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ADVENTHEALTH OCALA 1500 SW 1ST AVE OCALA, FL 34474 June 8, 2015
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on the facility's Policy and Procedures for Advance Directives, medical record review, and staff interview, the facility failed to ensure Advance Directives were honored for 1 of 10 patients reviewed (patient #1).

Findings:

Patient #1 at 4:30 PM, Coded in the Emergency Department. Advanced Cardiac Life Support (ACLS) protocol was followed and initiated, even though patient #1 had a DNR( Do Not Resuscitate) , and the patient had told the nurse that he was a DNR. Code Blue onset started at 4:32 PM with continuous chest compressions, epinephrine 1 milligram (mg.) 6 times, Intravenous fluids of Normal saline (NS), Sodium Bicarb 50 mg, Lidocaine, for 28 minutes from 4:32 to 5:00 PM, and he was intubated at 4:50 PM. Patient #1 was pronounced dead at 5:05 PM.

Interview on 06/09/2015 at 12:35 PM with Registered Nurse #1 (RN) revealed that she stated "the patient and the family told me that patient #1 had an Advance Directive of Do Not Resuscitate (DNR), but I failed to document that or to inform the physician."

Review of patient #1's Advance Directive from his previous visit to this hospital revealed that this document, a Living Will dated 12/09/2006, stated that patient #1 did not want Cardiac Pulmonary Resuscitation (CPR). He had also been treated at this facility on 07/18/2014 and there had not been any changes to his Advance Directive of Do Not Resuscitate.

Review of the facility's Policy and Procedure titled Advance Directives effective dated revealed the following: It is the purpose of Munroe Regional Medical Center to honor an adult patient's right to make decisions regarding treatment, including adult patient's right to consent, to refuse, or alter treatment plans, and the right to formulate advance directives which will govern if the patient should become incapacitated. Outpatient areas will call 911 in the event of a medical emergency and will keep advance directives on file as appropriate for service or program.

Further review of policies and procedures shows during the pre-registration process and or pre-admit testing, Munroe staff will request that patients bring their advance directives with them to admission. during the admitting process patients will be asked by the admitting clerk if they have an advance directive. All advance directives presented to registration will be copied, the original returned to patient/family, and a copy placed in the chart.

It is stated in nursing admission process that during the completion of the nursing database, the nurse will ask the patient if they have an advance directive.
If the patient answers "yes", the nurse will document in the nursing database the type of advance directive, i.e.; Living Will, Health Care Surrogate, Medical Power of attorney or State DNR. If the patient says that they gave it to us at their last or previous visit, the nurse will check the appropriate box within the nursing database.