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Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure staff obtained and documented in the medical record the intent of the patient's advance directives according to policy and procedure for two (#3, #5) of ten sampled records.

Findings include:

Review of the facility policy "Advance Directive" policy #B.03, last revised 8/2013, indicated the facility will determine if the patient has an advance directive or health care surrogate; (II) Procedure (B) Patient Access Department shall ask the patient (or patient's representative, if patient is not capable) whether the patient has executed an advance directive. If an advance directive has been executed, admissions personnel shall request a copy be provided for the patient's medical record; the admitting nurse will document in the patient's medical record whether or not the patient has executed an advance directive; (D) if a copy of the advance directive is not provided, the patient's nurse will record the substance of its contents on the Admission Data Form.

1. Patient #3 was admitted on 4/27/15. Review of the Conditions of Admissions form dated 4/27/2015 at 12:00 p.m. revealed the patient indicated with their initials she had advance directives and the patient was requested to supply a copy to the facility. Review of the medical record revealed the patient was transferred from a SNF (Skilled Nursing Facility) to the hospital. The SNF supplied a copy of the patient's facesheet from the SNF indicating the patient was a full code.

Review of the nursing admission history dated 4/27/2015 at 6:21 p.m. revealed no indication the nurse gathered the information of the patient's intent as stated in the advance directive.

2. Patient #5 was admitted on 4/26/15. Review of the Conditions of Admissions form revealed the patient indicated she had advance directives and a copy was requested to be placed on the medical record.

Review of the nursing admission history dated 4/27/2015 at 1:10 p.m. revealed the patient confirmed she had advance directives. Review of the documentation revealed no evidence the nurse documented the patient's intent that was indicated in the advance directives.

Interview with the Director of PCU (Progressive Care Unit) on 6/2/2015 at approximately 1:30 p.m. confirmed the above findings at the time of the medical record review.