HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interviews, medical staff failed to obtain consent from a patient or a patient's representative prior to issuing a Resuscitation Status order for 1 of 1 patients (#7).

Findings include:

Review of the hospital's policy and procedure titled "Withholding / Withdrawing / Forgoing Life-Sustaining Treatment Policy", last revised date of 03/2010, revealed "...Every adult patient who possesses the capacity to make decisions about his or her health is legally and ethically entitled to do so...The decision to initiate a DNR (do not resuscitate or revive from death with chest compressions, cardiac drugs, or placement of a breathing tube) order does not limit the appropriateness of any other medical or surgical treatment and does not imply that any other treatment modalities may be withheld or forgone. For patients with DNR orders...all other treatment measures ordered by the attending physician...should be continued...The following options should be considered when the patient lacks sufficient understanding or capacity to make or communicate decisions relating to his or her health care...life-prolonging measures may be withheld or discontinued upon the direction and under the supervision of the attending physicians with the concurrence of the following persons...A guardian of the patient's person...An individual who has established relationship with the patient, who is acting in good faith on behalf of the patient, and who can reliably convey the patient's wishes...DNR orders from a previous admission do not apply to a new admission. A new DNR order must be issued for each admission".

1. Closed medical record review on 01/20/2016 of patient #7's record revealed a 80 year old female who was admitted to the named facility on 01/15/2015 with a "Chief complaint" of "Fever for 2 days" according to the admitting physician's (MD #1) "...History & Physical" (H&P) dated 01/15/2016 at 1738 and electronically signed 01/15/016 at 1824. Patient #7's H&P reported a "Primary Diagnosis: (1) Sepsis (a life-threatening complication of an infection) associated hypotension (low blood pressure) (2) Acute kidney injury (a condition in which the kidneys suddenly cannot filter waste from the blood) (3) Hypernatremia (a high concentration of sodium (salt) in the blood) (4) SCHIZOPHRENIA (a brain disorder in which people interpret reality abnormally) (5) Dementia (a group of thinking and social symptoms that interferes with daily functioning) (6) Atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) with rapid ventricular (lower chamber of the heart) response (7) Anemia (a condition in which the blood does not have enough healthy red blood cells; red blood cells carry oxygen to all of the body's tissues) (8) Pneumonia (lung infection) ...Severe malnutrition (lack of sufficient nutrients in the body)...". Further review of patient #7's H&P revealed, "...Of note is that patient is DNR/DNI (do not intubate - no placement of a breathing tube will be performed) ...". Review of patient #7's "ER (Emergency Room) Physician Documentation" dated 01/15/2015 at 1535 and electronically signed on 01/15/2015 at 1538 by MD #2, revealed "...Physical Exam...She does not speak and does not respond to verbal stimuli. She does not follow commands...". Per MD #1's H&P "...Unfortunately, she is nonverbal at the time of evaluation. She has underlying dementia and schizophrenia but currently seems to be nonverbal because of sepsis...". Review of the MD #1's admission orders for patient #7 revealed a Code (resuscitation) Status order on 01/15/2015 at 1656 for "DNR". Further review of patient #7's record did not reveal documentation indicating MD #1 had discussed patient #7's code status with her family. Further review of patient #7's H&P, physician progress notes, and nursing progress notes did not reveal a documented discussion with patient #7's family regarding code status. Review of patient #7's nursing "...Adult Admission Assessment", completed by RN #3 on 01/15/2015 at 1758, revealed "...History Provided By...Medical Record...Resuscitation Status...Do Not Resuscitate...".

Telephone interview, on 1/21/2016 at 1158, with MD #1 revealed, "I took care of this lady (patient #7) in December - two weeks before she was readmitted. I had several discussions with her daughter at that time. The DNR status was already in place before I assumed care in December. She was discharged with the DNR in effect." MD #1 reported he based patient #7's DNR order on the records he had from the previous two weeks. He also stated patient #7's daughter was not available in the ER. MD #1 could not recall if he tried to call patient #7's daughter to see if things had changed regarding patient #7's code status. "It was the assumption the DNR was in effect. I didn't have a chance to verify. I knew the patient well."

Interview with RN #3, on 01/21/2016 at 1415, revealed RN #3 obtained patient #7's DNR status from MD #1's order.

Interview with the Hospitalist (a physician whose primary professional focus is the general medical care of hospitalized patients) Program Director (MD #9), on 01/21/2016 at 1705, revealed if a patient cannot speak for themselves, efforts are made to contact the family regarding code status. MD #9 stated discussions regarding code status should be documented in the patient's chart.

NC00113246 and NC00113731

Based on medical record review, DNR (do not resuscitate) performance improvement (PI) tracking form review, and staff interviews, facility staff failed to accurately monitor the hospital's new DNR order process for 3 of 7 patients (#15, #16, and #20).

