HospitalInspections.org

Based on interview and record review, the faciltiy failed to ensure that the patient's representative is informed of the discontinuation of patient care on 1 of 15 sampled patients (SP). (SP# 29).

Findings Include:

Review of sampled patient (SP) # 29 medical record revealed that the pt. came in through Emergency Department (ED) on 5/29/16 with altered mental status, and was unable to sign consents and documents, and had no advance directives noted. On 05/31/16 it was noted that the facility was able to obtain a copy of the court order, appointing a public legal guardian for SP# 29. The document was executed on May 3, 2016 that showed the following information:
1. Name of the Intake Coordinator of the Guardianship Program
2. Address of the Guardianship Program
3. Phone number of the Guardianship Program
4. Direct phone number of the Intake Coordinator
5. Fax number
6. Email address of the Intake Coordinator

Review of the Death/Expiration Log revealed that SP# 29 expired at 3:00 pm on June 13, 2016, name of the attending physician, family was not called, and the body was released to Miami Dade Public Interment Program (MDPIP) on June 30, 2016.

Review of SP# 29 Internal Medicine Progress Notes dated 06/13/16 revealed that on 07/10/2016, the Attending physician wrote an addendum after a discussion and advice from the chief medical officer (CMO). The addendum revealed that the Attending Physician saw SP# 29 on 06/13/16 and then later died and was not present during the expiration. The nurse called and informed the attending physician of the pt's. demise and provided a phone number from the pt' s. chart to call the family/guardian. The attending physician called and left message advising to call the intensive care unit (ICU) as soon as possible.

Interview of the Director of ICU on 08/16/16 at 10:15 am revealed that on July 5, 2016, the legal guardian called and spoke to her, and that the legal guardian was unaware of the death of SP# 29.

Interview with the Staffing Coordinator on 08/16/16 at 12:05 pm revealed that on 06/30/2016, the body of SP# 29 was released to the Miami Dade Public Interment Program (MDPIP) as there was no family/nearest of kin (NOK)/guardian that claimed the body.

Review of the electronic health record (E.H.R) via Cerner on 08/17/16 with the Director of ICU revealed that there was no social worker notes or social worker assessments for SP# 29.

Review of the Policy and Procedure Code No: 400.057 Subject: "Expired Patients" revealed that the attending physician or resident physician will notify the family or next of kin of pt's. death and if unable to locate the family, the physician will ask the Social Worker Services (SWS) to locate, and if SWS is unavailable, the Administrator in Charge (AIC) will assist in locating family or next of kin.

Based on interview and record review the facility failed to honor the patient/ family/ representative right to participate in the development and implementation of his plan of care in 1 of 15 sampled patients (SP # 29).

The findings:

Review of the medical record revealed that Sampled Patient (SP) # 29 came from a nursing home and was admitted to the hospital on 5/29/16 due to altered mental status and sepsis.
SP# 29 record also revealed that the patient was unable to sign consents and documents, and had no advance directives noted. A code blue was called on 06/13/16 and rescue attempts to resuscitate the pt. was unsuccessful and the pt. expired on 06/13/16.

On 05/31/16 it was noted that the facility was able to obtain a copy of the court order appointing a public legal guardian for SP# 29. The document was executed on May 3, 2016 that showed the following information:
1. Name of the Intake Coordinator of the Guardianship Program
2. Address of the Guardianship Program
3. Phone number of the Guardianship Program
4. Direct phone number of the Intake Coordinator
5. Fax number
6. Email address of the Intake Coordinator

Interview with the Chief Medical Officer on 08/16/16 at 10:30 am confirmed that there were no advanced directives.

Review of the electronic health record (E.H.R) via Cerner on 8/17/16 with the Director of ICU (Intensive Care Unit) showed there is no social worker notes or social worker discharge planning or assessments for SP# 29.

Interview on 8/16/16 at 11:00 am with Director for Case Management who stated that the Initial evaluation is completed within 48 hours for all patients by social workers and within 24 hours by the case managers. On the case of SP# 29, the pt. was not seen by a social worker during his hospital stay.


Review of the Death/Expiration Log revealed that SP# 29 expired at 3:00 pm on June 13, 2016, name of the attending physician, family was not called, and the body was released to Miami Dade Public Interment Program (MDPIP) on June 30, 2016.

Review of SP# 29 Internal Medicine Progress Notes dated 06/13/16 revealed that on 07/10/2016, the Attending physician wrote an addendum after a discussion and advice from the chief medical officer (CMO). The addendum revealed that the Attending Physician saw SP# 29 on 06/13/16 and then later died and was not present during the expiration. The nurse called and informed the attending physician of the patient ' s demise and provided a phone number from the patient ' s. chart to call the family/guardian. The attending physician called and left message advising to call the intensive care unit (ICU) as soon as possible.

Interview of the Director of ICU on 08/16/16 at 10:15 am revealed that on July 5, 2016, the legal guardian called and spoke to her, and that the legal guardian was unaware of the death of SP# 29.

Interview with the Staffing Coordinator on 08/16/16 at 12:05 pm revealed that on 06/30/2016, the body of SP# 29 was released to the Miami Dade Public Interment Program (MDPIP) as there was no family/nearest of kin (NOK)/guardian that claimed the body.

Review of the Policy and Procedure Code No: 400.057 Subject: "Expired Patients" revealed that the attending physician or resident physician will notify the family or next of kin of patient ' s death and if unable to locate the family, the physician will ask the Social Worker Services (SWS) to locate, and if SWS is unavailable, the Administrator in Charge (AIC) will assist in locating family or next of kin.

