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Based on record review and staff interview, the Hospital failed to follow their policy and procedure for initiating a Do Not Resuscitate (DNR) Order as evidenced by the physician failing to document in the progress notes the DNR discussion with the family, Power of Attorney and/or patient before DNR status was implemented for 2 of 2 (#4, #6) sampled patients and 1 of 1 (#R1) random patients reviewed for DNR status out of a total of 7 sampled medical records.

Findings:

Review of the hospital policy titled, "DNR Guidelines, LaPost" Policy No. TX-120, revealed in part the following:
A DNR/DNI order is executed to provide guidelines in the event of a code blue situation....The DNR order is only effective during the admission period in which it was obtained....
The physician must explain the nature of CPR, the possible outcomes, their likelihood, and the alternatives. The physician should offer explicit recommendations while giving the patient, or the patient's surrogate, appropriate choices....
If the patient is unable to understand the nature and consequences of his or her illness, or is incapable of making informed choices about treatment, the physician should consult with the patient's surrogate, in the presence of at least one witness, to arrive at a substituted judgment for the patient about forgoing resuscitation....
Documenting the Decision: Documentation in the progress notes of the medical record of discussions with the patient or the surrogate or others and of the views of the patient or surrogate concerning the LaPost or DNR order in the chart. Likewise, any evidence of advance medical directive prepared by the patient regarding resuscitation must be documented in the chart. The progress notes in the chart should reflect the reasons for the order, any review or reconsideration of the order, and any efforts made to resolve ethical or communication problems regarding the order.


Patient #4
On 08/21/17 at 2:45 p.m., the electronic medical record for Patient #4 was reviewed with S5RNCI and revealed the patient was a 56 year old admitted to the hospital on 08/19/16 with a diagnosis of Malignant Neoplasm of Ascending Colon. Review of the record revealed the patient expired on 08/22/16 at 10:52 a.m.

Review of the physician orders revealed an order dated/timed on 08/22/16 at 7:54 a.m. for, "DNR-Code Status." Review of the order revealed the order was entered into the electronic medical record by S8Physician and acknowledged by S7RN.

Review of the progress notes dated/timed 08/22/16 at 6:37 a.m. and documented by S8Physician revealed "no code" was documented. Further review of the progress notes dated 08/20/16 and 08/21/16 revealed no documentation of a discussion with the patient or the patient's family related to the "no code" status. Review of the Initial Consultation dated 08/19/16 from the office of S8Physician revealed no documentation related to a DNR status.
The above findings were confirmed by S5RNCI at the time of the electronic medical record review.

Review of the Discharge Summary dated/timed 08/23/16 at 7:43 a.m. revealed the following: This very pleasant 56 year old male with a history of metastatic colon carcinoma was admitted to the hospital due to profound weakness.... It was felt that all of his problems are due to his progressive disease. The patient was subsequently started on chemotherapy with Avastin and Folfox. The patient received his chemo and actually did well. His ammonia level was down to 48 on Monday. The patient looked extremely weak and poor condition. I had a lengthy discussion with the patient's wife with regards to continued therapy. It was all agreed that we will support patient and maintain measures of comfort. On the morning of 08/22/16, the patient had a respiratory arrest, blood pressure dropped, the patient was pronounced on Monday morning. Cause of death is complication secondary to progressive colon carcinoma.

In an interview on 08/21/17 at 5:20 p.m., S8Physician stated he had discussed the patient's status with the patient's wife and they had determined that they wanted only comfort measures and a no code was ordered. He confirmed he had discussed the patient's condition and the no code status with the patient's wife. After reviewing the progress notes S8Physician confirmed only "no code" was documented in the progress notes and stated he documented the discussion in the discharge summary.


Patient #6
On 08/22/17 at 9:40 a.m. the current electronic medical record for Patient #6 was reviewed with S5RNCI and revealed the patient was a 66 year old current patient admitted to the hospital on 08/18/17 at 4:30 p.m. with diagnoses of Intractable Pain and Possible Renal Cell Carcinoma.

Review of the physician orders revealed an order dated/timed on 08/18/17 at 9:27 p.m. for, "DNR-Code Status" entered by S9Physician.

