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Based on record review, policy review, and staff interviews, it was determined that the hospital staff failed to recognize the designee's power of attorney status, as evidenced by staff failure to identify and document the patient's power of attorney's status/information in a prominent location in the medical record.


The findings include:


The MedStar Washington Hospital Center Standard Practice #583.05, version June 19, 2014 titled, ' Informed Consent and Informed Refusal' stipulates: " III. Hierachy of Surrogate Decision Makers A. Durable power of attorney for health care decisions: A durable power of attorney for health care decisions allows the designated individual(s) to make decisions about medical care, if the patient becomes incapable of making a choice (or making his/her choices know to others) regarding a particular health care decision. In exercising authority under a durable power of attorney for health care, the designated individual(s) has a duty to act in accordance with the wishes of the patient, as expressed in the durable power of attorney for health care (or there advance directive)."

The MedStar Washington Hospital Center 's 'Patient Information Guide,' page 27 stipulates: " Advance Directives, Your Rights - to have an advance directive (Living Will and /or Durable Power of Attorney for Health Care Decisions), to have your advance directive (if you have one) included in your medical record, to have your advance directive followed to the extent that is medically appropriate and lawful."


Patient #1 was admitted to the hospital on August 14, 2014 with diagnoses that included Diabetes Mellitus, End Stage Liver Cirrhosis, Hepatitis C, Portal Hypertension, Esophageal Varices, and Gastrointestinal Bleeding.


On August 16, 2015 at approximately 8:30 PM, the decision was made by the [family member] (who indicated to the doctor that she was the patient's medical power of attorney) and the doctor to establish a Do Not Resuscitate (DNR) and a Do Not Intubate (DNI) status on the patient on the patient; and for the patient to receive comfort care only. On August 18, 2015, the [family member] stated s/he provided a copy of the power of attorney papers to a nurse to be placed on the medical record.


On August 31, 2015 at approximately 12:00 PM, during a review of the medical record, the power of attorney documentation was not found in the medical record; however, Durable General Power of Attorney documentation, signed by the patient's family member and dated April 19, 2002, was provided by Employee #3 during the investigation.


On August 31, 2015 at approximately 1:28 PM, a face-to-face interview was conducted with Employee #7, the palliative care physician. S/he was asked if Patient #1 had a power of attorney. S/he replied, "I don't know."


On August 31, 2015 at approximately 2:10 PM, a face to face interview was conducted with Employee #6, the hospitalist. S/he was asked if Patient #1 had a power of attorney. S/he responded that s/he did not know that the [family member] was the power of attorney and elaborated, stating, "Usually we would ask that question and put it inside the bottom of a note, but I didn't document that and I can ' t recall. Also, it could have been on the white board in the patient's room ... "


On August 31, 2015 at approximately 3:33 PM, a face to face interview was conducted with Employee #10, the social worker. When queried if the patient had a power of attorney, s/he responded, " If a patient appears to lack capacity or unresponsive, we try to find out if there is someone who has been assisting and the social worker asks for the power of attorney document. We document the power of attorney information in Midas [computer system], on the face sheet, in Amalga [computer system] under patient information, and in the scanned charts. When asked if that documentation occurred, s/he replied that s/he did not document the information. Employee #10 did not recall if the patient had a power of attorney.


On August 31, 2015 at approximately 4:00 PM, a face to face interview was conducted with Employee #8, the gastroenterologist. When asked if s/he was aware of the patient ' s power of attorney, s/he stated, " I don't recall seeing paperwork for power of attorney."


The hospital staff failed to identify the patient's power of attorney and document the information in the medical record.


The findings were acknowledged by Employees #2 and 10 on August 31, 2015 at approximately 5:30 PM.

Based on record review, policy review, and staff interviews, it was determined that the hospital staff failed to establish and implement a process to provide the patient's power of attorney appropriate education to assist in understanding the necessary care and treatment for the patient.


