HospitalInspections.org

Based on policy / procedure reviews, record reviews and interviews, the facility failed to ensure that the Do Not Resuscitate Order (DNR) implemented by the nursing staff was discussed with an Attending Physician for 1 (SP#3) of 7 Sampled Patients. In addition, the facility failed to ensure the DNR Order was written by an Attending Physician as stated in the facility's policy for SP#3 and SP#7.

Findings include:

Review of the facility's Policy No. HW.RI 1.15, Subject: Do Not Resuscitate (DNR) Orders, Last reviewed: 03/2020 included, but was not limited to:

Policy:
It is the responsibility of the attending physician to medically evaluate the resuscitative status of each patient.

Procedure:
(A) The attending physician is to medically evaluate the resuscitative status of each patient. (D) The physician(s) is (are) required to have a conference with the patent and/or health care surrogate/proxy. DNR orders are to be written in the electronic medical record. (H) Completion of the appropriate Physician Orders regarding do not resuscitate must be entered into the electronic medical record.

Record review conducted on 5/16/2023 revealed SP#3's Consent for DNR Order form on December 3, 2022 documented:

(1) "After a DNR determination is made, the attending physician must write orders specifying the scope of treatment." (The DNR order was not written by the attending physician per policy).

(2) "I/we have discussed this matter with the attending physician Dr.______________ ". (There was no physician identified on the DNR form).

(3) "I/we do hereby exercise, in good faith, my/our substituted judgement to effect patient's right of privacy to consent for a do not resuscitate order."

The first line for "Signature/Relationship to patient" is signed by god sister and witnessed by ("sister"). The second line for "Signature/Relationship to patient" is signed by 2 Registered Nurses (RN1 and RN2) and witnessed by ("RN").

Further record review revealed that SP#7's DNR order was written by the Advanced Practice Registered Nurse (APRN2) on 03/01/2023 at 5:40 PM. Additionally, APRN2 also witnessed the CONSENT FOR DO NOT RESUSCITATE ORDER form.

Interview with the Risk Manager conducted on 05/16/2023 at 11:56 AM revealed that no incident reports were filed. The Risk Manager reported speaking with SP#3's sister. The Risk Manager stated upon review of documentation, it was not clear the sister was at the bedside. The Risk Manager stated that a lot of the documentation refers to the god sister as the proxy . The Risk Manager stated that the investigation concluded that the protocol for identification of proxy by nursing was not followed.

The facility did not follow its DNR policy when the Code Status of DNR was written by APRN1 and APRN2. In addition, the Consent for DNR Order form was inappropriately completed by RN1 and RN2 without an Attending Physician.

Based on policy / procedure, review of records and interviews, the facility failed to ensure that the staff followed the six rights of drug administration for 1 (SP#5) of 7 Sampled Patients.

Findings include:

Review of the facility's Policy Number MM 21, Medication Administration, Last Revised 02/28/2023 included, but was not limited to:

Procedure: (E) Administer Medications Safely:
1. Medications are administered to one patient at a time
2. The individual who will be administering the medication verified the "six rights' of drug administration: Right patient, Right medication, Right dose, Right time, Right route, and Right documentation.

Review of the Physician's order for SP#5 dated 05/16/2023 at 1:51 PM documented the following medication was scheduled for administration: Enoxaparin (Lovenox) 40 mg subcutaneous (SC) daily.

An observation of SP#5's medication administration performed by Registered Nurse (RN1), on 05/18/2023 at 11:18 AM on Manson Tower 1 revealed:

RN1 verified the medication from the computer terminal prior to removing the medication from the storage area. RN1 washed hands, donned gloves, scanned SP#5's armband and then the medication. RN1 reviewed the medication with SP#5, cleaned the site and injected the medication. It was noted that when the medication was scanned, the time of administration was automatically documented in the electronic medical record revealing the medication was documented prior to its administration.

The surveyor discussed the sequence of events with RN1 who agreed that the system automatically documented the administration when the medication was scanned. The issue was also discussed with the Nurse Manager.

The facility policy was not followed for Right Documentation when the surveyor observed that the electronic medication scanning process also documented the medication administration in the Medication Administration Record prior to the medication actually being given.