HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights.

Findings include:

1. The Hospital failed to initiate and perform life saving measures for one patient (Pt #1), who had a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status ordered. As a result, Pt #1 was not resuscitated, and subsequently expired. A-132



The IJ began on 4/17/2024, due to the facility's failure to initiate and perform life saving measures for one patient (Pt #1), who had a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status ordered and subsequently expired. The IJ was identified on 4/24/2024 at 42 CFR 482.13, Patient Rights. The IJ was announced on 4/24/2024 at 11:20 AM during a meeting with the Chief Executive Officer, Chief Operating Officer, Interim Chief Nurse Officer and Quality Management Director, and was not removed by the survey exit date of 4/24/2024.

Based on document review and interview, it was determined that for 1 of 1 clinical record (Pt. #1) reviewed for a patient's death, the Hospital failed to initiate and perform life saving measures for one patient (Pt #1), who had a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status ordered. As a result, Pt #1 was not resuscitated, and subsequently expired.

Findings include:

1. "The Hospital's "Code Blue" Policy (dated 4/2018), was reviewed, and required, "Cardiopulmonary Resuscitation will be done on all patients with an absence of pulse or respiration unless a DNR [do not resuscitate] order is written by the physician ..."

2. The Hospital's policy titled, "Patient Rights" (dated 10/22), was reviewed, and required, " ...It is the policy of [Hospital] to have processes in place to ensure each patient's individual rights ...The hospital has mechanism in place to ensure the following: c) The right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital to comply with these directives ..."

3. The clinical record of Pt #1 was reviewed on 4/22/2024. Pt #1 presented to the ED (emergency department) for Altered Mental Status on 4/13/2024. Pt #1 was on ED hold and then transferred to the Intensive Care Unit (ICU) on 4/15/2024 at 4:29 PM. Pt #1 expired in the Hospital on 4/17/2024 at 6:41 AM. Pt #1's clinical record included the following:

- An ED Provider note, (dated 4/13/2024), documented by the ED Physician (MD #5), included, " ...nursing home patient ... [Pt #1] is a DNR [Do Not Resuscitate] ...has a history of advanced dementia [Pt #1] cannot give a history ..." MD #5's note indicated that Pt #1 was a DNR, however, there was no supporting documentation or paperwork on file.

-Pt #1's Nursing Admission Assessment (dated 4/14/2024), that included the Medical/Legal section, documented by the ED RN (E #15), was left blank. There was no Existing Advance Directive; Advance Directive provided; or Power of Attorney documented on this assessment.

- ED nursing notes documented by the ED RN (E #8), included:
- 4/15/2024 at 11:16 AM: "E #8 spoke with Pt #1's guardian."
- 4/15/2024 at 4:06 PM), included, "This pt is a Full Code."
- 4/15/2024 at 4:28 PM: "Spoke with [Z #1] the Guardian and [Z #1] is working with us to set up a DNR. Paperwork being faxed to [MD #1] now."

- A "Letter of Instruction: Office of the Cook County Public Guardian Adult Guardianship" form (dated 4/15/2024) indicating that Pt #1 had a State Guardian (Z #1).

- A Physician progress note, documented by the covering ICU Physician (MD #1), dated 4/15/2024 at 3:15 PM, included, "Transferred from ER to ICU ...Per ER notes patient is DNR. However, no DNR papers in chart ...No family. Called State Guardianship Office ...Spoke with [State Guardian/Z #1]. Surrogate paperwork is being completed. Until all paperwork completed [Pt #1] will be Full Code ..."

- Pt #1's Physician orders included an order (initiated on 4/15/2024 at 4:07 PM), for "Resuscitation Status" as Full Code.

- 4/17/2024 at 7:27 AM, nurse's note, documented by E #5: "Patient HR [heart rate] decreased to 30 BPM [beats per minute/low heart rate]. Kussmaul breathing [abnormal respirations] ...Unable to get a pulse or O2 [oxygen] saturation. Patient went asystole [pulseless] at 0622[AM]. House MD paged. Patient pronounced at 0641[AM]."
No resuscitative measures were initiated on Pt #1 who was a Full Code.

- A Physician progress note (dated 4/17/2024 at 6:47 AM) documented by the House Physician (MD #2) included: "I [MD #2] was called by the pt's nurse [E #5] to evaluate the pt for a death announcement. On exam the pt [Pt #1]was unresponsive to verbal and tactile stimuli. The patient had no spontaneous respirations. The pt had no palpable pulses. The pt had no heart sounds. The pt's pupils were fixed and dilated. The pt was pronounced dead at 6:41 AM on 4-17-24."

-The clinical record did not include a DNR order or a POLST (Practitioner Order for Life-Sustaining Treatment) form.

4. On 4/22/2024 at 10:23 AM, an interview was conducted with the House Physician (MD #2). MD #2 stated that the House Physician is called to all "Code Blues" and also called to pronounce a patient's death. MD #2 stated that MD #2 was called (on 4/17/2024), to pronounce Pt #1's death. MD #2 stated that when MD #2 arrived at the ICU where Pt #1 was, Pt #1 had no signs of life, and MD #2 then pronounced Pt #1's time of death. MD #2 stated that the RN on the unit is the one that confirms the patient's DNR/Code Status prior to calling the Code.

