HospitalInspections.org

Based on interview and record review, the facility failed to ensure a patients (Patient 10) Do Not Resuscitate (DNR, medical order that instructs healthcare providers to not perform life saving measures) wishes were carried out during his hospitalization when;

1. Patient 10 received Cardiopulmonary Resuscitation (CPR, life saving measures performed when the heart stops beating to pump blood to the brain and vital organs) after coding (cardiac or respiratory arrest). (Refer to A-0132).

This failure resulted in Patient 10 being in the Intensive Care Unit (ICU- hospital unit that provides critical care and life support to patients who are very ill) on a ventilator (life support machine that helps people breathe when they are unable to do so on their own), after receiving Cardiopulmonary Resuscitation (CPR). This failure also resulted in Patient 10's patients' rights to be violated by not being able to make informed decisions about his care.

Based on interview and record review, the facility failed to ensure a patients (Patient 10) Do Not Resuscitate (DNR, medical order that instructs healthcare providers to not perform life saving measures) wishes were carried out during his hospitalization.

This failure resulted in Patient 10 being in the Intensive Care Unit (ICU- hospital unit that provides critical care and life support to patients who are very ill) on a ventilator (life support machine that helps people breathe when they are unable to do so on their own), after receiving Cardiopulmonary Resuscitation (CPR, life saving measures performed when the heart stops beating to pump blood to the brain and vital organs). This failure also resulted in Patient 10's patients' rights being violated by the facility not honoring his informed decisions about his care.

Findings:

A review of Patient 10's medical record was conducted on August 7, 2024, at 9:20 a.m., with the Accreditation Regulatory Manager (ARM).

A facility document titled, "ED [Emergency Department] Note-Physician," dated August 4, 2023, at 9:26 p.m., authored by Physician 1 was reviewed. The document indicated, "...history of myasthenia gravis [autoimmune disease that impacts the neuromuscular system] is presenting with fever, cough, fatigue. The patient did have a trip and fall onto his left knee which had abrasions which she [sic] was seen at urgent care..." There was no documented evidence of code status on this physician note.

A facility document titled, "ED Screenings/History Adult," dated August 4, 2023, at 6:04 p.m., was reviewed. The document indicated, "...Advanced Directive [a legal document that outlines a persons preferences for medical care if they are unable to communicate their wishes]: No...Advanced Directive Additional Information: Information given...[Name of Registered Nurse 1, (RN 1)], August 4, 2023, at 6:03 p.m..."

A facility document titled, "Order Entry," dated August 6, 2023, at 6:57 a.m., was reviewed. The document indicated, "...Resuscitation Status...Routine, August 4, 2023, at 10:15 p.m.,...Full Resuscitation [the process of trying to restart someone's heart and lungs after they stop working]..."

A facility document titled, "History and Physical (H&P)," dated August 5, 2023, at 12:51 a.m., authored by Physician 2 was reviewed. The document indicated, "...Male who presents with acute complaints of fever, chills, fatigue, cough and has a chronic medical problems including myasthenia gravis, hypertension [high blood pressure], hyperlipidemia [excess fat in the blood], history of UTI [urinary tract infection]...Full code [if a patients heart or breathing stops, the medical team will try everything possible to save their life]..."

A facility document titled, "Med/Surge Frequent assessment," dated August 4, 2023, at 5:59 p.m., until 11:33 p.m., authored by RN 2, was reviewed. The document indicated, "...Code Status: Unknown..."

There was no documented evidence RN 2 discussed in the handoff to the admitting nurse that Patient 10 was a DNR status.

A facility document titled, "Physician Orders for Life-Sustaining Treatment (POLST)," dated August 18, 2019, was reviewed. The document indicated, "...CARDIOPULMONARY RESUSCITATION [CPR]...Do Not Attempt Resuscitation/DNR [Allow Natural Death]...MEDICAL INTERVENTIONS...Comfort-Focused Treatment- primary goal of maximizing comfort...ARTIFICIALLY ADMINISTERED NUTRITION...No artificial means of nutrition, including feeding tubes..." This document was signed and dated by Patient 10 on August 19, 2019, and electronically signed by Patient 10's physician on September 4, 2019, at 6:26 p.m. This document was faxed in the hospital EHR (Electronic Health Record), on October 5, 2019, at 12:29 (unknown a.m. or p.m.).

A facility document titled, "California Advanced Health Care Directive," dated February 19, 2024, was reviewed. The document indicated, "...INSTRUCTIONS FOR HEALTH CARE ...END-OF-LIFE DECISIONS...[Patient 10's initials] Choice Not To Prolong Life I do not want my life to be prolonged...RELIEF FROM PAIN...COMFORT MEASURES..."

