HospitalInspections.org

Based on interview, record review, review of hospital policy and procedure, the hospital failed to ensure patient rights were followed for 2 of 20 patient charts reviewed for advance directives.


The findings include:

Cross reference A 131: To ensure an incapacitated patient unable to make healthcare decisions for him/herself had his/her representative contacted to make informed decisions regarding his/her care.

Cross reference A 132: To ensure that hospital staff complied with the patient advance directives.

Based on interview, record review, review of hospital policy and procedure and coroners report, the hospital failed to ensure an incapacitated patient unable to make healthcare decisions for him/herself had his/her representative contacted to make informed decisions regarding his/her care for 1 of 20 patient charts reviewed. (Patient #1)

The findings include:

Record review on 10/28/24 at 4:30 PM of Patient #1's medical record revealed Patient #1 presented to the Emergency Department via Emergency Medical Services (EMS) on 03/14/23 at 2:22 PM after being found down in a ditch next to the road by a bystander with "palpable pulses, noted gunshot wound to posterior right occipital scalp, left clavicle and right hand. After EMS arrival on the scene, Patient #1 lost pulses with CPR started with return of spontaneous circulation achieved and brought to emergency room with apparent prolonged transport secondary to remote location with obvious bleeding from right occipital scalp, pupils fixed and dilated, i-gel (supraglottic airway device) in place with good end-tidal and bilateral breath sounds, does have good peripheral pulses. No other information is available at this time, no identification noted on patient. Trauma red (code called overhead for all department notification of emergent trauma) called prior to patient arrival and anesthesia and general surgery at bedside".

Review of Patient #1's chart revealed a DNR form signed by ED Physician #1 and Registered Nurse (RN) #1 on 03/14/23 and a physicians order for "Discharge Request (Transfer Out of Facility Request)" dated 3/14/23 at 4:21 PM. Further review of the chart revealed no documentation of a family member and/or a representative for Patient #1 who was contacted and/or present to make informed decisions on behalf of the patient for his/her care.

Review of General Surgery consult dated 3/14/23 at 3:15 PM revealed "Assessment/Plan: Patient has life-threatening injury to the brain. Neurosurgery has been consulted and Neurosurgeon #1 notified ...We will defer care to ER physician and Neurosurgeon #1 concerning further resuscitation and if not salvageable, organ donation ...".

Review of Neurosurgery consult dated 3/14/23 at 3:19 PM revealed "Assessment/Plan: Patient has sustained a gunshot wound to the head with a wound of entry in the right parieto-occipital region. A retained metallic fragment is in the right frontal lobe. There is generalized cerebral edema. Basilar cisterns around the midbrain are totally effaced. The patient is unresponsive. He/she is not breathing spontaneously. I concur with the recommendation to transfer the patient for organ donation".

Review of Hospital #1's "EMTALA Memorandum of Transfer" form revealed Patient #1 under "Medical Condition" was identified as "Patient unstable" at 3:14 PM; Risk and benefit analysis for transfer: Trauma Service; Patient consent to "medically indicated" or "Patient requested" transfer: marked as I hereby consent to transfer and signed by RN #1 and RN #2 at 3:35 PM. EMS #1 arrived at Patient #1 at 3:25 PM.

Review of EMS Patient Care Report on 10/29/24 at 6:45 PM revealed EMS crew was dispatched emergent for "Stat Transfer" to Hospital #1 to find a "male/female, unresponsive, airway intact, ventilations controlled, and weak carotid pulse. Unknown HX (history). Valid SC DNR".

Review of the County Coroners Case Report on 10/29/24 at 7:30 PM revealed the Coroner received notification of Patient #1's identification on 3/15/23 and Patient #1's identity was not made known to the patient's mother until 2:02 PM via telephone call.

During an interview on 10/31/24 at 3:45 PM to 4:00 PM, the ED Director stated "when a patient is unidentifiable, we use an alias name for the patient and if identified prior to leaving then we can merge the chart (with their name). We usually get law enforcement involved, and law enforcement is responsible for identification. A patient can be treated and transferred out as a John or Jane Doe. A physician would decide if a patient needs to be a DNR and transferred out to a higher level of care".

During an interview on 11/01/24 at 4:12 PM to 4:19 PM, ED Physician #1 stated, "The patient was a gunshot wound to the head, hand, and arm. He/she was found in the ditch and it was a prolonged arrival with EMS coming here. Once here we stabilized the airway with an ET (endotracheal tube), consulted with general surgery, trauma, and neurosurgeon. Sent for CT (Computed Tomography) scans. Based on the CT scans the Neurosurgeon said the patient was nonsurvivable injuries, the patient had a previous craniotomy with a pop off valve to allow for swelling of the brain which helped him/her out. Once neurosurgeon said unsurvivable- we transferred the patient out and he/she stated we should consult out for organ procurement. I spoke to trauma surgeon at Hospital #2 and he/she accepted the patient and we transferred him/her out to Hospital #2".

