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Based on medical record review, facility policy review, and interview, the facility failed to ensure one patient (#4), or the patient's legal representative, was informed of the right to formulate Advance Directives and determine the patient's current Advance Directives; and failed to ensure the current Advance Directives of one patient (#4) were acted upon prior to discontinuing care for one of five (#1, #2, #3, #4, and #5) patient records reviewed.
The facility's failure resulted in an Immediate Jeopardy.

The finding included:

REFER TO: A-117
The facility failed to ensure the patient, or the patient's legal representative, was informed of the right to formulate Advance Directives and determine the patient's current Advance Directives.

REFER TO: A-132
The facility failed to ensure the patient's current Advance Directives were acted upon prior to discontinuing care.

Based on medical record review, facility policy review and interview, the facility failed to determine if Advance Directives had been formulated for one patient (#4); and failed to inform one patient (#4), or the patient's representative, of the right to formulate Advance Directives prior to discontinuing care for one of five (#1, #2, #3, #4, and #5) patient medical records reviewed.

The findings included:

Patient #4 was admitted, via Emergency Medical Services (EMS) transport from home, on a non-emergency basis to the Emergency Department (ED) on August 15, 2010 at 2:26 p.m., for evaluation of constipation with no bowel movement for 5 days.

Medical record review of the Initial Assessment Form, dated August 15, 2010 at 2:26 p.m., revealed "...Chief Complaint: Constipation...no bm (bowel movement) X (times) 5 days, on hospice at home, vomited last night..."

Medical record review of the Emergency Provider Record (doctor #1), undated and timed at 2:58 p.m., revealed "...Historian: EMS...UNABLE TO OBTAIN HISTORY DUE TO: Severe Dementia...no family present at initial exam...on Hospice at Home...Progress: 11:02 p.m., spoke with the pt's dtr (daughter)...OK c/ (with) NGT (Naso-Gastric Tube)/rectal tube if necessary and admission as well..." Continued review of the Emergency Provider Record revealed no documentation the patient's daughter was asked if the patient had Advance Directives for health-care decisions or inform the daughter of the right to formulate an Advance Directive. Continued review of the Emergency Provider Record revealed "...Discussed with (named hospitalist) doctor (who) will see in ED...CLINICAL IMPRESSION: Obstipation...DISPOSITION ORDER TIME (August 16, 2010) 12:55 a.m....admitted...stable..."

Medical record review of the Nurses' Notes, documented by Registered Nurse (RN) #1 revealed RN #1 documented on August 16, 2010 at 2:19 a.m. that the Family Nurse Practitioner (FNP) had seen the patient and wrote admit (admission to the hospital) orders at 1:20 a.m. Continued review revealed RN #1 documented on August 16, 2010 at 2:21 a.m., the patient expired, had no pulse, no respirations, and was seen by the doctor at 2:10 a.m.

Medical record review of the (Hospital Admit) History and Physical, conducted by the Family Nurse Practitioner (FNP) for the Hospitalist group of physicians, dated August 16, 2010, at 2:00 a.m., revealed "...Chief Complaint: No bowel movement for 5 days, and this is per ER (Emergency Room) report...History of Present Illness: All information was taken through reviewing reports and talking to ER staff, as the patient did not answer any questions...Patient of note is a hospice patient. He is being cared for at home for advanced dementia...Past Medical History: Patient's past medical history was gleaned through a detailed chart review (obtained medical record of hospitalization in April 2010)...Social History:...He lives at home with family care...He is currently on hospice care...Code Status: Patient is a DNR (Do Not Resuscitate - if breathing/heart beat ceases, do nothing to attempt to revive)...We will honor Advanced Directives (as informed per ED doctor #1 for this admit) and have Case Management assist with discharge planning to return home to hospice when his Obstipation has resolved..."

