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Based on record review and interview the facility failed to ensure patient's rights were protected. This deficiency is evidenced by no documentation of patient/family agreement to do not resuscitate (DNR) orders for 1(Pt.#2) of 2 (Pt.#2, Pt.#3) reviewed patients changed from full code status to do not resuscitate status while hospitalized.
Findings:

Review of the hospital policy, "QAL.RISK.009 Advance Directives," reviewed 10/20, revealed in part:

"In accordance with the Patient Self Determination Act of 1991 and Louisiana RS 40.1299.58.3. any adult person (one who is emancipated for has reached the age of maturity) may, at any time, make a written declaration directing the withholding or withdrawal of life-sustaining procedures in the event such person should be diagnosed and certified in writing as having a terminal and irreversible condition by two physicians who have personally examined the patient, one of whom shall be the attending physician."

Review of Louisiana RS 40.1299.58.3 reveals in part:

A.(1) Any adult person may, at any time, make a written declaration directing the withholding or withdrawal of life-sustaining procedures in the event such person should have a terminal and irreversible condition.
(2) A written declaration shall be signed by the declarant in the presence of two witnesses.
(3) An oral or nonverbal declaration may be made by an adult in the presence of two witnesses by any nonwritten means of communication at any time subsequent to the diagnosis of a terminal and irreversible condition.
B.(1) It shall be the responsibility of the declarant to notify his attending physician that a declaration has been made.
(2) In the event the declarant is comatose, incompetent, or otherwise mentally or physically incapable of communication, any other person may notify the physician of the existence of the declaration. In addition, the attending physician or health care facility may directly contact the registry to determine the existence of any such declaration.
(3) Any attending physician who is so notified, or who determines directly or is advised by the health care facility that a declaration is registered, shall promptly make the declaration or a copy of the declaration, if written, or a notation of the existence of a registered declaration, a part of the declarant's medical record.
(4) If the declaration is oral or nonverbal, the physician shall promptly make a recitation of the reasons the declarant could not make a written declaration and make the recitation a part of the patient's medical records.

Review of the medical record of Patient #2 revealed the patient was admitted on 09/09/2021 with a diagnosis of heart failure, chronic anemia, Stage 3 chronic kidney disease, hypertension, diabetes mellitus and a sacral ulcer.

Review of orders for Patient #2 on 09/27/2021 at 3:20 p.m. revealed , " Resuscitation Status: Do Not Resuscitate," signed by S9MD. Further review of orders from 09/28/2021 at 3:05 p.m. revealed a change in status, "Resuscitation Status: Full Code,"also signed by S9MD.

Review of the progress note by S8NP dated 09/27/2021 revealed S8NP had a discussion with the patient's power of attorney (POA) by phone and in person that day. The patient's condition was explained to the POA and options for care after discharge were discussed. The note was co-signed by the attending S9MD. There was no documentation the POA agreed to DNR status. There was no documentation the POA was not able to provide a written declaration and witnesses were not provided. Further review of the progress notes revealed no explanation for the change back to full code status the following day.

In interview on 05/16/2022 at 9:25 a.m. S2DQ stated the hospital did not have a consent form for those choosing DNR status and she stated there was also no hospital policy on DNR status.

In interview on 05/17/2022 at 10:15 a.m. S2DQ verified the DNR was not properly documented.

Based on record review and interview the facility failed to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19. This deficient practice was evidenced by failure to ensure 100% vaccination rate, excluding those staff who have been granted exemptions to the vaccination requirements, 60 days after implementation of CMS Omnibus COVID-19 Health Care Staff Vaccination Regulations.
Findings:

On 05/17/2022 a review of the vaccination information for all individuals who provide care, treatment, or other services for the center and/or its patients was performed. The total number of individuals providing care for the facility was 756. 537 were fully vaccinated. There were 209 religious exemptions and 1 medical exemption. There were 9 employees who were partially vaccinated. The calculated vaccination rate was 98.8%.

In interview on 05/17/2022 at 12:40 p.m. S2DQ verified the COVID-19 vaccination information and S2DQ verified that facility did not have 100% vaccination rate.