HospitalInspections.org

Based on record review, observations of patients, review of policy and procedure, and interview with clinical and administrative staff, the hospital failed to ensure each patient's advance directive was honored for 1 (Patient #8) of 37 patients sampled. On 9/4/16, Patient #8 received cardiopulmonary resuscitation (CPR) for 20 minutes although a signed Do Not Resuscitated Order (DNRO) was in place. The failure to correctly band/identify a patient as a DNRO, resulted in CPR being conducted before the DNRO was discovered; thereby creating undue physical hardship rather than a dignified and pain-free end of life.

The potential for similar failure to honor advance directives were found for 2 (Patient #1 and #5) of the 36 current patients sampled. The CPR status of Patient #1 and #5 was not accurately communicated to staff.

Immediate jeopardy was identified as beginning on 9/4/16 and continuing. During the survey the hospital policy was re-written to include the bands/colors. Hospital staff were in-serviced on the policy.
Staff were interviewed to determine if the corrective actions put in place had been implemented. The staff interviewed had knowledge of the issues. All staff who were present in the hospital on 9/30/16 were confirmed to have received the education. As a result of the corrective actions being put in place and education confirmation, the jeopardy was abated on 9/30/16.

The facility failed to take adequate measures to prevent resuscitation of a patient with a DNR. This potential remained until intervention and re-education on 9/30/16. These cumulative deficits placed the patients at risk for not having their advance directives met resulting in the Condition of Participation being out of compliance.

(Refer to citation at standard A-129 for details)

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Based on record review, observations of patients, review of policy and procedure, and interview with clinical and administrative staff, the hospital failed to ensure each patient's advance directive was honored for 1 (Patient #8) of 37 patients sampled. On 9/4/16, Patient #8 received cardiopulmonary resuscitation (CPR) although a signed Do Not Resuscitated Order (DNRO) was in place. The failure to correctly band/identify a patient as a DNRO, resulted in CPR being conducted for 20 minutes, before the DNRO was discovered; thereby creating undue physical hardship rather than a dignified and pain-free end of life.

The potential for similar failure to honor advance directives were found for 2 (Patient #1 and #5) of the 36 current patients sampled. The CPR status of Patient #1 and #5 was not accurately communicated to staff.

The facility failed to take adequate measures to prevent resuscitation of a patient with a DNR. The potential remained until intervention and re-education on 9/30/16.

The findings included:

1. A review of Patient #8's chart revealed the patient was admitted to the hospital on 8/11/16. At the time of admission, the patient was determined to be a full code. (This was defined as all patients are considered as Full Code status, and will receive CPR and ALL appropriate life sustaining therapies including ventilator support).

Dialysis records of 8/17/16 at 9:00 a.m., showed 15 minutes after starting dialysis, Patient #8 was noted to have a blood pressure of 77/44 (low) with a pulse of 56 (slow). The patient was lethargic. Ultrafiltration was turned off, a normal saline flush was given, blood was returned, and a code was called. The dialysis treatment note dated 8/17/16 described the Patient #8 with a deep snore and small emesis (vomit), the patient remained unresponsive with the blood return, with a weak pulse, and poor color. CPR was started, and the patient returned to alert and awake condition. The patient's daughter was notified. The episode lasted 8 minutes.

The following day on 8/18/16, two nurses obtained verbal orders which were later signed by the physician for a DNR order for this patient.

A Code Blue form for Patient #8, dated 9/4/16 at 9:00 p.m., revealed the following. The monitor tech requested the nurse check on the patient in room ____. The "rhythm didn't look right." The nurse arrived in the room, found the patient's breathing to be erratic, and there was no palpable pulse. The nurse initiated CPR and a Code Blue was called. It was noted the patient did not have a "purple band" in place. There were continued efforts to revive the patient and 4 attempts to place a tube in the patient's lungs (intubation) to assist the patient's breathing. By 9:20 p.m., the patient's chart had been reviewed and the DNR order was found. The Code Blue efforts were stopped. Throughout the time from 9:00 p.m. to 9:20 p.m., staff were performing chest compressions and attempting to assist the patient's breathing.

On 9/28/16, at 2:55 p.m., the Risk Manager said she investigated the incident. She said the patient was supposed to have a purple band that indicated the patient was not supposed to be resuscitated. This patient did not have a band in place. She was not sure if it was ever on and was unaware of any documentation in the record about it (confirmed with record review). She said they evaluated the bands for sturdiness and durability, and had a "huddle" with the staff about the issue. Huddles were an informal communication with the staff about issues, and they are done before shift and occur relatively quickly. She agreed they had not completed any training and had no sign-in sheets to document education done regarding this issue.

