HospitalInspections.org

Based on documentation review and interview the facility failed to follow their policy ensuring a surrogate decision maker was included in and/or notified of the patient's plan of care for 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled, "Patient/Parent Rights and Responsibilities, Complaints and Grievances", no policy number, publication date 06/22/2023, indicated under Your rights as a patient: To participate in decisions about care, treatment and services, which may include family and loved ones, as permitted by the patient or decision maker; this includes the development and implementation of an inpatient care plan, outpatient treatment or care plan, pain management plan and discharge plan. To be informed of outcomes of care, treatment and services, including unexpected outcomes.

2. MR documentation for P1 indicated on 7/18/24 at 4:54 pm indicated P1 wished to remain full code and wanted his/her ex-spouse to be the medical decision maker of him/her because was unable to speak for themselves. Social Work note documentation dated 7/18/24 at 6:48 pm indicated social work staff confirmed with P1's ex-spouse that the patient did not have an advance directive prior to being sedated and intubated. The patient's ex-spouse was provided an overview of the roles/responsibilities of a surrogate decision maker and an overview of the State's Consent Law. It was then determined that P1's only living child declined the role of surrogate decision maker, P1's parents and/or siblings were no longer living, and the patient had no other living relatives. Due to this, P1's ex-spouse was made the surrogate decision maker for the patient. Procedure note documentation dated 7/20/24 indicated the patient was extubated on 7/19/24 then became hemodynamically unstable on 7/21/24 requiring reintubation, central line placement, and arterial line placement. MR (medical record) for P1 lacked documented of prior notification to his/her surrogate decision maker on 7/19/24 of the plan to extubate P1, and lacked documentation of notification on 7/20/24 of an update to his/her surrogate decision maker of patient's care plan related to P1 being extubated on 7/19/24.

3. In telephone interview on 8/22/2024 at approximately 12:51 pm with A1 (Manager of Accreditation & Regulatory) confirmed there was no documented family/surrogate decision maker notification related to P1's extubation on 7/20/2024.