Review of the progress notes dated 08/19/17, 08/20/17, and 08/21/17 revealed no documented evidence of discussion with the patient or the patient's family/surrogate related to the DNR.

Review of the H&P dated/timed 08/18/17 at 7:55 p.m. revealed, "Code status: DNR."

S5RNCI confirmed the above findings at the time of the record review.

In an interview on 08/22/17 at 11:15 a.m., S3DQ confirmed they could not provide any documented that Patient #6 had documentation of how the DNR status was decided. S3DQ confirmed there was no documentation of the discussion with the family regarding the DNR status in the physician progress notes or anywhere else in the patient's record. S3DQ confirmed there was no documentation of advance directive in the patient's record.


Patient #R1
On 08/22/17 at 11: 50 a.m. the current electronic medical record for Patient #R1 was reviewed with S5RNCI and revealed the patient was an 82 year old female admitted to the hospital on 08/14/17 at 11:53 a.m. with diagnoses of Failure to Thrive, Hepatic and Adrenal Mass.

Review of the physician orders revealed an order dated/timed on 08/14/17 at 7:16 p.m. for, "DNR-Code Status" entered by S10Physician.

Review of the H&P dated/timed 08/14/17 at 7:58 p.m. revealed, "Code status: DNR."

Review of the progress notes dated 08/15/17, 08/16/17, 08/17/17, 08/18/17, 08/19/17, 08/20/17, and 08/21/17 revealed no documented evidence of discussion with the patient or the patient's family/surrogate related to the DNR.

S5RNCI confirmed the above findings at the time of the record review.

In an interview on 08/22/17 at 12:20 p.m. the current paper record for Patient #R1 was reviewed with S4OncMgr and S3DQ and revealed no documented evidence of any advance directive for DNR status. Review of the binder containing Patient #R1's medical record revealed the chart was flagged as DNR. S4OncMgr confirmed the patient was confused. S4OncMgr stated the oncology physicians usually have the documentation of the DNR and send it with the patient. S4OncMgr stated they get the DNR order and proceed from there.

In an interview on 08/22/17 at 1:20 p.m., S3DQ stated she had spoken with S11Physician (Chief of Staff) about the discussion of the DNR status and he stated the physicians are having the discussion. S3DQ confirmed the records reviewed during the survey did not have the required documentation in the progress notes of the DNR discussion with the patient/family.

Based on record reviews and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by failing to conduct a medication reconciliation of the patient's home medications on admission to the hospital as directed in the physician orders and in accordance with hospital policy for 1 (#4) of 3 (#4, #5, #6) sampled patients reviewed for medication administration out of a total sample of 7 (#1-#7). The deficient practice resulted in Patient #4 not receiving the prescribed seizure medications for over 36 hours after admission to the hospital.

Findings:

Review of the hospital policy titled, "Medication Reconciliation, number TX-306 revealed in part the following:
Purpose: To establish a process for comparing the patient's current medications with those ordered for the patient while under the care of the hospital.
Policy: A complete list of the medications the patient is taking at home (including name, dose, route, frequency and indication for scheduled medications and (PRN) taken as needed) is created and documented in the patient's profile in Electronic Medical Record.... The nurse will complete an admission medication reconciliation request electronically upon admission for the attending physician to update/order during the patient's visit. Medications ordered during the patient's hospital stay will be compared to those on the list created at time of hospital entry or admission.
Inpatient Admission from Direct Admit to an inpatient unit:
When a patient arrives in the inpatient unit, home medications are recorded in the patient's profile in Clinical Care Station. If no med list is provided or accessible, the escalation protocol outlined in section 1 above must be initiated.
C. The following escalation protocol is put into practice if the patient arrives to the inpatient unit with home medication in need of clarification:
a. Contact the patient's home/retail pharmacy and request clarification on missing items. If unable to obtain,
b. Contact the office of the patient's primary care physician and request clarification on missing items. If unable to obtain,
c. Contact admitting physician and request assignment of dose, route, frequency as appropriate OR
d. Determine if a physician consult is necessary to re-start the appropriate home medications.
The admitting nurse will send an admission medication reconciliation to the attending physician which will be used to determine inpatient medication orders.
During change of care giver chart checks, the primary care nurse will ensure that the patient's medications were reconciled on admit. The reconciliation process for admission is not complete until admission medication reconciliation is completed by the physician....

