HospitalInspections.org

C 0812
485.608(a) Compliance with Federal Laws and Regulations related to the health and safety of patients, pertaining to Advanced Directives

Based on record reviews and interviews, the facility failed to assist current patient 1 in developing and executing Advance Directive care needs. The facility failed to provide information/confirmation receipt to patients about the facilities Advanced Directives (written instruction, such as a living will or durable power of attorney for health care) policy, ensure staff are knowledgeable of this policy, and failed to conduct any audits to ensure completion of medical records.

Findings include:

A. Record review of patient 1 admission on 6/6/2021 at 10:48 AM. Patient had a diagnosis of right inferior pubic ramus (pelvic) fracture and dementia. Patient had Co-power of attorneys (POA) listed. Patient 1 consent to treat form signed by Co-POA-A, with Advance Directive acknowledgement remained blank.

Interview with Co-POA-B on 6/8/2021 at 1225 PM (greater than 48 hours after admission) revealed no Advance Directive had been formulated for patient regarding fracture, or ongoing pain to determine appropriate levels of care for patient. Co-POA-B verbalized "I would like to talk to someone about coordinating care needs."

Observation on 6/9/2021 during 9 AM medication pass for patient 1 revealed patient was in extreme and rating pain at a 10 on 1-10 scale, 10 being the highest level of pain. RN 1 verbalized "staff have been working all morning to get patients pain under control". Patient refused to allow head of bed to be elevated to take pain medication. After 10 minutes the observation was suspended as no oral pain medication had been administered due to patient's refusal to raise head of bed to swallow medication. Record review revealed patient had received Intravenous Morphine the previous day.

B. Record review revealed 2 of 11 patients did not receive Advance Directive information. Patient records 6 and 28 indicated the patients did not have an Advance Directive nor did they receive information about Advance Directives.

Policy review reveals the facility is not following the Advance Directives Policy. The policy/procedure indicated at "an inquiry will be made by the Admitting Department during the admissions process as to whether or not the patient has completed an Advance Directive and, if so, where it is located."

The policy/procedure also indicated "If the patient does not have an advance directive, the patient/significant other will be provided with an information packet outlining the individual's rights to make decisions concerning medical care, by the admission staff or social service. Admitting Department personnel will document in the medical record whether the patient has completed an Advance Directive, where the Advance Directive is located and that information concerning Advance Directives has been given to the patient/significant other during the admission process. The admitting nurse documents this also in the Admission assessment." The policy also indicated, "Should the patient wish to formulate an Advance Directive, Social Services will be contacted to assist the patient to accomplish the formulation of a directive. Should the patient wish to review or revise his/her Advance Directive, social Services will be contacted to assist the patient. Education about Advance Directives will be provided."

Interview with the Chief Nursing Officer (CNO) on 6/9/2021 at 3:00PM indicated that the nursing staff document in the Admission Assessment. The CNO verbalized that the nurses ask about Advanced Directives with the first assessment. The CNO verbalized that the patient is asked "Do you want information about Advanced Directives?" and the nurse puts "yes" or "no" in the box and if they say "yes", it sends a referral to the Social Worker via the Electronic Health Record (EHR).

Interview with Social Worker (SW) on 6/9/2021 at 3:30 pm revealed that the question that is asked in the EHR is "Do you have an Advanced Directive?" and "Advanced Directive Information Provided" and "Advanced Directive on file". The SW pulled up an example of an electronic health record to demonstrate this. The SW also verbalized that the EHR did not send a note automatically to SW staff. SW verbalized the facility staff will either call or email if a patient needs to discuss the Advance Directive. The SW confirmed that it is unclear to staff about the EHR notification and that the process needs to be looked at. The SW obtained a packet that is available at the nurse's station titled "Advance Directives, The Patient's right to make health care decisions under the law in Nebraska".

Interview with RN 1 on 6/8/2021 at 12:30 pm indicated that the Social Worker is notified if a patient wants information about Advance Directives and the SW will then meet with them.

C. Record review reveals 11 of 40 records reviewed had incomplete "acknowledgements" on the consent to treat form, including the Advanced Directive portion.
Patient records 20, 28, 1, 3, 19, 11, 6, 26 did not have numerous sections on the "acknowledgements" page of the consent completed, including the Advanced Directive portion.

Interview with the Revenue Cycle Manager (RCM) on 6/9/2021 at 11:30 AM verbalized that all the sections on the "acknowledgements" page of the consent should be initialed, with a signature and date at the bottom of the form.
Policy review of the Legal Authorization and Consent for Treatment Policy revealed that the "acknowledgements" page was not addressed in the facility current policy.

Interview with Revenue Cycle Manager (RCM) on 6/9/2021 at 11:45 AM revealed that the policy did not address the Advanced Directives portion on the form. The RCM verbalizes "our policy needs some work and does not address several areas".
Interview with Health Information Manager (HIM) on 6/9/2021 at 2:00PM revealed that the record department did not monitor or audit the consent forms for completion or signature. The HIM verbalized "the other departments are responsible for completion of the consent forms", "medical record staff just scan them into the Electronic Health Record (EHR)".

C 0914 - Preventive Maintenance
Licensure Reference number
9.006.14B


Based on observation, interview and record review, the facility failed to provide ongoing preventive maintenance (PM) according to manufacturer's guidelines for 1 of 24 sampled pieces of medical equipment. This item was used for reprocessing of Endoscopy scopes (devices used to examine body cavities and organs). This had the potential to affect all individuals receiving scope exams.

Findings include:

Observation on tour of the surgical department on 6/8/2021 at 2:00PM reveals that the Medivator Reprocessing Machine did not have any type of inventory sticker or any other type of sticker indicating date of last PM.
Review of the preventive maintenance patient care equipment log reveals the Medivator Reprocessing Machine did not have a sheet available in the logging system.

Interview with the Chief Nursing Officer, (CNO), on 6/8/2021 at 4:30 PM revealed that there was no record of preventative maintenance (PM) for the Medivator Reprocessing Machine. CNO verbalized that "she will need to contact the service representative for that piece of equipment." Additional interview on 6/9/2021 at 2:30 PM CNO verbalized that the service representative replied to the email about the PM on the Medivator Reprocessing Machine. The service representative's response was, "Since this unit is so old we do not offer service agreements on this anymore. We do however provide PMs as needed." The CNO also verbalized that "The unit was purchased in 2004 and was last serviced on 11/30/2013." Product Bulletin for the Medivator Reprocessor revealed, "At a minimum, a Preventative Maintenance service is recommended annually."