Findings include:

Review of the hospital's policies and procedures did not reveal a policy and procedure for Quality Improvement Monitoring.

Interview on 01/21/2016 at 1500 with the hospital's Director of Risk Management (AS #10) revealed the hospital had identified issues in their DNR (do not revive from death with chest compressions, cardiac drugs, or placement of a breathing tube) process related to a patient complaint. AS #10 reported the facility looked at the DNR process and determined a patient's code status (choice to be resuscitated) should be assessed every admission. Per AS #10, it was found that physicians were not 100% compliant in completing the paper "DO NOT RESUSCITATE ORDER FORM", namely the second part of the order form "FACTORS SUPPORTING THIS ORDER" which included the patient's competency (the capacity to make or communicate health care decisions) and indication of a Healthcare Power of Attorney or family member involvement in the DNR decision if the patient was found to be incompetent. "All DNR orders are now electronic." AS #10 stated physicians are responsible for asking code status questions and documenting family discussion regarding code status. According to AS #10, today, physicians would confirm DNR status by completing a two-part order set which includes a patient's competency and how the DNR decision was reached. AS #10 stated the Risk Management Department is tracking all DNR orders daily to confirm completion and 100% compliance with the DNR order set. Review of open records with AS #10 on 01/21/2015 revealed delays in "daily" monitoring of current DNR orders. Delays of two to four days were found between when the patients' DNR order was initiated and when the patients were placed on the DNR PI tracking form and their orders assessed for completeness. AS #10 stated "That's a problem".

1. Open medical record review on 01/21/2016 of patient #16's record revealed a 95 year old female admitted on 01/06/2016 with a chief complaint of cough and shortness of breath according to MD #11's "... History & Physical" (H&P) dated 01/06/2016 at 1933. Review of the physician's orders revealed a "Resuscitation Status" order on 01/06/2016 at 1341 for "Full Code" (permission for a doctor to perform life saving interventions). Further review of the patient's record revealed a physician's order for "DNR" on 01/17/2016 at 1007 which indicated "Incompetent Patient...According to her niece...(Her POA (Power of Attorney) she doesn't want her to be resuscitated or intubated." Review of the DNR PI tracking form, revealed the completeness of patient #16's DNR order set was assessed on 01/19/2016 (2 days after the DNR order was placed).

Interview on 01/21/2016 at 1705 with the Hospitalist Program Director (MD #9) revealed the DNR two-part order sets should be completed, "Risk Management monitoring" daily. MD #9 stated if a patient cannot speak for themselves, efforts to contact the family should be made and DNR discussions should be documented in the patient's chart.

2. Open medical record review on 01/21/2016 of patient #15's record revealed a 92 year old female admitted on 01/20/2016 with a chief complaint of fever, nausea, vomiting, and lethargy (lack of energy) per MD #11's H&P dated 01/20/2016 at 1922. Review of the physician's orders revealed a "Resuscitation Status" order on 01/20/2016 at 1918 for "DNR". The second part of patient #15's DNR order set was not found to be complete. Review of the DNR PI tracking form revealed patient #15 was not listed on the DNR tracking form, therefore completeness of the DNR order was not assessed by Risk Management.

Interview on 01/21/2016 at 1705 with the Hospitalist Program Director (MD #9) revealed the DNR two-part order set should be completed, "Risk Management monitoring" daily. MD #9 stated if a patient cannot speak for themselves, efforts to contact the family should be made and DNR discussions should be documented in the patient's chart.

3. Open medical record review on 01/21/2016 of patient #20's record revealed a 84 year old male admitted on 01/15/2016 with a chief complaint of acute mental status change with acute confusion and increasing lethargy according to MD #12's H&P dated 01/15/2016 at 1801. The two-part physician DNR order was found to be complete and indicated "Incompetent Patient...Order based on Duly Executed Document: Universal DNR...". Review of the DNR PI tracking form revealed the completeness of patient #20's DNR order set was assessed on 01/19/2016 (4 days after the DNR order was placed).

Interview on 01/21/2016 at 1705 with the Hospitalist Program Director (MD #9) revealed the DNR two-part order set should be completed, "Risk Management monitoring" daily. MD #9 stated if a patient cannot speak for themselves, efforts to contact the family should be made and DNR discussions should be documented in the patient's chart.

Based on policy and procedure review, medical record review and staff interviews, nursing staff failed to report a change in a patient's condition per hospital policy and physician's order for 1 of 14 patients (#7).

