HospitalInspections.org

Based on record review and interview, the facility failed to follow their policies and procedures for documenting patient consent in 1 of 3 patient's with a do not resuscitate order (Patient #1) in a total of 10 patient medical record records reviewed.

Findings include:

Review of policy titled "Medical Emergencies: Code 4/Resuscitation" #211, revision date 7/2020 page 8, 5.7 Do Not Resuscitate Inpatients #3 revealed "Once the "code status" decision has been made, this directive shall be recorded... by the attending physician. The Medical Record shall contain documentation as to the patient's medical condition, the patient's... concurrence, and all other facts and considerations relevant to the decision."

Patient #1's medical record was reviewed and revealed Patient #1 is 59-year-old with a history hypertension, chronic obstructive pulmonary disease, coronary artery disease, diabetes mellitis, congestive heart failure and schizoaffective disorder who was transferred from another acute care facility 3/31/2021 at 7:59 PM for evaluation after a fall. S/he was admitted 4/01/2021 at 10:37 AM pending a cardiac consult. Physician order by Physician W, dated 4/01/2021 at 12:36 AM, revealed "Do Not Resuscitate [DNR] , Patient is DNR Yes, Intubation No, Antiarrhythmics No, Cardioversion No, Vasopressor No." Physician order by Physician Y on 4/02/2021 at 12:10 AM revealed "Full Resuscitation, Patient is DNR No, Intubation Yes, Antiarrhythmics Yes, Cardioversion Yes, Vasopressor Yes." The Informed Consent for a right heart catheterization on 4/02/2021 under Do-Not-Resuscitate (DNR) Orders, was not filled in, and it was signed by Patient #1 and Physician Z on 4/02/2021 at 6:33 AM. On 4/02/2021 at 10:34 AM order by Physician Z revealed "Full Resuscitation." There is no physician documentation as to the patient's medical concurrence and considerations relevant to the decisions surrounding the change from DNR to Full Resuscitation prior to the cardiac catheterization performed 4/02/2021.

On 4/26/2021 at 11:45 AM during interview with Inpatient Nursing Director H, Director H stated it is the expectation of the physician to document his discussions with the patient when placing orders for Do Not Resuscitate and Do Not Resuscitate/Selective orders.

On 4/26/2021 at 1:37 PM during interview with Inpatient Nursing Director H and Information Technology (IT) Specialist M, when asked to view the documentation of the discussion with the patient when the DNR status was changed from Do Not Resuscitate to Full Resuscitation on 4/01/2021 or 4/02/2021, the IT Specialist M confirmed "we didn't find anything."

Based on record review and interview the facility failed to take actions aimed to identify opportunities for improvement to ensure patient safety in 1 of 1 self reported events (Patient #2) on the Behavior Health Unit with a census of 12 on 4/22/2021 and 12 on 4/26/2021 during survey.

Findings include:

Review of policy "Patient Rights & Responsibilities #2689, revision date 12/12/2019, page 7 revealed "The patient... has the right to accept or refuse the treatment or procedure."

Review of Patient #2's medical record revealed patient was transferred from another acute care facility and admitted to the Behavioral Health Unit involuntarily on on a Chapter 51 hold (involuntary admission). A court date of 4/01/2021 was delayed. Patient #2 had refused multiple oral medications and was given intramuscular injections. The medical record confirmed Patient #2 had refused to take the oral risperidone (a psychotropic medication) on 4/02/21 and 4/03/2021 but it was charted Patient #2 had received risperidone oral solution 4/02/2021 at l:09 PM and 6:42 PM and 4/03/2021 at 9:29 AM and 7:28 PM "mixed in juice." There was no court order to administer Patient #2 medications. There was no signed informed consent for psychotropic medication administration in Patient #2's medical record.

Review of compliance report dated Sunday, April 5, 2021, by Registered Nurse (RN) V, revealed "A patient committed to the behavioral health unit ... involuntarily under WI statute Ch. 51 was being given psychotropic medication without her knowledge or consent." The issue was brought to the attention of the prescribing nurse practitioner, medical director, and unit manager on the evening of Saturday, 4/03/2021 and an ethics consult was sought by complainant who was instructed to raise concern with "risk management for legal counsel."

Review of "Code of Conduct" dated 12/2020 page 8 under Compliance & Integrity Program revealed "The three main objectives of the program are to prevent, detect and correct violations."

Review of "Incident (Patient Safety Event) Reporting/Sentinel Event Management" #166, revision date 7/30/2019, under Immediate Response to Events revealed "Any team member who discovers witnesses or is in (sig) involved in a Patient Safety Event shall complete a web-based incident report as soon as possible .... d) Certain Patient Safety Events may not be easily categorized as to whether a Sentinel Event ... In such cases, site and system risk management, compliance, ... any other clinical or departmental area involved in the event shall work collaboratively to determine the appropriate response and plan of coordination ... This incident reporting/sentinel event process is designed to review and improve patient care." Under 5.3 Significant Event b) i. revealed "A root cause analysis will be performed on all potential Sentinel Events ... for analysis and improvement purposes." Appendix A, #166 A titled "Patient Safety Event Reporting" under Patient safety events related to medications ... Report if ... medication event is suspected."

On 4/26/2021 at 2:30 PM during interview with Aurora St Lukes South Shore President O, when asked if this was a sentinel event, s/he stated it was not determined to be, because there was no permanent damage, it wouldn't "reach that level."

On 4/26/2021 at 2:30 PM during interview with Behavior Health Chief Nursing Officer (CNO) R, CNO R stated "no" they had not completed a Root, Cause, Analysis for performance improvement on this incident or completed any auditing, to ensure continued compliance with administration of emergency medications was being maintained.