Medical record review of the Transfer of Care (note from doctor #1 going off duty in ED to doctor #2 coming on duty in ED to assume the care of the patient), no date or time noted, revealed "...94 y/o (year old) wm (white male) admitted this A.M. for Obstipation...REEVALUATION/IMPRESSION: (August 16, 2010) 2:08 a.m. "...re-examined...Called by nurse to see pt b/c (because) no response...Pt had no palpable pulse on arrival. He is DNR. (DNR per order hospital admit order written by FNP) He was technically admitted to the hospital service and had been seen by (FNP) Hospitalist...Time of death 2:08 a.m. (August 16, 2010)..."

Review of the facility policy (not numbered) Advance Directives, last reviewed by the facility on March 10, 2008, revealed "...will provide written information to individuals...to make decisions concerning their medical care, including the right to formulate advance directives...provides care in a manner consistent with these directives...Advance Directive: An individual instruction or a written statement relating to the subsequent provision of health care for the individual, including, but not limited to, a durable power of attorney for health care...Universal Do Not Resuscitate Order: A written order that applies regardless of the treatment setting and that is signed by the patient's physician which states that in the event the patient suffers cardiac or respirator arrest, cardiopulmonary resuscitation would not be attempted...Adults...should be informed on admission of their right to make medical decisions and to execute a written Advance Directive...If the patient is unable to comprehend the information, it should be given to the patient's representative..."

Interview in the conference room with Registered Nurse (RN) #3 on October 19, 2010 at 1:00 p.m., revealed RN #3 was the charge nurse on duty at the time of the admit for the patient. RN #3 related the "Code Status" (measures to take in the event of cessation of respirations and/or heart beat) of an ED patient would be "Full Code" (take any and all measures to revive the patient) unless otherwise directed and, if possible, attempt to determine if there were any Advance Directives (instructions from the patient or the legal representative on measures to take, if any, in the event of the cessation of respiration and/or heart beat). Continued interview revealed RN #3 related a "Hospice" (patient receiving end of life care for a terminal illness) patient would be a DNR. Continued interview revealed RN #3 had received no training related to Code Status for Hospice patients.

Interview in the conference room with RN #2 on October 19, 2010 at 1:20 p.m., revealed RN #2 provided care for patient #4 from admit until 10:00 p.m. Continued interview confirmed "...(the patient) arrived by EMS...do not recall any papers or information from EMS on code status or hospice...Hospice can be DNR or Full Code"

Interview in the conference room with doctor #1 on October 19, 2010 at 1:35 p.m., revealed doctor #1 was on duty and cared for the patient from arrival at the ED until 11:00 p.m. Continued interview confirmed the patient was "...brought to the ED by EMS...no Code status was available...information from EMS did indicate the patient was hospice...(doctor #1) spoke with the daughter but did not discuss Code status and daughter did not mention the patient's Full Code status ...did not review the patient's most recent hospital admit record (April 2010) to determine the code status (which was documented in the April 2010 medical record as Full Code)...did not think the patient was a full code as the patient was a Hospice patient...after the patient's daughter requested a conference after the death of the patient, the chart was reviewed; the facility became aware of the issue of the physician #1's lack of understanding related to possibilities for the Code status of Hospice patients'; and this was discussed by Risk Management with the Medical Director of the ED on October 5, 2010 to clarify a patient on Hospice could be a full code and Code status would need to be determined on Hospice patients..."

Interview in the conference room with RN #1 on October 19, 2010 at 1:55 p.m., revealed RN #1 was on duty and had care of the patient when the patient expired. Continued interview revealed "...gave report for admit (to nurse receiving the patient on the medical surgical unit)...patient was fine when seen 15 - 30 minutes before I went to get last set of (ED) vital signs before transfer and the patient wasn't breathing...did not start CPR...I received information the patient was a No Code from the doctor's (FNP Hospitalist) orders written for admit to the hospital...I went to get the (ED) doctor (#2) to see the patient after I discovered the patient wasn't breathing..."