5. On 4/22/2024 at 10:35 AM, an interview was conducted with the Social Worker (E #3). E #3 stated that Pt #1's Public Guardian (Z #1) told E #3 that Z #1 came into the hospital and met with Pt #1's RN to fill out the DNR form. E #3 stated that Z #1 left the DNR forms with the nurse to have them filled out. E #3 stated that Z #1 wanted the DNR form faxed back to Z #1's office once the form was completed. E #3 stated that there was going to be a meeting at the Public Guardian's office to discuss the patient's DNR status and get approval. E #3 stated that Pt #1's DNR papers were not faxed back to the office, since Pt #1 had already expired. E #3 stated that 2 physicians are required to sign the POLST form. E #3 stated that Pt #1 would have still been considered a Full Code until the required paperwork was in the chart.

6. On 4/22/2024 at 11:25 AM, an interview was conducted with the ICU RN (E #4/RN who admitted Pt #1). E #4 stated that when the ED was going to transfer Pt #1 to the ICU, E #4 noticed that there was no Code status in the system for Pt #1. E #4 stated that the ED nurse then put the order in as Full Code (on 4/15/2024), prior to Pt #1 transferring from the ED. E #4 stated that if a patient does not have a DNR order, then the patient is treated as a Full Code. E #4 stated that for the 2 days that E #4 took care of Pt #1, Pt #1 was a Full Code.

7. On 4/22/2024 at 1:15 PM, a phone interview was conducted with the ICU Physician (MD#1/covering Pt #1). MD #1 stated that Pt #1's Code Status was uncertain. MD #1 stated that MD #1 spoke with Pt #1's Guardian (Z #1) to clarify the Code Status. MD #1 stated that Z #1 faxed over the DNR paperwork, and MD #1 signed the papers. MD #1 stated that the DNR papers require 2 physicians to sign it. MD #1 stated that in the meantime, before the DNR form is completed, the patient would still be considered a Full Code.

8. On 4/22/2024 at 1:30 PM, a phone interview was conducted with the ED RN (E #8). E #8 stated that while Pt #1 was boarded in the ED, there was no Code Status for Pt #1. E #8 called Pt #1's Guardian (Z #1). E #8 stated that Pt #1 was not a DNR at that time, but that Z #1 and the nursing home were trying to initiate the DNR since Pt #1's condition was declining. E #8 stated that Z #1 told E #8 that Pt #1 was still a Full Code until the DNR process was completed. E #8 stated that when report was given to the ICU RN (E #4) on 4/15/2024 on day shift. E#8 reported that Pt #1 was still a Full Code.

9. On 4/23/2024 at 8:47 AM, a phone interview was conducted with the ICU RN (E #5/cared for Pt #1 when Pt #1 expired). E #5 stated that Pt #1's monitors were alarming, and it was noted that the patient's heart rate was dropping. E #5 stated that E #5 went into Pt #1's room and noticed the patient was with heavy breathing. E #5 stated that Pt #1's pulse was then checked and at that time, there was no pulse and within a minute, the patient expired. E #5 stated that Pt #1 was not Coded (resuscitated) since E #5 was told in report that Pt #1 was a DNR. E #5 stated that the House Doctor (MD#2) was then called to pronounce Pt #1's death. E #5 stated that when MD #2 came up and reviewed Pt #1's chart, it was identified that Pt #1 was actually still a Full Code and not DNR. E #5 stated that it was a misunderstanding about Pt #1's Code status. E #5 stated that the usual process for patients with DNR status, is that the "RED" (POLST form) would be located on the front of the patient's chart and nurses would look to verify their Code status. E #5 stated that after the incident, E #5 let the Nursing Supervisor (E #10), the Attending MD (MD #1), and the Chief Nurse Executive (E #2), know on 4/17/2024. E #5 stated that there had been no further communication from Administration regarding the incident.

10. On 4/23/2024 at 10:25 AM, an interview was conducted with the Interim ICU Manager (E #12). E #12 stated that E #12 made the nursing staff aware every day that Pt #1 was here, that the patient was a Full Code and not a DNR until we got the paperwork. E #12 stated that E #12 advised the nurses that we still must treat Pt #1 as a Full Code until those papers get faxed over. E #12 stated that the morning that Pt #1 expired, E #12 was told by the Nursing Supervisor (E #10) that Pt #1 expired. E #12 stated that E #12 asked if the pt was "Coded". E #10 told E #12 "no" since Pt #1 was a DNR. E #12 stated that a Code should have been done on Pt #1.

11. On 4/23/2024 at 9:50 AM, an interview was conducted with the Chief Nursing Executive (E #2). E #2 stated that E #2 was aware of Pt #1's incident. E #2 stated that there had been no incident report completed and no follow-up actions implemented (as of 4/23/2024).