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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0121 The hospital must establish a clearly explained procedure for the submission of a patient's written or verbal grievance to the hospital. Based on interviews and document review, the facility failed to ensure grievances were identified and classified as grievances in 1 of 4 complaints reviewed (Patient #2).

A-0132 The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives. Based on interviews and document review, the facility failed to ensure patients who had an advanced directive were informed of a change to their resuscitation status, prior to undergoing invasive procedures, in 3 of 3 medical records reviewed for patients whose resuscitation status was changed (Patients #2, #8, and #10).

Based on interviews and document review, the facility failed to ensure grievances were identified and classified as grievances in 1 of 4 complaints reviewed (Patient #2).

Findings include:

Policy:

The Patient Complaints, Handling of policy read, the grievance process definition was any written complaint or any verbal complaint that cannot be resolved at the time of the complaint by the staff present, where the topic of the complaint relates to patient care, abuse or neglect or issues related to Medicare compliance with hospital conditions of participation.

1. The facility failed to identify a grievance when a complaint could not be resolved at the time of complaint.

a. Patient #2's daughter filed a complaint with the patient relations advocate (PR #1) on 5/31/18 regarding her mother's care on 3/13/18. According to the complaint, PR #1 spoke with Patient #2's daughter by telephone on 6/4/18. Further review revealed a meeting was held on 6/27/18 with Patient #2's daughter, PR #1, and two physicians.

b. On 3/12/19 at 9:38 a.m. an interview was conducted with PR #1. PR #1 stated she reviewed the complaint with her director, and she should have refiled the complaint as a grievance. PR #1 stated she should have sent a letter to Patient #2's daughter. PR #1 stated she was confused about the process and felt the term "real time" meant the total time it took her to resolve a complaint or grievance. PR #1 also stated because she felt it was resolved at the meeting on 6/27/18 the complaint did not need to be refiled as a grievance.

c. On 3/12/18 at 12:08 p.m. an interview was conducted with the director of performance improvement (Director #2). Director #2 stated the complaint should have been a grievance.

Based on interviews and document review, the facility failed to ensure patients who had an advanced directive were informed of a change to their resuscitation status, prior to undergoing invasive procedures, in 3 of 3 medical records reviewed for patients whose resuscitation status was changed (Patients #2, #8, and #10).

Findings Include:

Facility Policy:

The Do Not Resuscitate DNR/CODE policy read, if a decision to alter the CODE status on the patient is reached at anytime during hospitalization, a countermanding order must be written by the attending physician. If the patient leaves the unit for temporary diagnostic studies (i.e. radiology, stress lab, operating room, or any other areas), the department conducting the study/operation is responsible for checking for a DNR band.

The Advance Directives policy read, individuals have the right to make decisions regarding their medical care, including the right to accept or refuse treatment and the right to formulate advanced directives. Outpatients and Surgical Patients being admitted on an outpatient-basis will be informed of their right to formulate Advanced Directives as described in sections 1-6 above. Outpatients undergoing sedation will be informed that Advanced Directives or CPR Directives are suspended during the procedure and recovery.

1. The facility failed to ensure patients who had a do not resuscitate (DNR) advanced directive in place during their hospitalization were informed their resuscitation status was rescinded prior to undergoing invasive procedures.

a. On 3/14/19 at 12:47 p.m., an interview was conducted with Registered Nurse (RN #7). RN #7 stated any patient who left the unit for a procedure would have their DNR rescinded, by a physician, and an order would be placed in the medical record regarding the change in resuscitation status. RN #7 stated the physician was responsible for discussing the DNR changes with the patient. The physician was then required to document the discussion in the medical record. RN #7 stated the process of changing a patient's resuscitation status should occur prior to a procedure because it was important the patient and family had a clear understanding of what could happen.

b. Review of Patient #2's Emergency Department (ED) Disposition form showed Patient #2 was admitted on 3/12/18 with a diagnosis of non-ST elevation myocardial infarction (a type of heart attack) and respiratory failure.

According to the Progress Note written by Physician #5 on 3/13/18 at 6:56 a.m., the day Patient #2 underwent a cardiac catheterization procedure, Patient #2's code status was do not resuscitate (DNR). Physician #5 documented per Patient #2's wishes the daughter would be the patient's decision maker.

Patient #2's resuscitation status remained DNR from the time of admission on 3/12/18 until a physician's order on 3/13/18 at 5:57 p.m., after the patient underwent a cardiac catheterization procedure, and required cardiopulmonary resuscitation (CPR) in the cardiac catheterization lab (cath lab).

