HospitalInspections.org

Based on facility policy review, medical record review, other facility medical record reviews, physician interview, and staff interview, the facility failed to ensure that advanced directives status was addressed and formulated for 1 of 10 sampled patients (#5)

Findings include:

A review of the facility's policy "Advance Directive Patient Self-Determination ACT" (revised 05/2010) revealed "Every patient has the right to be involved in the determination of and to participate in their care process. The ___(name of facility) honors all patient Advance Directives. 1..During the registration process, all adult patients are asked if they have written advance directive which address health care issues. Patients admitted as inpatients are required to sign an advance directive acknowledgement form and given upon request the Advance Directive literature which contains information about advance directives and how to formulate one if they desire. Patients are asked if they have a written advance directive and this is documented on the registration form. 4...If a patient states they have an Advance Directive and it is not on file, Registration and the nursing unit will receive a notification "Advance Directive Not on File". It will be documented that the family was asked to bring it in, and in addition, the physician is to document the patient's wishes in the record. 6...In the event the patient or family is unable to complete the process, this will be indicated at the bottom of the acknowledgement form. Nursing staff will receive a copy of the acknowledgement form indicating that the patient was unable to complete the process. The nurse will notify the physician of the absence of the advance directive."

A closed medical record review on 02/22/2012 for patient #5 revealed that the patient was a 84 year old female that was admitted to the hospital on 02/25/2011 with a diagnosis of "Chest Pain and Atrial Fibrillation with Rapid Ventricular Rate" after being transferred from another acute care hospital for a higher level of care. The documentation of the patient's medical record for 02/25/2011 during the patient's admission assessment revealed that the patient was asked the question, "Do you have Advance Directive on file? answer documented as "No". A further review of the patient's "Admission Assessment" documented by the facility's registered nurse admitting the patient revealed documentation that the patient had no advance directives, but did document that the patient had a "living will". An interview with the hospital's administration staff revealed that the nurse documented a computer key click accidentally and that the patient at the time of admission did not bring any living will or advance directives to the hospital. The assessment documentation also revealed that the patient was alert and oriented at the time of admission.

Documentation review of the hospital's "Advance Directive Acknowledgement Form" that asked if the patient had a living will, health care power of attorney revealed that the information was checked as no and obtained from the patient's daughter on 02/28/2012 (total of three days after admission and patient was intubated on 02/28/2011) by the hospital's staff. No documentation was found in the medical record as to why it took a total of three days from the time of the patient's admission to complete the form.

Documentation review of the physician's documentation and physician orders in the patient's medical record revealed no documentation that addressed or indicated what the patient's code status was during the hospitalization. No documentation was found from either the physicians or the nursing staff that addressed the patient's wishes for her reported "Living Will" in the medical record. No documentation was found that the facility's staff followed up to determine what the patient's "Living Will" contained.

Review of a physician's order revealed an order to obtain an outside history and physical and discharge summary from a recent hospitalization of the patient at another acute care facility. Review of the received documentation revealed during admission from the other acute care provider that the patient was a DNR/DNI (Do no resuscitate/Do not intubate). There was no documentation that the facility's physician staff addressed the patient's code status after receiving the medical records.

A telephone interview on 02/22/2012 at 1615 with the patient's attending physician revealed that the patient did not have any known advance directives to him for her hospitalization. The interview also revealed that he or other medical staff did not document any code status or wishes as suggested in policy for the patient. "I do not remember any documentation for the code status. We did discuss with the family their requests to continue with treatments and intubations, but we did not document any information with the patient herself before she became unresponsive."

An interview on 02/22/2012 at 1650 with the facility's administrative nursing staff revealed that the facility staff and the physician staff did not document any follow up to the patient's code status after receiving the information from the other hospital. The interview also revealed that no reason could be given as to why there was no further documentation of the patient's living will from the nursing staff or medical staff after she did indicate on admission that she had a living will but their was no copy on file.


Reference Investigation NC00078791.