Findings include:

Review of the hospital's policy and procedure titled "ROUTINE VITAL SIGNS", last revised date "...5/2014 REVIEWED: ...4/2014", revealed "...Vital signs outside the normal range or the range ordered by the physician must be reported to the physician...". Review of the hospital's policy and procedure titled "Standards of Nursing Practice", last revised date July 2011, revealed "...The RN (Registered Nurse)/LPN (Licensed Practical Nurse) communicates pertinent data about the patient's response to interventions, changes in status and abnormal findings...to the physician...in a timely manner...". Review of the hospital's policy and procedure titled "General Nursing Guidelines for Intensive Care Patient and the ICU (Intensive Care Unit) Environment", last date of revision "2013", revealed "...4. The staff nurse will report any change in his/her patient's condition directly to the physician. The charge nurse may be utilized to report the information if needed. The nurse will ensure a physician is aware of all lab reports and assessment changes. The staff nurse will keep the charge nurse informed of changes in the patient's condition...31. The nurse/physician will notify families of significant deteriorations in the patient's condition. Rationale: The family has the right to determine when they wish to attend their family member...". Review of the hospital's policy and procedure titled "Withholding / Withdrawing / Forgoing Life-Sustaining Treatment Policy", last revised date of 03/2010, revealed "...Every adult patient who possesses the capacity to make decisions about his or her health is legally and ethically entitled to do so...The decision to initiate a DNR (do not resuscitate or revive from death with chest compressions, cardiac drugs, or placement of a breathing tube) order does not limit the appropriateness of any other medical or surgical treatment and does not imply that any other treatment modalities may be withheld or forgone. For patients with DNR orders...all other treatment measures ordered by the attending physician...should be continued...".

1. Closed medical record review on 01/20/2016 of patient #7's record revealed a 80 year old female who was admitted to the named facility on 01/15/2015 with a "Chief complaint" of "Fever for 2 days" according to the admitting physician's (MD #1) "...History & Physical" (H&P) dated 01/15/2016 at 1738 and electronically signed 01/15/016 at 1824. Patient #7's H&P reported a "Primary Diagnosis: (1) Sepsis (a life-threatening complication of an infection) associated hypotension (low blood pressure) (2) Acute kidney injury (a condition in which the kidneys suddenly cannot filter waste from the blood) (3) Hypernatremia (a high concentration of sodium (salt) in the blood) (4) SCHIZOPHRENIA (a brain disorder in which people interpret reality abnormally) (5) Dementia (a group of thinking and social symptoms that interferes with daily functioning) (6) Atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) with rapid ventricular (lower chamber of the heart) response (7) Anemia (a condition in which the blood does not have enough healthy red blood cells; red blood cells carry oxygen to all of the body's tissues) (8) Pneumonia (lung infection) ...Severe malnutrition (lack of sufficient nutrients in the body)...". Further review of patient #7's H&P revealed, "...Of note is that patient is DNR/DNI (do not intubate - no placement of a breathing tube will be performed) ...". Review of patient #7's "ER (Emergency Room) Physician Documentation", dated 0/15/2015 at 1535 and electronically signed by MD #2 on 01/15/2015 at 1747, revealed physical exam findings and a progress note which included, "...The patient is tachypneic (increased rate of respiration) but not using accessory muscles to any significant degree or retracting (the muscles between the ribs pull inward with each breath)...Patient has a low-grade temp (temperature) here, she is in AFib (Atrial Fibrillation) on the monitor with a rate (heart rate) between 90 and 110...the rate was controlled between 90-110 and did not require specific intervention...". Per MD #1's H&P, patient #7 was admitted the to the Intensive Care Unit (ICU) "...Plan...for close hemodynamic monitoring...Broad-spectrum (acts against a wide range of disease-causing bacteria) antibiotics (medication used to treat infection)...rehydration (replacement of fluids)...Patient is currently dehydrated (a condition caused by the excessive loss of water from the body, which causes a rise in blood sodium levels) due to sepsis. Ventricular rate has been up to 110. Check digoxin (medication used to treat heart rhythm problems by slowing the heart rate) level and consider resuming digoxin if level is okay...". Further review of patient #7's record did not reveal a physician's order for digoxin or any other heart rate control medication. Review of patient #7's medication administration record did not reveal administration of digoxin or any other heart rate control medication. Review of patient #7's admission orders revealed a physician's order by MD #1, dated 01/15/2015 at 1656, to "Call MD If: ...Systolic (the pressure when the heart beats while pumping blood) BP (blood pressure) above 190 or below 90, Diastolic (the pressure when the heart is at rest between beats) BP above 110 or below 30, Pulse (heart rate) above 120/(per) minute or below 55/minute, Respiration (a single breath) above 28/minute or below 10/minute...". A nurse's note on 01/15/2015 at 1749 by RN #3 stated, "ARRIVED TO ICU...PT NOT RESPONDING AT THIS TIME TO COMMANDS. VITALS - HR (heart rate) 106 BP SYSTOLIC 91, RR (respiratory rate) 42 KUSHMAL (Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis (occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body) and kidney failure). SAT (oxygen saturation - estimate of blood oxygen level) 90 (values under 90 percent are considered low) ON 2L (2 liters of oxygen) ...". Further review of the nursing documentation did not reveal notification of the physician for a respiratory rate outside of the range ordered by MD #1. A nursing note by RN #3 at 1845 revealed "DAUGHTER CALLED ICU - UPDATED ON STATUS OF PT AT THAT TIME." Review of the patient's vital sign assessment on 01/15/2015 at 2200 by RN #4 revealed a respiratory rate of "33 bpm (breaths per minute)". No documentation was found which indicated a physician was notified that the patient's respiratory rate was outside the range ordered by MD #1. Continued review of the nursing documentation revealed a note by RN #4 , on 1/15/2015 at 2216, "TURNED AND REPOSITIONED...BECOMES TACHYPNEIC (increased rate of respiration) WITH ANY CARE...HR INCREASED TO 160 WITH CARE...". At 2230 RN #4 documented, "PT. IS RESTING AT TIME...RESP (respirations) STILL INCREASED TO 32/MIN...". Further review of the nursing documentation did not reveal notification of the physician for a respiratory rate or heart rate outside of the range ordered by MD #1, nor did the documentation indicate patient #7's family was notified of the patient's status. A note by RN #4 at 2248 reported, "ST (sinus tachycardia - rapid heart rate) 168...RR 48...PT. HAS GLASSY LOOK TO EYES. NO COMMANDS FOLLOWED...". Documentation did not reveal a physician, or the patient's family, was notified regarding a change in patient #7's condition. Continued review revealed nursing documentation by RN #4 at 2251, "HR DECREASED TO 40. . .BP UNOBTAINABLE AT TIME. AGONAL (gasping) RESPIRATIONS NOTED. PUPILS FIXED AT TIME." Further review of the nursing documentation did not reveal notification of the physician for a blood pressure and heart rate outside of the range ordered by MD #1. Per RN #4 at 2253, patient #7 had "ASYSTOLE (no heart rate) ON CARDIAC MONITOR. .NO SPONTANEOUS RESPIRATIONS NOTED. . .NO APICAL (heartbeat heard with a stethoscope over the heart) PULSE AUSCULTATED (heard). NO PALPABLE PULSE FELT. . .VERIFIED WITH (RN #5) ...(MD #6) PAGED AT TIME." Nursing documentation by RN #4 on 01/15/2015 at 2313 revealed, "DAUGHTER...NOTIFIED OF TIME OF DEATH."