On 9/29/16, interviews were conducted from 11:22 a.m. through 12:30 p.m. with 5 registered nurses (RN Staff B, C, D, E, and F), the Risk Manager, and a physical therapy assistant. During each interview, the staff confirmed they would depend on the purple band being on the patient so they would easily know the patient's DNR status. If the band was not present, they would start the Code Blue and begin compressions and intubation. In all interviews, they indicated they would confirm the patient's DNR status after resuscitation efforts were begun. All staff further indicated it was the responsibility of the patient's nurse to assure the purple band was in place. All except 1 staff confirmed they would not document the placement of a band. On 9/29/16 at 11:30 a.m., RN Staff B said she would document an application or removal of the purple band if the patient's code status had changed.

A review of the hospital's DNR policy dated March 2014 revealed the policy contained no mention of "purple bands." The policy speaks to the physician's responsibilities, the hospital's responsibilities, and gives definitions of the 3 categories of code status the hospital acknowledges. The policy also provided information about verbal orders and showed the form used in the hospital for DNR orders.

In an interview on 9/29/16 at 11:30 a.m., the Risk Manager/QA (Quality Assurance) staff were unsure why the purple bands were not in the policy and indicated the system with the purple bands had been in place a long time.

On 9/29/16 at 1:30 p.m., the Administrator, Director of Nursing, and the Risk Manager all agreed they had no policy about the bands. They confirmed they did not have documentation regarding when the banding was to be applied or removed from patients.

The Risk Manager provided a policy, from the previous hospital owner dated April 2005, stating the patient would receive a clear identification band upon admission. After the nurse assessment, along with therapies, other bands would be added as patient needs were identified. For example: A yellow band indicated the patient was at risk for falls, pink for swallowing precautions, purple if there was a DNRO in the patient's record, red for the patient had an allergy, pale green for no blood draws on that extremity, and dark green with numbers indicated the patient had been type and cross matched for blood.


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2. On 9/29/16 at 11:15 a.m., the Chief Nursing Officer (CNO) confirmed Patient #5 had a DNR order in her chart. At 11:20 a.m., the CNO verified Patient #5 did not have a purple DNR band on either of her wrists.

On 9/29/16 at 11:30 a.m., Patient #5's husband said Patient #5 never had a purple DNR arm band on her wrist since her admission on 9/16/16.

3. Observation on 9/29/16 at 11:50 a.m., revealed the facility had a system where the telemonitor screen tracing for patients who have DNR orders was turned to purple in color, so they are easily differentiated for the patients who have full code status. The monitor technician had a list of patients with their DNR status noted.

On 9/29/16 at 11:15 a.m., the CNO confirmed the code status for Patient #1 as DNR in his chart. A review of the telemonitor and monitor tech Staff K's worksheet revealed Patient #1's code status as full code (FC) and his cardiac graph on Staff K's monitor appeared as white.

On 9/29/16 at 1:00 p.m., Licensed Practical Nurse (LPN) Staff J said Staff K's worksheet is correct, 100% of the time. LPN Staff J confirmed Staff K's worksheet had not been updated to reflect a change in code status from full code to DNR for Patient #1. The cardiac graph remained white in color for Patient #1.

On 9/29/16 at 1:20 p.m., Staff K said he was informed by LPN Staff J, that Patient #1's code status was changed to DNR. Staff K said she updated her "Telemetry Worksheet" and changed the color of his cardiac graph on the monitor from white (full code) to purple (DNR). Staff K said during the time his monitor was white, if there was a cardiac event, she would have called for a full code. Staff K said that is why her worksheet and color of the graph is so important.

Immediate jeopardy was identified as beginning on 9/4/16 and continuing. The hospital policy was re-written to include the bands/colors. Hospital staff were in-serviced on the policy.
Staff were interviewed to determine if the corrective actions put in place had been implemented. The staff interviewed had knowledge of the issues. All staff who were present in the hospital on 9/30/16 were confirmed to have received the education. As a result of the corrective actions being put in place and education confirmation, the jeopardy was abated on 9/30/16.

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Based on interview and record review, the facility failed to obtain physician orders for daily restraints for 3 (Patient #9, #13, and #15) of 6 patients sampled for restraint monitoring.

The findings included:

On 9/30/16, a review of the facility's policy for Restraints effective June 2000 documented:
(2) Restraint for Acute Medical and Surgical Care (c) Orders for Restraints (1) All restraints are used only upon the individual order of a physician or other LIP [licensed independent practitioner] permitted by the State and hospital. (2) if unavailable, and a situation requires an immediate response, a registered nurse [RN] may initiate the restraint based upon an appropriate assessment of the patient and will notify the physician soon (not more than 30 minutes) after initiation of restraints. (3) if the initiation of the restraint is based upon a significant change in the patient's condition, the RN must notify the physician immediately. (4) a written order, based upon the examination of the patient by a physician is entered into the patient's medical record within one calendar day of the initiation of the restraint device.

