HospitalInspections.org

Based on interview, record review and policy review, the facility failed to have a process in place to ensure patients had the right to formulate an Advance Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) and/or failed to follow-up and get a copy for those who said they had an AD for six patients (#4, #6, #8, #33, #41 and #43) of six patients reviewed. The facility census was 418.

Findings included:

1. Review of the facility's policy titled, "Nursing Inpatient Adult Admission Assessment Policy," dated 10/2017, showed the following:
- If the patient has an AD, review the document with the patient/family and mark as reviewed.
- Place a copy of the AD into the patient's medical record.
- If a copy is not available, ask the family to bring a copy to the hospital.
- If the patient has no AD, offer information to the patient/family and document this was offered.

Review of the facility's policy titled, "AD Policy," dated 07/31/17, showed the following staff responses/choices when documenting:
- Declined (Patient does not have an AD and does not wish for additional information);
- Need to Obtain (Patient has an AD but doesn't currently have a copy to scan);
- Not Received (default status for this document type);
- Received (a copy should be scanned along with this option);
- Request information - Booklet given (information has been provided to the patient); and
- Unable to assess (only to be used if patient or representative is unable to respond).

During an interview on 10/24/18 at 4:32 PM, Staff GG, Nursing Excellence Registered Nurse (RN), stated that:
- The admission nurse should assess the status of the AD upon admission and each shift thereafter.
- If the patient was not able to answer, the responsible party should be contacted for the information.
- There were six options to choose in the computer during the assessment, which were: unable to assess (required a note to explain why); declined (did not have one and did not want one); on file (previously scanned into the system); asked to bring; other (required a note to explain); and, Pastoral care to address (did not have one and wanted assistance to complete one).
- If the option "declined" or "on file" was chosen, the need for daily follow-up by staff was eliminated (dropped off of the staffs' task list).

Review of Patient #8's admission documentation in the electronic medical record (EMR) showed he was admitted on 10/01/18 and he declined having an AD (the patient was not alert and oriented at admission).

Review of follow-up assessments regarding the patient's AD showed:
- The nursing assessment (completed each shift) showed, "Unable to assess," for the AD section.
- The nursing assessment showed, "On file," for the AD section.
- The nursing assessment showed, "Unable to assess," for the AD section.

Review of the patient's record, with assistance of Staff GG, showed no AD information had been offered to Patient #8 or his representatives, and, there was none on file.

During an interview on 10/22/18 at 3:15 PM, Patient #4's husband stated that the patient had an AD.

Review of Patient #4's admission documentation in the EMR, on 10/22/18, showed she was admitted on 10/18/18, and staff were unable to assess the patient's AD status. Staff failed to follow-up with the patient and/or her representative to address or obtain a copy of the AD.

Review of Patient #6's EMR, on 10/22/18, showed she was admitted on 10/18/18 and there was an AD on file.
Further review of scanned documents in the EMR, showed no AD on file for Patient #6.

Review of Patient #41's medical record on 10/24/18, showed that the patient was admitted on 10/10/18 and the following nursing documentation was noted in the ongoing assessments:
- 10/11/18, staff documented Unable to Assess AD.
- 10/16/18, staff documented Unable to Assess AD.
- 10/23/18, staff documented Unable to Assess AD.
- 10/24/18, staff documented Unable to Assess AD.
No documentation was noted in the nursing assessments that showed that the patient or family had been approached and educated on AD. Also, Patient #41 was not confused and was alert.

During an interview on 10/23/18 at 9:37 AM, Patient #41, stated that she had never been approached regarding an AD.

Review of Patient #33's medical record on 10/24/18, showed that the patient was admitted on 10/15/18 and throughout his admission the following nursing documentation was noted:
- 10/18/18, AD on file;
- 10/19/18, AD on file;
- 10/21/18, AD on file; and
- 10/23/18, AD on file.

Review of Patient #33's AD in the medical record on 10/24/18, showed an AD from 2014 with no signature for authentication.

During an interview on 10/23/18 at 10:30 AM, Patient #33 stated that the hospital had his updated AD on file.

Review of Patient #43's medical record on 10/24/18, showed that the patient was admitted on 10/03/18 and throughout his admission the following nursing documentation was noted:
- 10/03/18, AD received and on file;
- 10/06/18, AD on file;
- 10/08/18, AD on file;
- 10/11/18, AD on file;
- 10/12/18, AD on file;
- 10/14/18, AD unable to assess;
- 10/18/18, Asked family to bring AD to the hospital; and
- 10/21/18, Declined AD.

During an interview on 10/23/18 at 10:10 AM, Patient #43, stated that the hospital had his AD on file.









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Based on observation, interview, record review and policy review, the facility failed to develop and/or update two patients' (#8 and #41) care plans to include the use of restraints (devices used to restrict the freedom of movement) out of two patients reviewed with restraints. This had the potential to affect the care all patients received while in restraints. The facility census was 418.

Findings included:

1. Review of the facility's policy titled, "Physical Restraint," dated 10/15/18, showed documentation should include daily/shift progress toward restraint goal(s). This policy did not specifically address care planning of restraints to include the problem, goals, and interventions.

Review of the facility's policy titled, Interdisciplinary Care Planning," dated 10/15/18 showed:
- The care plan is initiated within 12 hours of admission and reflects the patient's individualized needs identified during assessment including medical and psychological goals.
- The care plan is developed and modified with patient participation and is appropriate to the patient's needs, strengths, limitations and goals.
- The care plan should be modified by all professional disciplines participating based upon assessment, goals and interventions, education re-assessment, the patient's need for further care, treatment or services, and achievement of care plan goals.
- Progress toward goals is updated at least every 24 hours and with any changes in condition.

Review of Patient #8's nursing assessment from 10/04/18 through 10/23/18, in the electronic medical record (EMR), showed:
- He was admitted the Progressive Care Unit on 10/01/18.
- He had bilateral wrist restraints on beginning on 10/04/18.
- The patient had a tendency to pull at his medical tubes.

Observation on 10/23/18 at 9:45 AM, showed Patient #8 remained in bilateral wrist restraints.

Review of the patient's care plan dated 10/01/18, showed staff failed to identify the wrist restraints, and failed to develop a care plan with goals and appropriate interventions specific to Patient #8's needs.

Review of Patient #41's nursing assessment in the EMR showed:
- She was admitted on 10/10/18.
- She was placed in bilateral wrist restraints on 10/14/18 through 10/21/18.
- Staff failed to develop a care plan with appropriate interventions for restraints for 10/14/18 and 10/15/18.

During an interview on 10/23/18 at 9:50 AM, Staff C, Registered Nurse in Charge, stated that it was the assigned nurse's responsibility to develop the restraint care plan when the restraint was first ordered. Or, as soon thereafter, the care plan should be updated to include the restraint use, goal(s) and interventions.







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