Interview in the conference room by phone with the Family Nurse Practitioner (FNP) on October 19, 2010 at 3:35 p.m., revealed the admit orders to the hospital were written by the FNP and the Code Status was ordered as DNR. Continued interview revealed the FNP spoke with the ED doctor (doctor #1) and the ED nurse (RN #1), and reviewed the most recent hospital admission record of April 2010 and the current ED record. Continued interview revealed the recent hospital record of April 2010 had the patient's Code Status as Full Code. Continued interview revealed the DNR status for the patient's admit orders was obtained from the ED doctor of DNR for the patient's current admit. Continued interview revealed the FNP understood a designation of Hospice does not equate with a Code Status of DNR. Continued interview revealed the FNP did not work for the doctors in the ED group and was not able to take orders from the doctors in the ED group. Continued interview confirmed the FNP did not obtain clarification of the different code status of Full Code listed in the patient's most recent hospitalization record of April 2010 versus information obtained from the ED doctor before writing the order for DNR; and the FNP did not clarify with the family the desired measures to be taken for end of life care.

Interview by phone with doctor #2 on October 20, 2010 at 10:20 a.m., revealed doctor #2 was doctor who pronounced the death of the patient on August 16, 2010. Continued interview revealed the patient had been admitted to the hospital; seen by the Family Nurse Practitioner who wrote the hospital admit orders; and the patient was awaiting transfer to the medical surgical unit. Continued interview revealed doctor #2 was notified by RN #1 that the patient had passed away. Continued interview revealed doctor #2 "...immediately went to see the patient...no breathing...no palpable carotid pulse...asked nurse patient code status and was informed the patient was a DNR...death was then pronounced..." Continued interview revealed doctor #2 "...always does a full code on any patient unless there is information to the contrary...no assumptions about a hospice patient being a DNR..."

Interview in the conference room with the Risk Manager and the Chief Nursing Executive on October 19, 2010 at 4:00 p.m., confirmed the patient was not provided any type of life saving measures when the patient's breathing and heart stopped; and change of the code status for the patient from Full Code to DNR status was not clarified with the family. Continued interview confirmed the facility's policy on Advance Directives was not carried out.

Based on medical record review, facility policy review and interview, the facility failed to ensure staff had knowledge of obtaining, clarifying and implementing Advance Directives for one patient (#4) prior to discontinuing care for one of five (#1, #2, #3, #4, and #5) patient medical records reviewed.

The findings included:

Patient #4 was admitted, via Emergency Medical Services (EMS) transport from home, on a non-emergency basis to the Emergency Department (ED) on August 15, 2010 at 2:26 p.m., for evaluation of constipation with no bowel movement for 5 days.

Medical record review of the Initial Assessment Form, dated August 15, 2010 at 2:26 p.m., revealed "...Chief Complaint: Constipation...no bm (bowel movement) X (times) 5 days, on hospice at home, vomited last night..."

Medical record review of the Emergency Provider Record (doctor #1), undated and timed at 2:58 p.m., revealed "...Historian: EMS...UNABLE TO OBTAIN HISTORY DUE TO: Severe Dementia...no family present at initial exam...Progress: 11:02 p.m., spoke with the pt's dtr (daughter)...OK c/ (with) NGT (Naso-Gastric Tube)/rectal tube if necessary and admission as well..." Continued review of the Emergency Provide Record revealed no documentation the patient's daughter was asked if the patient had Advance Directives for health-care decisions or inform the daughter of the right to formulate Advance Directives, Continued review of the Emergency Provider Record revealed "...Discussed with (named hospitalist) doctor (who) will see in ED...CLINICAL IMPRESSION: Obstipation...DISPOSITION ORDER TIME (August 16, 2010) 12:55 a.m....admitted...stable..."

Medical record review of the Nurses' Notes, documented by Registered Nurse (RN) #1 revealed RN #1 documented on August 16, 2010 at 2:19 a.m. that the Family Nurse Practitioner (FNP) had seen the patient and wrote admit (admission to the hospital) orders at 1:20 a.m. Continued review revealed RN #1 documented on August 16, 2010 at 2:21 a.m., the patient expired, had no pulse, no respirations, and was seen by the doctor at 2:10 a.m.

