HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure hospital staff and Practitioners complied with a patient's advanced directives related to no cardiopulmonary resuscitation (CPR) for 1 of 10 patients (Patient #1).

Findings:

The hospital's "DNR (Do Not Resuscitate)" policy, last revised 6/25/2018, states, "DNR means that NO cardiopulmonary resuscitation (Code BLUE) is to be performed on the patient"; "To alert all staff that this is a DNR patient, code status will be listed in the electronic health record, on the order screen under Code/Isolation/Advance Directives category as well as in the chart summary screen and a purple clip will be attached to the patient's bracelet" and "The patient's rights will be respected at all times".

Patient #1's medical record contained an advance directive, dated 8/10/20, that stated the patient was not to receive CPR.

A physician's order by MD #1, dated 8/10/2020 at 9:42 PM, for a DNR was written.

A decision was made that the patient would be admitted to the hospital; however he/she remained in the Emergency Department (ED) awaiting an inpatient bed.

Documentation in the record stated CPR was initiated on 8/11/20 at 1:26 PM and ended at 1:55 PM. The patient expired at 1:55 PM.

During interviews, multiple staff stated that the purple clip, that was to be attached to the patient's bracelet, was not used in the ED. These interviews were conducted with the following individuals on the following dates and times:

- Registered Nurse (RN) #1, who works in the ED, on 9/1/2020 at 1:15 PM;
- RN #2, who works in the ED, on 9/1/2020 at 2:15 PM;
- RN Leader of the ED, on 9/2/2020 at 8:15 AM;
- RN #3, who works in the ED, on 9/2/2020 at 9:45 AM;
- A Doctor of Osteopathic Medicine (DO), who works in the ED, on 9/2/2020 at 10:00 AM;
- RN #4, who works in the ED, on 9/2/2020 at 10:30 AM.

On 9/2/2020 at 10:47 AM, the Nurse Director of the ED confirmed the DNR order was not followed.