HospitalInspections.org

Based on staff interview, review of one (1) of two (2) medical records of patients with a current Do Not Resuscitate (DNR) status (#4), and review of facility policy and procedure, it was determined that the facility failed to ensure implementation of the facility policy regarding DNR.

Findings include:

Reference: Facility policy titled: "Allow Natural Death (AND)/ Do Not Resuscitate (DNR)" states, " ...DEFINITIONS: AND/DNR: Allow Natural Death/Do Not Resuscitate: No cardiopulmonary resuscitation efforts will be initiated in the event of cardiac and/or respiratory arrest. ... POLICY: ... All orders not to resuscitate (AND/DNR) shall be written in the patient's chart with appropriate documentation. ...PROCEDURE FOR IMPLEMENTATION: ... The "ALLOW NATURAL DEATH/DO NOT RESUSCITATE (AND/DNR) ORDER" should be entered by the attending physician/advanced practice nurse primarily responsible for the patient's care. ...B) The AND/DNR status must be documented in the medical record by completing the appropriate AND/DNR progress note (Attachment A) as well as documentation in the physician progress note."

1. The medical record of Patient #4 was reviewed on 7/8/2021 in the presence of Staff #9. The following was identified:

a. The patient presented to the Emergency Department (ED) on 11/20/2020 at 8:41 PM via EMS (Emergency Medical Services) after being found to be aphasic with associated right-sided weakness and left-sided gaze.

b. The patient had an AND/DNR order placed on 11/20/2020 at 9:54 PM by Staff #22, a physician. The medical record lacked documentation of an AND/DNR progress note or a physician's progress note indicating that Staff #22 had a discussion with the patient or the patient's family regarding the AND/DNR orders placed.

c. The patient had an updated AND/DNR order placed on 11/20/2020 at 11:00 PM by Staff #24, a surgeon. The medical record lacked documentation of an AND/DNR progress note or a physician's progress note indicating that Staff #24 had a discussion with the patient or the patient's family regarding the AND/DNR orders placed.

d. The AND/DNR order was discontinued on 11/21/2020 at 2:38 AM by Staff #23, a physician. The medical record lacked evidence of any documentation as to why the AND/DNR order was discontinued.

e. The patient had a FULL CODE order placed on 12/12/2020 at 10:34 AM by Staff #25, a physician.

f. The medical record reflects "code status: No qualifying data" as an indication that the patient did not have a documented code status from 11/21/2020 until 12/12/2020.

2. The above findings were confirmed by Staff #9 on 7/8/2021 at 12:09 PM.

Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure the discharge needs of a patient are arranged in one (1) out of twelve (12) medical records reviewed (Medical Record #1).

Findings include:

Reference: Facility policy titled "Facility policy, titled: "Discharge of a Patient and Discharge Instructions" states: " ...The interdisciplinary team members collaborate throughout the patient's visit to provide care and arrange for services prior to discharge ....."

1. Patient #1 presented to the facility on 5/14/2021 with complaints of an accidental opioid overdose. The medical record of Patient #1 was reviewed and the following was identified:

a. A consultation note by Staff #28, an Addiction Medicine physician, on 5/17/2021 at 4:47 PM identified a plan for Patient #1 that stated " ...patient will require counseling ... ."

b. A consultation note by Staff #28, an Addiction Medicine physician, on 5/18/2021 at 8:33 PM identified a plan for Patient #1 that stated "...patient will require counseling ... ."

c. A consultation note by Staff #28, an Addiction Medicine physician, on 5/19/2021 at 10:03 PM identified a plan for Patient #1 that stated " ...patient will require counseling ... ."

2. The medical record lacked evidence that opioid counseling was arranged for Patient #1 post-discharge.

3. Staff #1 and Staff #5 confirmed the above findings on 7/8/2021 at 10:31 AM.

Based on staff interview, review of policies and procedures, and medical record review, it was determined that the facility failed to ensure that the family is educated regarding the discharge needs of the patient in one (1) out of twelve (12) records reviewed (Medical Record #1).

Findings include:

Reference #1: Facility policy titled: "Care Management Scope of Services" states: " ...Reassessments are completed when there is a substantive change in the patient's condition requiring a potential change in the discharge plan or the utilization of resources ....."

Reference #2: Facility policy titled: "Discharge of a Patient and Discharge Instructions" states: " ...The discharge process includes documenting, printing and explaining the following to the patient/caregiver: -disposition -medications and vaccines -diet -activity limitations ... -follow-up instructions and appointments -post discharge care and relevant education topics ....."

1. The medical record of Patient #1 was reviewed and the following was identified:

a. Patient #1 presented to the facility on 5/14/2021 with complaints of an accidental opioid overdose. The patient required physical therapy services and the initial plan was for the patient to be discharged to a subacute rehabilitation hospital, but the discharge plan was changed and the patient was discharged home to the care of the family.

b. A physical therapy (PT) note written by Staff #27 on 5/21/2021 at 5:54 PM stated: " ...Plan: Frequency: ...up to 5 x/wk [times per week] ... Treatments Planned: Balance Training, Bed Mobility training, Gait training, ...Stair training, Therapeutic Activities, Therapeutic exercises, Transfer training ... Therapy Recommendations: Continue with current therapy plan, Will continue to require skilled therapy on discharge Assessments: PT Impairments or Limitations: Ambulation deficits, Balance deficits, Bed mobility deficits, Cognitive deficits, Endurance deficits, Muscle weakness, Transfer deficits Barriers to Safe Discharge PT: Severity of deficits, Mobility deficits ..."

c. A social work progress note written by Staff #26 on 5/24/2021 at 5:08 PM stated: " ...Patient's [family member and phone number] called this SW [social worker] to discuss patient's DC [discharge] needs, PT's [physical therapy] recommendation presented. [Patient's family member] verbalized understanding ....."

d. A social work progress note written by Staff #26 on 5/25/2021 at 1:27 PM stated: "SW received multiple calls from patient's [family member and phone number] requesting patient's DC plan be changed to home not SAR [subacute rehabilitation] facility ... family has agreed to take patient home. Primary RN [registered nurse] notified of family's decision ... ."

2. The medical record of Patient #1 lacked evidence that the patient's family was educated regarding the physical therapy needs of the patient after discharge.

3. The medical record of Patient #1 lacked evidence that the patient's family was assessed to determine if the physical therapy needs of the patient could be met at home by the family.

4. Staff #1 and Staff #5 confirmed the above findings on 7/8/2021 at 10:31 AM.