A facility document titled, "California Power of Attorney for Health Care and Health Care Instruction Form," dated September 26, 2011, was reviewed. The document indicated, "...I make the following instructions to my agent...I do not want effects made to prolong my life and I do not want life-sustaining treatment to be provided or continued...If I am in an irreversible coma [a state where person is unresponsive] or persistent vegetative state [a chromic state of brain dysfunction in which a person shows no sign of awareness]; or if I am terminally ill [a medical term that refers to someone who has a disease that is incurable and will eventually lead to death] and the provision of life sustaining procedures would serve to artificially delay the moment of my death; then, I make the following instructions, by placing my signature in front of my request...I authorize the treatment needed to provide me with food, water, and pain control, and to keep me comfortable, but otherwise do not authorize active treatment of my medical conditions..."

A facility document titled, "CODE BLUE RECORD," dated August 5, 2023, at 11:54 p.m., was reviewed. The document indicated, "...Time of First Assisted Ventilation: 11:55 p.m., ...Invasive Airway: Inserted...Insertion Time : 12:03 a.m...Time Chest Compressions Started: 11:54 p.m...Defibrillator Pads On: Yes...Time Resuscitation Event Ended: 12:03 a.m...Status: Alive..."

A facility document titled, "Progress Note," authored by Physician 3, dated August 6, 2023, at 11:28 a.m., was reviewed. The document indicated, "...Patient's CODE STATUS is noted to be DNR in this case of repeat cardiac arrest, however at this time we will continue medical treatment and reassess goals of care with the patient's family in the next 48 hours..."

A facility document titled, "PATIENT RIGHTS & RESPONSIBILITIES," dated April 21, 2018, was reviewed. The document indicated, "...Formulate advanced directive. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioner who provide care in the hospital shall comply with theses directives. All patients' rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf..."

A document letter from the facility, addressed to Patient 10's family member, dated August 17, 2023, was reviewed. The document indicated, "...When you arrived at the ED, you gave his nurse his California Advanced Health Care Directive (DNR) and proceeded to talk to the ED doctors about his care...the nurse called a Code Blue...It appears that this was the likely breakdown in the communication as to your father's Code status...On August 6, 2023, the physician in ICU [Intensive Care Unit] made her notes and documented your father's code status was noted to be DNR...We understand your concerns and truly hope your family had a different experience. We apologize for the misinterpretation/misunderstanding made..."

During the record review the Demographic bar in Patient 10's Electronic Health Record (EHR), indicated the code status was unknown and there was no documented evidence a purple DNR band was placed on Patient 10.

An interview and record review were conducted with the Clinical Emergency Department Manager (CEDM) on August 7, 2024, at 10:55 a.m. The CEDM stated if the family hands the nurse the DNR the expectation is for the nurse to document he/she received the forms, place a DNR band (purple) on the patient, and a call to social services should be made to verify the forms. The CEDM further stated Advanced Directive is also asked on triage and the nurses are expected to answer appropriately, The CEDM further stated, the expectation would be for the ED nurse to communicate to the admitting floor nurse the patients DNR status. She further stated it does not look like this happened in this case.

An interview was conducted with Patient 10's family member on August 8, 2024, at 9:47 a.m., who stated the DNR paperwork was handed to the male nurse, who walked away to make copies, and returned and stated it is already in the system. The family member further stated, "the facility was given the DNR paperwork several times in the past and I can not believe that they stuck a tube in my 90-year-old dad against his wishes, we were very upset and could not believe this happened."

An interview and record review were conducted with the ARM on August 8, 2024, at 11:01 a.m. The ARM stated there were many issues with this case. The triage nurse documented no advanced directive, the ED physician did not document code status, the admitting physician documented incorrect code status, the physician placed a full resuscitation order, there was no documentation of a handoff report from the ED nurse to the admitting nurse of the code status, and the demographic bar had code as unknown. The ARM further stated the policies and procedure were not followed.

A review of the facility's policy and procedure (P&P) titled, "EMERGENCY DEPARTMENT PROCESS OF CARE," dated January 19, 2023, was reviewed. The document indicated, "...All patients presenting to the Emergency Department requesting care (or on whose behalf care is requested) shall be entered into the hospitals electronic medical record...Data collected by Emergency Department personnel is guided by the relevant electronic or paper form. Information asked for by the forms shall be collected to the extent relevant and consistent with the operation or clinical concern..."

A review of the facility's P&P titled, "ADVANCED HEALTH CARE DIRECTIVE," dated September 7, 2023 was conducted. The document indicated, "...MANDATED REQUIREMENTS FOR ALL HOSPITALS: Both the federal and state law attempt to improve utilization of advanced health care directives as follows...All adult inpatients...To ask patient about the existence of and advanced health care directive. To record responses to the above questions. To provide patients without such a document with information regarding their right to establish one. To provide a mechanism for the Hospital to follow-up with the patients during their hospitalization regarding a health care directive...A complete and signed advanced health care directive take effect immediately..."