HospitalInspections.org

Based on clinical record review, review of policies, and interviews with staff for 1 of 2 patients (Patient #306) the hospital failed to ensure that the patient's advance directive was followed. The findings include:

Patient #306 was readmitted to the hospital on 2/5/14 with increasing abdominal pain. Review of the record identified that gastrointestinal, surgical and pulmonary consultations were performed. However, review of the record and interview with MD #5 on 9/3/14 identified that the patient aspirated on 2/7/14 and required intubation while undergoing a V/Q scan (ventilation/perfusion lung scan) in nuclear medicine. Although review of a Physician Order dated 2/5/14 directed do not resuscitate (DNR), the family requested that the patient be a full code during the event. The Anesthesia Progress Note at 12:30 PM indicated that the patient was intubated and copious amounts of vomitus was suctioned multiple times. Patient #306 was successfully resuscitated and transferred to the intensive care unit. Review of the record and MD #5 identified that the patient sustained severe anoxic brain injury and was unresponsive. MD #5 indicated that after neurology consultation and many family meetings, the patient was made comfort measures only on 2/11/14 and expired shortly after.
The hospital policy for "do not resuscitate" directs in part, that staff are to rely on the patient's DNR decision even if it is opposed by the patient's family members.

Based on review of clinical records, review of hospital policy, review of hospital documentation and interviews with hospital personnel for one surgical patient who required resuscitation, documentation and interviews failed to reflect that the hospital's cardiopulmonary resuscitation policy was followed. The findings include:

Patient #305 was admitted to the hospital on 7/7/14 for a left pneumonectomy. Review of the History and Physical dated 7/2/14 identified that the patient was diagnosed with left upper lobe non-small cell cancer of the lung in 2011. The patient was treated with radiation and a subsequent PET scan demonstrated hypermetabolism in the left lung apex in November 2013. The patient underwent a left anterior thoracotomy and mediastinoscopy in January 2014 to document presence of carcinoma. Review of the clinical record and interview with the thoracic surgeon, MD #8 on 9/2/14 indicated that after multiple presentations to the multidisciplinary tumor board, the consensus recommendation was to proceed with chemotherapy in order to consider the patient for resection. In May 2014, the chest CT scan showed reasonable response to the chemotherapy. The record and MD #8 identified that Patient #305 was a surgical candidate because the patient underwent the thoracotomy in January, was in reasonably good health with normal pulmonary function and had no contraindications to a pneumonectomy. MD #8 indicated that patient education during follow-up clinic visits included risks and benefits of the pneumonectomy surgery, and patient consent was obtained.
Review of the Operative Note dated 7/7/2014 and interview with MD #8 identified that Patient #305 suffered myocardial infarction with right heart failure during the surgery, as well as arrhythmia with pericardial closure (which was immediately released). Review of the Anesthesia Record and interview with CRNA #1 identified that the patient was hemodynamically unstable with an estimated blood loss (EBL) of 1200 cc and was transfused with 3 units of packed red blood cells (pRBCs). Review of the record and interviews with MD #8 and CRNA #1 identified that Patient #305 arrested when being transferred to a supine position and cardiopulmonary resuscitation (CPR) was performed. However, the Code Team was not called. Patient #305 was unable to be resuscitated and expired in the OR at 6:20 PM on 7/7/14. Review of the CPR Policy indicated that the code team members were to provide necessary life support in all areas including the OR and PACU on all three shifts. Although the patient received appropriate life saving measures by members of the surgical team, documentation and interviews failed to reflect that the hospital's CPR Policy was followed when a "code" was not called.