Interview with RN #7 on 01/20/2016 at 1020 revealed patients with DNR orders are treated the same as patients without DNR orders in that abnormalities in heart rate or blood pressure are treated according to the treatment options decided by the physician and the patient's family. RN #7 stated the nursing staff will notify the doctor with a change in the patient's status. RN #7 indicated she would "call right away" if there is a change in a patient's status. RN #7 stated all nurses carry a portable phone and can call the patient's physician while at the patient's bedside.

Interview with RN #4 on 01/21/2016 at 1030 revealed RN #4 would call a physician with an acute change in a patient's status. RN #4 reviewed her electronic documentation for patient #7 on 01/15/2015 at 2216, "TURNED AND REPOSITIONED...BECOMES TACHYPNEIC WITH ANY CARE...HR INCREASED TO 160 WITH CARE", and stated it was a change in the patient's status but she would not call the physician since the patient "was septic." RN #4 stated she did not believe she would let a patient remain tachypneic for a long period of time. "Her (patient #7) condition changed very quickly."

Interview, on 01/21/2016 at 1125, with the unit charge nurse (RN #5) during the night of 01/15/2015 revealed RN #5 did not recall any details of patient #7's status changing. "I don't recall being directly involved in her care." RN #5 reported most hospitalists (a physician whose primary professional focus is the general medical care of hospitalized patients) will enter orders for vital sign parameters and if a patient is outside of the ordered parameters, she would call the doctor.

Interview with the ICU Nurse Manager (NM #8) on 01/21/2016 at 1134 revealed, "I expect the nurses to follow all doctor's orders." NM #8 stated the hospitalists have admission orders with vital sign parameters that are "generic orders and not specific to the patient." After reviewing patient #7's electronic nursing documentation, NM #8 stated she was "a little concerned about the respirations" at 2230 as it "looks like a small change in condition" and she would "definitely call the doctor" after the reviewing the vital signs at 2248. "We treat our DNRs. We still treat the problem unless they tell us not to." According to NM #8, the expectation is for nurses to call the physician with a change in status. Nurses are to notify the doctor with a change in condition, then notify the family with the change in condition and plan of care.

NC00113246 and NC00113731