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.

CHEYENNE REGIONAL MEDICAL CENTER 214 EAST 23RD STREET CHEYENNE, WY 82001 July 3, 2012
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


































Based on medical record review, policy and procedure review, staff and patient interview, and observation, the facility failed to ensure 3 of 10 sample patients (#5, #8, #9) had information provided for advanced directives/or known advanced directives filed in the medical record. The findings were:

Review of the facility policy and procedure titled "Advanced Directives: Living Will, Durable Power of Attorney for Health Care, or Do Not Resuscitate Order" showed it was revised on April 2007, and according to the quality manager it was a facility wide policy. The policy showed information about the patient's right to form advanced directives was to be provided at or before each time of admission. In addition, if the patient had an advanced directive, the patient was encouraged to provide a copy to be filed in the medical record, and the document would then be accessible through the electronic medical record for the current and future visits. Furthermore, if the patient had an advanced directive but did not have it with them at the time of admission, the location of the advanced directive should be added to the nursing staff notes, and the social worker would make 3 attempts to obtain the advanced directive documenting all three attempts in the patient's open chart. The following concerns were identified with failure to follow the policy:

1. Review of the medical record for patient #5 showed s/he was a patient at the hospital emergency department (ED) on seven occasions from 10/20/11 to 6/18/12. On each of these visits, record review showed the patient signed a consent for treatment, and code status was determined. On the 10/20/11 and 6/18/12 visits, the patient was admitted to the hospital for further observation/treatments. Review of a grievance filed on 3/20/12 showed the patient complained of being treated contrary to his/her living will. With the complaint, s/he provided a copy of the living will. Review of the facility response in a letter dated 3/22/12 stated there would be no adjustment because the patient had consented to treatment, and the living will would be scanned and placed on the patient's medical record. The following concerns were identified:
a. Review of the medical record showed there was no evidence of the living will. Interview with the quality director on 7/3/12 at 1:42 PM verified the document had not yet been scanned into the patient's medical record, and this should have been done in March.
b. Review of the medical record for visits dated, 10/20/11, 10/24/11, 11/7/11, 11/29/11, 12/18/12, 6/4/12, and 6/18/12 failed to show any question of the patient to inquire about advanced directives.
c. Interview with ED nurse manager #1 on 7/3/12 at 2:20 PM revealed when patients came in through the ED, they were sometimes asked about advanced directives; however, it depended on what symptoms they were presenting with, and who was doing the triage. It was not standard to ask every patient. The nurse manager stated a question related to code status was asked for all ED patients; however, he acknowledged this was not the same as an advanced directive. Subsequent interview with this nurse manager on 7/3/12 at 2:30 PM revealed the patient had provided a copy of the living will on 12/24/12 to the ED department. The nurse manager presented a copy and stated it was scanned in as an attachment to the patient's ED record on that date. However, the system used in ED was different from the permanent medical record, and the attachment was not available in the other system.
d. Interview with the quality manager on 7/3/12 at 2:09 PM verified there was not any specific policy and procedure for inquiring about advanced directives for ED patients.

2. On 7/2/12 at 2:05 PM patient #9 stated s/he did not receive information on patient rights. The patient further stated s/he came in through the emergency department (ED) on 6/23/12, and the code status while in ED was listed as "Full Code." Review of the "Critical Condition Directives DNAR [Do Not Attempt Resuscitation]" dated 6/25/12 showed DNAR was checked, but a sticky note was attached to the form. The note read "This is not valid at this time. Please see chart for current orders. This pt [patient] is full code Thanks, Nursing." Full review of the chart showed the only acknowledgement of the patient's wishes was an unnoted telephone order dated 6/25/12 to "cancel DNR at this time per pt request to be full code." On 7/2/12 at 11:38 RN #1, the charge nurse, and RN #2, who cared for the patient that day, both stated they were unaware of the note. RN #2 thought the patient chose to be DNAR during a biopsy procedure.
On 7/2/12 at 3 PM, the quality manager stated the Patient Rights pamphlets were given to all patients, even those in ED. She also stated a "Guest Services" book containing information on advance directives was located in each patient's room.
Review of the patient's admission form showed the area for initialing receipt of patient rights information was blank. A second interview with the patient and observation of his/her room on 7/3/12 at 9 AM revealed the patient wished to be resuscitated but "has not signed anything." However, the patient also stated "...no ventilator...does not want to be a vegetable...doesn't yet understand." Observation of the patient's room showed no evidence of the "Guest Services" book. Observation of the patient's room and of an additional vacant room, #7222, by RN #3 at 9:12 AM showed the "Guest Services" book was not in either room. The RN stated it "should be out and visible."

