HospitalInspections.org

Based on record review and interview the facility failed to follow their policy and procedures to address or provide information on advance directives on 2 patients (Patient #7 and #9) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Advance Directives" last revised 1/20/2021, revealed all admitted patients "will be informed of their right... to complete an Advance Directive." If the patient is unable to communicate at the time of admission, they will "ask family members... if an advance directive document exists." If a patient does not have advance directives, the patient will be asked if he/she would like additional information and/or assistance. If so... a referral will be made to the Case Management Department for forms, additional information and assistance in completing the document."

Review of Patient #7's medical record revealed Patient #7 was a 42-year-old admitted 9/27/2021 with shortness of breath after testing COVID-19 positive 10 days prior to presentation. Advanced directive screening was completed 9/27/21 at 8:14 PM with referral to Care Management for additional follow-up. Patient #7 was discharged home on 10/01/2021. There was no documentation that Patient #7 was given additional information and/or assistance with advanced directives.

Review of Patient #9's medical record revealed Patient #9 was a 50-year-old admitted 9/26/2021 with shortness of breath after testing COVID-19 positive 5 days prior to presentation. Advanced directive screening was completed 9/27/21 at midnight with referral to Care Management for additional follow-up. Patient #9 was discharged home on 10/06/2021. There was no documentation that Patient #9 was given additional information and/or assistance with advanced directives.

On 10/14/2021 at 11:19 AM during interview with Care Management Regional Manager G, Manager G confirmed, follow-up of advanced directives was not completed for Patients #7 and #9 stating it "was a miss."