The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST LUKES HOSPITAL 915 EAST 1ST STREET DULUTH, MN 55805 March 30, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview and document review, the hospital failed to ensure staff communicated and implemented a patient's advanced directive or written instructions to initiate CPR or chest compressions and/or artificial breathing when P1 was found unresponsive for 1 of 10 (P1) patient records reviewed. The hospital was found to be out of compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

Findings include:

On 9/11/2016, when admitted to the hospital, P1 requested a do not resuscitate order or no CPR including intubation, ventilatory assistance, and/or chest compressions if P1 became unresponsive. On 9/17/2016, P1 signed an advanced directive or health care directive in the presence of a notary public who was an employee in the medical records department of the hospital, that instructed the hospital to initiate CPR. The change was not communicated to the hospital nursing staff and/or physician. Instead, the document was taken to the medical records department for scanning into the electronic medical record within a twenty four hour timeframe according to hospital policy. That same evening, P1 was found unresponsive without respirations and heart rate. P1 was not wearing a purple wrist band provided to patients with a DNR order therefore, staff initiated chest compressions and called for the rapid response team for continued CPR. As per hospital policy, the licensed staff obtained the paper medical record for P1 that contained the order for DNR. That was communicated to the rapid response team and CPR was stopped. P1 expired within a few minutes after CPR was stopped.

Refer to the deficiency at 42 CFR 482.13 (c)(2), A0144.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, document review and interview, the hospital failed to ensure staff communicated and implemented a patients advanced directive or written instructions for cardio-pulmonary resuscitation (CPR) including ventilator support and chest compression if found unresponsive without respirations and/or a pulse for 1 of 10 (P1) patient records reviewed.

Findings include:

On 3/28/2016, at 10:03 a.m. observation was made of the 2 west hospice/oncology unit where P1 was admitted and 5 east the general surgical unit where P1 was transferred to on 9/17/2015. The process to identify a patient's DNR request was reviewed. Staff placed a purple wrist band on patients with DNR, the physician's order was kept in the paper medical record, and DNR stickers were placed on the front of the paper chart.

P1's medical record was reviewed and revealed on 9/11/2015, at 12:30 p.m. P1 presented to the hospital's emergency department (ED) with intractable or severe constant pain related to left foot ischemia with gangrene or death of tissue from lack of blood flow, of the third, fourth, and fifth toes with severe peripheral vascular disease (PVD). Additional diagnoses included [DIAGNOSES REDACTED]. While in the ED, a consult was made with a vascular surgeon with treatment options provided to P1 that included a left below the knee amputation or hospice/ comfort care. When admitted to the hospital, P1 choose comfort care that included treatment of his pain and an antibiotic for a probable infection. Following discussion with P1 and his family, the admitting physician wrote an order for do not resuscitate or (DNR). Throughout P1's hospitalization , P1's level of alertness fluctuated and P1 had difficulty deciding between comfort care or to proceed with the surgical amputation of the left lower extremity. On 9/16/2015, P1 decided to proceed with the surgical amputation of the left lower extremity. On 9/17/2015, at 4:19 p.m. P1 was transferred to a surgical floor in preparation for the scheduled left below the knee amputation the following day.

Review of the nursing progress note dated 9/17/2015, at 10:29 p.m. (documentation time) established nursing assistant (NA)-C entered P1's room and discovered P1 not breathing. P1 did not have a purple wrist band therefore NA-C initiated the code protocol, started chest compressions, and the rapid response team came to P1's room for continued life saving measures. The registered nurse obtained and reviewed P1's paper medical record that contained a DNR physician's order and a DNR sticker on the front of the medical record. CPR was stopped and P1 died at 8:55 p.m. The note had no times of the code being called or when CPR was stopped.

