HospitalInspections.org

Based on policy review, record review, and family and staff interview, the Critical Access Hospital (CAH) failed to protect and promote each patient's rights by failing to inform the patient and/or family representative of their health status, care planning and treatment, policies and procedures concerning advance directives, and the right to make informed decisions regarding their care (Refer to C2513) and by failing to follow policies and procedures concerning advance directives (Refer to C2515). Failure to inform patient and/or family representatives of their health status and not following advance directive preferences, limited the patient's and/or family representative's ability to exercise their rights.

Based on policy review, record review, and family and staff interview, the Critical Access Hospital (CAH) failed to inform the patient and/or family representative of their health status, the right to be involved in care planning and treatment, and the right to make informed decisions regarding their care, as allowed under state law, for 1 of 10 closed Emergency Department (ED) records reviewed (Patient #19). Failure to inform patient and/or family representatives of their health status limited their ability to exercise their rights.

Findings include:

Review of policy titled "Code Status" occurred on 10/17/23. This policy, revised 04/2023, stated, "Level of therapeutic effort (Code Level) is to be designated by the Provider . . . after discussion with patient/legal agent and consideration of any advance directives . . . ."

Review of policy titled "Patient Rights and Responsibilities" occurred on 10/17/23. This policy, revised 9/2022, stated, "All patients (or significant others as appropriate) are to be informed of his/her rights and responsibilities. . . and can expect to have those rights respected . . . . The patient has the right to: Right to make informed decisions regarding your care . . . able to request or refuse treatment in accordance with law and regulation. . . . Right to formulate health care directives and have hospital staff and practitioners comply with these directives. . . . "

Review of Patient #19's record occurred on 10/17/23. Diagnoses included partial thickness burns of multiple sites and COPD (Chronic Obstructive Pulmonary Disease). A nursing home transferred the patient by ambulance to the CAH's ED. Documentation sent with the patient included a copy of the nursing home's admission record identifying Patient #19's POA (Power of Attorney) and Advance Directive. The Advance Directive stated, "ND POLST (North Dakota Physicians Orders for Life Sustaining Treatment) (A) DNR/Do Not Attempt Resuscitation. . . . (B) Comfort Measures only . . . Use medication . . . wound care and other measures to relieve pain. . . . Use oxygen. . . . Do not transfer to hospital for life sustaining treatment . . . Transfer if comfort needs cannot be met in current location."
The record stated that on arrival the patient was in respiratory distress and immediately intubated. The ED staff arranged to transfer Patient #19 by air ambulance to a burn center. The record lacked evidence the hospital staff contacted Patient #19's POA to discuss treatment options.

During an interview on 10/17/23 at 4:26 p.m. the POA of Patient #19 stated the nursing home informed her of an accident that happened at the nursing home [name of nursing home] and the nursing home transferred Patient #19 to the hospital [name of hospital]. She stated she received no communication from the hospital on Patient #19's condition or plan of care. She stated she was upset with the transfer and Patient #19 was a DNR (Do Not Resuscitate). She stated after she tried to find out where the hospital transferred Patient #19, a provider from a burn center called her, informed her of Patient #19's condition and code status. She informed the burn center not to continue with advanced care. The burn center took Patient #19 off life support, and he passed away soon after.

During an interview on 10/17/23 at 5:42 p.m. an ED provider (#6) stated he believed staff informed family and was not aware of any family present in the ED.

The CAH failed to inform patients and/or representatives of their health care status and limited their ability to exercise their rights to request or refuse treatment.

Based on policy review, record review, family and staff interview, the Critical Access Hospital (CAH) failed to provide care in accordance with advance directives for 1 of 10 closed Emergency Department (ED) records reviewed (Patient #19). Failure to follow advance directives limited the patient and/or family representatives ability to exercise their rights.

Findings include:

Review of the policy titled "Code Status" occurred on 10/17/23. This policy, revised 04/2023, stated: "Level of therapeutic effort (Code Level) is to be designated . . . after discussion with patient/legal agent and consideration of any advance directives . . . . All Emergency Room patients will be considered a Full Code unless there is evidence of a healthcare directive stating otherwise . . ."

Review of the policy titled "Patient Rights and Responsibilities" occurred on 10/17/23. This policy, revised 9/2022, stated, "All patients (or significant others as appropriate) are to be informed of his/her rights and responsibilities while a patient at CHI (Catholic Health Initiatives) St (Saint) Alexius Devils Lake Hospital and can expect to have those rights respected. . . . The patient has the right to: Right to make informed decisions regarding your care . . . including pain management, end of life care . . . able to request or refuse treatment in accordance with law and regulation . . . . Right to formulate health care directives and have hospital staff and practitioners comply with these directives. . . ."

Review of Patient #19's record occurred on 10/17/23. Diagnoses included partial thickness burns of multiple sites and COPD (Chronic Obstructive Pulmonary Disease). A nursing home transferred the patient by ambulance to the CAH's ED. Documentation sent with the patient included a copy of the nursing home's admission record identifying Patient #19's POA (Power of Attorney) and Advance Directive. The Advance Directive stated, "ND POLST (North Dakota Physician Orders for Life Sustaining Treatment) (A) DNR/Do Not Attempt Resuscitation . . . . (B) Comfort Measures only . . . Use medication . . . wound care and other measures to relieve pain . . . . Use oxygen . . . . Do not transfer to hospital for life sustaining treatment . . . Transfer if comfort needs cannot be met in current location."
The record stated that on arrival the patient was in respiratory distress and immediately intubated. The ED staff arranged to transfer Patient #19 by air ambulance to a burn center.

During an interview on 10/17/23 at 10:20 a.m., an ED staff member (#5) stated staff determine the code status of a patient by looking at documentation sent with a patient, asking family, and/or looking in the electronic health record.

During an interview on 10/17/23 at 4:26 p.m., the POA of Patient #19 stated [name of nursing home] informed her of an accident that happened at [name of nursing home] and transferred Patient #19 to [name of hospital]. She stated she received no communication from the hospital on Patient #19's condition or plan of care. A friend of Patient #19, who was at the hospital, called her and informed her the hospital treated Patient #19 and transferred him to a burn center. She stated she was upset with the transfer and Patient #19 was a DNR (Do Not Resuscitate). She stated after she tried to find out where the hospital transferred Patient #19, a provider from a burn center called her, informed her of Patient #19's condition and code status. She informed the burn center not to continue with advanced care. The burn center took Patient #19 of life support, and he passed away soon after.

During an interview on 10/17/23 at 5:42 p.m. an ED provider (#6) stated patient's code status can be found in documentation sent with patients, listed, or received from family members. ED Provider (#6) stated he did not look for Patient #19's code status. He stated when Patient #19 arrived, he assessed the patient, noticed the patient had a compromised airway and made the decision to intubate. He stated the intubation was difficult because of swelling of the airway. He stated he followed protocol and made transfer arrangements for higher level of care. He stated he believed staff informed family and was not aware of any family present in the ED.

The facility failed to follow Advance Care Health Directives and failed to promote and protect patients exercising their rights.