The findings include:


Pursuant to the National Library of Caregivers, " ... both hospice and palliative care protocols call for patients to receive a combined approach where medications, day-to-day care, equipment, bereavement counseling, and symptom treatment are administered through a single program. Where palliative care programs and hospice care programs differ greatly is in the care location, timing, payment, and eligibility for services ...
Hospice - Generally, once enrolled through a referral from the primary care physician, a patient ' s hospice care program, which is overseen by a team of hospice professionals, is administered in the home. Hospice often relies upon the family caregiver, as well as a visiting hospice nurse. While hospice can provide round-the-clock care in a nursing home, a specially equipped hospice facility, or, on occasion, in a hospital, this is not the norm. You must generally be considered to be terminal or within six months of death to be eligible for most hospice programs or to receive hospice benefits from your insurance. Before considering hospice, it is important to check on policy limits for payment. While hospice can be considered an all-inclusive treatment in terms of payment (hospice programs cover almost all expenses) insurance coverage for hospice can vary. Some hospice programs offer subsidized care for the economically disadvantaged, or for patients not covered under their own insurance. Many hospice programs are covered under Medicare. Most programs concentrate on comfort rather than aggressive disease abatement. By electing to forego extensive life-prolonging treatment, hospice patients can concentrate on getting the most out of the time they have left, without some of the negative side-effects that life prolonging treatments can have ...
Palliative Care - Palliative care teams are made up of doctors, nurses, and other professional medical caregivers, often at the facility where a patient will first receive treatment. These individuals will administer or oversee most of the ongoing comfort-care patients receive. While palliative care can be administered in the home, it is most common to receive palliative care in an institution such as a hospital, extended care facility, or nursing home that is associated with a palliative care team. There are no time restrictions. Palliative care can be received by patients at any time, at any stage of illness whether it be terminal or not. Since this service will generally be administered through your hospital or regular medical provider, it is likely that it is covered by your regular medical insurance. It is important to note, however, that each item will be billed separately, just as they are with regular hospital and doctor visits. If you receive outpatient palliative care, prescriptions will be billed separately and are only covered as provided by your regular insurance. In-patient care however, often does cover prescription charges ... Since there are no time limits on when you can receive palliative care, it acts to fill the gap for patients who want and need comfort at any stage of any disease, whether terminal or chronic. In a palliative care program, there is no expectation that life-prolonging therapies will be avoided ...There are some hospice programs that will provide life-prolonging treatments, and there are some palliative care programs that concentrate mostly on end-of-life care. "


Patient #1 was admitted to the hospital on August 14, 2014 with diagnoses that included Diabetes Mellitus, End Stage Liver Cirrhosis, Hepatitis C, Portal Hypertension, Esophageal Varices, and Gastrointestinal Bleeding.


A medical record review was conducted on August 31, 2015 at approximately 10:30 AM. The following information was revealed:


August 16, 2015 at approximately 8:30 PM, the decision was made by the patient ' s family member (who indicated to the doctor that s/he was the patient ' s medical power of attorney and had presented documentation to the staff) and the doctor agreed to establish a Do Not Resuscitate (DNR) and a Do Not Intubate (DNI) status on the patient; and for the patient to receive comfort care only.


August 17, 2015 at approximately 8:05 AM, a physician ' s note indicated that the [named family member] requested DNR/DNI, hospice and comfort care; and that palliative care would be called the following day.


A physician ' s order dated August 17, 2014 and timed at 1:33 PM revealed orders for comfort care. The comfort care orders included palliative care, not hospice care.


Palliative Care consulted on August 18, 2014 at approximately 11:51 AM. Palliative services were explained to the patient ' s family member and the hospice benefit was offered. The palliative care physician explained that the [named family member] agreed to comfort care and managing the patient ' s pain and symptoms; but communicated that s/he thought the patient was already in hospice and did not want the patient moved from the hospital.


A Palliative Care note dated August 19, 2014 and timed at 11:18AM revealed that the [named family member] was unaware of hospice benefits.


A physician ' s note dated August 20, 2105 and timed a 1:04 PM indicated that Employee#6 had a discussion with the patient ' s family member about hospice, after receiving a call from the patient advocate. Employee #6 indicated that the patient ' s family member wanted to " continue comfort care/hospice in the hospital. " However, there was no prior indication that the patient was receiving hospice services.


The first indication of a possible referral for hospice services was a note documented by the social worker. The social worker documented in the ' Multidisciplinary Rounds ' note at 2:00 PM on August 20, 2014 that the discharge plans were uncertain for hospice; howbeit, there was no documented evidence in the record that the case manager or the social worker communicated with or involved the power of attorney in Patient #1 ' s discharge plans.


Physician progress notes dated August 21 through August 24, 2015 revealed that Patient #1 was receiving comfort care, palliative care and pain management, until her death on August 25, 2015. There was no indication in the notes that the patient was receiving hospice care in the hospital.