Review of the form titled Health Care Directive signed by P1 and a notary public on 9/17/2015, and not timed appointed P1's spouse as the primary health care agent with two additional family members as the first and second alternate health care agent. The Health Care Directive instructions indicated P1's medical treatment preferences included ventilator support for short term use if it would lead to breathing on his own and a reasonable attempt with CPR. The Health Care Directive resended the DNR order previously written for P1.

The hospital's Health Care Directive form not dated, stated if completed when hospitalized , the hospital would provide a notary public to witness the signature and copies of the form would be made for the medical record and the patient's physician.

An interview with NA-C was conducted on 3/29/2016, at 2:52 p.m. established she went into P1's room the evening shift of 9/17/2015. NA-C said P1 was unresponsive to verbal commands and not breathing. NA-C said P1 was not wearing a purple wrist band to identify DNR, so she used the call system to notify the health unit coordinator who called a code over the hospital's speaker system. NA-C positioned P1 on his back and started chest compressions. Less than thirty seconds later staff brought in a crash cart, the rapid response team arrived in the room, and took over CPR. Shortly after that, the registered nurse came into P1's room with P1's paper medical record and informed the team P1 status was DNR. CPR was stopped at that time.

An interview conducted with the medical records secretary/notary public (MRS)-A on 3/29/2016, at 2:26 p.m. established she received a request from an unknown individual to witness the signing of P1's health care directive on 9/17/2015, sometime late morning. MRS-A met with P1 and unknown individuals in P1's room. After reviewing the form with P1, she obtained P1's signature and notarized the form. MRS-A provided copies of the health care directive to family and took the hospital's copy to the medical records department to be scanned into P1's electronic medical record within twenty-four hours according to hospital policy. The information was not shared with the nursing staff or P1's physician.

An interview with the manager of processing and data integrity-D was conducted on 3/28/2016, at 2:16 p.m. revealed on 9/17/2015, MRS-A was requested to P1's room for a notary public signature for a health care directive. It could not be determined who had contacted the medical records department but usually nursing staff made the request. MRS-A followed the hospital policy at the time and brought P1's signed health care directive to the medical records department to be scanned into P1's medical record. At that time, scanning was completed by staff one time a day. The health care directive requesting CPR for P1 was not scanned into P1's electronic medical record or communicated to nursing staff prior to P1 death.

An interview conducted with physician-B, P1's primary physician on 3/29/2016, at 1:32 p.m. established she communicated with P1 and his family that P1 was a high risk for complications with surgery due to P1's severe PVD and declining health. The day following P1's death, physician-B contacted P1's family for a courtesy follow-up call. At that time, physician-B was told by family that P1 had requested CPR. Physician-B had not been informed of P1's change in his health care directive.

An interview with family member (FM)-E was conducted on 3/28/2016, at 5:03 p.m. established FM-E visited P1 the morning of 9/17/2015. At that time, P1 requested to be resuscitated or CPR should P1 stop breathing and/or P1's heart stop. A notary public came into the room and the advanced directive requesting CPR was signed by the patient and a staff person/notary public. FM-E said the notary public said a copy of the advance directive would be placed in P1's medical record.

An interview with quality improvement leader (QIL)-G conducted on 3/30/2016, at 8:36 a.m. stated the hospital conducted a root cause analysis (RCA) regarding the hospital's failure to communicate P1's advanced directive. The RCA identified the hospital's failure to immediately communicate an inpatients change in advanced directives to the appropriate staff. In addition, the RCA identified an issue with confirming patients with a DNR have the appropriate purple wrist band placed. The RCA identified an action plan for policy revisions regarding immediate notifications of the nurse and/or physician of a change in a patient's advanced directive and/or code status and within one hour of receipt scanned into the electronic medical record. In addition, the RCA action plan in respect to placement of the appropriate patient wrist band, the electronic charting was changed to ensure nursing staff check patient wrist bands every shift. The staff were educated regarding the policy and documentation updates. The hospital had not implemented a monitoring system to ensure compliance with the policy and documentation changes.