HospitalInspections.org

Based on review of documents and interviews with staff, the facility failed to ensure that 1 of 4 patients whose records were reviewed was informed of the right to receive or discontinue care; Patient #1 was assigned a do not resuscitate (DNR) status with no documented communication between patient (or patient's family) and physician prior to the physician order.

Findings were:

The facility policy ADM-114, entitled, Advance Directives - Acceptance/Refusal of Medical Treatment, states that " SMMC will provide written information to all adult (age 18 or over) inpatients on admission regarding their right to ...execute an advance directive. " Additionally, the Medical Staff Rules and Regulations state under Section D(g), that the medical record should contain records of communication with the patient regarding care and treatment; also, in Section D(l), the medical record should contain evidence of known advanced directives.

Patient #1 had a DNR status while inpatient at SMMC. This was ordered by ED physician Staff #6 at the time of admission as an inpatient on 2/16/2013. Admission paperwork entitled CONSENT FOR TREATMENT AND ADMISSION was completed by SMMC staff. Patient #1 gave verbal consent to treat because due to the nature of the illness, the patient was unable to sign the form. This was witnessed by 2 staff members. The portion of the consent applying to Advanced Directives was not completed, however. This section includes the statement " I have received information about my right to accept or refuse treatment and my right to make advance directives concerning my health care. " This statement was not checked and was left blank.

In an in-person interview conducted the afternoon of 4/3/2013, the Director of the Medical Surgical Unit, Staff #7, acknowledged that no communication was documented regarding Patient #1's decision to refuse resuscitation. Additionally, the Director acknowledged that the admission CONSENT FOR TREATMENT AND ADMISSION was incomplete in the area referring to the patient's right to accept or refuse treatment and make advance directives concerning health care.