On August 31, 2015 at approximately 1:28 PM, a face to face interview was conducted with Employee #7, the physician and consultant for Palliative Medicine. Employee #7 was asked to explain palliative care and hospice. S/he stated that palliative care is a discipline which focuses on pain and symptom management through counseling and therapeutics, and it also assists in end of life care. Employee #7 stated that " some may not have a clear understanding of the difference between hospice and palliative care. " S/he continued explaining that hospice is a " care paradigm and service that has an insurance benefit that focuses on comfort care. " S/he explained that patients may receive hospice services as an inpatient, home or in a hospice hospital. S/he elaborated that s/he does not make hospice referrals. They are made by the social worker.


When queried if s/he recalled Patient #1 and the patient ' s family member, Employee #7 stated that s/he remembered the patient was very sick and the [named family member] was very clear that s/he wanted the patient to be comfortable. Employee #7 explained that s/he described the hospice benefit to the [named family member]. S/he stated the family member thought the patient was already in hospice and did not want him/her moved because s/he thought the patient was going to pass that night.


On August 31, 2015 at approximately 2:10 PM, a face to face interview was conducted with, Employee # 6, the hospitalist. Employee #6 was queried about Patient #1, the family member, and how s/he handled patients in palliative care. S/he stated, " We keep patients comfortable and communicate with the palliative care doctors. " S/he explained, " Not everybody stays in the hospital, so they are usually transferred home with hospice or to an inpatient hospice. " When queried if s/he recalled Patient #1 and her family member, s/he said the patient was in comfort care, when s/he received the patient. Employee # 6 explained that s/he did not know that the family member was the patient ' s power of attorney and elaborated, " Usually we would ask that question and put it inside the bottom of a note, but I didn ' t document that and I can ' t recall. Also, it could have been on the white board in the patient ' s room ... " Employee #6 explained that the complainant wasn ' t receptive to hospice. S/he stated the family member made it clear that s/he had communicated with the palliative care team and didn ' t want the patient to go out for hospice. " I could tell the [named family member] just wasn ' t processing this. " Employee #6 was asked to explain what the family member wasn ' t processing. S/he responded that s/he was not sure, but mainly the patient ' s passing is what the family member had a hard time processing. Employee # 6 was asked how s/he assisted the family member through the process. S/he stated that s/he and the nursing staff spent a lot of time with the family member to make him/her comfortable, but " there was a lot of drama associated with the death [of the patient]. "


Employee #6 was asked to explain the difference between hospice, comfort care, and palliative care. S/he stated, " Hospice is end of life care, keeping patients comfortable in a dignified manner. Comfort care is similar, pretty much the same. Palliative is pain management and symptom management, keeping people comfortable. They ' re all interchangeable. "


On August 31, 2015 at approximately 3:33 PM, a face to face interview was conducted with Employee #10. When asked if s/he recalled Patient #1, Employee #10 said that Patient #1 was one of his/her first patients. S/he couldn ' t recall the patient ' s discharge planning details so s/he looked for the note. S/he did not find it in the record. When asked to provide the discharge planning progress note to indicate the patient ' s change in status, ongoing discharge planning needs, and disposition, s/he could not produce the note. Employee #10 stated, " I ' m not sure why I didn ' t generate a note. I ' m not sure if I was working independently. I was still being assisted by a supervisor. "


On August 31, 2015 at approximately 5:30 PM, a face to face interview was conducted with Employee #9. S/he was asked to explain the case management and/or social work discharge planning for Patient #1 and to provide the progress notes. S/he stated the case was opened on August 16, 2014 and no potential discharge needs were noted; that included social work needs. On August 18, 2014 the social work screen just showed a header for status, and there were no further case management or social work progress notes. Employee #9 could not explain why there was no case management or social worker documentation relative to the patients change in status, ongoing discharge planning needs, and disposition.


There was no evidence that Employee #6 had an accurate understanding of the differences between hospice and palliative care; therefore, Employee #6 could not effectively communicate the information for the power of attorney to understand the patient ' s plan of care to make informed decisions. There was no documented evidence that the discharge planner had relevant communication with the power of attorney or involved the power of attorney in the patient ' s discharge plan of care. As a result, the facility staff failed to provide the necessary information to the power of attorney to make decisions about Patient #1 ' s care and discharge plans.


The findings were acknowledged by Employees #2 and #9 on August 31, 2015 at approximately 5:40 PM.

Based on record review, policy review, and staff interviews, it was determined that the hospital staff failed to document essential information regarding the patient ' s plan of care as evidenced by the discharge planner's failure to document significant changes to the patient's discharge plan, clinical condition, patient/family involvement in the discharge plan, family dynamics, psychosocial issues affecting discharge planning, and the patient's disposition; in accordance to hospital policy.


