HospitalInspections.org

Based on policy review, clinical record review and staff interview, it was determined the facility failed to contact the actual legal representative for 1 (#1) of 10 sampled patients for health care decisions for an incapacitated patient. the continued use of this practice does not ensure that the incapacitated patient's rights are being honored.

Findings include:

Patient #1 was admitted to the facility on 8/23/12 with respiratory failure; cardiopulmonary arrest; anoxic encepholopathy, status asthmaticus and essential hypertension. The physicians plan included to continue the patients Full Code as per the family's wishes.

The original in-house face sheet; revealed the patient was admitted on 8/23/12 at 5:00 pm. The next of kin and person to notify listed the patient's spouse. Further review of the face sheet reviewed ,written in ink, contact information for his brother, sister and " emergency contact for a common law wife ". (Note that in the state of Florida there is no distinction in law for a common law wife.) Written next to the spouse's information is "legal wife" .

The case management/social services documentation dated 8/28/12 at 3:00 pm, revealed the case manager had called the spouse and left a message. A case management (CM)/social services assessment was completed on 9/10/12 at 3:53 pm. The patient was listed as unable to participate due to being unresponsive. The family composition/support structure list the "significant other" (not the legal wife). There were no other family members listed as being a part of the assessment/conference.

An entry by CM dated 9/10/12 at 3:59 pm revealed the " significant other " wants a DNR status for the patient. An entry dated 9/13/12 at 9:00 am revealed the significant other went to CM office to sign Health Care Proxy Designation and reiterated the DNR status. At 5:40 pm the CM spoke with the attending physician concerning the DNR status. The physician asked for clarification from Legal regarding the legitimacy of DNR request per Health Care Proxy by significant other.

There was no documentation of any further attempts to contact the legal spouse or family concerning health care decision of the patient up to 9/17/12.

There was no evidence of a previous advance directive filed by the patient in the clinical record.

An interview was conducted on 11/14/12 at 12:00 p.m., with the main CM involved with the patient, significant other and family. The CM was questioned why she had not attempted to contact the spouse listed on the face sheet. She stated that she had not looked at the face sheet and was unaware of the spouse. She had been talking with the "significant other" since she had been at the patient's bedside. The CM was questioned concerning verification of the "significant others" position with the patient and her having legal rights concerning the patient. The CM stated she had not tried to verify any of these until the physician asked her to have Legal take a look at the Healthcare Proxy and DNR.