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Based on records reviewed and interviews the Hospital failed to follow its procedure for activating the Health Care Proxy for three of three patients (Patient #2, #3 and #6).

According to the Hospital policy titled Advance Directives, date of issue June 2016, the assessment of incapacity is performed and documented by the attending in the medical record. A Health Care Proxy or Advanced Directive will be valid only during that period of time that the patient is determined to be incapacitated.

Patient #2 entered the Hospital with leg pain after two occlusions of a surgical graph. On 4/21, 4/23, and 4/24/17 Patient #2's medical record indicated 4 informed consents were signed including an amputation of Patient #2's leg by Patient #2's representative. Neither the Surveyor nor the Nurse Manager were able to locate the documentation of Patient #2's incapacity or the activation of the identified Health Care Proxy.

Patient #3 entered the Hospital with chest pain and subsequently experienced three cardiac arrests (the heart stopped). Patient #3's medical record indicated his/her code status and plan of care was determined by family. Neither the Surveyor nor the Nurse Manager were able to locate the documentation of Patient #3's incapacity or the activation of the identified Health Care Proxy.

Patient #6 entered the Hospital with shortness of breath. On 4/11, 4/13 and 4/14/17 Patient #6's medical record indicated 3 informed consents were signed including a chest surgery by Patient #6's representative. Neither the Surveyor nor the Nurse Manager were able to locate the documentation of Patient #6's incapacity or the activation of the identified Health Care Proxy.

The Surveyor interviewed Physician #3 in the ICU at 2:00 P.M. on 4/25/17. Physician #3 said he would consider a patient who was vented and sedated as lacking capacity. Physician #3 said the process to activate the Health Care Proxy was that documentation would be entered into the medical record to reflect the patient's incapacity and activation of the Health Care Proxy.