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Based on record reviews and interviews, the hospital failed to ensure a patient who did not have an advanced directive or living will and had physician orders for "do not intubate" had documentation of the decision to not intubate in accordance with the "Louisiana Living Will Law" and La. R.S. 40:1299.58.5 as evidenced by having no documented evidence of a declaration made to the physician by the husband of the patient in the presence of two witnesses for 1 (#1) of 2 (#1, #3) patient records reviewed with do not intubate/do not resuscitate orders from a sample of 5 patients.
Findings:

Review of the "Louisiana Living Will Law Title 40 Public Health and Safety Code Part XXIV-A. Declarations Concerning Life-Sustaining Procedures" revealed the right of certain individuals to make a declaration pursuant to which life-sustaining procedures may be withheld or withdrawn from an adult patient who is comatose, incompetent, or otherwise physically or mentally incapable of communication in the event of such adult patient is diagnosed and certified as having a terminal and irreversible condition. Declaration is defined as a witnessed document, statement, or expression voluntarily made by the declarant (a person who has executed a declaration) , authorizing the withholding or withdrawal of life-sustaining procedures . The declaration may be made in writing, orally, or by other means of nonverbal communication. Qualified patient was defined as a patient diagnosed and certified in writing as having a terminal and irreversible condition by two physicians who have personally examined the patient, one of who shall be the attending physician. In the event the declarant is comatose, incompetent, or otherwise mentally or physically incapable of communication, any other person may notify the physician of the existence of the declaration. When a comatose or incompetent person or a person who is physically or mentally incapable of communication has been certified as a qualified patient and has not previously made a declaration, any of the following individuals in the following order of priority, if there is no individual in a prior class who is reasonably available, willing, and competent to act, may make a declaration on the qualified patient's behalf: (a) any person or persons previously designated by the patient, while an adult, by written instrument signed by the patient in the presence of at least two witnesses, to have the authority to make a declaration for the patient in the event of the patient's inability to do so; (b) the judicially appointed tutor or curator of the patient if one has been appointed; (c) the patient's spouse not judicially separated. Any attending physician who has been notified of the existence of a declaration or at the request of the proper person as provided I R.S. 40:1299.58.5 upon diagnosis of a terminal and irreversible condition of the patient shall take necessary steps to provide for written certification of the patient's terminal and irreversible condition, so that the patient may be deemed to be a qualified patient.

Review of the "2011 Louisiana Laws Revised statutes Title 40 - Public health and safety RS 40:1299.58.5 - Procedure for making a declaration for a qualified patient who has not previously made a declaration" revealed the above listed individuals in the listed priority may make a declaration when a comatose or incompetent person or a person who is physically or mentally incapable of communication has been certified as a qualified patient and has not previously made a declaration. When such a declaration is made, there shall be at least two witnesses present at the time the declaration is made.

Review of the hospital policy titled "Informed Consent", presented as a current policy by S2CNO, revealed obtaining informed consent is the physician's responsibility. Informed consent means that the patient or person legally authorized to give informed consent to the patient is entitled to a full explanation of the proposed medical treatment or surgical procedure including its nature, purpose, prospects of success and risk of, and alternative treatment options. Staff members should not take it upon themselves to provide any additional information. Any questions or concerns should be directed to the physician. Any one of the following persons in the following order of priority, if there is no person in a prior class who is reasonable available, willing, and competent to act, is authorized, and empowered to consent, either orally or otherwise, to any medical treatment or surgical procedure that requires consent: 1) any competent adult, age 18 or older for himself; 2) The judicially appointed curator of a patient, if one has been appointed; 3) an agent acting pursuant to a valid mandate (power of attorney) specifically authorizing the agent to make health care decisions, 4) the patient's spouse not judicially separated.

Review of the hospital policy titled "Do Not Resuscitate", presented as current policy by S2CNO, revealed the policy addressed do not resuscitate only and made no mention of do not intubate, perform compressions only, shock only once, and administer no drugs.

Review of Patient #1's medical record revealed she was presented to the ER on 08/12/17 (Saturday) at 12:37 p.m. with a chief complaint of shortness of breath and difficulty breathing as documented by S3RN. Further review revealed the note included that the family member wanted to know why Patient #1 was put on Levaquin if she had a history of seizures. Further review revealed Patient #1 complained of pain to her ankles, knees, shoulders, and neck.

