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Based on interview and review of documentation Hospital #3 failed to ensure that an Advanced Directive was properly executed for one of 10 applicable patients (Patient #1).

Findings included:

Review of the Policy/Procedure titled Limitation of Treatment Directives effective 4/1/10, indicated the Attending Physician or designated assistant was responsible for entering appropriate orders on the Orders for Limitation of Treatment Directives Form and a progress note in the patient's record describing the discussions leading to the decision to limit treatment. Changes in preferences regarding limitations of treatment were indicated on the Orders Form.

Review of Physician Orders dated 3/23/11 at 4:36 P.M. indicated Patient #1 was a full code and that family was discussing the code status.

Review of the Complainant's letter received 7/15/11 indicated that a physician (identified by name and determined to be the Renal Fellow) spoke with Patient #1 and family regarding DNR status. The letter indicated that the Renal Fellow was told Patient #1 was a DNR status at both Hospital #1 and Hospital #2.

The Renal Fellow was unable to be interviewed because he was no longer assigned to Hospital #3 and was out of the country at the time of the survey.

Review of the Initial Patient Progress Note entered by Cardiologist #2 dated 3/23/11 at 6:14 P.M. indicated Patient #1 was a DNR status.

Cardiologist #2 said when Patient #1 was first admitted he/she was DNR status. Cardiologist #2 said he spoke with Patient #1 regarding the DNR status because Patient #1's ACID had been temporarily turned off and therefore would not shock. Cardiologist #2 said he was concerned about what actions to be taken if Patient #1 went into a sustained life-threatening arrhythmia and discussed options with Patient #1. Cardiologist #2 said Patient #1 wanted actions to be taken and therefore the DNR was rescinded.

Review of Physician Orders dated 3/23/11 and 3/24/11 indicated there were no orders regarding Patient #1's DNR status.

Review of the scanned medical record indicated an Orders for Limitation of Treatment Directives Form was not completed.