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Based on interview and record review, the hospital failed to identify and adhere to Do Not Resuscitate (DNR) status for 1 of 3 patients reviewed for Advance Directives (AD) (#1).

Findings:

Patient #1 was a 66-year-old transferred from a Skilled Nursing Facility (SNF) to the Emergency Department (ED) on 9/14/21 due to chest pains.

The "ED Physician Sheet", dated 9/14/21 at 3:34 AM, revealed the patient arrived at the hospital via ambulance and presented with chest pain. Patient #1 was admitted to an Inpatient unit for further evaluation and treatment.

Documents received from the SNF revealed a face sheet with "DNR" documented in the Advance Directives section. A Medication Review Report was also included and revealed a physician order dated 5/11/21 for DNR.

A "Timed Event" note, dated 9/15/21 at 12:05 AM, read, "patient arrived... post code, pt [patient] placed on monitor showing asystole, no pulse present, began compressions....and activated code blue." A "Timed Event" note, dated on 9/15/21 at 12:08 AM, read "RT [Respiratory Therapist] responded to code blue, bagged pt and assisted with intubation."

The "Code Blue Note", dated 9/15/21, read, "Code blue called at 0007 [12:07 AM] for asystole. Compressions started ...Intubated 0020 [12:20 AM]....Lost pulse again 0032 [12:32 AM] and resumed compressions." The patient was transferred to the Intensive Care Unit (ICU), another code blue was called in the ICU, and the time of death was "ultimately called at 0117 [1:17 AM]."

"The term "Code Blue" is a hospital emergency code used to describe the critical status of a patient. Hospital staff may call a Code Blue if a patient goes into cardiac arrest, has respiratory issues, or experiences any other medical emergency." (Retrieved from https://www.webmd.com-What is a Code Blue on 10/08/21).

On 9/24/21 at 3:25 PM in a telephone interview, patient #1's family member stated the patient was transferred to the hospital on 9/14/21 from the SNF where he resided, due to complaints of chest pain. The family member said the patient had a DNR order, but Cardiopulmonary Resuscitation (CPR) was performed at the hospital. She stated the ICU physician told her a full code was performed on the patient because the SNF had not sent the patient's DNR form with him to the hospital. The family member stated she did not know if the hospital asked the patient about his wishes regarding DNR prior to CPR being performed. She said patient #1 did not want to die the way he did.

On 9/29/21 at 11:08 AM and 11:58 AM, Risk Manager (RM) A stated code status would usually be discussed by the patient's provider, and Advance Directives were discussed at admission. RM A stated in review of the patient's clinical records, documentation regarding a discussion of the patient's code status could not be found. Review of scanned records from the SNF showed no marigold color Florida DNR order.

On 9/29/21 at 12:13 PM, the ED Nurse Manager (NM) stated documents bought in to the ED with patients would be reviewed by the physician. They would also receive a verbal report from Emergency Medical Services (EMS). The ED NM stated if the patient had a community/SNF DNR, that DNR should be sent with the patient. If the DNR was not sent, the hospital would reach out to the SNF by sending a formal request for the patient's medical record. A note would be documented by the Health Unit Coordinator when the request was faxed to the SNF. Review of the clinical records by RM A revealed a request/order for the patient's medical records from the SNF was not initiated.

On 9/29/21 at 2:58 PM, a telephone interview was conducted with Registered Nurse (RN) B. She stated she received a report from the ED that patient #1 came in for chest pain, and was admitted to the floor for further management. RN B stated she did not receive a report from ED regarding the patient's code status. She stated the admission process included the completion of various forms, which would be populated electronically for her to complete. Included would be the personal health history (PHH) which had questions regarding Advance Directives. RN B stated the PHH did not populate for her because it was completed prior to the patient's admission to her unit. She verbalized the patient was awake, alert, and oriented and she did not recall talking about his AD or code status.

On 9/30/21 at 11:48 AM in a telephone interview with RN C, she recalled patient #1 was awake, alert, and oriented; she received bedside report, but his code status was not discussed during report. RN C stated it was usually understood that if the patient was not DNR, he/she was a full code. She said patient #1 was found unresponsive, and she called a Code Blue. RN C stated if code status was not discussed in report, nurses could review the patient's code status in the patient profile in the electronic medical record (EMR).

Review of the banner bar of patient #1's EMR revealed the patient profile information included allergy, weight, isolation status, visitor status, sex, age, date of birth, patient location, and Code status. The area for code status was blank, full code/DNR was not identified.

On 9/30/21 at 12 PM, RM A said a discussion between the Orange County Fire Department and the ED NM, revealed paperwork would be sent with the patient when EMS was transporting a patient from the SNF to the hospital. If the patient's code status was DNR, the original marigold color DNR form should also be included in the paperwork provided to EMS. RM A stated sometimes the DNR form was not sent, and in that case, the hospital would contact the facility for any needed information.

On 9/30/21 at 12:15 PM, RN D stated she was working in the ED on 9/14/21 as an admission specialist, and completed patient #1's admission health history. RN D verbalized that in completing the admission documents, she reviewed paperwork from the SNF to see if the patient had a community DNR in his chart but there was none. When asked if she reviewed the patient's face sheet for Advance Directives, RN D stated she usually would not look on the face sheet if the patient was awake, alert, and oriented.

The personal health history obtained on 9/14/21 revealed the following documentation for Advance Directives: "Existing Advance Directive: No. New Advance Directive Requested: No."

The facility's policy "Do Not Resuscitate (Allow Natural Death) and Limited Resuscitation" with effective date 3/15/2021 read, "Process for Emergency Department, Inpatient, Outpatient and Observation Patient...Patient arrives without a Department of Health (DOH) State of Florida DNR Order Form: a. The physician will check the box Do Not Resuscitate (DNR Order) on the AdventHealth Orlando Do Not Resuscitate (DNR) (Allow Natural Death) Order form after discussion and agreement with the patient /LAP. This discussion is to be documented in the physician progress note .... e. The patient's resuscitation status will be ordered and indicated in the electronic medical record (EMR)...The patient's code status will display on the banner bar and the communication tab of the electronic medical record."

Interview and record review revealed the hospital staff did not follow protocol regarding DNR. Documentation was not found to indicate the patient's code status was discussed with the patient/family member/SNF, and CPR was provided for patient #1 on three separate occasions on 9/15/21 after he coded. Patient #1 eventually expired.