HospitalInspections.org

Based on the follow-up visit, four medical records reviewed (R.R) with "Do Not Resuscitate" (DNR) orders and "Do Not Intubate" (DNI), review of DNR and DNI protocols and policies/procedures, with the Institutional Program Director (employee #8), it was determined that the facility failed to ensure that policies and procedures related to advance directives for DNR and DNI orders are followed for four out of four records reviewed with DNR and DNI orders (R.R #6, #7, #8 and #9).

Deficiencies Not Corrected.

Findings include:

1. R.R #6 is a 91 year old female admitted to the facility on 10/14/12 with a diagnosis of Systemic Inflammatory Response Syndrome and Acute Renal Failure. The record was reviewed on 10/24/12 at 10:00 am and was found that the patient was receiving care at the facility and her health care ordered included DNR/DNI on 10/14/12 at 3:00 pm. A consent to Do not Intubate Do not provide Cardio respiratory Resuscitation (CPR) and Do not provide Advance Cardiac Life Support (ACLS) was found signed by a patient's relative on 10/14/12 at 2:00 pm in the event that the patient extubated or needed cardiopulmonary resuscitation. The facility's policies and procedures for DNR/DNI protocol was reviewed on 10/24/12 at 10:00 am and stated that "The physician's order for DNR/DNI was documented in the daily progress notes and the reason to take this decision in accordance with the patient and their relatives. The physician's order has to be renewed every seven days and re-evaluated every 24 hours and the results are to be documented related to this re-evaluation in the physician progress note". However, no evidence was found related to the physician's DNR/DNI order re-evaluation. No evidence was found in the physician's progress notes of the justification for the daily DNR/DNI order.

2. R.R #7 is a 62 year old male admitted to the facility on 9/27/12 with a diagnosis of Acute Myocardial Infarct (AMI). The record was reviewed on 10/24/12 at 10:30 am and was found that the patient was receiving care at the facility and her health care ordered included DNI on 10/7/12 at 9:00 pm, and re-evaluated the order on 10/13/12 at 3:10 pm, on 10/18/12 at 7:10 pm, on 10/19/12 at 7:50 pm and 10/23/12 at 6:00 pm. A consent to Do not Intubate was found signed by a patient's relative on 10/5/12 at 2:50 pm in the event that the patient needs intubation. However, evidence was provided that the physician ordered DNI two days after the patient signed the DNI consent. In the event that an emergency arises it is not clear what will happen with the patient since the patient or his relative signed the DNI consent, but there is no physician's order for the DNI after two days. The facility's policies and procedure for DNR/DNI protocol was reviewed on 10/24/12 at 10:00 am and states that "The physician's order for DNR/DNI was documented in the daily progress notes and the reason to take this decision in accordance with the patient and their relatives. The physician's order has to be renewed every seven days and re-evaluated every 24 hours and the results are to be documented related to this re-evaluation in the physician progress note". However no evidence was found related to the physician's progress note daily DNI re-evaluation and justification.

3. R.R #8 is an 86 years old female admitted to the facility on 10/17/12 with a diagnosis of Acute Renal Failure, Diabetes Mellitus Urosepsis and Dementia. The record was reviewed on 10/24/12 at 11:06 am and was found that the patient was receiving care at the facility and her health care ordered DNI on 10/23/12 at 1:00 pm. A consent to Do not Intubate was found signed by the patient's relative on 10/23/12 at 1:00 pm. No evidence was found related to the physician's DNI patient relative orientation and a physician justification to take this decision with the patient's relative.

4. R.R #9 is a 67 year old female admitted to the facility on 9/28/12 with a diagnosis of Congestive Heart Failure (CHF), Urinary Tract Infection (UTI) and Diabetes Mellitus (DM). The record was reviewed on 10/24/12 at 11:55 am and was found that the patient was receiving care at the facility and her health care ordered DNI on 10/10/12 at 6:30 pm and be re-evaluated on 10/17/12 at 11:15 am. A consent to Do not Intubate was found signed by the patient's relative on 10/9/12 at 2:25 pm in the event that the patient needs to be intubated. In the event that an emergency arises it is not clear what will happen with the patient since the patient or her relative signed the DNI consent, but there is no physician's order for the DNI after one day that the patient signed the consent. The facility's policies and procedures for DNR/DNI protocol was reviewed on 10/24/12 at 10:00 am and states that "The physician's order for DNR/DNI was documented in the daily progress notes and the reason to take this decision in accordance with the patient and their relatives. The physician's order has to be renewed every seven days and re-evaluated every 24 hours and the results are to be documented related to this re-evaluation in the physician progress note". However no evidence was found related to the physician's DNI justification and patient and relative orientation related to the need of DNI order. No evidence was found in the physician's progress notes related to the physician's re-evaluation of the need of DNI order.