According to the Cardiology Consultation Notes, created on 3/14/18 at 7:08 p.m., Patient #2 was seen and evaluated by the cardiologist (Cardiologist #4) on 3/13/18. Cardiologist #4 documented he spoke with Patient #2 and provided her with the option of medical therapy versus diagnostic angiography and percutaneous coronary intervention (a procedure where a catheter was inserted into the blood vessels to evaluate the heart, and interventions are done to restore blood flow to the heart).

Review of the document titled, Consent for Cardiac Catheterization, Angiography, and Endovascular Procedures, revealed Patient #2 signed the consent for the procedure at 1:05 p.m. Within the document, possible risks were listed as: decreased respirations, respiratory arrest, and cardiac arrest.

There was no documentation located within the medical record that Cardiologist #4 informed Patient #2 the patient's DNR directive would be invalid during the cardiac procedure.

Review of the document titled, Cath Lab Procedure Log, revealed on 3/13/18 at 3:06 p.m., a code blue (cardiopulmonary arrest, requiring a team of providers for resuscitation) was called in the cardiac catheterization lab, and CPR (cardiopulmonary resuscitation) was initiated at 3:11 p.m. At 3:13 p.m., Patient #2 was intubated (inserting a tube through the mouth into the airway to assist with breathing).

On 3/13/18 at 5:57 p.m. Physician #5 wrote an order to discontinue Patient #2's DNR and an order for full code (all life saving measures would be performed) was placed. This was two hours and 46 minutes after CPR was initiated.

i. On 3/14/19 at 12:47 p.m., a review of Patient #2's medical record was conducted with RN #7. RN #7 stated Patient #2 was determined to be a DNR on 3/12/18, when the patient was admitted, and the patient's daughter was determined to be the decision maker. RN #7 stated there was no documentation in the medical record, prior to the procedure, the patient or family were notified Patient #2's DNR would be rescinded during to the cardiac catheterization procedure. RN #7 stated the steps to rescind a DNR were important because resuscitating a DNR patient was against their rights.

ii. On 3/12/19 at 2:14 p.m., an interview was conducted with Catheterization Lab Nurse Manager (Manager) #6. Manager #6 stated a patient's DNR status did not apply when they came to the cardiac catheterization lab for a procedure because a patient could easily go into an abnormal cardiac arrhythmia which could require resuscitation. Manager #6 stated if the cardiac catheterization lab was aware a patient had a DNR in place they would not bring the patient to the cardiac catheterization lab, because once a patient was in the cardiac catheterization lab all measures would be taken to save their life.

Manager #6 stated she was unaware of any policy or process to follow for DNR patients because it was something the physician handled and they were responsible for speaking with the patient regarding their resuscitation status.

iii. On 3/18/19 at 7:10 a.m., an interview was conducted with Physician #5. Physician #5 stated the physician performing the procedure for a patient was the physician who would be responsible for having a formal discussion with a patient regarding their DNR status. Physician #5 stated an order would be placed, as well as a physician note put the patient's electronic medical record. Physician #5 stated it was important to follow the wishes of a patient regarding their code status and going against those wishes would be going against their right to make decisions for themselves.

iv. On 3/12/19 at 4:20 p.m., an interview was conducted with Cardiologist #4. Cardiologist #4 stated if a patient with a DNR in place was going to have an invasive procedure it would be necessary to rescind the DNR, and a note would be placed in the patient's medical record under the consult note. Cardiologist #4 stated the reason the DNR needed to be rescinded was because staff would need to be able to deal with any complications which could occur during the procedure, to include a cardiac arrhythmia or cardiac arrest. Cardiologist #4 stated it was important for the patient to consent to rescinding the DNR and understand and remain informed of the care they would receive.

During the same interview a review of Patient #2's medical record was conducted with Cardiologist #4. Cardiologist #4 confirmed there was no documentation the patient, or the family, were aware the DNR would be rescinded. Cardiologist #4 stated maybe he forgot to document the conversation. Cardiologist #4 also confirmed there was not an order placed for full code prior to the cardiac catheterization procedure.

c. Review of Patient #10's Emergency Department (ED) Disposition form showed Patient #10 was admitted on 1/24/19 with a diagnosis of fever, pneumonia, and dyspnea (shortness of breath).

Review of the document, Colorado Medical Orders for Scope of Treatment (MOST), located in Patient #10's medical record and dated 1/13/18, revealed Patient #10 requested no CPR be performed in the event the patient did not have a pulse, and was not breathing. Additionally, the form stated Patient #10 requested comfort-focused treatment with a primary goal to maximize comfort.

According to the History and Physical (H&P), written by Physician #3 on 1/24/19 at 10:47 p.m., Patient #10 was evaluated by Physician #3. Physician #3 documented Patient #10's code status as DNR. Physician #3 also documented Patient #10's durable power of attorney for health care would be his sister.

