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Based on review of 15 medical records (nine open and six closed), it was determined that the hospital failed to allow full participation in the plan of care for a terminally ill patient (patient #15) when the clinical team failed to notify the family of the change in code status (from full code to do not resuscitate) after the physician team determined that continued aggressive interventions were medically futile.

Definitions

Intubation is the insertion of a tube to allow passage of air into a patient's lungs and is utilized in patients unable to breath on their own whether due to a restricted airway or other clinical need.

Extubation is the removal of a breathing tube.

A Do Not Intubate (DNI) order precludes the insertion of an intubation tube.

A Do Not Resuscitate (DNR) order precludes making resuscitative efforts in the event a patient stops breathing and their heart stops beating.

Findings

Patient #15 was an elderly patient who presented to the hospital in November 2017 via ambulance with a chief complaint of a cough for three days. Patient #15 had a complex medical history including two advanced terminal conditions.

Review of the medical record revealed that in the section for documenting about advance directives, staff documented Patient #15 did not have an advance directive. Further comprehensive review of the medical record during administrative review on 10/11/18, corroborated that there was no advance directive in the medical record for patient #15.

Review of the medical record during administrative review on 10/11/18, revealed that on 11/29, the patient's daughter was asked if she had a current MOLST for Patient #15 and RN staff documented the daughter stated she believed she had it and could bring it in, but stated patient #15 was full code. Five MOLST forms were found in the medical record (several carried forward from prior admissions). Four of the five MOLST forms indicated the patient was full-code and one was available for use but was not completed.

On 11/29/18 the surrogate decision maker had indicated the patient was full code. Consistent with this report a physician order was entered indicating the patient was to be full code; and this same designation was reflected in progress notes entered the same day.

Review of the medical record revealed that Patient #15 could no longer protect his/her airway which is a frequent complication in patients with advanced Parkinson's disease. On 12/18/17 medical staff documented that the patient remained intubated (after one failed attempt at extubation) with refractory respiratory failure related to advanced Parkinson's disease.

Review of the medical record revealed that consideration was given to placement of a tracheostomy to address the airway concern but on 12/18/27 medical staff documented discussion with the ENT physician specialist, who concurred that conducting the procedure to place a tracheostomy in this patient would introduce significant risk to the patient with no benefit due to his/her advanced terminal condition.

Review of the medical record revealed that on 12/18/17, medical staff also documented conferring with the patient's oncology (medical staff specialist) and he agreed that in addition to the respiratory failure, the patient had terminal refractory leukemia and continuing aggressive care interventions would be medically futile.

On 12/19/17, the provider documented a 12/18/17 conversation with the patient's surrogate decision maker. The documented plan discussed with the family on 12/18/17 was to extubate with no reintubation (DNI). Per physician notes the family agreed with the plan to extubate with no reintubation. The medical record documentation however did not indicate the code status was discussed with the family at this time. In an interview following the survey, the surrogate decision maker for Patient #15 stated that they were not informed that no resuscitation efforts would be attempted after extubation in the event of an emergent cardio-pulmonary event.

Although contrary to stated wishes of the family, the physician team documented the clinical judgement that continued aggressive care was futile due to the advanced terminal state of the patient. On 12/20/17 orders were entered for extubation with no reintubation, and the patient's code status was changed from full code to "No CPR - Do Not Resuscitate."

Medical record documentation revealed that the breathing tube was removed without immediate clinical complications but the following morning the patient monitor alarmed indicating both a low heart rate and low blood oxygen level; and Patient #15's then went into cardiac arrest and expired. Although the family was notified of and agreed to the plan to extubate without reintubation, the clinical team failed to notify the family of the change in Patient #15's code status.

.Based on review of 15 medical records (nine open and six closed), it was determined that the hospital failed to ensure a patient decision maker was fully informed of treatment planning and treatment changes when the patient's code status was changed to Do Not Resuscitate without notice to the family.

Definitions

Intubation is the insertion of a tube to allow passage of air into a patient's lungs and is utilized in patients unable to breath on their own whether due to a restricted airway or other clinical need.

Extubation is the removal of a breathing tube.

A Do Not Intubate (DNI) order precludes the insertion of an intubation tube.

A Do Not Resuscitate (DNR) order precludes making resuscitative efforts in the event a patient stops breathing and their heart stops beating.

