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CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRING ROAD CARLISLE, PA 17015 July 3, 2014
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that good quality care and high professional standards were provided to one of one medical record reviewed (MR1).

Findings include:

A review on July 3, 2014, of the medical record revealed "Date of Admission 06/19/2014, Chief Complaint: weakness, vomiting, and shortness of breath. History of present illness: This 67 - year - old white female has multiple medical problems including long- standing type 2 diabetes mellitus with extreme insulin resistance, O2 - dependent COPD, pulmonary hypertension, Obstructive sleep apnea, [DIAGNOSES REDACTED] and iron-deficiency anemia ..." A review of the physician orders revealed "orders" form "6/19/14, 15:30 ... 3. code status (nothing was indicated in the check boxes) ..." Further review revealed " additional orders" form "6/20/14, 6:00 AM Ok for BiPAP. Do not intubate. repeated and verified. TO (names redacted) ..."

A review on July 3, 2014, of the "ICU Flow Sheet" revealed " 6/24/14 ...11:00 To dialysis via bed ... 13:30 Code Called. see code sheet ..."

A review on July 3, 2014, of the "Progress Notes" revealed " 6/24/14 14:35 Code blue called in HD at 13:29 Pt became unresponsive ... Met with family (2 sons) very upset since Pt was made DNR/DNI on 6/20/14. Code status sheet on chart says "Full Code" ..."

A review on July 3, 2014, of facility policy "Code Status, reviewed July 2014" revealed "Policy: Carlisle Regional Medical Center acknowledges that it is the physician's role, when appropriate, to initiate a code status order and/or to respond to the patient's/patient's surrogate request for a code status order ... Principles: ... 7. A code statue order can be changed at any time ... Definitions: DNR order - A physician's order specifying "Do not initiate cardiopulmonary resuscitation." On Code Status Sheet listed as "no resuscitation efforts." DNI - A physician's order specifying "Do Not Intubate" the patient in an attempt to resuscitate ... Implementation of a Code Status Decision: ... Nursing services has the responsibility of communicating to the other members of the staff and with other departments as appropriate that a code status order has been written by documenting the degree of resuscitative effort that is being ordered for the patient on the code status sheet. This sheet is to be placed in the advance directive section of the medical record and a duplicate copy on the bed side chart ... "

An interview conducted on July 3, 2014, at 1:10 PM with EMP3 confirmed that the physician order was not transcribed properly and the DNR sheet was not placed on the back of the patient's medical record that is kept at bedside.