Patient #10's resuscitation status remained DNR from the time of admission, on 1/24/19, until the patient was discharged from the facility on 1/30/19.

On 1/28/19 at 10:06 a.m., according to the Cardiology note located in the Care Plan, the physicians assistant (PA # 12) documented, the procedure was discussed, as well as the risks, and benefits. PA #12 documented Cardiologist #4 would proceed with the transesophageal echocardiogram, (TEE, a probe containing an ultrasound transducer is passed into the patient's esophagus to evaluate the heart).

According to the Transesophageal Echocardiogram Report, documented as completed by Cardiologist #4 on 1/28/19 at 12:51 p.m., Cardiologist #4 documented informed consent for Transesophageal Echocardiogram was obtained prior to the procedure for Patient #10.

Review of the document titled, Consent for Trans-esophageal Echocardiogram, revealed Patient #10 signed the consent for the procedure at 9:00 a.m. Within the document, possible risk were listed as: respiratory arrest and cardiac arrest.

Review of the document titled, Cath Lab Procedure log revealed, on 1/28/19, Patient #10 was admitted to the catheterization lab and a TEE was performed. Patient #10's resuscitation status remained DNR. There was no documentation located within the medical record that Patient #10 was informed the DNR directive would be invalid during the procedure.

i. On 3/18/19 at 9:34 a.m., an interview was conducted with the cardiac catheterization lab registered nurse (RN # 13). RN #13 stated all patients who underwent a procedure in the catheterization lab were full code. RN #13 stated these procedures include cardiac catheterization, TEE's, cardioversions (a procedure which sends an electric shock through the heart in an attempt to restore normal heart rhythm), and any other procedure done in the cardiac catheterization lab. RN #13 stated if a patient had a DNR in place prior to a procedure the DNR would not be valid in the cardiac catheterization lab. RN #13 stated it was important DNR patients be informed their DNR would be rescinded during a procedure because they may not want to be resuscitated, and patients should be informed the catheterization lab team would do everything possible to save their life while they were in their department. RN #13 stated it was important to protect patient wishes regarding resuscitation because it was their body and they had the right to make decisions for their life and what procedures were done to them.

ii. On 3/18/19 at 10:21 a.m., an interview was conducted with the cardiovascular services director (Director #14). Director #14 stated the physician was responsible for discussing DNR status with a patient, and the discussion was documented in their physician notes, within the medical record. Director #14 stated this process should occur prior to a patient undergoing a procedure. Director #14 stated it was important because patients should be informed of the risks of a procedure so they could decide what was right for them. Director #14 stated he was unaware of what procedures in the cardiac catheterization lab required a DNR be rescinded prior to the procedure, and he was unaware of any policy or guidance on cardiac catheterization lab procedures related to advance directives. Director #14 stated he would look to the physician for guidance on DNR patients, and the process would be different on a case by case basis. Director #14 stated all cardiac catheterization lab procedures carry a risk of death.

d. Review of Patient #8's Emergency Department (ED) Disposition form showed Patient #8 was admitted on 6/27/18 with a diagnosis of an upper gastrointestinal (GI) bleed (bleeding which comes from the upper GI tract), elevated troponin (a test which measures the level of troponin in the blood to help detect heart injury), and cardiac ischemia (a lack of oxygen and blood flow to the heart).

According to the H&P, written on 6/27/18 at 5:53 p.m., Patient #8 was evaluated by Physician #10. Physician #10 documented Patient #8's code status as DNR/DNI (do not resuscitate/do not intubate). Physician #10 also documented Patient #8's daughter was the medical decision maker if Patient #10 was unable to make decisions.

Patient #8's resuscitation status remained DNR from the time of admission, on 6/27/18, until the patient was discharged from the facility on 7/1/18.

According to the H&P, written 6/19/18 at 9:58 a.m., Patient #8 was evaluated by Physician #10. Physician #10 documented Patient #8 had a code status of DNR/DNI, but did want to proceed with the EGD. Physician #10 also documented they discussed the option of monitoring given advanced age, but patient wished to proceed with the EGD and the procedure was planned that day. There was no documentation Patient #8 was informed his DNR directive would be invalid during the procedure, or the DNR/DNI was discussed with the certified registered nurse anesthetist (CRNA) or gastroenterology physician.

On 6/29/18 at 12:03 p.m., according to the Anesthesia Plan located in the Preprocedure Note, the certified registered nurse anesthetist (CRNA #15) documented, the plan was discussed with the patient, and written consent was obtained.

Review of the document titled, Informed Consent and Authorization for Anesthesia, revealed Patient #8 signed the consent for the procedure at 10:49 a.m. Within the document, possible risk were listed as: stroke, brain damage, heart attack, cardiac arrest, or death.

