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Based on record review, interview and facility policy review, the facility failed to ensure a patient who was confused was assessed to determine competence prior to switching the patient from a Full Code to a DNR-CCA. The facility also cut the patient's hair without a physician's order that suggested the patient needed treatment for any conditions of the hair or scalp that would require staff to cut her hair.

See A132 and A144

Based on record review, staff interview, and facility policy review, the facility failed to ensure a patient was of sound mind when changing resuscitation status. This affected one (Patient #6) of ten patients reviewed.

Findings include:

The patient was transported to the facility's emergency department (ED) by squad on 09/17/21 at 9:20 PM. The patient complained of worsening shortness of breath. According to the ED physician's progress note, the patient was hypoxic on room air with oxygen saturations at 87 to 88 percent. The patient was placed on two liters of supplemental oxygen and her oxygen saturations improved to 89 to 90 percent. The patient was admitted to the Acute Medical unit, located on the second floor of the facility. The patient's code status was full code.

A nursing note dated 09/21/21 at 5:30 AM documented Patient #6 was found with the oxygen tubing around her her neck and the non-rebreather mask in her hand. The patient agreed to BiPAP for "time being and is considering being a DNR-CCA with no intubation/reintubation." In house palliative care was consulted.

An event description composed by a palliative care team member on 09/21/21 stated the following: "Patient sitting in recliner on high flow oxygen. Patient does not wish to transfer to another hospital as condition is worsening." The patient advised the palliative care staff member that she did not "want life support either." Code status was discussed with the patient. The event description stated that the patient did not wish to change her code status at this time. The note stated "No advanced directives completed and patient does not wish to complete." The note also stated that the patient was "slower to respond with questions."

A progress note dated 09/23/21 at 7:45 AM on 09/23/21 documented the nurse reviewed code status options with patient in detail. Patient expressing wishes to maintain Full Code status. At 12:30 P.M., a palliative care nurse returned to the patient's bedside to speak with the patient. He/She explained the code status levels. The that the patient requested to be made a DNR-CCA. The patient's nurse explained to the palliative care nurse that the patient had requested to maintain her Full Code status only hours earlier. The patient's code status was changed to DNR-CCA.

A physician's order dated 09/23/21 changed the patient's code status to a DNR-CCA.

The facility's required form for DNR Comfort Care revealed the attending physician signed the form changing the patient's code status on 09/18/21. The space for the patient's signature was blank.

A nursing note dated 09/24/21 at 12:53 PM stated the patient was more confused. The nurse described an incident where the patient was holding her cell phone to her ear acting like she was talking to someone, however, the phone was not on. The patient stated, "I feel a little confused." The primary care physician was notified. The physician ordered a consult by a neurologist.

The neurologist concluded in his/her progress note that the patient's symptoms were "probably" related to sadness secondary to being in the hospital and being away from her spouse but might be related to delirium. "If symptoms of confusion persist or worsen," a CT of the head would be obtained.

A nursing note dated 09/25/21 at 11:10 AM documented Patient #6 requested to leave against medical advice (AMA). Staff members offered to make patient a DNR-CC with hospice care. The patient stated, "I don't want to die." The patient decided to stay for further treatment. The patient's spouse was "updated on this situation." At 7:20 PM the patient's sibling was called and given an update. At the time of the update, the patient's sibling stated another sibling was on a ventilator. The patient's sibling also gave the staff member the number to reach the patient's child. The patient's child was called and updated. The child stated she was also hospitalized with COVID-19 but she would be discharged the next day and would quarantine at home with Patient #6's spouse. At 8:25 PM it was documented the BiPAP machine was alarming. When the nurse entered the room, the patient had removed the oxygen and was holding the tubing in her hand. Her oxygen saturation was reading 84 percent. Patient #6 was more pale and the nurse noted the patient still appeared "distant and not fully at previous cognitive baseline."

Nursing notes dated 09/26/21 documented Patient #6 continued to refuse to wear the supplemental oxygen. The patient's spouse was called and informed that the patient was refusing to wear oxygen. At 10:50 AM a staff member discussed switching the patient's code status to DNR-CC. The patient's spouse was further informed that the patient appeared gray and dusky in color and that she was "declining." The spouse was told he should come to the hospital to visit the patient as the patient was "end of life." The patient's spouse asked staff to "wait to switch code status" until he could see the patient.

