HospitalInspections.org

Based on document review and interview, the facility failed to include the surrogate decision maker in the plan of care for one of ten patients (patient #1) resulting in denying a patient's surrogate decision maker the ability to be involved in the decision making process. Findings include:

On 8/31/2022 at 1315 a document review of patient #1's medical record was conducted. According to the patient's medical record the patient arrived at the Emergency Department (ED) on 6/24/2022 at 1004. A nursing note by staff R, stated the following: "Pt (patient) to ED via Dearborn Heights EMS (emergency medical services) (from home for self-inflicted GSW (gunshot wound) to chin. Per EMS, pt's hospice nurse was at the home checking on pt., walked out of room and pt. shot himself with .38, upward through chin. Pt arrived at ED, EMS using suction, blood noted from mouth and nose. Pt has swelling and blood noted in L eye. EMS placed L IO (left intraosseous access - fluids via a large bore IV in the bone marrow), infusing saline. Pt (patient) opening R (right) eye, attempting to talk and respond to staff and following basic commands. Resp (respirations) regular, o2 sat 97% on RA (room air). ST (sinus tachycardia - rapid heart rate) on cardiac monitor. Writer spoke w/ hospice nurse states patient is complete DNR (Do Not Resuscitate) but paperwork is unavailable at this time. RN made aware that paperwork is required."

Further document review of patient #1's medical record included documentation by the ED physician, staff S dated 6/24/2022 at 1202. According to the documentation the patient was described as the following: "84 y/o (year-old) male s/p (status post) GSW, self-inflicted, to lower jaw/face. Per EMS patient was at home with home care nurse, nurse left the room and heard the GSW. Patient is confused, following simple commands, attempting to talk but unable due to facial trauma. GCS 14 (Glasgow coma scale - is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma events. Scale ranges from 0 to 15 with 15 being oriented, eyes opening spontaneously, and full motor response). Pulse variable from 100's-150's appears to be A.fib (atrial fibrillation - a heart dysrhythmia). Concern for airway protection and ongoing swelling therefore after appropriate pre-oxygenation with all difficult airway instrumentation at bedside RSI (rapid sequence intubation) was performed by the department of anesthesia. Per EMS patient is on home hospice care with DNR/DNI (Do Not Resuscitate / Do Not Intubate). Unfortunately, no initial documentation was present. Left femoral CVC (central venous catheter) catheter placed. CT imaging was additionally performed with multiple facial fx (fracture), likely left globe (eye) rupture, submandibular wound. Ortho (orthopedic), ENT (Ear Nose Throat) consults ~10:40 the patient had his DNR paperwork scanned into the chart and available for review. DNR/DNI with no resuscitative measures. At this time PRBC's (packed red blood cells), TXA (tranexamic acid - medication to treat bleeding) held. D/w (discussed with) family as they are available with likely withdrawal of care. Cnt (continue) comfort measures. Hospice consult. Admit to trauma ICU (intensive care unit)."

On 6/30/2022 at 1434 documentation by staff T stated the following: "On Admitted to the hospital after gunshot. was under hospice care due to congestive heart failure. Family decided for comfort care and terminal wean he was admitted under trauma team in ICU. Palliative care consulted Discussed with family members extubated and transferred to tenth floor for comfort approach. Started on IV Dilaudid and IV Ativan drip. Tube placed in oral cavity due to active bleeding at that time. We will remove tube today and no difficulty noted with no active bleeding at the time. Patient expired Immediately after tube removal. Family notified nursing staff at the bedside along with respiratory therapist. Time spent with patient 30 minutes more than 50% counseling and coordinating."

On 8/31/2022 at 1415 an interview was conducted with staff T the palliative physician caring for patient #1. Staff T was asked if patient #1's family was made aware of the plan to extubate patient #1 on 6/30/2022. Staff T stated, "The family knew all along that the patient was going to be extubated." Staff T was then asked if the family was made aware that the patient's family was notified on 6/30/2022 that the patient was being extubated. Staff T replied, "The family was in agreement that the patient was going to extubated when the bleeding from the gunshot wound stopped." Staff T did not answer if the patient's family were aware of the time that the patient was being extubated. Staff T was then queried if he had listed the cause of death for patient #1. Staff T stated the case had been sent to the medical examiner who made the determination that patient #1's primary cause of death was by attempted suicide by a gunshot wound.

On 9/1/2022 at 0855 an interview was conducted with staff O, the registered nurse caring for patient #1 on 6/30/2022. Staff O was queried if he contacted the emergency contact on 6/30/2022 to let them know of the pending extubation of patient #1. Staff O stated, "I called the patient's wife several times and left messages for her to call the unit." Staff O was then asked if a return call was received from the patient's wife. Staff O stated, "It wasn't until after the patient had been extubated and had passed."

On 9/1/2022 at 0920 an interview was conducted with staff P, the respiratory therapist caring for patient #1 on 6/30/2022. Staff P was asked what care she provided for patient #1 on 6/30/2022. Staff P stated, "I received an order to extubate the patient." Staff P was asked who was present at the time of the extubation. Staff P stated, "The nurse (staff O) and me." Staff P was asked if family was notified of the extubation. Staff P stated, "I just received the order to extubate ...I extubated the patient, gathered the supplies, threw them away and left."

On 8/31/2022 at 1535 a document review occurred of the policy titled, "Patient Rights and Responsibilities," policy number 11526828 dated with an effective date of 5/11/2022. According to the policy under section titled, "III. Procedure," it states, "9. Patients have the right to participate in decisions regarding treatment planned by their doctor. When a patient is unable to make decisions about their care, treatment and services, the hospital involves a Surrogate Decision-Maker in making these decisions," and "10. Patients or Surrogate Decision-Maker have the right to refuse care as allowed by law." On 9/1/2022 at 0910 during an interview with staff A she was asked to provide policy for the extubation of a patient and contacting the patient's family or surrogate Decision-Maker. Staff A stated a review of policies had been conducted and a policy did not exist for the extubation of a patient and contacting the patient's family or surrogate Decision-Maker other than the policy, "Patient Rights and Responsibilities." No updates had been made to policy as of 9/1/2022 at 0910.

On 9/1/2022 at 1000 an interview was conducted with staff I, the manager of patient experience. According to staff I an investigation was conducted for a grievance filed by patient #1's daughter. Staff I stated that a communication gap had been identified and the grievance had been closed with notification to the family of findings of the investigation. No facility interventions or changes were noted to the communication process after the grievance investigation had been completed and the communication gap had been identified.

On 9/1/2022 at 1130 an additional interview with staff T occurred. Staff T was queried if he had any indication that the patient would expire immediately post extubation. Staff T stated, "No. I did not expect the patient to die immediately after the breathing tube was removed."