Review of Patient #1's "ER Physician Clinical Report" documented by S4MD revealed her chief complaint was Dyspnea and Stage 4 metastatic lung cancer with an increase in seizures that the family seems to relate to a recently prescribed antibiotic Levaquin. Further review revealed S4MD reassured the family that the treatment by the prescribing physician was appropriate, but if there was concern, they could stop the antibiotic. Further review revealed her dyspnea was improved with oxygen (had been waiting for weeks for home O2; O2 sat is 87% on room air today). Review of her respiratory system revealed respiratory distress, wheezing present, and rhonchi present. S4MD documented that he discussed Patient #1's case with S5MD and reviewed test results. S5MD agreed upon treatment and the plan and would see Patient #1 in the hospital. S4MD's clinical impression was Dyspnea, Metastatic end stage right upper lobe lung cancer with brain metastasis.

Patient #1 was admitted to the Med/Surg unit on an observation status on 08/12/17 at 3:35 p.m.

Review of Patient #1's H&P documented by S5MD on 08/13/17 at 9:31 a.m. revealed the following:
Chief complaint: none recorded.
Inpatient Diagnoses: secondary malignant neoplasm of brain; primary malignant neoplasm of lung
History of present illness: admitted through ER for oxygen because of shortness of breath. Attempt was made to get home oxygen but being the weekend that was not possible, and so she was admitted essentially for comfort care. She is accompanied by her husband who has been treating her with herbal supplements and oils rather than going through chemotherapy. He is very upset that she was seen in ER several days ago and evaluated and had Levaquin started. It sounds like she had a seizure subsequent to the Levaquin. He has looked up side effects and has decided that the seizure and decreased mental status is due to having been given Levaquin, and it should have never been given. I tried to talk with him about the fact that since she has brain metastasis that it is more likely the brain metastasis is worsening slowly and that they are an obvious cause for seizure. However, the patient was not willing to have that discussion. He is also very upset because it has taken so long for her to get home O2 and feels that if she had had that she would be doing much better. I did try to talk with him about the fact that she is going to die of her cancer, and he is very resistant to that idea.
Physical exam: thin emaciated female propped in bed. Does not respond to verbal stimuli.
Neurologic: was not completely tested due to husband's desire for her to be left alone.
Lab work has not been performed.

Review of S6RN's nurse's notes dated 08/13/17 at 12:00 p.m. revealed she updated Patient #1's daughter on S5MD's assessment and visit. Further review revealed all questions were answered. Further review revealed the family verbalized understanding. Further review revealed S6RN spoke with the family about Patient #1's code status. The family stated they want one round of CPR with no intubation. Further review of the note revealed S6RN educated family that Patient #1 does not have IV access and would require intraosseous access in the event of a code blue.

Review of Patient #1's physician's orders revealed an order was written by S4MD on 08/12/17 at 4:05 p.m. for full code status and get a copy of the living will. Further review revealed an order on 08/13/17 at 5:17 p.m. by S5MD for Do Not Intubate and get a copy of the living will. Further review revealed an order on 08/13/17 at 7:18 p.m. by S5MD for Code status DNI, no drugs, and just compressions.

Review of Patient #1's medical record revealed no documented evidence of a discussion in the presence of two witnesses conducted by S5MD with Patient #1's husband regarding his expectations of end of life care in the event Patient #1 coded.

In a telephone interview on 06/07/18 at 9:40 a.m., Regan Breaux, RN indicated he was told everything about plans for resuscitation of Patient #1 from the previous nurse during report and also by talking with her husband and family who were in the room. He indicated Patient #1's husband told him later that he wanted Patient #1 "not intubated, no drugs in the body, would treat her with herbs, they could shock her one time, and that's it." He indicated he knows the husband was upset because they didn't shock her, and he explained they don't shock asystole and tried to explain it only required CPR and drugs, but he didn't want drugs pushed in her body.

