HospitalInspections.org

The Hospital failed to ensure Patient #1's guardian or representative was involved in the participation of making informed decisions regarding Patient #1's care and formulating advanced directives for end of life decision making.

Refer to tag: A-0132

Based on record review and interviews, the Hospital failed for 1 (Patient #1) Patient out of 10 records reviewed, to maintain the Patient's Full Code (full resuscitation) order by changing the order two times (on 1/11/20 and on 4/26/20) during Patient #1's admission 1/8/20 - 7/1/20 without obtaining the Court's legal permission.

Review of the Hospital's Patient Rights Policy, dated 1/3/2019 indicated that every patient shall have the right:

(e) to formulate advanced directives and to have the hospital staff and practitioners who provide care in the hospital comply with these directives.

Patient #1 was admitted on 1/8/20 with a past medical history which included Down Syndrome, dysphasia and recurrent aspiration pneumonias. Patient #1 was sent to the Hospital from his/her group home with increased shortness of breath and cough.

The Hospital Medicine History and Physical Examination Report dated 1/8/20 indicated that the Patient's resuscitation status was a Full Code. The Group Home where Patient #1 lived told the physician that the patient's family (legal guardian) had essentially abandoned him/her and that they are seeking a guardian for him/her.

The Case Management Progress Note dated 1/9/20 indicated that the caregiver at the group home said that the group home is in the process of applying for new guardianship and it has not been finalized yet. The Case Management Progress Note further indicated that the group home care giver said that Patient #1 should be a Full Code.

The Hospital Medicine Progress Note dated 1/11/20 indicated that Patient #1 was admitted on 1/8/20 at 1:01 P.M. and with a status of Full Code.

The Code Status Order History dated 1/11/20 indicated that the Patient is a DNR (Do Not Resuscitate). There is no evidence that the Hospital obtained Court Approval for the change of this code status from Full Code to Do Not Resuscitate.

The Transfer of Care Note dated 1/12/20 indicated that Patient #1 was a DNR and that the group home was in the prolonged process of obtaining guardianship because the family member responsible for the patient no longer is involved in Patient #1's care.

The Hospital Medicine Daily Progress Note dated 1/13/20 indicated that there was documentation that the patient was Full Code, however was ordered DNR.

The Code Status Order History dated 1/13/20 indicated the Patient was a Full Code.

The Social Work Progress Note dated 1/14/20 indicated that the Social Worker placed a call to the Hospital's legal department regarding the possibility of emergency guardianship. The Social Work Progress note indicate the Legal Department said, current options are limited as emergency guardianships can take place only when the patient is facing imminent serious and irreversible harm (such as death within 24 hours) without it.

The ICU IP Death Summary indicated that on 1/22/20 Basic Guardianship was obtained in court and the new guardian was unable to make end of life decisions. On 2/5/20 the Case Manager placed a call to the Patient's Guardian to inquire about seeking expanded guardianship. The Guardian reported that the Patient's court appointed attorney had stated she would oppose any expansion or extension of guardianship status sought. On 3/6/20 the Attorney stated to the Case Manager that the Patient was part of a class action lawsuit that entitles Patient #1 to have all his/her medical needs met and at the highest level of care.

The Daily Progress Note dated 4/23/20 indicated that the Hospital was still trying to obtain an earlier court date so hopefully the guardian would be able to make end of life decisions on behalf of the patient for comfort measures only, but that may take weeks. The Daily Progress Note further indicated that the Guardian was unable to make end of life decisions and not allowed to withdraw support.

The Daily Progress Note dated 4/26/20 indicated that on 4/23/20 the Hospital Legal Department said that it was ok to change Patient #1 to a partial code (OK for intubation and Noninvasive positive pressure ventilation, but not for Cardiopulmonary Resuscitation) by utilizing the Hospital Policy applied for patients with poor prognosis.

The Code Status Order History dated 4/26/20 indicated that the Patient was a Partial Code. There was no evidence that the Hospital obtained Court Approval for the change of this code status from Full Code to Partial Code.

In an interview with the Chief Medical Officer on 7/17/20 at 8:30 A.M., the Chief Medical Officer said that if a patient had a guardianship and was a Full Code, the code status would remain full until the legal court process determined otherwise.

In an interview with the Chief Quality Officer on 7/17/20 at 9:30 A.M., the Chief Quality Officer said that if there was ever a disagreement regarding code status, the case would have to be brought to the Ethics Committee for determination. The Chief Quality Officer said that if a patient's next of kin was unavailable, then it was reviewed by the Ethics Committee and the Court. He said that the code status would remain unchanged until the Hospital had a court decision.