1. On 9/30/16, a review of Patient #9's medical chart revealed he did not have a physician order for application of physical restraints dated 9/23/16. Patient #9 had a "Restraint Documentation" form in his chart reflecting he was placed in restraints from 9/23/16 at 6:00 p.m. through 9/24/16, when a signed physician order was given.

2. On 9/30/16, a review of Patient #13's medical chart revealed an unsigned physician order dated 9/28/16, for application of physical restraints dated 9/28/16. Patient #13 had a "Restraint Documentation" form in his chart reflecting he was placed in restraints at 8:00 a.m. and left in restraints at least through 6:00 a.m. on 9/29/16.

3. On 9/30/16, a review of Patient #15's medical chart revealed unsigned physician orders dated 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/24/16, and 9/25/16, for application of physical restraints. Patient #15 had "Restraint Documentation" forms in his chart reflecting he was placed in restraints starting on 9/20/16 at 8:00 a.m., and continuing through 9/25/16.

4. On 9/30/16 at 10:00 a.m., after reviewing the medical charts for Patients #9, #13, and #15, the Chief Nursing Officer (CNO) confirmed Patient #9 was missing a restraint order for 9/23/16. She confirmed he was placed in restraints without an order as evidenced by the documentation on the "Restraint Documentation" form. The CNO confirmed Patient #13 was placed in restraints on 9/28/16, without a signed order by the physician as evidenced by the documentation on the "Restraint Documentation" form. The CNO confirmed Patient #15 was placed in restrains without a physician order for dates of 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/24/16, and 9/25/16, as evidenced by unsigned physician orders for those dates and by the documentation on the "Restraint Documentation" form. The CNO said there is no excuse for the physician not signing the order. They know they have one day to sign it.
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Based on record review reports and interview with administrative and clinical staff, the hospital failed to ensure the quality assurance program intervened, monitored, and assessed the patient safety of their Do Not Resuscitate (DNR) practices, for 3 (Patients #8, #5 and #1) of the 37 patients sampled. There was inadequate systemic evaluation of the advance directive practices to assure patients who had DNR orders were not resuscitated.

The findings included:

1. A review of Patient #8's chart revealed the patient was admitted to the hospital on 8/11/16. At the time of admission, the patient was determined to be a full code. (This was defined as all patients are considered as Full Code status, and will receive CPR and ALL appropriate life sustaining therapies including ventilator support).

Dialysis records of 8/17/16 at 9:00 a.m., showed 15 minutes after starting dialysis, Patient #8 was noted to have a blood pressure of 77/44 (low) with a pulse of 56 (slow). The patient was lethargic. Ultrafiltration was turned off, a normal saline flush was given, blood was returned, and a code was called. The dialysis treatment note dated 8/17/16 described the Patient #8 with a deep snore and small emesis (vomit), the patient remained unresponsive with the blood return, with a weak pulse, and poor color. CPR was started, and the patient returned to alert and awake condition. The patient's daughter was notified. The episode lasted 8 minutes.

The following day on 8/18/16, two nurses obtained verbal orders which were later signed by the physician for a DNR order for this patient.

A Code Blue form for Patient #8, dated 9/4/16 at 9:00 p.m., revealed the following. The monitor tech requested the nurse check on the patient in room ____. The "Rhythm didn't look right." The nurse arrived in the room, found the patient's breathing to be erratic, and there was no palpable pulse. The nurse initiated CPR and a Code Blue was called. It was noted the patient did not have a "purple band" in place. There were continued efforts to revive the patient and 4 attempts to place a tube in the patient's lungs (intubation) to assist the patient's breathing. By 9:20 p.m., the patient's chart had been reviewed and the DNR order was found. The Code Blue efforts were stopped. Throughout the time from 9:00 p.m. to 9:20 p.m., staff were performing chest compressions and attempting to assist the patient's breathing.

2. An incident report dated 9/4/16 noted found Patient #8 in bed, agonal breaths and pulseless. Code Blue was called due to no purple DNR (Do Not Resuscitate) band on patient. Patient was coded for 20 minutes until staff found DNR order in chart. The code was ended at 9:20 p.m. when DNR order confirmed. The patient was on telemetry and listed as DNR with the monitor tech, although DNR status was not related to the room while code in progress.
The investigation attached to the incident report said the patient was coded despite a DNR order. Once the DNR order was verified, the code was ceased. They were unable to determine how the purple DNR wrist band was removed.

