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Based on review of Patient #2's (P2) record, including the patient's Advanced Directive and the MOLST form, it was determined that the hospital failed to comply with the patient's wishing regarding placement of a tube for the purposes of artificial feeding. Also, no Certification of Incapacity was found for the patient which was necessary in order for the Power of Attorney (POA), listed in the Advanced Directive, to make decisions regarding the patient's care and treatment.

P2 was a 75+ year old patient who resided in a Skilled Nursing Facility at the time of admission to the hospital. P2 was transported by EMS to the hospital with symptoms of a stroke and evaluation/testing on arrival to the Emergency Department confirmed this diagnosis. The patient had multiple comorbidities including but not limited to diabetes, an autoimmune disorder, a heart condition and high blood pressure.

P2's Advanced Directive, signed by P2 in August 2018, stated "My agent's authority becomes operative when my attending physician and a second physician determine that I am incapable of making an informed decision regarding my healthcare". Furthermore, the patient initialed under the section that stated "If I become so sick or seriously injured from a progressive condition that I am unable to make medical decisions and I am completely dependent on others with no reasonable hope of recovery, I direct that my life: Not be extended by any medical treatment except comfort care and medication to alleviate pain, even if the pain medication would shorten my remaining life".

P2's most recent MOLST (Medical Order for Life-Sustaining Treatment) form prior to this admission stated "may give fluids for artificial hydration as a therapeutic trial, but do not give artificially administered nutrition". Documentation from the hospital confirmed that a copy of the patient's Advanced Directive and the MOLST were on file and reviewed by staff.

Review of the medical record determined that 15 days into the patient's stay, P2 was still unable to pass a swallowing test and was unable to communicate appropriately with staff due to confusion or inability to communicate beyond intermittent facial expressions. According to the physician's documentation, the family stated "they were refusing PEG tube placement" and "they insist on following the patient's MOLST form and Advanced Directive wishes". However, the physician stated on multiple occasions that there were "Extensive discussions regarding PEG tube placement with family", "I discussed the feeding tube with family members at length" and "explained to family that it is temporary as patient is not felt to be end-stage and removal will be contemplated in 6-8 weeks if patient does not improve clinically".

Palliative Care (specialized medical care for people living with a serious illness) was consulted to discuss options for the patient. Review of the note from the Palliative Care team showed that the family continued to refuse the placement of the feeding tube and then it was documented that "the patient meets criteria of not being able to make medical decisions and being dependent on others". Palliative care also documented that they gave the family extensive literature on PEG/feeding tubes even after continued refusals.

The feeding tube was eventually placed and the patient's MOLST was changed by the family after the procedure to include the desire to have the feeding tube in place. No documentation was found to confirm that a Certification of Incapacity was signed by two physicians. Based on the patient's own wishes, as expressed in P2's advance directive, this Certification was necessary for the family/POA to have the authority to make these decisions for the patient. Placement of the feeding tube went against the patient rights and wishes that were clearly stated in the Advanced Directive and MOLST form.

Based on review of Patient #7's (P7) record, it was revealed that P7 received an injectable psychotropic (any medication capable of affecting the mind, emotions and behavior) medication which was not a standard treatment or dosage for their condition or behavior.

This was a 20+ year old patient who was admitted to the Behavioral Health Unit after demonstrating symptoms of paranoia and agitation. On admission and during the patient's first few days, it was documented by the psychiatrist and nursing staff that P7 was "not aggressive and was easily redirected". However, an order was written for the patient to receive an injectable psychotropic medication every 4 hours with the indication as 'moderate agitation'. Moderate agitation was not defined, nor were objective behavioral parameters included in the order.

Further documentation review revealed a physician note and nursing note that each stated the patient was "woken at 2:30 am to be given injectable dose of medication and patient was unable to fall back asleep afterwards". The patient was also noted to have a "large bruised area to the left forearm and various bruises noted to the left thigh area" due to multiple injections in those areas.

No documentation was found to support that the patient was 'moderately agitated' prior to administration of this medication including and especially when the patient was woken up in the early morning in order for the medication to be given. The order was in effect and given every 4 hours for 3 days before it was discontinued by the physician.