HospitalInspections.org

Based on document review and interview, it was determined for 2 of 11(Pt #3 and 5) clinical records reviewed, the Hospital failed to ensure the informed consent for patient treatment was executed as required.

Findings include:

1. The clinical record of Pt #3 was reviewed on 2/2/17 at approximately 10:15 AM. Pt #3 was an 88 year old male admitted on 1/30/17 with diagnoses of syncope and collapse. Pt #3's clinical record did not include a signed Consent For Treatment.

2. The clinical record of Pt #5 was reviewed on 2/2/17 at approximately 10:30 AM. Pt #5 was an 63 year old male admitted on 2/1/17 with a diagnosis of anemia. Pt #5's clinical record did not include a signed Consent For Treatment.

3. Hospital policy entitled, "Patient Consent For Hospital Treatment," (revision date 2/13) reviewed on 2/3/17 at approximately 12:40 PM required, "I...Patient consent for hospital treatment must be obtained at the time of admission."

4. The Director of Quality (E #1) stated during an interview on 2/3/17 at approximately 10:30 AM that the clinical records did not contain a consent for treatment signed on admission but should have.

Based on document review and interview, it was determined for 1 of 3 (Pt #1) clinical records reviewed of patients admitted from the Emergency Department (ED) with advance directives, the Hospital failed to ensure DNR was executed as required by policy.

Findings include:

1. On 2/2/17 at approximately 1:00 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was an 86 year old female admitted on 12/25/16 with a diagnosis of sepsis (infection). The clinical record of Pt. #1 included a "Uniform Do-Not-Resuscitate (DNR) Advance Directive" form signed by Pt. #1's daughter who was identified as the agent under healthcare power of attorney. Pt. #1's clinical record lacked a DNR Order from the physician.

2. On 2/3/17 at approximately 10:00 AM, the Hospital's policy titled, "Patient Rights and Responsibilities" (revision date 11/15) was reviewed and indicated, "...You have a right to make an advance directive and appoint someone to make health care decision for you if you are unable..."

3. On 2/3/17 at approximately 10:15 AM, the Hospital's policy titled, "Advance Directives" (revision date 9/16) was reviewed and indicated, "... Advance Directive: ... Advance Directives include, but are not limited to: 1.) health care power of attorney... 4. Do-Not-Resuscitate (DNR) /Practitioner Orders For Life Sustaining Treatment (POLST)..."

4. On 2/3/17 at approximately 10:55 AM, the Hospital's policy titled, "Forgoing Life Sustaining Treatment" (revision date 12/09) was reviewed and indicated, "... B... 3.... In the case of a Durable Power of Attorney for Healthcare, the desires of the patient's agent based on knowledge of the patient's wishes or beliefs, personality and lifestyle shall be followed within the context of the principles of this policy. The attending physician will discuss treatment options with the agent as set forth in (A) above... A... 3. Once a decision has been made to forgo some or all life-sustaining treatment, the attending physician or his/her authorized representative should complete the DNR Order/Limitation of Treatment Order Set..."

5. On 2/2/17 at approximately 1:15 PM, an interview was conducted with E #1 (Director of Quality and Patient Safety). E #1 stated that the Physician who completed the DNR form should have completed a DNR order but did not see a DNR order in Pt. #1's clinical record.

6. On 2/3/17 at approximately 11:00 AM, an interview was conducted with MD #3 (ED Attending Physician). According to MD #3, he completed the DNR Form signed by Pt. #1's daughter. MD #3 stated that he did not document the DNR discussion with Pt. #1's daughter because he was under the assumption that it had been done. Regarding the DNR order, MD #3 stated that he will usually defer to the receiving physician on the unit to enter the DNR order.

Based on document review and interview, it was determined for 1 of 3 (Pt #1) clinical records reviewed of patients with advance directives, the Hospital failed to ensure the clinical record contained the required documentation to execute the patient's wishes.

Findings include:

1. Hospital policy entitled, "Advance Directives," (revision date 9/16) required, "III...Definitions...Advance Directive: A legal document used to provide guidance about the types of treatments a patient wants...Advance directives include, but not limited to: 1) health care power of attorney...V. Procedure: Patients have the right to facilitate their own health care decisions...and the right to make an advance health care directive...4. Implementation of a Health Care Power of Attorney (POA): The healthcare power of attorney allows the patient to choose someone to make healthcare decisions for them...The attending physician consults with patient's agent to discuss medical options..."

2. Hospital policy entitled, "Forgoing Life Sustaining Treatment," (revision date 12/09) required, "I. Policy: It is the policy of...to guide health care professionals and patients or their proxies in decision making decisions to limit or forgo life-sustaining treatment...B. Forgoing life-sustaining treatments for patients lacking decisional capacity who have advance directives: 1. The attending physician shall document the patient's lack of decisional capacity...2. The attending physician shall review the patient's advance directive...3...In the case of a Durable Power of Attorney for Healthcare, the desires of the patient's agent based on knowledge of the patient's wishes or beliefs...4. The attending physician will document in the progress notes, when writing orders, the patient' preferences as expressed...and relevant discussions held with the patient's agent..."

3. Hospital policy entitled, "State of Illinois DNR Orders," (revision date 12/09) required, "I. It is the policy of...to honor the uniform State of Illinois Do Not Resuscitate (DNR) Order form...III. Procedures...Only a completed...DNR/Limitation of Treatment Order Set/Power Plan will be honored in the inpatient setting."

4. The clinical record of Pt #1 was 2/2/17 at approximately 10:55 AM. Pt. #1 was an 86 year old female admitted on 12/25/16 with an admitting diagnosis of sepsis, unspecified organism (presence of bacteria, other infectious organisms, or toxins in the bloodstream). Pt. #1's clinical record contained an "Admission Record " dated 12/25/16 that indicated, " ...Adv (Advance) Dir (Directives): Power of Atty (Attorney), Ver (unable to define by E #1) Date: 12/25/16 ... " Pt #1's clinical record lacked physician documentation that the Power of Attorney had been contacted and her wishes were for Pt #1 to be made a DNR.

5. The ED physician (MD #3) stated during an interview on 2/3/17 at approximately 11:00 AM that he did not document the DNR status because he thought the discussion and documentation had been completed by the previous physician. MD #3 stated that he documents in the clinical record regarding discussion of patient's code status and stated he did not write a note because he was under the assumption that documentation had been done.