Facility policy, entitled "Advance Directives: Withholding or Withdrawing Treatment" last revision date 10/2021, revealed "(From SC law regarding Durable Power of Attorney): T. Where a patient is unable to consent , decisions concerning his/her healthcare may be made by the following persons in the following order of priority: 5. A parent of the patient; 6. An adult sibling of the patient, or if the patient has more than one adult sibling, a majority of the adult siblings who are reasonably available for consultation; ...9. A person given authority to make healthcare decisions for the patient by another statutory provision. 10. If, after good faith efforts, the hospital or other health care facility determines that the person listed in 1-8 ar unavailable to consent on behalf to the patient, a person who has an established relationship with the patient, who is acting in food faith on behalf of the patient, and who can reliably convey the patient's wishes but who is not a paid caregiver or a provider of healthcare services to the patient. For the purposes of this item, a person with an established relationship is an adult who special care and concern for the patient, who is generally familiar with the patient's health care views and desires, and who is willing and able to become involved in the patient's health care decisions and to act in the patient's best interests. The person with an established relationship shall sign and date a notarized acknowledgement form, provided by the hospital or other healthcare facility in which the patient is located, for placement in the patient's records setting forth the nature and length of the relationship and certifying that he meets such criteria. Along with the notarized acknowledgement form, the hospital or other health care facility shall include in the patient's medical record documentation of its efforts to locate persons with higher priority under this statue as required by subsection (B) of the Adult Health Care Consent Act (Title 44 Chapter 66). Documentation of efforts to locate a decision maker who is a person identified above should be recorded in the patient's medical record ...2. A patient's inability to make decisions for themselves should be certified by two (2) physicians, each of whom has examined the patient. In an emergency, the patient's inability to make healthcare decisions may be certified by a physician responsible for the care of the patient. The physician should document in the patient's record that the delay occasioned by obtaining certification from two (2) physicians would be detrimental to the patient's health ...".

Based on interview, record review and review of hospital policy and procedure, the hospital failed to ensure that hospital staff complied with the patient advance directives for 1 of 20 patient charts reviewed for advance directives. (Patient #18).

The findings include:

Record review on 10/30/24 at 9:55 AM of Patient #18's chart revealed Patient #18 was from the nursing home and presented to the hospital on 10/14/24 at 9:59 AM with a "Physician's Certification of Resident's Decision" dated "10/09/24 stating he/she is able to make Health Care Decisions". Review of "Resident/Family Consent for Cardiopulmonary Resuscitation" revealed Patient #18 marked "I understand that CPR constitutes an extraordinary measure and SHOULD be done on Patient #18" dated 10/04/24.

Record review on 10/30/24 at 9:55 AM of Patient #18 revealed Patient #18 presented to the Emergency Department (ED) on 10/14/24 with a chief complaint of cardiac arrest at 9:59 AM. Review of ED Physician #1's History of Present Illness" revealed "Patient is a male with metastatic melanoma with obvious tumors noted throughout his/her body, presents from nursing home with cardiac arrest according to EMS the patient had been given pain medications this morning and became very dyspneic and was noted to be breathing about 60 times a minute, before EMS could administer Narcan the patient apparently coded and they began CPR, he/she was intubated by EMS with a 7 oh ET (endotracheal tube), they state he/she went into V. tach (ventricular tachycardia) and was defibrillated was given multiple rounds of epinephrine, he/she presents with Lucas device administering compressions and he/she is currently being bagged via ET tube, he/she is otherwise unresponsive. Per nursing home the patient was a full code but on further discussion with ICU (intensive care unit) physician here the patient had been made a DNR on his/her most recent visit and is unclear how there was communication with the nursing home. No family is available. No other history available".

Review of Patient #18's "Summary of Care" revealed documentation that the patient's daughter and power of attorney confirmed that she was under the impression the patient was a DNR and wants him/her to be a DNR, apparently there was confusion at the nursing home as they needed the daughter to sign a form of a.m. DNR therapy and would not except the form that was sent form the hospital...the daughter is requesting that we withdraw care she does not want the patient intubated she would like the ET tube to be removed, she will also wants us to stop all antibiotics and pressors as she knows this is end-of-life for patient. She understands that with the withdrawal of all the support that the patient will likely pass quickly, she is asking that we keep him/her comfortable, this conversation was confirmed with charge nurse and ICU physician who with me signed a DNR and we proceeded with extubation given the futility of continuing care for this critically ill patient with metastatic melanoma who was obvious daily at end-of-life". Further review of the chart revealed an undated SC Emergency Medical Services DNR order for Patient #18 signed by 2 physicians. Review of the chart revealed no documentation of the patient's daughter being the designated power of attorney.

During an interview on 10/31/24 at 11:12 AM, the Emergency Department (ED) Manager stated, "the daughter made the decision for the patient because he/she was unable to make the decision for him/herself. The two doctors signing the DNR is our standard for a patient to be considered a DNR".

Facility policy, entitled "Advance Directives: Withholding or Withdrawing Treatment" revealed "IV. Policy:...B. The patient (inpatient and outpatient) has the right to formulate advance directives, and to have hospital staff implement and comply with their advance directive...".

Based on interview and record review, the hospital failed to ensure hospital staff involved with patient care received training in Organ Procurement Organization (OPO) for 39 of 39 ED Medical Providers educational files reviewed.

The findings include:

Review of Emergency Department (ED) Providers educational files on 10/31/24 between 1:51 PM to 2:46 PM revealed no documentation of OPO education for 39 of 39 providers.

Review of Lifelink Organ Procurement Agreement dated 12/17/14 revealed "Education and Collaboration: D.1. The Foundation and Donor Hospital shall work collaboratively to provide and receive ongoing education of their respective staffs to ensure all appropriate personnel are knowledgeable regarding the organ donation program and are able to function within each other's procedures and protocols and to encourage cooperation in assessing donor suitability for the organ recovery and transplant programs...".

During an interview on 11/01/24 at 9:08 AM, the Administrative Director of Patient Safety stated that the doctors do not get any OPO training, only the nursing staff.