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Based on record reviewed and interview the Hospital failed to follow the Hospital's internal policy and procedure for activating the Health Care Proxy (HCP) in three of five patients (Patient #1, Patient #5 and Patient #6) who lacked the capacity to make health care decisions.
Findings included:

The Hospital policy titled Health Care Proxies and Living Wills, dated 9/13, indicated the physician was to document in the medical record the determination of the patient's lack of capacity to make health care decisions and indicate the surrogate decision maker (i.e. the Health Care Proxy, Legal Guardian or Next of Kin).

Patient #1 was diagnosed with respiratory failure and was treated with sedation and mechanical ventilation. Patient #1 underwent three invasive procedures on 2/7/16; a bronchoscopy (visualization of the lungs), the insertion of a central line (an intravenous line into a major blood vessel) and the insertion of an arterial line (a catheter inserted into an artery). These procedures required informed consent and were signed by Patient #1's family member. The Medical Record lacked the physician's determination of Patient #1's lack of capacity to make health care decisions and the activation of the Health Care Agent was not written until the time of survey at 8:30 A.M. on 2/11/16.

Patient #5 was post-operative from an abdominal surgery. Patient #5 was treated with sedation and mechanical ventilation. Patient #5 required multiple procedures requiring informed consent (i.e. surgery, the insertion of a central line, blood transfusion and an invasive heart tracing) that were signed by Patient #5's family member. The Medical Record lacked the physician's determination of Patient #5's lack of capacity to make health care decisions and the activation of the Health Care Agent.

The Surveyor interviewed one of Patient #5's physicians at 1:45 P.M. on 2/11/16. The physician said she was not familiar with the process to activate the surrogate decision maker.

Patient #6 was diagnosed with altered mental status and respiratory failure and was treated with sedation and mechanical ventilation. The Medical Record lacked the physician's determination of Patient #6's lack of capacity to make health care decisions and the activation of the surrogate decision maker.