Medical record review of the (Hospital Admit) History and Physical, conducted by the Family Nurse Practitioner (FNP) for the Hospitalist group of physicians, dated August 16, 2010, at 2:00 a.m., revealed "...Chief Complaint: No bowel movement for 5 days, and this is per ER (Emergency Room) report...History of Present Illness: All information was taken through reviewing reports and talking to ER staff, as the patient did not answer any questions...Patient of note is a hospice patient. He is being cared for at home for advanced dementia...Past Medical History: Patient's past medical history was gleaned through a detailed chart review (obtained medical record of hospitalization in April 2010)...Social History:...He lives at home with family care...He is currently on hospice care...Code Status: Patient is a DNR (Do Not Resuscitate - if breathing/heart beat ceases, do nothing to attempt to revive)...We will honor Advanced Directives (as informed per ED doctor #1 for this admit) and have Case Management assist with discharge planning to return home to hospice when his Obstipation has resolved..."

Medical record review of the Transfer of Care (note of information from doctor #1 going off duty in ED which was provided to doctor #2 coming on duty in ED to assume the care of the patient), no date or time noted, revealed "...94 y/o (year old) wm (white male) admitted this A.M. for Obstipation...REEVALUATION/IMPRESSION: (August 16, 2010) 2:08 a.m. "...re-examined...Called by nurse to see pt b/c (because) no response...Pt had no palpable pulse on arrival. He is DNR. (DNR per order hospital admit order written by FNP) He was technically admitted to the hospital service and had been seen by (FNP) Hospitalist...Time of death 2:08 a.m. (August 16, 2010)..."

Review of the facility policy (not numbered) Advance Directives, last reviewed by the facility on March 10, 2008, revealed "...will provide written information to individuals...to make decisions concerning their medical care, including the right to formulate advance directives...provides care in a manner consistent with these directives...Advance Directive: An individual instruction or a written statement relating to the subsequent provision of health care for the individual, including, but not limited to, a durable power of attorney for health care...Universal Do Not Resuscitate Order: A written order that applies regardless of the treatment setting and that is signed by the patient's physician which states that in the event the patient suffers cardiac or respirator arrest, cardiopulmonary resuscitation would not be attempted...Adults...should be informed on admission of their right to make medical decisions and to execute a written Advance Directive...If the patient is unable to comprehend the information, it should be given to the patient's representative..."

Interview in the conference room with Registered Nurse (RN) #3 on October 19, 2010 at 1:00 p.m., revealed RN #3 was the charge nurse on duty at the time of the admit for the patient. RN #3 related the "Code Status" (measures to take in the event of cessation of respirations and/or heart beat) of an ED patient would be "Full Code" (take any and all measures to revive the patient) unless otherwise directed and, if possible, attempt to determine if there were any Advance Directives (instructions from the patient or the legal representative on measures to take, if any, in the event of the cessation of respiration and/or heart beat). Continued interview revealed RN #3 related a "Hospice" (patient receiving end of life care for a terminal illness) patient would be a DNR. Continued interview revealed RN #3 had received no training related to Code Status for Hospice patients.

Interview in the conference room with RN #2 on October 19, 2010 at 1:20 p.m., revealed RN #2 provided care for the patient from admit until 10:00 p.m. Continued interview confirmed "...(the patient) arrived by EMS...do not recall any papers or information from EMS on code status or hospice...Hospice can be DNR or Full Code..."

