HospitalInspections.org

Based on findings from document review, medical record (MR) review and interview, in 2 of 6 MRs reviewed for Do Not Resuscitate (DNR) or Do Not Intubate (DNI) orders, the attending physician did not appropriately document the basis for DNR/DNI order. This lack of documentation could lead to patient wishes concerning their provision of care in certain situations not being followed.

Findings include:

-- Per review of hospital policy and procedure (P&P) titled "End of Life, Including DNR and MOLST," last revised 8/23/17, it indicated that all DNR orders should be documented on the appropriate hospital DNR/DNI form.

-- Per review of the hospital form titled "Adults (not developmentally disabled) DNR/DNI," last reviewed 11/2015, the physician should complete the appropriate section of the form depending on the basis of the order. Section 1 is completed for continuation of a previous DNR and/or DNI order, which indicates the patient consented to a previous DNR/DNI order and the physician agrees the DNR/DNI order should continue. Section 2 of the form is completed for a new DNR and/or DNI order, based on patient's consent, which indicates the patient had capacity to consent and the physician spoke to the patient about his/her medical condition and the risks and benefits of CPR (cardiopulmonary resuscitation) and mechanical ventilation. After completion of the form the attending physician should complete the DNR/DNI order.

-- Per review of Patient #1's MR, the 79 year old female was admitted to the hospital on 10/11/17 with failure to thrive since diagnosis of Stage 4 adenocarcinoma of the left lung. On 10/11/17 at 7:00 pm, Staff A (physician) entered a DNR/DNI order in the patient's MR. However, the required DNR/DNI form was not completed by an attending physician until 7 days later, on 10/18/17 at 2:00 pm.

-- During interview of Staff B (registered nurse) on 10/19/17 at 11:45 am, he/she acknowledged the above finding and indicated the DNR/DNI form should have been completed at the time the DNR/DNI order was written.

-- Per review of Patient #2's MR, the 29 year old female was admitted to the hospital on 10/14/17 with cystic fibrosis exacerbation. Patient #2 had a Medical Orders for Life-Sustaining Treatment (MOLST) form, dated 5/17/17, that indicated the patient had a DNR order. On 10/15/17, Staff C (physician) entered a DNR/DNI order in the patient's MR. However, a DNR/DNI form was not completed.

-- Per interview of Staff C on 10/18/17 at 1:45 pm, he/she had spoken with Patient #2 regarding her previous DNR/DNI and placed the order in the MR before the completion of the hospital Adult DNR/DNI form.

Based on findings from observation and interview, facility staff did not ensure that patients' clinical information was kept confidential. This lapse in confidentiality practices placed patients' health information at risk for disclosure to the public.

Findings include:

-- During observation on the oncology unit on 10/18/17 between 1:45 pm and 2:00 pm, the computer screen on an unattended workstation on wheels (WOW) was noted to be displaying a patient's confidential health information (e.g., diagnosis, code status, age, allergies, vital signs, etc.) in the hallway. The information was visible to anyone (patients, visitors, staff, etc.) in the area.

-- During interview of Staff D on 10/18/17 at 1:50 pm, he/she acknowledged the WOW had been left unattended and that he/she should have logged out of the system when he/she stepped away. He/she was unaware if the screen would time out and/or lock when not in use.