In a telephone interview on 06/07/18 at 10:12 a.m., S5MD indicated he vaguely remembered the patient. He indicated he had talked with the nurses who had talked with the family about what they wanted done if the patient coded. He indicated he was told the family wanted CPR, no drugs, and do not intubate. He indicated the only interaction he had with her husband was during his H&P, and he didn't see the family after that. He confirmed he did not discuss with Patient #1's husband what care he wanted done if Patient #1 coded.

Based on observations, record reviews, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to ensure the RN obtained a physician's order for parameter settings for patients being cardiac-monitored by telemetry for 4 (#2, #3, #4, #5) of 4 patient records reviewed for telemetry monitoring from a sample of 5 patients.
2) Failing to ensure the RN documented an assessment of a patient who received an injection of Demerol 25 mg, Phenergan 25 mg, and Ativan 1 mg IM that indicated the need for the injection that was ordered by the physician for 1 (#1) of 1 patient record reviewed in which the patient received an injection of Demerol, Phenergan, and Ativan from a sample of 5 patients.
Findings:

1) Failing to ensure the RN documented] a physician's order for parameter settings for patients being cardiac-monitored by telemetry:
Observation on 06/06/18 at 12:10 on the Med/Surg unit revealed 4 patients were being monitored by telemetry as follows:
Patient #2's telemetry was set at 145 as the high rate and 45 as the low rate.
Patient #3's telemetry was set at 150 as the high rate and 50 as the low rate.
Patient #4's telemetry was set at 130 as the high rate and 40 as the low rate.
Patient #5's telemetry was set at 140 as the high rate and 40 as the low rate.

Review of the physician orders for Patients #2, #3, #4, and #5 revealed the order was written as "cardiac monitoring ongoing." There was no documented evidence the physician's order included the heart rate parameter settings at which the telemetry was to be set.

Review of the policy titled "Introduction to the Department of Nursing Service", revealed the hospital utilizes "Elsevier Performance Manager", which was formerly known as "Mosby", for clinical nursing procedures.
Review of the "Cardiac Monitor Setup and Lead Placement", presented as the procedure from "Elsevier Performance Manager" by S2CNO, revealed to customize the alarms to meet the patient's needs by adjusting the upper and lower limits based on the patient's current clinical status and heart rate. Further review revealed to never turn off the monitor alarms. There was no documented evidence that the procedure addressed that the RN had to obtain a physician's order for parameter settings of the telemetry.

In an interview on 06/06/18 at 12:10 p.m., S8RN confirmed the above-listed telemetry settings for Patients #2, #3, #4, and #5. She indicated the doctor doesn't write an order for the parameters at which the telemetry should be set. She further indicated he verbally tells the nurse at what rate he wants to be notified and bases it on the rate of the patient and any medications the patient may be prescribed. She confirmed the RN doesn't document the physician's order for telemetry settings as a verbal or telephone order.

2) Failing to ensure the RN documented an assessment of a patient who received an injection of Demerol 25 mg, Phenergan 25 mg, and Ativan 1 mg IM that indicated the need for the injection that was ordered by the physician:
Review of Patient #1's medical record revealed a physician's order on 08/13/17 at 7:18 p.m. by S5MD for Meperidine 25 mg IM every 4 hours for 5 days prn pain, Promethazine IM 25 mg every 4 hours (no indication for use), and Lorazepam IM 1 mg every 6 hours for 5 days prn anxiety. Further review revealed an order by S5MD on 08/13/17 at 7:32 p.m. for Promethazine IM 25 mg every 4 hours to be given with Demerol prn nausea.

Review of Patient #1's MAR revealed she received Demerol 25 mg and Promethazine 25 mg IM on 08/13/17 at 7:30 p.m. and 7:31 p.m. respectively by S6RN and Lorazepam 1 mg IM on 08/13/17 at 9:29 p.m. by S7RN.
Review of Patient #1's nursing assessments revealed no documented evidence of an assessment by a RN of Patient #1 complaining of pain, nausea, or anxiety when the above medications were administered.

In a telephone interview on 06/07/18 at 12:12 p.m., S6RN indicated she called S5MD for the order for Demerol and Phenergan. She indicated all Patient #1's daughters and her sister were in the room when Patient #1 was thrashing in the bed, and the family asked her to do something. S6RN confirmed she didn't document her assessment of Patient's #1 need for the injection in the medical record.