Interview in the conference room with doctor #1 on October 19, 2010 at 1:35 p.m., revealed doctor #1 was on duty and cared for the patient from arrival at the ED until 11:00 p.m. Continued interview confirmed the patient was "...brought to the ED by EMS...no Code status was available...information from EMS did indicate the patient was hospice...(doctor #1) spoke with the patient's daughter but did not discuss Code status and daughter did not mention the patient's Full Code status ...did not review the patient's most recent hospital admit record (April 2010) to determine the code status (which was documented in the April 2010 medical record as Full Code)...did not think the patient was a full code as the patient was a Hospice patient...after the patient's daughter requested a conference after the patient's death, the chart was reviewed; the facility became aware of the issue of the physician #1's lack of understanding related to possibilities for the Code status of Hospice patients'; and this was discussed by Risk Management with the Medical Director of the ED on October 5, 2010 to clarify a patient on Hospice could be a full code and Code status would need to be determined on Hospice patients..."

Interview in the conference room with RN #1 on October 19, 2010 at 1:55 p.m., revealed RN #1 was on duty and had care of the patient when the patient expired. Continued interview revealed "...gave report for admit (to nurse receiving the patient on the medical surgical unit)...the patient was fine when seen 15 - 30 minutes before I went to get last set of (ED) vital signs before transfer and the patient wasn't breathing...did not start CPR...I received information the patient was a No Code from the doctor's (FNP Hospitalist) orders written for admit to the hospital...I went to get the (ED) doctor to see the patient after I discovered the patient wasn't breathing..."

Interview in the conference room by phone with the Family Nurse Practitioner (FNP) on October 19, 2010 at 3:35 p.m., revealed the admit orders to the hospital were written by the FNP and the Code Status was ordered as DNR. Continued interview revealed the FNP spoke with the ED doctor and the ED nurse, and reviewed the most recent hospital admission record of April 2010 and the current ED record. Continued interview revealed the recent hospital record of April 2010 had the patient's Code Status as Full Code. Continued interview revealed the DNR status for the patient's admit orders was obtained from the ED doctor of DNR for the patient's current admit. Continued interview revealed the FNP understood a designation of Hospice does not equate with a Code Status of DNR. Continued interview revealed the FNP did not work for the doctors in the ED group and was not able to take orders from the doctors in the ED group. Continued interview confirmed the FNP did not obtain clarification of the different code status of Full Code listed in the patient's most recent hospitalization record of April 2010 versus information obtained from the ED doctor before writing the order for DNR; and the FNP did not clarify with the family the desired measures to be taken for end of life care.

Interview by phone with doctor #2 on October 20, 2010 at 10:20 a.m., revealed doctor #2 was doctor who pronounced the death of the patient on August 16, 2010. Continued interview revealed the patient had been admitted to the hospital; seen by the Family Nurse Practitioner who wrote the hospital admit orders; and the patient was awaiting transfer to the medical surgical unit. Continued interview revealed doctor #2 was notified by the ED nurse that the patient had passed away. Continued interview revealed doctor #2 "...immediately went to see the patient...no breathing...no palpable carotid pulse...asked nurse patient code status and was informed the patient was a DNR...death was then pronounced..." Continued interview revealed doctor #2 "...always does a full code on any patient unless there is information to the contrary...no assumptions about a hospice patient being a DNR..."

Interview in the conference room with the Risk Manager and the Chief Nursing Executive on October 19, 2010 at 4:00 p.m., confirmed the ED staff did not have an understanding of the Hospice patient's ability to be a Full Code. Continued interview confirmed the facility policy on Advance Directives was not followed.

Based on medical record review, review of Advance Directives policy, review of facility bylaws, review of Nurse Practitioner Privileges, and interview, the facility failed to ensure a Family Nurse Practitioner practiced within the scope of the privileges granted.