The findings include:


The MedStar Washington Hospital Center's #2340, version June 9, 2014, titled,
' Documentation: Case Manager and Clinical Resource Coordinator ' stipulates,
" Purpose: Case Manager (CM) documentation provides essential information to the physicians and members of the healthcare team regarding the status of the patient's plan for care ...Policy: Ongoing documentation occurs when there are significant changes to the patient ' s discharge plan, clinical condition, or other case management related events. Frequency of continuing documentation is determined by the patients ' needs and changes, but a progress note must be entered at least weekly ...Ongoing documentation: documentation includes: 1. Short and long term goals for the patient ... 3. Patient/family involvement in the discharge plan ...9. Relevant communication with the family ...12. Disposition note upon discharge including patient location/destination and level of care."


The MedStar Washington Hospital Center ' s #2345, version June 9, 2014, titled, ' Documentation: Discharge Planner-DCP (Social Worker/Case Manager) ' stipulates: " Purpose: Discharger Planner ' s documentation provides essential information to the physicians and members of the healthcare team regarding the status of the patient ' s plan for continuing care and relevant psychosocial issues ... Policy: Ongoing documentation occurs by DCP when there are significant changes to the patient ' s discharge plan, continuing care needs, clinical condition, or family dynamics or psychosocial issues affecting discharge planning ... Ongoing documentation: documentation in the patient ' s medical record includes: 1. Short and long term goals for the patient. 2. Initial and ongoing discharge planning activities. 3. Patient/family involvement in the discharge plan. 4. Activities/interventions carried out by the DCP relative to the discharge process for the patient. 6. Patient and family have been informed of their right to choice. 10. Family meeting, including the outcome. 13. Disposition note upon discharge including patient location/destination and level of care."


Patient #1 was admitted to the hospital on August 14, 2014 with diagnoses that included Diabetes Mellitus, End Stage Liver Cirrhosis, Hepatitis C, Portal Hypertension, Esophageal Varices, and Gastrointestinal Bleeding.


On August 31, 2015 at approximately 12:00 PM, a medical record review revealed the following documents:


A 'Clinical Resource Management Progress Note/Discharge Planning Initial Screening' dated August 16, 2014 and timed at 12:27 PM with the following comments, "Patient assessed for potential discharge planning needs. No discharge planning needs identified at this time. Will continue to monitor for potential needs."


A 'Multidisciplinary Rounds' note on August 20, 2014 and timed at 2:00 PM indicated that the patient's discharge plan was uncertain for hospice.


The medical record lacked evidence that the case manager or clinical resource coordinator documented the significant changes in the patient's clinical condition and discharge plan, short and long-term patient goals, family involvement and relevant communication with the family, and the patient's disposition.


The medical record lacked evidence that the social worker documented the significant changes to the patient's discharge plan, the patient's continuing care needs and clinical condition, family dynamics or psychosocial issues affecting discharge planning, short and long term goals for the patient, initial and ongoing discharge planning activities, patient/family involvement in the discharge plan, activities/interventions carried out by the DCP relative to the discharge process for the patient, that the patient and family had been informed of their right to choice, and the disposition note upon discharge.


On August 31, 2015 at approximately 3:33 PM, a face to face interview was conducted with Employee #10. When asked if s/he recalled Patient #1, Employee #10 said that Patient #1 was one of his/her first patients. S/he couldn't recall the patient's discharge planning details so s/he looked for the note. S/he did not find it in the record. When asked to provide the discharge planning progress note to indicate the patient's change in status, ongoing discharge planning needs, and disposition, s/he could not produce the note. Employee #10 stated, "I'm not sure why I didn't generate a note. I'm not sure if I was working independently. I was still being assisted by a supervisor."


On August 31, 2015 at approximately 5:30 PM, a face to face interview was conducted with Employee #9 regarding the aforementioned findings. Employee #9 was asked to explain the case management and/or social work discharge planning for Patient #1 and to provide the corresponding progress notes. S/he stated the case was opened on August 16, 2014 and no potential discharge needs were noted; that included social work needs. On August 18, 2014 the social work screen just showed a header for status, and there were no further case management or social work progress notes. Employee #9 could not explain why there was no case management or social worker documentation relative to the patients change in status, ongoing discharge planning needs, and disposition.


The findings were acknowledged and confirmed by Employees #2 and 9 on August 31, 2015 at approximately 5:40 PM.