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Based on a review of 11(Patients #1 through #11) of 12 patient records, interview with staff, the hospital failed to have clear documentation of the patient's advance directive status for patients #1 through #12 except for #7. This lack of knowledge of the patient's status places the patients at risk for not having their wishes honored.

The findings included:

1. A review of the policy and procedures related to advanced directives policy # Rl104 revised 8/17. The policy indicated the admission staff are to initiate the advanced directive questioning. The admission staff are to document on the hospital face sheet if the patient had an advanced directive (yes/no). The admission staff is then to initiate the Advance Directive Questionnaire form #009-0021 (1/11). On 10/6/18 at 10:30 a.m., the Director of Patient Access agreed this was the policy. The nurse was then to document the contents of the Advance Directives from the patient. (The hospital preferred to have a copy of the Advanced Directive). The nurse was then to verify the patient's advance directive and the nurse may document the content of the patient's advanced directive on the Advance Directive Questionnaire.

2. Patient #2 and #4 both had an advance directive questionnaire. The form has a series of 5 questions about the patient's advanced directives. Both patients' answered as having a living will but it was not brought in when the patient was admitted. Both forms were signed by the patient and an admission staff. This was on 10/21/14 for patient #3 (admission dated 10/18/18). For patient #4 signed by patient and staff member on 9/26/13 (patient admitted on 10/25/18). There was no documentation on either form determining if the patient had the same advanced directive in place nor was there documentation about the contents of the advanced directive present in the record.

On 11/6/18 at 10:30 a.m., PCU nurse G was asked about advanced directives. She said a lot of patients are bringing them if they have a copy will be put in the front of the chart. Case management may follow up with the advanced directive if the patient doesn't bring in. The nurse does not have to document the advanced directive on the record. Reviewed patient 1,2,3 and 4's charts, they did not have an advanced directive in it.

3. On 11/6/18, the face sheet for patients #1 through #12 were reviewed. All of the patient face sheets except for #7 did not have documentation indicating whether the patient has an advanced directive. The area for this was blank.

4 On 11/6/18 at 11:30 a.m., the Risk Manager and the Director of Quality Management both agreed the hospital should do better in the area of advance directive.