HospitalInspections.org

Based on medical record review (MR) and interview, in 1 of 10 MRs (Patient #1), the facility failed to determine who could make medical decisions for a patient and what health care decisions could be made. This could lead to a patient's wishes concerning their provision of care to not be followed.

Findings include:

-- Per MR review, on 3/28/2025 Patient #1 presented to the emergency department (ED) via emergency medical services (EMS) with nausea and vomiting and increased work of breathing. Patient #1 was triaged as an emergency severity index (ESI- algorithm for ED patients to determine the severity of presenting illness and ED needs) of 3 (1-emergent, 5- non-urgent). Patient #1 had a past medical history of cognitive impairment, small bowel obstructions without surgical intervention, and prior sigmoid colectomy.

Patient #1 was diagnosed with influenza A, possible pneumonia, and CT revealed a high-grade small bowel obstruction (complete obstruction in the bowel). Patient #1 was admitted to the hospital.

A surgical consult was completed. There was a potential need for surgical intervention, which was discussed with Patient #1's sibling.

Another CT was completed which revealed the small bowel obstruction was worse. Patient #1 was scheduled for surgery for 4/3/2025. Verbal consent was obtained from their sibling.

Patient #1 was taken to the operating room for a laparoscopic repair of their small bowel obstruction. During surgery, a complication occurred that resulted in conversion to an open exploratory laparotomy.

Following their procedure, Patient #1 was brought to the intensive care unit (ICU) for monitoring and supportive care.

On 4/5/2025, Patient #1 was seen by an intensivist who noted they were starting to show signs of septic shock.

A CT scan of their abdomen revealed changes from a small bowel resection with ascites and evidence of peritonitis (infection of the peritoneal lining in the abdomen). The findings were compatible with peritonitis related to a post-operative leak.

Patient #1 was seen by Staff A, Clinical Staff, following new onset sepsis (bloodstream infection), Staff A spoke with Patient #1's sibling extensively regarding the concerns that if Patient #1 does not have operative intervention, that it will be a terminal issue and Patient #1 will die from sepsis. Patient #1's sibling declined surgery and opted for supportive care. Aggressive supportive care was provided to Patient #1.

On 4/9/2025 at 12:17 pm, Staff B, Clinical Staff, reached out to Patient #1's residential facility to clarify who can make medical decisions for them. Patient #1 did not have a health care proxy (HCP). Patient #1's sibling can make medical decisions unless the recommendation is to withhold treatment or change code status.

At 2:47 pm, a surgeon discussed Patient #1's legal status who was a "ward of the state" and their sibling could not "withhold treatment". The surgeon opined it was reasonable for Patient #1 to go to the OR for surgical intervention. The plan was discussed with Patient #1's sibling who agreed and consent was obtained. Patient #1 was taken to the OR for repair of their small bowel.

The MR lacked documentation of a HCP or medical decision making documention when surgery was withheld on 4/5/2025.

-- During interview of Staff C, Quality Personnel, on 9/16/2025 at 2:00 pm, they confirmed Patient #1 did not have a health care proxy.