HospitalInspections.org

Based on document review and interviewit was determined that one of ten medical records reviewed in the survey sample had the paper copy of the Do Not Resuscitate Order (DNR) not dated or timed (Patient #9).

The findings included:

Patient #9's medical record was reviewed on August 13, 2014 and August 14, 2014. A Do Not Resuscitate Order was found dated 08/13/2013 and timed at 10:45 am in the Electronic Medical Record. The order had been entered by Staff #10.

Documentation in Patient #9's electronic medical record on 08/13/2013 by Staff #10 states case discussed with the son/daughter of Patient #9. "No more pressors will be added. She/he is do not resuscitate as outlined above. RN witnessed his/her agreement to not escalate therapy beyond the parameters as outlined above."

Documentation in Patient #9's electronic medical record by Staff nurse caring for the patient on 08/13/2014 at 9:56 am states patient's son/daughter "is now agreeing to DNR with current medications in use. No compressions."

Documentation in Patient #9's electronic medical record by Pastoral Care on 08/13/13 indicates the patients' son/daughter had agreed to the DNR.

An order for a DNR was also found on the "Pink Sheet" which is placed in the patient's hard copy of the medical record. This order had been filled out in part by Staff #10. The form had Staff #10's signature but did not have a date or time on the form. Staff #10 was shown the form on 08/13/2014 at approximately 12:30 pm and confirmed the "Pink Sheet" did not have a time or date on the form. Staff #10 confirmed the box was not checked which indicated the patient and/or family had consented to the DNR. Staff #10 verified the documentation pertaining to the family's agreement to the DNR was in the electronic medical record.

The policy titled Determination of Code Status was requested, and received on 08/13/2014 at 11:00 am. The policy states that it is the responsibility of the physician to document on the pink code status sheet the name of the patient/surrogate decision maker providing consent and to document the date and time and sign the pink "Code Status" sheet. The policy states either A or B is to be selected. Selection A indicates a DNR and Selection B indicates code alternatives (limited code) and requires the physician to select which alternatives they will use such as ambu bag assisted ventilation, cardiac compressions, intubation, mechanical ventilation, and other modalities. Staff #10 selected A and selected NO (by putting a line through the column) for any alternative measures on the DNR (pink sheet) code status paper order form for Patient #9.

During the medical record review it was noted five of ten medical records (Patient Records #1, #2, #6, #7, and #8) reviewed with the paper copy of the DNR order (pink sheet) did not have the box checked indicating the family or patient had consented to the DNR. All electronic medical records reviewed had documentation of a DNR order and the consent of the patient and/or family.

Staff #1 was present during the findings in the medical records.