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The hospital was found to be out of compliance with the Condition of Participation of Provision of Services. Based on interview and document review the hospital failed to follow their policies and procedures when a patient (P)1 was not provided with cardiopulmonary resuscitation (CPR) according to his wishes, and P1 died.

Due to the serious nature of this failure the hospital is unable to ensure adequate Provision of Services.

Therefore, the hospital is unable to meet the Condition of Participation of Provision of Services at 42 CFR 485.635.

Findings include: See C 1006: Based on interview and document review, the hospital failed to follow orders for full code status for 1 of 10 patients (P1) who had orders for full code status, did not receive CPR when his heart stopped. P1 died.

Based on interview and document review, the hospital failed to follow orders for full code status for 1 of 10 patients (P1) who had orders for full code status, did not receive cardiopulmonary resuscitation (CPR) when his heart stopped. P1 died.

P1's Discharge Summary dated 1/27/22, indicated P1 was admitted to the hospital on 1/7/22, at 12:00 a.m. with a diagnosis of COVID-19. The patient developed respiratory failure and was intubated on 1/10/22.

P1's Physician Orders dated 1/7/22, indicated P1 had orders for full code resuscitation status.

On 1/27/22, P1's progress notes indicated P1's heart stopped, but CPR was not initiated by hospital staff. P1 died 1/27/22, at 7:30 p.m.

On 2/9/22, at 11:50 a.m. P1's family member (FM)-E was interviewed and stated the family understood P1 was supposed to be a full code resuscitation status. FM-A stated on 1/27/22, they entered P1's room, and he was deceased. FM-A stated the staff nurse told them CPR was not attempted, and all the cords for P1's ventilator were unplugged, and he was deceased.

On 2/9/22, at 12:30 p.m. P1's physician, MD-F was interviewed and stated he verbally ordered P1 be a no code resuscitation status because CPR would be futile, as P1 was dying. MD-F stated P1's organs were failing and he was not going to be able to leave the hospital. MD-F stated he repeatedly informed P1's family of the patient's grave prognosis.

On 2/9/22, at 1:38 p.m. registered nurse (RN)-H was interviewed and stated P1 was deteriorating due to COVID-19. RN-H stated during the day shift P1 had no urine output, and his organs were not functioning. P1's heart rhythm changed. Nursing staff notified the medical provider, and they did not do CPR because the doctor (MD)-F verbally ordered the patient to be "no code blue" which meant do not perform CPR.

On 2/10/22 at 9:06 a.m. nurse practitioner (NP)-J was interviewed and stated CPR was not performed on P1 because MD-F verbally told staff that P1 was a "no code blue" patient, CPR should not be initiated if his heart stopped, and natural death should be allowed to occur.

P1's medical record lacked indication of the change in resuscitation order, or a discussion of the change with P1's family.

On 1/9/22, at 2:08 p.m. the Vice President of Patient Care (VP)-A was interviewed and stated when a patient has an order for full code, the patient should receive CPR. VP-A further confirmed that the process for withholding or forgoing life sustaining treatment was not followed for P1.

P1's progress notes dated 1/27/22, indicated P1 died on 1/27/22, at 7:20 p.m.

The facility policy Allowing Natural Death: DNR and forgoing Life Sustaining Treatment, revised 2/20, directed:
When conflicts arise from situations regarding withholding or withdrawing life-prolonging treatment, and interdisciplinary care conference will be called by the social worker or case manager. If the problem cannot be resolved at this level, the ethics committee will convene for a case consultation. If disagreements cannot be resolved after reasonable efforts, direction from a court may be sought by the attending physician or the hospital.

The policy Health care Directive reviewed 4/20, directed: In the absence of a written Advance Directive the patient will be considered to be in a full code status unless their wishes are known through clinical orders from another facility, or the agent or patient expresses their wishes to the physician, and they are implemented by clinical orders.

The policy Provider Care Patient Order Management reviewed 3/2/20, directed: Verbal orders are all orders communicated verbally ...to staff to be entered into the EMR. Verbal and telephone orders will be given by the provider to appropriate nursing staff only in emergency situations or when it is unreasonable for the provider to electronically place an order. The staff member will write down or electronically enter and read back the order to the provider before it is electronically placed. Any further clarification of order content will be through additional nursing staff communication with the provider prior to initiation of the order. Authentication of verbal and telephone orders by the provider must occur within 48 hours.