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Based on a review of facility documentation, medical records (MR) and interview with facility staff (EMP) it was determined that the facility failed to follow their adopted policy by failing to place a copy of the patient's advance directive in the medical record in two of five medical records. (MR2, MR3)

Findings Include:

Review of the policy entitled "Patient Rights & Responsiblities", dated April 1, 2017, revealed "... A patient or a parent or legal guardian of an unemancipated child 18 or younger, you have the right to expect the following from our physicians and healthcare personnel ... That your wishes regarding medical care-spelled out in an advance directive, such as a living will, healthcare proxy or durable power of attorney for healthcare will be honored by the hospital to the extent permitted by law and hospital policy ... ."

Indiana Regional Medical Center Policy #: P.C. No: 170 Subject: Advance Directive (Living Will, Durable Power of Attorney for Healthcare (DPAHC)) Department of Origin: Administration dated August 22, 2019. "Purpose: To define Indiana Regional Medical Center policy surrounding the formulation, assessment, and honoring of a patient's advanced healthcare directive (s). ... I. Definitions Advance Directive: Either an oral or written document that expresses a patient's wishes and instructions relative to health care decisions when patient lacks decision making capacity or is unconscious. Also referred to as 'living wills' and DPAHC.' This document, that is to be scanned into the medical record, remains in effect until it is updated or modified. ... II. Procedure for Obtaining an Advance Directive: Inpatient/Observation Patient/Ambulatory Care Setting The following applies to patients admitted to any inpatient setting: ... If the patient has a written directive in his/her possession, it shall be noted, and a copy of the directive shall be placed in the patient's medical record. If the patient has a written directive not in his/her possession, it shall be so noted, and the patient/family will be asked to provide a copy to be placed in the patient's medical record. ... During the nursing assessment, questions are to be asked about advance directives/living wills to ensure the healthcare team is aware of patient requests, and the documents are to be copied into the patient's medical record. ... ."


1) Review of five open inpatient of medical records (MR2-MR6) was conducted to ascertain documented evidence of Advance Directives. The applicable check box in the EMR related to the location of the Advance Directive revealed, "Copy obtained from previous records, Copy placed on chart, Family to bring in copy from home, Scanned into EMR, Unable to obtain copy, Other." Two ICU medical records (MR2 admitted August 4, 2020, and MR3 admitted August 2, 2020) failed to reveal documentation of the location of the Advance Directive following documented evidence that the patient had one.


Interview with EMP1, and EMP15 on August 12, 2020, confirmed the above findings.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to follow their adopted Patient Rights Policy, by failing to ensure care in a safe setting, by failing to ensure that 1:1 observation was implemented following receipt of an order for 1:1 observation, for one of one medical records reviewed (MR1) and failed to follow adopted Fall Risk Assessment and Prevention Strategies policy by failing to complete a post fall assessment for one of six medical records reviewed (MR1).

Findings include:

Review of the policy entitled "Patient Rights & Responsiblities", dated April 1, 2017, revealed "... A patient or a parent or legal guardian of an unemancipated child 18 or younger, you have the right to expect the following from our physicians and healthcare personnel ... Care in a safe setting ... ."

Indiana Regional Medical Center Policy #: 165 Subject: Fall Risk Assessment and Prevention Strategies Department of Origin: Quality dated February 4, 2019. "Purpose: To protect all patients, promote a culture of safety and make fall reduction a priority. To accurately assess, identify and institute evidence based interventions with patients who are at risk for falling/injury. To educate patients, families, supports and healthcare team members on measures to prevent falls and promote safety. Definition: A fall is defined as an unplanned, assisted or unassisted descent to the floor either with or without injuries to the floor either with or without injuries to the patient/resident/client either witnessed or unwitnessed. Responsibility: It is the responsibility of all healthcare workers to make safety a top priority, recognizing that all patients are to be considered at risk for falls and to continue appropriate interventions. Practice Guideline: Almost all hospitalized patients are at risk for falls/safety injuries and have the right to expect a safe environment. ... 2. A Post Fall assessment to include Morse Fall Scale, Post Fall Evaluation and Post Fall Monitoring within the patient's chart are to be completed immediately after a fall ... ."


1. Review of MR1 revealed an order for a Patient safety attendant (PSA) (1:1 sitter), dated April 3, 2020, 20:51. Review of MR1 also revealed documentation that the patient sustained a fall at approximately 22:00. Review of Sitter documentation within the medical record, revealed no documentation until 22:28. During review of MR1, it was also noted that there was no documentation of a post fall evaluation completed.

Interview with EMP2 on August 12, 2020, at 1:45PM, confirmed that there was no post fall evaluation documentation on the patient's medical record. It was also confirmed at 2:00 PM, that there was an order placed at 21:38 for the patient to have a 1:1 sitter, and first sitter documentation occurred at 22:28, which occurred following the patient's fall.


Review of facility documentation by EMP11, relative to the patient associated with MR1, revealed that the sitter had not arrived to the patient's room when transported, stating that this is not unusual as it takes time for the sitter to be scheduled and report to the patient's room.