Patient #4
On 08/21/17 at 2:45 p.m., the electronic medical record for Patient #4 was reviewed with S5RNCI and revealed the patient was a 56 year old admitted to the hospital on 08/19/16 with a diagnosis of Malignant Neoplasm of Ascending Colon. Review of the record revealed the patient expired on 08/22/16 at 10:52 a.m.

Review of the "Admission Orders" dated/timed 08/19/16 at 10:03 a.m. from the office of S8Physician revealed an order to, "Identify home meds."

Review of the document titled, "Initial Consultation" identified by S5RNCI as the H&P and dated 08/19/16 revealed the patient was being admitted for chemotherapy due to increasing somnolence, confusion, LFTs. Review of the past medical history revealed the patient had a history of seizure disorder. The medications listed included Depakote 500 (Seizure medication-Valproic Acid) mg tablet delayed release and Diovan 320 mg tablet.

Review of the Patient Profile Report provided by S5RNCI as the form used to document medications for reconciliation revealed no documented evidence that the patient's home medications were included on the profile report on admission. Further review of the profile report revealed on 07/23/16 (prior admission) the patient was on Depakene (Seizure medication-Valproic Acid) 500 mg three times a day and Valsartan (Diovan) 320 mg once a day.

Review of the physician orders dated 08/20/16 at 10:27 p.m. revealed a verbal order for Valproic Acid 500 mg three times a day was received by S13RN from S12Physician. Review of the physician orders dated 08/20/16 at 11:59 p.m. revealed a verbal order for Valsartan 320 mg. once a day was received by S13RN from S12Physician.

Review of the medication administration record revealed the Valproic Acid (Depakene) 500 mg was administered to the patient on 08/20/17 at 11:20 p.m., over 36 hours after the patient was admitted to the hospital. The MAR revealed the Valsartan 320 mg was administered to the patient on 08/21/17 at 9:31 a.m. over 47 hours after the patient was admitted to the hospital.

In an interview on 08/22/17 at 10:00 a.m., S14RN reviewed the initial nursing assessment and confirmed she did the admission assessment on Patient #4. She stated when she does an admission, she used an admission sheet from computer and part of the sheet is medications. S14RN stated she asked the patient or family if they the medications with them or have a list of medications. She stated often patients don't know or don't have the list or medications with them. S14TN stated if the patient/family don't have knowledge or have the medication bottles with them then she would call the patient's pharmacy. S14RN stated if the family is going home she would ask them to bring a list or the medications. S14RN stated there could be many reasons for a delay in obtaining a medication reconciliation, like waiting for the family to bring the medications to the hospital. S14RN stated she did not usually look at the H&P for the medications the patient is on for reconciliation, stated she does not have time to look at that. S14RN stated she did not remember this patient. S14RN stated she was unable to explain why medication reconciliation was delayed. S14RN confirmed Depakote was a medication that should be continued in the hospital. S14RN stated it was the responsibility of the primary nurse to complete a medication reconciliation. S14RN stated the medication reconciliation should be completed within 24 hours of admission.

In an interview on 08/22/17 at 10:10 a.m., S4OncMgr was also present for the above interview and confirmed the patient's home meds were not ordered within the 24 hour window for reconciliation of patient meds. He was unable to explain why there was no medication reconciliation. S5OncMgr stated that when he does an admit he confirms patient medications from the patient's list or from the actual medications and does not review the H&P or information from the physician's office. S4OncMgr stated he did not know why this patient's medications were delayed and stated it could have been they were waiting on information from the family. S5OncMgr stated the staff may have tried to obtain the information but may not have documented the attempts. S5OncMgr stated either way the reconciliation was to be completed in 24 hours of admit.

In an interview on 08/22/17 at 11.30 a.m. S6RNCI reviewed the EMR and confirmed there was no update to the medication profile when the patient was admitted. She sated the nurse should have entered the date the medications were verified and added any medications the patient was currently on. She confirmed this was not done for Patient #4.