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Based on observation, interview, and record review, the facility failed to document patient Advanced Directives for 6 (#s 1, 2, 3, 4, 6, and 7) of 6 sampled ED (emergency department) patients. In the event of an emergency medical situation, this deficiency could cause the providers to be unaware of a patient's wishes. Findings include:

During record review on 2/28/24, patients #1, 2, 3, 4, 6, and 7 medical records did not show an advanced directive was entered in the patients medical record. The Emergency department documentation did not show the patients were asked if they had an Advance Directive.

During an observation and interview on 2/28/24 at 11:00 a.m., two staff members, staff member B and staff member N, were asked to locate the Advance Directives in the medical records for patients 1, 2, 3, 4, 6, and 7. Staff member B and staff member N were unable to find the Advance Directives in the medical records, and they stated they were not sure where to find them. Staff member N stated the ER staff does not routinely ask patients about Advance Directives, and she stated she was sure she was not going to find them.

During an interview and record review on 2/28/24 at 11:15 a.m., staff member N stated, "We do not routinely ask about code status or advanced directives. We would only have that discussion if someone was very critical. Typically, the nurses don't do that anyway, it would be up to the doctor to ask." Review of patient #3's medical record showed the patient was a 94-year-old female who arrived in the ED via ambulance for a sudden onset of severe epigastric pain and nausea. When staff member N was asked if patient #3 would be the type of patient staff member N would consider "very critical," she stated, "Yes, she would be someone that it would be important to know if she had advanced directives." Staff member N stated it was not her expectation that her nursing staff would ask any patient about their advance directives or code status. She stated the doctor would do that, and the doctor would document that conversation in the medical record. Review of patient #3's emergency physician documentation did not show the patient was asked about Advance Directives or her code status.

During an interview on 2/28/24 at 2:40 p.m., staff member W stated the emergency department registration staff does not ask patients about Advance Directives. She stated registration staff only discussed Advance Directives if a patient asked about it, or brought their Advance Directives to the hospital to be scanned into their medical record. Staff member W stated registration staff does not keep any information concerning Advance Directives to give to patients to inform them of how they can obtain Advance Directives.

Review of a facility policy titled, "Advance Directives," dated 11/23, showed, "This facility endorses and respects each patient's right to participate in decisions regarding their medical care. It is the intent of the facility to comply with the Patient Self Determination Act and carry out the wishes of patients in decision making."