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Based on medical record review, document review, policy review, and interview, in one of ten medical records reviewed, it was determined the facility failed to protect and promote the rights of all patients by not completing the process for obtaining advance directives and medical orders for life sustaining treatment, which resulted in Patient #1 being intubated against their expressed wishes.

Reference:
482.13 (b)(3)- Patient Rights: Informed Decisions

Based on policy review, medical record review, and interview, in one of ten medical records reviewed, it was determined the facility failed to complete the process for obtaining advance directives and medical orders for life sustaining treatment, which resulted in Patient #1 being intubated against their expressed wishes.

Findings include:

Review of the policy "Medical Orders for Life Sustaining Treatment including do not resuscitate (DNR)" dated on 10/26/20 revealed a physician will place an order for do not resuscitate (refrain from cardiopulmonary resuscitation), do not intubate (do not insert breathing tube), and/or other life sustaining treatment. Do not intubate orders are patient specific. Orders go into effect once they are signed. The medical orders for life sustaining treatment order (MOLST) form must be filled out completely and signed by the patient or delegated individual, the physician, nurse practitioner, or physician Assistant and at least one witness. Staff are then notified of the do not resuscitate/life sustaining treatment order.

Review of the medical record for Patient #1 revealed on 09/23/24 at 04:50 PM, a medical order for life sustaining treatments (MOLST- selected treatment options permitted by the patient, family, or proxy) form was completed and signed by Patient #1 and Staff (W), Physician. The document indicated cardiopulmonary resuscitation would be performed if the heart stops beating, with a trial of non-invasive ventilation only (external supply of oxygen for breathing support). If the trial ventilation failed, do not intubate (insert tube into throat to provide breathing support by a machine). The form lacked the signature of at least one witness. On 09/25/24 at 05:11 AM, Patient #1 was found on the floor in the restroom bleeding from the rectum and vomiting blood. Patient #1 was intubated and transferred to the surgical intensive care unit.

Interview on 11/19/24 at 11:55 AM with Staff (K), Registered Nurse, revealed on 09/25/24 at 05:00 AM, a rapid response (overhead nursing emergency page requesting additional help for a declining patient) was called after Patient #1 fell. Patient #1 was unstable and confused. The MOLST form in the medical record was incomplete, there were no witness signatures. Patient #1 was moved by staff from the floor to the bed and intubated (breathing tube inserted into mouth and throat to support breathing) them due to deteriorating breathing. Nurses are responsible for ensuring advance directive forms are completed and in the medical record when applicable.