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Based on medical record review and staff interview, it was determined the facility failed to ensure compliance with Federal laws and regulations related to advanced directives for 2 of 13 adult inpatients (#19 and #30) whose records were reviewed for advanced directives. This resulted in a lack of documentation in patients' records that they were informed of their right to formulate advanced directives, such as a living will or durable power of attorney. Findings include:

An advanced directive is defined at 42 CFR 489.100 as "a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated." In accordance with the provisions of 42 CFR 489.102(a), the advanced directives regulations apply to CAHs. 42 CFR 489.102(b)(1) requires that notice of the CAH's advanced directives policy be provided at the time an individual is admitted as an inpatient.

42 CFR 489.102(b)(2), states the CAH is required to "Document in a prominent part of the individual's current medical record, or patient care record in the case of an individual in a religious non-medical health care institution, whether or not the individual has executed an advance directive." The hospital failed to comply with this Federal regulation as follows:

1. Patient #19's medical record documented an 81 year old female who was admitted as a swing patient on 7/22/12 following gall bladder surgery. She was discharged on 7/26/12. Her medical record did not state if she had developed an advance directive. The record did not state what her wishes for health care were should she not be able to make those wishes known. The record also did not state who could make medical decisions for her if she was unable to direct her care.

The Quality Manager reviewed Patient #19's medical record on 9/11/12 beginning at 4:15 PM. She stated documentation regarding an advance directive was not present in the record.

The CAH did not document whether Patient #19 had an advance directive or whether she was afforded the opportunity to develop one.

2. Patient #30's medical record documented a 48 year old female who was admitted on 9/12/12 where she had total knee surgery. She was currently a patient as of 9/13/12. The section labeled "Review-ADVANCE DIRECTIVE," dated 9/05/12 at 1:30 PM, stated "Yes/Location: on file at hospital." The medical record did not contain the referenced advance directive.

The RN who documented that the advance directive was on file was interviewed on 9/13/12 beginning at 11:50 AM. She was not able to locate the advance directive. She stated she did not know where advance directives were kept at the hospital. The RN stated she documented Patient #30 had an advance directive at the hospital because the patient had told her this during a pre-admission interview. The RN stated she had not seen the advance directive.

The Quality Manager also reviewed Patient #19's medical record on 9/13/12 at 11:50 AM. She stated she did not know where advance directives were kept.

The CAH did not ensure Patient #19's advance directive was available to staff.

Based on staff interview and review of medical records and CAH policies, it was determined the facility failed to ensure appropriate policies for the provision of pain procedures had been developed. This affected the care of 3 of 3 pain procedure patients (#35, #37, and #38) whose records were reviewed. This resulted in a lack of direction to staff and had the potential impact patient care. Findings include:

1. The policy "EPIDURAL STEROID: LUMBAR," dated 8/01, discussed the scheduling, equipment, and set up of the procedure. The policy did not specify what type of preoperative work up, such as a history and physical examination, the practitioner was required to perform.

The CRNA who performed epidural steroid injections for Patients #35 and #37 was interviewed on 9/13/12 beginning at 3:00 PM. He confirmed the policy. He stated primary care physicians examined patients in their offices. He stated pain procedures were then scheduled at the CAH. He stated the results of history and physical examinations were not typically sent to the hospital prior to the procedures. He said he did not normally conduct a physical examination of patients prior to the procedures.

The epidural steroid policy did not define the work up for pain procedure patients.

2. Patient #35's medical record documented a 70 year old male who had a lumbar epidural steroid injection performed on 9/06/12 beginning at approximately 1:25 PM. Patient #35 was discharged at 2:25 PM on 9/06/12. The "Outpatient Record-Nursing Department" form, dated 9/06/12, stated Patient #35 received Versed 2 mg IV during the procedure. Patient #35's medical history was not present in the medical record. In addition, a physical examination was not documented by a practitioner prior to the procedure.

The Quality Manager reviewed Patient #35's medical record on 9/13/12 beginning at 2:20 PM. She confirmed a medical history was not documented. She confirmed a physical examination of Patient #35 by the practitioner was not documented.

The CAH did not document a medical history or physical examination of Patient #35 prior to epidural steroid injection.

3. Patient #37's medical record documented a 75 year old female who had an epidural steroid injection performed on 8/20/12 beginning at approximately 9:00 AM. Patient #37 was discharged at 9:45 AM on 8/20/12. The "Outpatient Record-Nursing Department" form, dated 8/20/12, stated Patient #37 received Versed 2 mg IV during the procedure. Patient #37's medical history was not present in the medical record. In addition, a physical examination was not documented by a practitioner prior to the procedure.

The Quality Manager reviewed Patient #37's medical record on 9/13/12 beginning at 2:20 PM. She confirmed a medical history was not documented. She confirmed a physical examination of Patient #37 by the practitioner was not documented.

The CAH did not document a medical history or physical examination of Patient #37 prior to epidural steroid injection.

4. Patient #38's medical record documented a 36 year old male who had an epidural steroid injection performed on 8/15/12 beginning at approximately 1:40 PM. Patient #38 was discharged at 2:20 PM on 8/15/12. The "Outpatient Record-Nursing Department" form, dated 8/15/12, stated Patient #38 received Versed 4 mg IV during the procedure. Patient #38's medical history was not present in the medical record. In addition, a physical examination was not documented by a practitioner prior to the procedure.

The Quality Manager reviewed Patient #38's medical record on 9/13/12 beginning at 2:20 PM. She confirmed a medical history was not documented. She confirmed a physical examination of Patient #38 by the practitioner was not documented.

The CAH did not document a medical history or physical examination of Patient #38 prior to epidural steroid injection.