3. Review of the admission information showed patient #8, who was admitted on [DATE] for surgery and discharged on [DATE], indicated s/he had advance directives; however, the location was documented as "n/a [non-applicable]." Review of the medical record showed the "Critical Condition Directives DNAR" form was blank. On 7/3/12 at 8:53 AM the quality manager and RN #3 stated they had no idea why "n/a" was written in for the location of the directive. At 10:38 AM that day RN #3 stated the question of advance directives was asked when staff provided education for surgery. However, if the patient did not bring the directive, then it was not in the facility. Review of the record showed no evidence the facility made any further attempts to obtain the directive during the patient's hospitalization .
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and staff interview, the facility failed to develop care plans for 2 of 10 sample patients (#8, #10) that addressed issues impacting each patient's care. The findings were:

1. According to the admission information, patient #10 was admitted on [DATE]. Review of the admission assessment and the 7/1/12 nursing documentation showed the patient had redness and excoriation of the skin under both breasts and in the perineal and rectal areas. Review of the care plan showed this issue was not addressed. After reviewing the care plan on 7/2/12 at 2 PM the charge nurse, RN #1, stated the patient's impaired skin integrity should have been addressed on the care plan.

2. According to the medical record, patient #8 was admitted on [DATE] for a surgical procedure that day. Review of the 6/20/12 post-anesthesia care unit discharge summary showed the patient received two autologous units of packed red blood cells (PBRCs), four units of leukoreduce PRBCs, two units of leukoreduce fresh frozen plasma (FFP), and 1 unit of either FFP or PRBCs, for a total of nine units in two hours while in surgery. Review of the postsurgical care plan and nursing documentation showed no evidence staff were aware of the amount of blood the patient received or that a delayed reaction was possible.
Reference:
"Clinical Nursing Skills Basic to Advanced Skills," Smith, Duell, and Martin, Seventh Edition, 2008. "CLINICAL ALERT Most clients can tolerate a flow rate of one unit of packed cells in 1 1/2-2 hours."

"Nursing Interventions & Clinical Skills" Elkin, Perry, and Potter, 4th Edition, 2007. According to this reference, there is always the possibility of a delayed reaction to a blood transfusion.
VIOLATION: VERBAL ORDERS Tag No: A0408
Based on medical record review and staff interview, the facility failed to ensure staff handled verbal orders appropriately for 1 of 10 sample patients (#9). The findings were:

According to the medical record, patient #9 was admitted through the emergency department (ED) on 6/23/12, and the code status while the patient was in ED was listed as "Full Code." Review of the "Critical Condition Directives DNAR [Do Not Attempt Resuscitation]" dated 6/25/12 showed DNAR was checked, but a sticky note attached to the form indicated this was not correct and the patient was actually a "full code." Detailed review of the chart showed the only acknowledgement of the patient's wishes was a telephone order dated 6/25/12 to "cancel DNR at this time per pt [patient] request to be full code." The order had not been noted by 7/2/12. Further review of the record showed two additional telephone orders were also present, one dated 6/23/12 and the other dated 6/27/12; neither had been noted. In addition, the 6/23/12 order for the initial Bipap setting per the cardiopulmonary protocol had not been noted. On 7/2/12 at 12 noon, RN #3 stated all orders, including verbal orders of any kind, should be noted. On 7/3/12 at 4:30 PM the quality manager stated the facility did not have a policy and procedure for noting orders.