HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the Advance Directive brochure was provided to one of four sampled patients (Patient 2) as per the hospital's P&P, creating the risk of violating the patient's rights.

Findings:

Review of the hospital's P&P titled Advance Directives dated 7/23/21, showed upon hospital admission or early during the hospitalization when the general consent is initially obtained, each patient or patient surrogate will be asked whether the patient has an advance directive, including POLST. The response will be noted in the appropriate field of the general consent form and in the automated electronic system. The patient, or the designee, will be provided a copy of the Advance Directive brochure, "Your Right to Make Decisions About Medical Treatment."

On 2/13/25 at 1300 hours, Patient 2's closed medical record was reviewed with the Licensing Coordinator.

Patient 2's medical record showed Patient 2 was admitted to the hospital on 12/5/24 and discharged on 12/6/24. Patient 2's medical record showed Patient 2 did not have an advance directive. However, further review of Patient 2's medical record failed to show if the Advance Directive brochure was provided. When asked, the Licensing Coordinator stated if a patient wished further information about advance directive, the social worker would be referred. In this case, a social worker was not referred, so the Advance Directive brochure was not provided to Patient 2.

The Licensing Coordinator verified the above findings.