HospitalInspections.org

Based on review of Hospital documents and staff interview, it was determined that for 1 of 1 (Pt #1) patients transferred to inpatient Hospice, the Hospital failed to ensure a physician's order was written authorizing the transfer.

Findings include:

1. The Hospital's "Rules and Regulations" (effective 10/7/10) required, "2. Admission and Discharge of Patients:..2.7. Patients shall be discharged only on the order of a Member, LIP or resident physician."

2. The clinical record of Pt #1 was reviewed on 10/3/12. Pt #1 was a 72 year old male that was admitted to the Hospital on 12/6/11 at 1:08 PM with diagnoses of Cardiac Arrest/Aspiration. Pt #1 arrived by ambulance intubated and non responsive. Pt #1's Discharge Summary dated 12/9/11 included that Pt #1 was under the "Care of the Public Guardian." On 12/9/12, physician documentation included, "I spoke with OPG (office of public guardian) and they agree to Hospice. They requested that son see Pt. After this Pt can be extubated." A physician's telephone order dated 12/9/12 at 4:05 PM included "May extubate or turn off ventilator...Admitted to Hospice." The clinical record lacked a physician's order discharging Pt #1 from the Hospital and admitting to Hospice.

3. On 10/03/13 at approximately 10:35AM MD #1 was interviewed by telephone. MD#1 explained that he spoke to a case worker and Supervisor from the Public Guardian's Office who agreed with the Hospice plan for Pt. #1. MD #1 stated that they were waiting for word from the "lawyers" from the Public Guardian's Office for approval to remove life support. MD #1 stated that he was not aware that Pt. #1 was removed from life support and transferred to another unit until he arrived the next day. MD #1 stated that he did not give an order to discharge and send Pt #1 to Hospice.

Based on review of Hospital documents and staff interview, it was determined that in 1 of 2 (Pt #1) clinical record reviewed of patients with a Public Legal Guardian, the Hospital failed to ensure the Guardian was involved in all aspects of patient care.

Findings include:

1. Hospital policy entitled, "Withholding or Withdrawing Medical Care (including DNR)," (reviewed 11/07) required, A. General Guidelines:.5. .f. The surrogate decision maker and one(1) adult witness shall sign the documentation in the patient's medical record which indicates that life-sustaining treatment shall be withdrawn or withheld. 6. If the patient lacks decision making and has a qualifying condition, but there is no health care surrogate decision maker, decisions about withdrawing life sustaining treatment should be made by a court appointed guardian."

2. The clinical record of Pt #1 was reviewed on 10/2/12. Pt #1 was a 72 year old male that was admitted to the Hospital on 12/6/11 at 1:08 PM with diagnoses of Cardiac Arrest/Aspiration. Pt #1 arrived by ambulance intubated and non responsive. Pt #1's Discharge Summary dated 12/9/11 included that Pt #1 was under the "Care of the Public Guardian." The clinical record contained two (2) DNR (do not resuscitate) orders from the Office of The Cook County Public Guardian. The first dated 12/7/11 included, "The Public Guardian is NOT consenting to the removal of the ventilator at the present time. An additional directive would need to be submitted by the Public Guardian of Cook County before such action can be taken..." The second DNR order dated 12/9/11 does not include a directive to remove Pt #1 from the ventilator. A physician's order dated 12/8/12 included, "Pt do not resuscitate, do not withdraw therapy, do not escalate therapy." On 12/9/11, physician documentation included, "I spoke with OPG (office of public guardian) and they agree to Hospice. They requested that son see Pt. After this Pt can be extubated." The physician's documentation does not include the signature of the surrogate decision maker and an additional witness as required by Hospital policy. A physician's order dated 12/9/11 included "May extubate or turn off ventilator." Respiratory documentation indicated that Pt
#1 was extubated on 12/9/11 at 5:03 PM, however, the clinical record lacked a signed consent form, from the Guardian, for removal of life support.

3. On 10/03/12 at approximately 10:35AM, MD #1 was interviewed by telephone. MD#1 explained that he spoke to a Case Worker and Supervisor from the Public Guardian's Office who agreed to Pt. #1's Hospice plan. MD #1 stated that they were waiting for word from the "lawyers" from the Public Guardian's Office for approval to remove life support and that he was not aware that Pt. #1 was removed from life support and transferred to another unit until he arrived the next day.

Based on review of Hospital documents and staff interview, it was determined that for 1 of 3 records reviewed (Pt. #2) of patients on medical restraints, the Hospital failed to ensure a restraint order included the time limitation for the restraints, justification for use of restraint, duration of use and type of restraints to be used, as required by the Hospital policy.

Findings include:

1. The Hospital policy titled, "Use of Restraints" (revised 2/11) required, "3. Orders for Restraint: ...The initial order must be time limited not to exceed twenty-four (24) hours, and must specify clinical justification for the restraint ...and the duration of use, the type of restraints to be used...."

2. The clinical record of Pt. #2 was reviewed on 10/2/12 at approximately 10:50 AM. Pt. #1 was a 75 year old female admitted on 9/30/12 with a diagnosis of Volume Depletion. Pt. #1 was intubated on 9/30/12 and the clinical record contained a physicians order for medical restraints dated 10/1/12 at 8:00 PM. The restraint order lacked the justification, time limitation, duration, and type of restraints to be used on Pt. #2.

3. The Director of Nursing for the ICU verified the finding and stated that it is the Hospital's expectation that all medical restraint orders are completed to include the justification, time limitation, duration, and the type of restraints to be used.