Findings

Patient #15 was an elderly patient who presented to the hospital in November 2017 via ambulance with a chief complaint of a cough for three days. Patient #15 had a complex medical history including two advanced terminal conditions.

Review of the medical record revealed that in the section for documenting about advance directives, staff documented Patient #15 did not have an advance directive. Further comprehensive review of the medical record during administrative review on 10/11/18, corroborated that there was no advance directive in the medical record for patient #15.

Review of the medical record during administrative review on 10/11/18, revealed that on 11/29, the patient's daughter was asked if she had a current MOLST for Patient #15 and RN staff documented the daughter stated she believed she had it and could bring it in, but stated patient #15 was full code. Five MOLST forms were found in the medical record (several carried forward from prior admissions). Four of the five MOLST forms indicated the patient was full-code and one was available for use but was not completed.

On 11/29/18 the surrogate decision maker had indicated the patient was full code. Consistent with this report a physician order was entered indicating the patient was to be full code; and this same designation was reflected in progress notes entered the same day.

Review of the medical record revealed that Patient #15 could no longer protect his/her airway which is a frequent complication in patients with advanced Parkinson's disease. On 12/18/17 medical staff documented that the patient remained intubated (after one failed attempt at extubation) with refractory respiratory failure related to advanced Parkinson's disease.

Review of the medical record revealed that consideration was given to placement of a tracheotomy to address the airway concern but on 12/18/27 medical staff documented discussion with the ENT physician specialist, who concurred that conducting the procedure to place a tracheotomy in this patient would introduce significant risk to the patient with no benefit due to his/her advanced terminal condition.

Review of the medical record revealed that on 12/18/17, medical staff also documented conferring with the patient's oncology (medical staff specialist) and he agreed that in addition to the respiratory failure, the patient had terminal refractory leukemia and continuing aggressive care interventions would be medically futile.

On 12/19/17, the provider documented a 12/18/17 conversation with the patient's surrogate decision maker. The documented plan discussed with the family on 12/18/17 was to extubate with no reintubation (DNI). Per physician notes the family agreed with the plan to extubate with no reintubation. The medical record documentation however did not indicate the code status was discussed with the family at this time. In an interview following the survey, the surrogate decision maker for Patient #15 stated that they were not informed that no resuscitation efforts would be attempted after extubation in the event of an emergent cardio-pulmonary event.

Although contrary to stated wishes of the family, the physician team documented the clinical judgement that continued aggressive care was futile due to the advanced terminal state of the patient. On 12/20/17 orders were entered for extubation with no reintubation, and the patient's code status was changed from full code to "No CPR - Do Not Resuscitate."

Medical record documentation revealed that the breathing tube was removed without immediate clinical complications but the following morning the patient monitor alarmed indicating both a low heart rate and low blood oxygen level; and Patient #15's then went into cardiac arrest and expired. Although the family was notified of and agreed to the plan to extubate without reintubation, the clinical team failed to notify the family of the change in Patient #15's code status.

Based on review of nine open and six closed medical records, including two restraint/seclusion patient records, it was determined that for restraint patient #1 (Pt #1), the hospital failed to 1) obtain a timely restraint order for one seclusion episode and 2) obtain an order for another seclusion episode.

Pt #1 presented to the emergency department (ED) with an acute medical problem and reported not feeling well. Pt #1 also had a history of a mental illness. Documentation with in the record indicted patient became increasingly disruptive and the patient was placed in the Behavioral Health Unit (BHU) within the ED. The hospital had trouble placing the patient, necessitating a four-day stay in the BHU ED.

1. Review of Pt #1's record revealed one late seclusion order. On day three in the ED at 1030hrs, Pt#1 was placed in seclusion. The order was placed more than 1.5 hours later, at 1157hrs.

2. Record review revealed that on day two in the ED, Pt #1 was placed in violent 4-point restraints at 1300hrs. Per restraint flow sheet, the RN documented at 1315hrs under "Restraint Care Needs Q1 Hour" " ...locked door, restraints." An order for the 4-point restraint was found, however an order for seclusion was not found. The provider's face-to-face assessment also listed both seclusion and physical restraints as the "Behavioral restraint types" for this episode. Pt # 1 was released from restraints at 1351hrs.

Based on a review of nine open and six closed medical records, including two restraint/seclusion patient records, it was determined that for restraint patient #1 (Pt #1), the hospital failed to obtain new restraint orders between restraint events.