The medical record lacked documentation the spouse was informed that the patient's code status was changed from a Full Code to a DNR-CCA days prior, on 09/23/21.

The patient's condition improved and she was discharged home on 10/04/21.

During interview on 01/06/22 at 1:41 PM, Patient #6's spouse stated he was unaware that Patient #6's code status had been changed to a DNR until this option was mentioned when he was called to come to the hospital to visit Patient #6 as it was determined that it was end of life. He asked staff members to wait to change Patient #6's code status until after he could see her.

During interview on 01/06/22 at 1:43 PM, Patient $6 stated she was "pretty sure" that someone from the hospital talked to her about a code status change but could not recall whom. she stated "All I know is that I didn't want to die. I just wanted to be with my husband."

During interview on 01/10/22 at 6:03 AM, Patient #6's sibling didn't think Patient #6 intended to change her code status from a Full Code to a DNR-CCA. The sibling believed Patient #6 was "oxygen-deprived and not thinking clearly." No family member was informed of the patient's decision to change her code status.

During interview on 01/13/22 at 4:35 PM, Staff B verified the numerous staff accounts of the patient's confusion. Staff B confirmed that assessment of the patient's competence should have been determined to ensure she understood the ramifications of not instituting CPR.

Review of the facility policy titled "DNR/Comfort Care, DNR/Comfort Care-Arrest, Resuscitation Status", approved by the Chief Nursing Officer and Chief of Staff, documented establishing a procedure and protocol for providing care consistent with the patient's wishes when a Do Not Resuscitate Order is written, the attending physician has the primary responsibility for initiating and documenting the resuscitative order in the medical record. When a patient is competent, the resuscitation status will be discussed to determine that the order is medically and ethically appropriate by the patient and physician. Competence means the patient understands the nature of his illness and the ramification of not instituting CPR or discontinuing life-sustaining treatments. If the patient is incompetent, this decision will be reached by the designated surrogate or next highest in priority whether it be:

*Guardian/Healthcare Power of Attorney (HCPOA)
*Spouse
*Majority of adult children reasonably available
*Parents
*Adult brothers and sisters reasonably available
*The next adult related by blood or adoption. If there is a split, a decision cannot be made.

The official DNR order form is required after obtaining the order and is to be completed by the physician.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a safe setting for patients related to cutting the hair of a patient. This affected Patient #6.

Findings include:

Record review revealed Patient #6 presented to the facility's ED via squad on 09/11/21 at 5:38 AM with reports of coughing and a sudden shortness of breath. The patient received supplemental oxygen but by the morning of 09/12/21 was on room air. The patient was discharged home later that day.

The patient presented to the ED and was discharged numerous additional times before the decision was made to admit the patient on 09/17/21. The patient became confused during the hospitalization, removing supplemental oxygen often. The medical record documented low oxygen saturations throughout the patient's hospitalization.

A nursing notes dated 10/03/21 documented the patient was resting in bed after being medicated with Ambien, a sleeping medication. The patient had only removed oxygen three times this shift. After being medicated with Ambien, the patient fell asleep and woke up soaked in urine. The patient was assisted in getting a thorough bath soaking feet in warm soapy water. Her hair was washed. Patient #6 had a large matted area in back of head. The patient asked staff to trim her hair "to get the matted area out." The patient's hair was cut by a staff nurse.

The medical record lacked any physician order to suggest the patient needed treatment for any conditions of the hair or scalp that would require staff to cut hair.

During interview on 01/06/22 at 01:43 PM, Patient #6 became tearful when discussing a staff member cutting her hair. She stated "I don't know why they did that to me." Patient #6 stated her hair was past her buttocks prior to staff cutting it during this hospitalization. Patient #6 said her hair was cut into a "short bob."

During interview on 01/13/22 at 3:30 PM, Staff B was asked if any of the staff nurses received any specialized training in cutting hair. She stated none had received any training.

Review of the facility's Patient Information Handbook containing it's Patient Rights revealed patients have a right to respectful care. The policy stated that patients have the right to consideration for person dignity, values and beliefs, and contribute to a positive self-image.