On 9/28/16, at 2:55 p.m., the Risk Manager said she investigated the incident report. She said the patient was supposed to have a purple band that indicated the patient was not supposed to be resuscitated. This patient did not have a band in place. She was not sure if it was ever on and was unaware of any documentation in the record about it (confirmed with record review). She said they evaluated the bands for sturdiness and durability, and had a "huddle" with the staff about the issue. Huddles were an informal communication with the staff about issues, and they are done before shift and occur relatively quickly. She agreed they had not completed any training and had no sign-in sheets to document education done regarding this issue.


3. The DNR status of the current patients was conducted. On 9/29/16 at 11:15 a.m., the Chief Nursing Officer (CNO) confirmed Patient #5 had a DNR order in her chart. At 11:20 a.m., the CNO verified Patient #5 did not have a purple DNR band on either of her wrists.

On 9/29/16 at 11:30 a.m., Patient #5's husband said Patient #5 never had a purple DNR arm band on her wrist since her admission on 9/16/16.

4. Observation on 9/29/16 at 11:50 a.m., revealed the facility had a system where the telemonitor screen tracing for patients who have DNR orders was turned to purple in color, so they are easily differentiated for the patients who have full code status. In addition, the monitor technician had a list of patients with their DNR status noted.

On 9/29/16 at 11:15 a.m., the CNO confirmed the code status for Patient #1 as DNR in his chart. A review of the telemonitor and monitor tech Staff K's worksheet revealed Patient #1's code status as full code (FC) and his cardiac graph on Staff K's monitor appeared as white.

On 9/29/16 at 1:00 p.m., Licensed Practical Nurse (LPN) Staff J said Staff K's worksheet is correct, 100% of the time. LPN Staff J confirmed Staff K's worksheet had not been updated to reflect a change in code status from full code to DNR for Patient #1. The cardiac graph remained white in color for Patient #1.

On 9/29/16 at 1:20 p.m., Staff K said he was informed by LPN Staff J, that Patient #1's code status was changed to DNR. Staff K said she updated her "Telemetry Worksheet" and changed the color of his cardiac graph on the monitor from white (full code) to purple (DNR). Staff K said during the time his monitor was white, if there was a cardiac event, she would have called for a full code. Staff K said that is why her worksheet and color of the graph is so important.

5. On 9/29/16, interviews were conducted from 11:22 a.m. through 12:30 p.m. with 5 registered nurses (RN Staff B, C, D, E, and F), the Risk Manager, and a physical therapy assistant. During each interview, the staff confirmed they would depend on the purple band being on the patient so they would easily know the patient's DNR status. If the band was not present, they would start the Code Blue and begin compressions and intubation. In all interviews, they indicated they would confirm the patient's DNR status after resuscitation efforts were begun. All staff further indicated it was the responsibility of the patient's nurse to assure the purple band was in place. All except 1 staff confirmed they would not document the placement of a band. On 9/29/16 at 11:30 a.m., RN Staff B said she would document an application or removal of the purple band if the patient's code status had changed.

A review of the hospital's DNR policy dated March 2014 revealed the policy contained no mention of "purple bands." The policy speaks to the physician's responsibilities, the hospital's responsibilities, and gives definitions of the 3 categories of code status the hospital acknowledges. The policy also provided information about verbal orders and showed the form used in the hospital for DNR orders.

In an interview on 9/29/16 at 11:30 a.m., the Risk Manager/QA (Quality Assurance) staff were unsure why the purple bands were not in the policy and indicated the system with the purple bands had been in place a long time.

On 9/29/16 at 1:30 p.m., the Administrator, Director of Nursing, and the Risk Manager all agreed they had no policy about the bands. They confirmed they did not have documentation regarding when the banding was to be applied or removed from patients.

The Risk Manager provided a policy, from the previous hospital owner dated April 2005, stating the patient would receive a clear identification band upon admission. After the nurse assessment, along with therapies, other bands would be added as patient needs were identified. For example: A yellow band indicated the patient was at risk for falls, pink for swallowing precautions, purple if there was a DNRO in the patient's record, red for the patient had an allergy, pale green for no blood draws on that extremity, and dark green with numbers indicated the patient had been type and cross matched for blood.

During the survey, the hospital policy was re-written to include the bands/colors. Hospital staff were in-serviced on the policy.
Staff were interviewed to determine if the corrective actions put in place had been implemented. The staff interviewed had knowledge of the issues. All staff who were present in the hospital on 9/30/16 were confirmed to have received the education.