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Based on findings from medical record (MR) review and interview, the facility failed to protect patient's rights to not have cardiopulmonary resuscitation (CPR) when the patient has a do not resuscitate (DNR) order. Also, the facility failed to place a copy of patient's advanced directives (AD) e.g., health care proxy (HCP) in their MRs. These failures could lead to lack of facility compliance with patients' advanced directives.

Findings include:

See Tag 132




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Based on findings from medical record (MR) review and interview, the facility failed to protect patients rights. Specifically patient do not resuscitate (DNR) status was not easily identifiable to all staff leading to the potential for cardiopulmonary resuscitation (CPR) to be started on a DNR patient. Additionally, in 6 of 10 MR's reviewed, the facility did not obtain and place a copy of the patient's advanced directive (AD) e.g., health care proxy (HCP) in the MR.

Findings include:

-- Per review of Patient #1's MR, a physician order stated "Full Code". Patient
#1's Kardex also indicated full code. During interview of Staff A on 12/10/15 at 11:30 am, he/she indicated that a patient's AD, e.g., DNR or Full Code, is documented in the patient's MR and Kardex. Also, the patient's primary care nurse carries a paper with this information on it when starting the shift after patient assignments are discussed.

-- Per interview of Staff B on 12/10/15 at 12:20 pm, when asked how a staff member would know a patient's code status, he/she verbalized concern that there is no system currently in place to identify a patient's code status. Staff B requested not to be identified to the facility. When further queried, Staff B indicated staff would not be able to identify a patient's DNR status unless they were assigned to the patient.

During interview of Staff A and Staff C on 12/10/15 at 12:45 pm, both indicated if a patient was found breathless and pulseless, the primary care nurse and his/her back up would be aware of the code status. If the primary care nurse and back up were unavailable, a rapid response would be called and CPR would be initiated. If they found out the patient was a DNR, CPR would be stopped.

During interview with Staff D and Staff E on 12/11/14 at 9:30 am, both indicated no other system, other than MR & Kardex documentation, has been put in place to identify patients with DNRs. The hospital is fearful that staff may forget to change the identification of a DNR patient if the patient should change to a full code. The facility would prefer to start CPR and stop it if the patient is a DNR rather then not resuscitate a full code patient whose DNR identification was incorrect.

-- Per MR review, Patient #2's Consent for Medical Treatment form, completed on the day of admission, 12/5/15, indicated he/she had a HCP. However, as of 12/10/15, 5 days after admission, a copy of the HCP was not in the MR.

-- Per MR review, Patient #3's Consent for Medical Treatment form, completed on the day of admission, 12/6/15, indicated he/she had a HCP. However, as of 12/10/15, 4 days after admission, a copy of the HCP was not in the MR.

The same lack of ensuring a copy of a HCP was placed in patient medical records, after the patient indicated he/she had a HCP, was found in Patient #4, Patient #5, Patient #6 and Patient #7 MR's.

-- During interview with Staff F on 12/11/15 at 1:00 pm, the lack of HCP placement in patient's MRs was acknowledged.