. Patient's spouse called back and was updated. The provider stated " ...told (him/her) that I did not expect patient to survive the morning. (He/she) understands."

Another addendum by the physician at 0634 mentioned one of the patient's adult children called from out of state and stated they were the POA (Power of Attorney) and "insisted that patient be intubated for "short trial of intubation". No documentation of this on chart, but decision made to intubate at (adult child) insistence."

Addendum at 0642 stated patient's child had been updated regarding successful intubation and line placement.

Addendum at 1741 mentioned "plan to reassess Monday if not better and likely withdrawal vent support per patient's request of "short vent" trial."

Per nursing note written on the day of intubation, the RN mentioned the MD was at the beside, "Pt states does not want to be intubated will administer PRN pain and anxiety meds"

Patient was successfully extubated and survived after being intubated for four days.

In summary, no advance directive, health care agent or POA was found in the patient's chart. The hospital failed to carry-out the stated "very clear" wishes of the patient who was alert, oriented and capable of making decisions. Instead, the hospital superseded patient #2's wishes, and acted on the wishes of patient #2's child who had no standing to make that decision and provided no proof of being the POA or surrogate decision maker appointed by the patient.

A request was made for emergency department restraint events and quality monitoring. It was revealed that the hospital had difficulty accessing restraint data which was revealed to be a quantitative rather than qualitative process. Likewise, the hospital was asked to produce seclusion data and monitoring with similar results. Based on this, the hospital failed to monitor the quality of high-risk restraint/seclusion events.