Based on the follow-up visit, observational tour of the Medicine/Surgery ward, record review and interview with the Infection Control Nurse (employee #5) and Director of Nursing (employee #6), it was determined that the facility failed to provide care in an environment that is considered to be a safe setting related to appropriate surveillance related to falls and failed to ensure that patients are protected in a proper and secure manner at the emergency room.

New Deficiency.

Findings include:

1. During the record review of the Medicine/Surgery ward with the Infection Control Nurse (employee #5) on 10/24/12 from 10:35 am through 11:45 am, the following was determined:

a. R.R #20 is a 78 years old female evaluated at the emergency room on 10/19/12 at 3:37 pm and admitted to the Medicine ward on 10/19/12 with a diagnosis of Acute Coronary Syndrome. The patient was placed in the bed and stayed in the emergency room until 10/19/12 in the Intensive Care Unit (ICU #2) from 10/23/12 because no rooms with telemetry were available in the medicine ward. The patient was receiving care in the emergency room and the evaluation of fall risk was performed on 10/19/12 at 3:37 pm, in accordance with the patient's evaluation, it has eight points based on the criteria, the intervention levels for this evaluation requires nursing rounds every 30 to 60 minutes, however no evidence of these nurses rounds were found. According with a nurse (employee #4) on 10/24/12 at 11:00 pm, nursing notes from 10/22/12 at 2:05 pm, the patient is disoriented and she jumps from the bed and fell down, the nurse's notes provided evidence that she placed the patient in her bed and was evaluated by the physician (employee #1) and called the physician (employee #2) and the telephone order was received (the nurse's notes did not describe the physician orders). Nursing notes provided evidence that at 2:30 pm that the patient pulled out her intravenous (IV) lines and the nurse canalized her and administered medications but did not write what kind of medications she administered according with the physicians' order. The nurse's notes on 10/22/12 at 6:00 pm provided evidence that the patient was pending to perform a CT scan and head X-ray. On 10/23/12 at 7:25 am the patient was transferred to the Cardiovascular Laboratory to perform a Left Heart Catheterism then went to the emergency room. On 10/23/12 at 9:20 pm the nurse's notes provided evidence that the patient was admitted to the Medicine Ward and continued with Tridil at 3 ml./hour, Foley catheter, oxygen at 2 liters per minutes and telemetry however, the nurse's notes provided evidence that no telemetry monitors were available and she notified the physician and he referred to place a telemetry when available.

b. The facility failed to activate "Fall Prevention Protocol" on 10/22/12.

c. On 10/14/12 at 12:05 pm the patient was visited and was observed a laceration on the right ear and right arm. The patient was interviewed and she stated: "I fell at the emergency room but I do not know how it was because I was feeling bad and was like stunned. Thanks to God I feel better". No evidence was found of the nurse's and physician's documentation related to the patient's laceration and skin treatment.

d. The patient's daughter was interviewed and she stated during the interview on 10/24/12 at 12:05 pm "When my mother fell down she was alone because I had to leave to do some personal things. When I return at 5:00 pm I saw her sleepy I ask the nurse how was my mother and she said that she was ok and we administered "Xanax" because she was taking out her IV line. Then the physician called me because they were going to perform a head study and he told me she fell".

e. No evidence was found on 10/24/12 at 1:30 pm of the incident reported at the QAPI committee to determine if the hospital is identifying the problem and performing evaluations to take measures to ensure patient's safety.

Based on the follow-up visit, records reviewed (R.R) with the Institutional Program Director (employee #8), it was determined that the facility failed to promote the patient's right to be free of restraints for one out of one records reviewed (R.R #8).

Deficiencies Not Corrected.

Findings include:

R.R #8 is an 86 years old female who was admitted on 10/17/12 with a diagnosis of Acute Renal Failure, Diabetes Mellitus Urosepsis and Dementia. The record review was performed on 10/24/12 at 11:06 am with the Institutional Program Director (employee #8) and provided evidence that the physician placed a telephone order on 10/23/12 at 1:15 pm for restrictions. The patient was maintained on restrictions on 10/24/12, based on a telephone order. No evidence was found of the information in the physician's progress notes related with the patients restrictions orders and justification for the restriction. The facility failed to comply with restriction protocol which establishes that patients' restrictions must be justified based on a decisional algorithm which includes a complete assessment and evaluation of the patient.