According to the GI Procedure History and Physical, documented by the gastroenterology physician (Physician #16) on 6/29/18 at 11:05 a.m., there was no documentation Patient #8 was informed his DNR directive would be invalid during the procedure.

Review of the document titled, Informed Consent to Upper GI Endoscopy Procedure (EGD, a procedure to examine the esophagus, stomach, and the first portion of the small bowel using a tube with a camera) revealed Patient #8 signed the consent for the procedure at 11:06 a.m. Within the document, possible risk were listed as: aspiration (inhalation of stomach contents into the lungs), arrhythmia (abnormal heart rhythm), and death.

Patient #8's resuscitation status remained DNR during the time he underwent the EGD procedure. There was no documentation located within the medical record that Patient #8 was informed the patient's DNR directive would be invalid during the procedure.

i. On 3/18/19 at 9:02 a.m., an interview was conducted with the GI lab registered nurse (RN #17). RN #17 stated the DNR directive should be addressed during the pre-op process, and the GI lab suspended the DNR during the procedure while the GI concern was addressed. RN #17 stated if a patient had a DNR code status in their medical record then the GI lab staff would discuss it with the physician, the patient, and their family. RN #17 stated the purpose of this was to clarify the patient's wishes. RN #17 stated a note needed to be placed, by the physician, in the patient's medical record, stating what the patient's wishes were regarding their resuscitation status and what resuscitation measures the patient would, or would not like done. RN #17 also stated there would be a note in the GI lab nursing documentation as well, regarding the advanced directive in the GI lab. RN #17 stated a patient could keep their DNR in place during an EGD, and a written note in the medical record would specify the patient's wishes. RN #17 stated this was important for patient safety, and the decision was ultimately up to the patient.

Patient #8 was taken to the GI lab for an EGD on 6/29/18, and there was no documentation in the medical record to clarify what resuscitation measures Patient #8 agreed to during the procedure.

ii. On 3/18/19 at 8:51 a.m., an interview was conducted with CRNA #18. CRNA #18 stated she was able to see if a patient was a DNR when she reviewed the electronic medical record (EMR). CRNA #18 stated her process for rescinding a DNR during a procedure was to inform patients during the anesthesia consent discussion. CRNA #18 stated she would probably be the provider to rescind the DNR, but she would have to have a discussion with the physician to clarify. CRNA #18 stated she would then write a note regarding the DNR resuscitation discussion in the patient's EMR. CRNA #18 stated the DNR would be reinstated when the patient was discharged from the operating room (OR) following the procedure.

e. On 3/14/19 at 12:47 p.m., an interview was conducted with RN #7. RN #7 stated he was unaware of any policy which provided guidance for DNR patients who underwent procedures. RN #7 stated he had not received any training from the facility regarding this process. RN #7 stated he had worked at the facility for a couple of years before learning patients going to the OR could not have a DNR in place during their surgery or procedure and DNR patients would be resuscitated while in the surgery suite. RN #7 stated he was informed of this process by a post-anesthesia care unit (PACU) nurse.

i. On 3/18/19 at 9:34 a.m. an interview was conducted with the cardiac catheterization lab nurse (RN #13). RN #13 stated her training for the DNR patient process in the cardiac catheterization lab occurred verbally. RN #13 stated she was told by her preceptor DNR directives were inactive in the cardiac catheterization lab and this applied for all patients who chose to undergo procedures. RN #13 stated a DNR did not matter in the cardiac catheterization lab. RN #13 stated patient's advance directives were irrelevant in an emergency procedure, because staff would do the procedure regardless of a patient's directive, to save their life. RN #13 stated the alternative would have been for the patient to choose not to undergo the procedure. RN #13 stated the physician spoke with the patient regarding their resuscitation desires during the consent process.

ii. On 3/18/19 at 10:21 a.m., an interview was conducted with the catheterization lab director (Director #14). Director #14 stated staff did not receive training regarding the process for patients who had a DNR directive in place prior to a cardiac catheterization procedure. Director #14 stated the process staff followed was the physician was responsible for asking the patient about their DNR status and resuscitation options. Director #14 stated the cardiac catheterization lab staff would not ask about DNR directives.

iii. On 3/12/19 at 12:08 p.m., an interview was conducted with the director of performance improvement (Director #2). Director #2 stated the Advanced Directive policy applied for the cardiac catheterization lab, GI lab, and surgical services throughout the facility. Director #2 stated although the policy read "outpatients undergoing sedation" it was also intended for inpatients undergoing sedation and procedures. Director #2 confirmed she had not provided training to staff regarding the process for DNR patients undergoing surgery or procedures.