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Based on medical record review and interview the facility failed to implement the advance directives for one of seven patients sampled during investigation of this complaint.

Patient #1, a seventy-five year old male presented to the emergency department of the facility via ambulance on 6/14/2019 at 0017. The patient had requested ambulance transport to the hospital due to difficulty breathing and severe scrotal pain. The patient had a present history of hypertension, heart failure, end stage renal disease, and chronic obstructive pulmonary disease and was maintained on home oxygen.

Findings:

The emergency department physician (Staff E) completed the emergency department history and physical examination on 6/14/2019 at 0129. Review of this document indicates the patient reported to the ED physician that he will absolutely never do dialysis and wants to be on hospice care at home. Patient states he is only here to manage his scrotal pain and that he wants nothing else to be done.

Review of ED nursing notes dated 6/14/2019 at 0130, 0201, 0205, and 0807 indicate the patient is only here for treatment of pain, and refused other interventions that were offered by hospital staff (dialysis treatment, intravenous fluids). Nursing staff recorded that the patient stated at 0807 "I don't want any treatment."

ED nursing notes dated 6/14/2019 indicate that a physician (Staff F) responded to the bedside of the patient at 0955 for report by nursing staff of low blood pressure. The patient declined to have intravenous fluids administered to treat the low blood pressure. The progress note indicates a discussion between the patient's primary care physician (Staff B) and the ED physician (Staff F) and that the patient desires to be placed on hospice, he is refusing all treatment at this time. He (patient #1) states he would like to be a DNR/DNI.

Review of a physician progress note timed 6/14/2019 at 0955 in the electronic medical record shows the patient's attending physician is at the bedside to see the patient. He, (Staff B) entered an order for DNR on 6/14/2019 at 1016.

Review of the patient's "CONFIDENTIAL NURSING REPORT-HAND OFF FAX REPORT," an informational record documenting the patient's care in the ED, indicates the patient's Code status to be "Full." The document was faxed to the medical surgical floor at 1449. ED nursing notes dated 6/14/2019 at 1509 indicate report was called to the medical surgical floor, and the patient left the ED for the medical surgical floor at 1539.

Review of the patient's admission history and physical completed by the attending physician and dictated on 6/14/2019 at 1517 indicates: "He would like to be a DO NOT RESUSCITATE. That will be honored.

Review of the electronic medical record shows that the attending physician's DNR order now includes DNI (Do not intubate) as well. This revised order is dated 6/14/2019 at 1536. This order was acknowledged by nursing staff A at 1549.

Staff A was interviewed via telephone by DOH survey staff on 10/30/2019 at 10:00 AM. She stated on interview that the ED nursing staff had indicated the patient to be a "Full Code" on the "hand-off" report. She "acknowledged" a physician order from staff B for DNR. Upon receipt of this physician order she checked the patient's chart for a completed DNR form. There was no DNR form in the chart. She then completed a DNR form with the patient and his family and placed it in the chart for the physician to sign. She stated she did not place a purple bracelet on the patient's wrist because the DNR form was not signed yet.

Review of Form PHY-DNR-001 entitled DO NOT RESUSCITATE (DNR) AND WITHHOLD/WITHDRAW LIFE SUSTAINING TREATMENT FORM (Rev. 11/10) indicates the patient has decisional capacity, that the patient has given consent to a DNR order, that the patient gave oral consent in the presence of witnesses. The form is signed by two witnesses. It is not signed by a physician. The time the form was completed is not documented.

Review of the Respiratory Therapy progress notes in the patient's medical record indicates that after receiving a nebulizer treatment by respiratory therapy on 6/14/2019 at 2030 the patient became unresponsive to voice and sternal rub. The Respiratory Therapist checked for a "purple bracelet" on the patient's wrist, and initiated CPR because no purple bracelet was present.

A physician progress note indicates that a code was called 6/14/2019 at 2057 for a witnessed respiratory arrest, the patient then became pulseless. Life sustaining treatment (cardio-pulmonary resuscitation) was admininistered and . the patient was intubated and placed on a ventilator. The electronic medical record documented a DNR/DNI but the paper chart contained the above Form PHY-DNR-001 unsigned by a physician. Additionally the patient was never given a "purple bracelet" indicating DNR.

The patient had indicated to multiple staff members throughout his time at the hospital that he did not want life sustaining treatment administered.

Based on interview and record review the facility failed to promptly investigate and analyze an adverse patient event which occurred on 6/14/2019 in which a patient who had directed facility staff to withhold CPR was resuscitated after experiencing a respiratory arrest. Findings are:

-Review of the medical record competed during the 10/29/2019 site visit by DOH Survey staff revealed that the patient, who had given oral instruction to facility staff to withhold CPR, was resuscitated. (See A 132).

-Staff C, interviewed by telephone on 10/30/2019 at 10:30 AM, stated that the nursing supervisor on duty during the resuscitation was made aware that the patient, who had not wanted life sustaining treatment, was resuscitated and placed on a ventilator.

-DOH survey staff interviewed the patient safety officer during the site visit on 10/29/2019 and requested the incident report and investigation of the event. The patient safety officer stated on interview that there was no incident report documenting the event.

The NYSDOH investigation determined that nursing staff failed to file an incident report of this event with the hospital patient safety officer. This resulted in a missed opportunity for review and analysis by the hospital wide QAPI program of an important patient safety event.