HospitalInspections.org

Based on review of 8 open and 2 closed patient records, it is revealed that 1) although patient #3 was documented as having an advance directive; that her Granddaughter was identified as being Power of Attorney (POA); and that alternately the granddaughter was documented as being patient #3's healthcare agent; no supporting advance directive, POA or healthcare agent documentation is found, giving the granddaughter rights to make healthcare decisions for patient #3; 2) No statements of incapacity to make healthcare decisions are found in the record, and 3) the hospital allowed patient #3 to sign her own Medicare Important Message, though patient #3's direction was not sought related to healthcare decision-making.


Patient #3 is a 92-year-old admitted to the hospital on 2/18/2013 via the emergency department following her presentation for abdominal pain, nausea, vomiting, and cough. Patient #3 ' s admission spanned 12 days, with final diagnoses of gastroenteritis vs. urinary tract.


Documentation of 2/18 reveals that patient #3 signed her own Important Message from Medicare though she was assessed as having an altered mental status. However, her granddaughter signed the hospital General Conditions of Admission and Treatment form. Review of the record reveals that on admission that patient #3 was stated to have an Advance Directive (AD), but that AD was not found on the record.


On 2/20, a social worker note states in part, " Writer spoke w/granddtr ...who reports she is pt's POA (Power of Attorney). Pt live w/granddtr (sic) and is indep ADLs (Activities of daily living), uses walker to ambulate, uses grab bars for safety .... " No documentation as to the type of POA (financial or medical) is noted, nor is an actual POA found in the record.


A physician note of 2/27/13 at 1049 states "This is a 93-year-old lady with mild dementia who was at home, fairly independent, brought into the hospital with nausea and cough; found to have mental status changes, which are probably multifactorial with urinary tract infection as a contributing factor. However; the patient seems to continue to decline slowly for which Palliative Care is consulted. "


While patient #3 was largely documented as being oriented only to self, no documentation of physician capacity statements regarding patient #3 ' s ability/inability to make her own healthcare decisions, were found on the records.


On 2/27, the physician documents talking with the Granddaughter who informed him that " ...two days prior when a feeding tube was unsuccessfully attempted, patient #3 asked her granddaughter not allow anybody to stick any tubes in her. She also stated that based on prior conversations that patient #3 would not want chest compressions, no intubations, no dialysis, no tube feedings, and no pressors, want (sic) to be full DNR and to be provided only medical treatments, and if unsuccessful would prefer for her to be kept comfortable and allow a natural process. DNR form was completed and put in the chart. "


On 2/28/13, a Code Status Orders form was filled out by the Granddaughter who was documented as the "Healthcare Agent." No documentation in the record reveals assignment by patient #3 of her granddaughter as her healthcare agent.


In summary, while patient #3's granddaughter may well have had the right to make healthcare decisions for patient #3, it was never shown. Therefore, the hospital failed to 1) Utilize a process by which patient #3's decision-making rights were protected, 2) Assess patient #3 for her ability/inability to make decisions, and follow with capacity statements, 3.) obtain verification of patient #1's advance directive, and when not produced 3) obtain verification with content and scope of the POA. Based on the fact that these processes were not completed, the hospital failed to support patient #1's right to formulate advance directives.

Based on review of 8 open and 2 closed patient records, it is revealed that open records for patients # 6 and #7 had no History and Physical (H&P).

Review of patient #6 ' s record, admitted 5/8/13 reveals no H & P. Additionally, H & P is found for patient #7, admitted 5/25/13.