The findings included:

Review of the facility document, Medical Staff Bylaws, approved by the Board of Directors on February 21, 2008, revealed "...Allied Health Professionals (AHP)...Individuals other than a licensed physician...who exercise independent judgment within the area of their professional competence and who are qualified to render medical and surgical care under the supervision of a Physician who has been accorded privileges to provide such care in the hospital...Position Evaluation and Descriptions: Written guidelines for the Performance of specified services by AHP will be developed by the Administrator and Medical Staff with input, where applicable, from the chief of the clinical services involved. For each category of AHP's, such guidelines must include, without limitations:...A description of services to be provided and procedures performed...Definition of the degree of assistance that may be provided to a practitioner in the treating of patients...including the degree of practitioner supervision required for each service...Prerogatives of Allied Health Professionals:...Provide specifically designed patient care services under the supervision or direction of a physician member of the Medical Staff and consistent with the limitations stated in the Bylaws...Write orders only to the extent specified in the Medical Staff rules and regulations, and consistent with the limitations stated in the Bylaws..."

Review of the facility document Nurse Practitioner Privileges revealed (named) NP (Nurse Practitioner)...Requested: The Nurse Practitioner will practice under the supervision of the physician with the following privileges: Assists in gathering and recording patient data and documentation...Performs H&P (History and Physicals),...Order routine patient care including medications, tests, labs and treatment for non-critically ill patients within their protocols..."

Interview in the conference room by phone with the Family Nurse Practitioner (FNP) on October 19, 2010 at 3:35 p.m., revealed admit orders to the hospital's medical surgcal unit for patient #4 were written by the FNP on August 16, 2010, and the Code Status was ordered as DNR. Continued interview revealed the FNP spoke with the ED doctor #1 and reviewed the recent hospital admission record of April 2010 and the current ED record. Continued interview revealed the recent hospital admission record of April 2010 had the patient's Code Status as Full Code. Continued interview revealed the code status of DRN for the patient's admit orders was obtained from the ED doctor #1 for the current admit. Continued interview revealed the FNP did not work for the doctors in the ED physician's group and was not able to take orders from the doctors in the ED physician's group. Continued interview confirmed the FNP worked for the Hospitalist physician's group.

Interview in the conference room with Risk Manager and the Chief Nursing Executive on October 19, 2010 at 4:00 p.m., confirmed the FNP did not obtain clarification of the lack of documentation in the ED record of the patient's Code Status as compared to the Full Code Status information available in the hospital record of April 2010 when reviewed by the FNP; and the FNP granted privileges did not allow the FNP to work for or take orders from physicians other than the Hospitalist physicians group. Continued interview confirmed the FNP was not following the Bylaws or Privileges granted for the FNP.

Based on medical record review and interview, the facility failed to ensure medically necessary information related to code status was provided to the receiving hospital for one patient (#5) being transferred for five Emergency Department patients reviewed.

The findings included:

Patient #5 was admitted to the Emergency Department (ED) on August 15, 2010 with Chief Complaint of Abdominal Pain and Vomiting.

Medical record review revealed the ED physician examined patient #5, ordered labs, initiated IV (intravenous) fluids, and ordered IV anti-nausea medication and IV pain medication. Continued medical record review revealed "...Diagnosis: Biliary Pancreatitis..."

Medical record review of the Emergency Provider Record, not dated, timed at 11:30 p.m., revealed the "...Clinical Impression: Biliary Pancreatitis...Transfer..." Continued review revealed the ED physician discussed the findings related to patient #5 with (named) doctor at (named) receiving facility accepting patient #5 in transfer.

Continued medical record review of the Nurses' note, dated August 16, 2010 at 12:32 a.m., revealed "...Transferred to (named) hospital...Transferred by private vehicle..."

Continued medical record review of the Documentation of Transfer record, dated August 15, 2010 at 11:55 p.m., revealed "...Alert, cooperative...Family/Significant other present at Transfer: Boyfriend...Resuscitation Status: (left blank)...AOX4 (alert and orient to person, time, place, situation)...Hx (history of) Gallbladder problems, (medications received prior to transfer listed)..."

Interview in the conference room with the Risk Manager on October 19, 2010 at 3:00 p.m., confirmed the Code Status was not made available on the transfer papers of patient #5 for the receiving hospital. Continued interview confirmed the Code Status is considered necessary transfer information.