Review of the policy "Recording Guidelines: Patient Assessment & Discharge Planning" dated ( 03/2014) showed under advance directives : indicate if the patient has an advance directive, ability/wish to complete or is decline. The discharge planner will check the system to search an advance directive executed on prior admissions. Any advance directives found will be reviewed with the patient/family/representative for any changes and placed in the patient's medical record. If the patient has a legal guardian, a copy of the court order should be placed in the patient's medical record.

Based on interview and record review the facility failed to honor the patient/family/legal guardian rights to formulate Advanced Directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives for 1 of 15 sampled patients (SP # 29).

The findings:

Review of the medical record revealed that Sampled Patient (SP) # 29 came from a nursing home and was admitted to the hospital on 5/29/16 due to altered mental status and sepsis.
SP# 29 records also revealed that the patient was unable to sign consents and documents, and had no advance directives noted. A code blue was called on 06/13/16 and rescue attempts to resuscitate the pt. was unsuccessful and the pt. expired on 06/13/16.

On 05/31/16 it was noted that the facility was able to obtain a copy of the court order appointing a public legal guardian for SP# 29. The document was executed on May 3, 2016 that showed the following information:
1. Name of the Intake Coordinator of the Guardianship Program
2. Address of the Guardianship Program
3. Phone number of the Guardianship Program
4. Direct phone number of the Intake Coordinator
5. Fax number
6. Email address of the Intake Coordinator

Interview with the Chief Medical Officer on 08/16/16 at 10:30 am confirmed that there were no advanced directives.

Review of the electronic health record (E.H.R) via Cerner on 8/17/16 with the Director of ICU (Intensive Care Unit) showed there is no social worker notes or social worker discharge planning or assessments for SP# 29.

Interview on 8/16/16 at 11:00 am with Director for Case Management who stated that the Initial evaluation is completed within 48 hours for all patients by social workers and within 24 hours by the case managers. On the case of SP# 29, the pt. was not seen by a social worker during his hospital stay.


Review of the Death/Expiration Log revealed that SP# 29 expired at 3:00 pm on June 13, 2016, name of the attending physician, family was not called, and the body was released to Miami Dade Public Interment Program (MDPIP) on June 30, 2016.

Review of SP# 29 Internal Medicine Progress Notes dated 06/13/16 revealed that on 07/10/2016, the Attending physician wrote an addendum after a discussion and advice from the chief medical officer (CMO). The addendum revealed that the Attending Physician saw SP# 29 on 06/13/16 and then later died and was not present during the expiration. The nurse called and informed the attending physician of the patient ' s demise and provided a phone number from the patient ' s. chart to call the family/guardian. The attending physician called and left message advising to call the intensive care unit (ICU) as soon as possible.

Interview of the Director of ICU on 08/16/16 at 10:15 am revealed that on July 5, 2016, the legal guardian called and spoke to her, and that the legal guardian was unaware of the death of SP# 29.

Interview with the Staffing Coordinator on 08/16/16 at 12:05 pm revealed that on 06/30/2016, the body of SP# 29 was released to the Miami Dade Public Interment Program (MDPIP) as there was no family/nearest of kin (NOK)/guardian that claimed the body.

Review of the Policy and Procedure Code No: 400.057 Subject: "Expired Patients" revealed that the attending physician or resident physician will notify the family or next of kin of patient ' s death and if unable to locate the family, the physician will ask the Social Worker Services (SWS) to locate, and if SWS is unavailable, the Administrator in Charge (AIC) will assist in locating family or next of kin.

Review of the policy "Recording Guidelines: Patient Assessment & Discharge Planning" dated ( 03/2014) showed under advance directives : indicate if the patient has an advance directive, ability/wish to complete or is decline. The discharge planner will check the system to search an advance directive executed on prior admissions. Any advance directives found will be reviewed with the patient/family/representative for any changes and placed in the patient's medical record. If the patient has a legal guardian, a copy of the court order should be placed in the patient's medical record.

The policy " Patient's Rights And Responsibilities" ( dated 05/2013) showed the patient, their advocate or legal respresentatives have the right, in collaboration with their physicians, to make decisions involving their care.

Based on interview and record review, the facility failed to provide a discharge assessment and planning evaluation for 1 of 15 sampled patients (SP# 29).

Findings:

Review of the medical record revealed that Sampled Patient (SP) # 29 came from a nursing home and was admitted to the hospital on 05/29/16 due to altered mental status and sepsis. A code blue was called on 06/13/16 and rescue attempts to resuscitate the pt. was unsuccessful and the pt. expired on 06/13/16.

Review of the electronic health record (E.H.R) on 8/17/16 with the Director of ICU (Intensive Care Unit) showed there was no social worker/ case manager notes, discharge planning, or assessments for SP# 29.

Interview on 08/16/16 at 11:00 am the Director for Case Management stated that the Initial evaluation is completed within 48 hours for all patients by social workers and within 24 hours by the case managers. On the case of SP# 29, the pt. was not seen by a social worker during his hospital stay.

Review of the Policy and Procedures Section: 200; Subject: "Recording Guidelines: Patient Assessment & Discharge Planning" (03/2014) showed that the discharge planner - Clinical Resources Management/ Social Work Department shall complete an Initial Discharge Planning Assessment plan early in the admission and if the assessment cannot be completed, information will be reflected in the progress notes.

The policy " Patient's Rights And Responsibilities" ( dated 05/2013) showed the patient, their advocate or legal respresentatives have the right, in collaboration with their physicians, to make decisions involving their care.