Pt #1 presented to the emergency department (ED) with an acute medical problem and reported not feeling well. Pt #1 also had a history of a mental illness. Documentation within the record indicted patient became increasingly disruptive and the patient was placed in the Behavioral Health Unit (BHU) within the ED.

Review of Pt #1's record revealed orders for four violent restraint episodes and three seclusion episodes while in the ED. However, Pt #1 had an additional four violent restraint episodes and three seclusion episodes in the ED without orders.

On Pt #1's second day in the ED, patient was placed in violent 4-point restraints at 17:00hrs with an appropriate order. During that evening/night shift, staff clearly documented Pt #1 had been released from the restraints and placed back into restraints four times without new orders. For example, per nursing progress note at 0215hrs, it was documented patient received care and was released from restraints. The RN documented "Patient returned to bed. (Patient) stated that (he/she) would stay in the bed. Pt was informed that if (he/she) tries to get up without calling us that we would have to restraint (him/her) again for (his/her) safety." The RN documentation indicated Pt #1 was released from restraints and placed back into restraints around 0219hrs without a new physician order.

On Pt #1's second day in the ED, Pt #1 was placed in seclusion at 10:30hrs with an order for " ...escalating violence and repeated threats/acts of suicide nature." During the day, staff clearly documented patient had been released from seclusion and placed back into seclusion three times without a new order.

In summary, nursing restrained patient #1 PRN (as needed) without obtaining new orders. Pt #1 was in restraints for approximately nine hours without an order in total and six hours in seclusion without any orders or physician oversight.

Based on review of nine open and six closed medical records, including two restraint/seclusion patient records, it was determined that the hospital failed to conduct or complete all elements of a face-to-face assessment by a physician within one hour of initiation of restraint/seclusion for patient # 1 and #10.

See tag A-169 for Patient #1.

A review of Pt#1's record revealed no evidence of a face-to-face assessment for two ordered restraints/seclusion episodes that occurred on the fourth day Pt#1 was in the ED.

The face-to-face assessment for a seclusion episode on the third day Pt#1 was in the ED was completed approximately 30 minutes late. Pt #1 was placed in seclusion at 1030hrs, the face-to-face was conducted at 1157hrs.

Additionally, for Pt#1, documentation of five face-to-face assessments did not contain all four required components. Three restraint episodes lacked the decision making on whether to continue or terminate the restraint or seclusion. Documentation of a face-to-face assessment related to a seclusion episode on the fourth day of Pt #1's ED stay lacked criteria related to the assessment of Pt#'1s medical condition and the need to continue or terminate the seclusion. Additionally, a face-to-face for an inpatient seclusion episode did not include documentation of Pt #1's medical condition and failed to indicate an awareness of the impact of the seclusion episode on the patient's acute medical condition.

Pt# 10, a minor, presented to the Emergency Department (ED) by law enforcement on an Emergency Petition due to self-injurious and threatening behaviors. On arrival to the ED at 1450hrs, Pt#10 was documented as "physically aggressive" and "a risk to self and others". Pt# 10 was placed into 4-point violent restraints at 1500hrs and remained in 4-point restraints until 1600hrs. No evidence was found in the chart of a face-to-face assessment.

Based on review of nine open and six closed medical records, including two restraint/seclusion patient records, it was determined that the hospital failed to properly monitor a patient in simultaneous restraint and seclusion.

Pt #1 presented to the emergency department (ED) with an acute medical problem and reported not feeling well. Pt#1 also had a history of a mental illness. Documentation within the record indicted patient became increasingly disruptive and the patient was placed in the Behavioral Health Unit (BHU) within the ED.

Record review revealed on the second day Pt#1 was in the ED, Pt #1 was placed in both violent 4-point restraints and locked door seclusion at 1300hrs. Per restraint flow sheet, the RN documented at 1315hrs under "Restraint Care Needs Q1 Hour" " ...locked door, restraints." Per technician progress note at 1316hrs, it was documented "light and door shut to encourage pt to sleep." The provider face-to-face assessment also listed both seclusion and physical restraints as the "Behavioral restraint types" for this episode. Per surveyor review of the behavioral health unit, rooms did not have audio monitoring capability. Pt #1 was placed in simultaneous restraint and seclusion with the lights off. No evidence of continuous 1:1 safety monitoring of Pt #1 during the episode was found in the medical record. Pt # 1 was released from restraints at 1351.