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.

BAPTIST HEALTH CORBIN ONE TRILLIUM WAY CORBIN, KY 40701 Nov. 29, 2017
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interviews, record review, review of a facility timeline, and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. The Governing Body and Chief Executive Officer failed to ensure the facility's policies for grievance resolution and resuscitation were implemented by facility staff.

Patient #1's family (Family Member #1) expressed concerns that the facility failed to ensure they notified the correct family when making a death notification on 09/21/17, and that a physician's order for Patient #1 not to receive resuscitation was invalid. The facility acknowledged the family's grievance on 09/21/17, but failed to follow their grievance policy. The facility failed to address the family's grievance that a Do Not Resuscitate (DNR) order did not exist and that the facility had the wrong information for Patient #1 (refer to A0057, A0115, A0118, and A0131).
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, record review, review of a facility timeline, and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. The Governing Body failed to ensure the facility's policies for grievance resolution and resuscitation were implemented by facility staff (refer to A0115, A0118, and A0131).

The findings include:

Review of the facility's "By Laws" dated 08/29/17, revealed the Board of Directors would be responsible for overseeing the quality of care and services provided to patients...and ensure compliance with Medicare Conditions of Participation. Further review of the policy revealed the Patient Safety, Quality, and Patient Experience Committee would oversee, guide, and promote patient safety, quality, and excellent experiences with service. According to the By Laws, the Board of Directors selected and employed a Chief Executive Officer (CEO), who was charged with the responsibility and given the authority to see that the aims and objectives of the facility were carried out.

A review of Patient #1's medical record revealed the facility admitted the patient on 09/20/17, and the patient expired on [DATE].

Interview with Patient #1's family (Family Member #1) on 11/21/17 at 1:15 PM, revealed that during the patient's hospitalization , she expressed concerns that the facility failed to ensure they notified the correct family when making a death notification on 09/21/17. Family Member #1 also notified the facility on 09/22/17, when RN #1 called the family member to report that Patient #1's condition was rapidly declining, that the patient was supposed to receive life-sustaining measures; however, the facility failed to provide any interventions for the patient and the patient expired. Although the facility acknowledged that Patient #1's family members were misinformed that Patient #1 had expired, the facility failed to implement their grievance policy and review the concern and provide notification of the results of the review and actions taken on the patient's behalf.

A review of Patient #1's medical record revealed a physician's order was in existence on 09/20/17, for Patient #1 not to receive life-sustaining measures; however, Patient #1's family voiced on several occasions their beliefs that the order for Patient #1 not to receive resuscitation was invalid. However, the facility failed to address the family's grievance that a Do Not Resuscitate (DNR) order did not exist and that the facility had the wrong information for Patient #1.

Interview with the CEO on 11/29/17 at 11:00 AM, revealed he was responsible for ensuring that all policies and procedures were implemented for the facility. Continued interview revealed that he was unaware nursing staff and medical staff were not following the facility's policies and procedures related to DNR orders and grievances.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, review of a timeline completed by the facility, and review of the facility's policies, it was determined the facility failed to protect and promote the rights of one (1) of ten (10) patients (Patient #1). Patient #1 was hospitalized from [DATE] until his/her death on 09/22/17. On 09/21/17, the facility misidentified Patient #1's family and notified them that Patient #1 was dead, despite the patient being alive and moved to a different patient room. Patient #1's family voiced a grievance; however, the facility did not follow their grievance policy to ensure a resolution was reached.

Beginning on 09/22/17, Patient #1's family voiced concerns that Patient #1 did not receive life-saving measures on 09/22/17, and stated that the physician-ordered Do Not Resuscitate (DNR) order for Patient #1 was not "valid." Again, the facility failed to ensure their grievance policy was implemented.

In addition, a review of Patient #1's medical record revealed that all required documentation by the physician was not present in the patient's medical record pertaining to the DNR order for Patient #1. Interviews with staff revealed there were inconsistencies in the staff's understanding of when to perform Cardiopulmonary Resuscitation (CPR).
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, review of a timeline completed by the facility, and review of the facility's grievance policy, it was determined the facility failed to ensure the grievance/complaint policy was implemented and grievances for one (1) of ten (10) sampled patients (Patient #1) were resolved promptly. On 09/21/17 at approximately 10:00 AM, Patient #1's family was misinformed by facility staff that Patient #1 had passed away. Due to Patient #1's family voicing concerns that the facility had made the mistake, a Patient Advocate employed by the facility was sent to discuss the incident with Patient #1's family. Although the facility did acknowledge Patient #1's family had made a complaint, the facility decided the complaint had been resolved after the family spoke to the Patient Advocate and failed to follow their Grievance/Complaint Policy. Beginning on 09/22/17, Patient #1's family voiced concerns that the Do Not Resuscitate (DNR) order was not "valid" and that Patient #1 did not receive life-saving measures on 09/22/17 at approximately 5:32 AM. However, the facility failed to follow their grievance policy.

The findings include:

Review of the facility policy titled "Resolution of Patient Grievances and Complaints," dated 07/25/16, revealed a patient grievance was a formal/informal written/verbal complaint that was made to the facility by a patient or patient's representative which could not be immediately resolved. If the complaint could not immediately be resolved, staff was required to contact Patient Relations staff. The policy specified that Patient Relations staff would complete an intake form, contact the patient/patient representative, obtain information relevant to the complaint, and verbally advise the patient/patient representative of the anticipated timeline for resolution of the grievance. The policy also stated that Patient Relations would document all communications with the patient/patient representative.

Continued review of the Resolution of Patient Grievances and Complaints policy revealed upon receiving a complaint, Patient Relations staff would delegate review of the complaint to appropriate persons as determined by the nature of the complaint. The facility's policy stated Patient Relations staff determined whether the review could be completed within seven days. If it was reasonably anticipated that it could not be completed within seven days, Patient Relations was required to send a letter to the patient/patient's representative advising an additional 30 days would be needed to complete the review of the complaint. In the event the review could not be completed within the additional 30 days, Patient Relations would send correspondence with regular status updates to the patient or patient representative. The policy further stated that upon completion of the review, the facility would send a letter indicating the results of the review and actions taken on their behalf.

1. A review of Patient #1's medical record revealed the facility admitted the patient on 09/20/17, with diagnoses that included Abdominal Pain, Diarrhea, and Shortness of Breath.

Review of a timeline provided by the facility revealed on 09/21/17, the Patient Safety Officer received a phone call from "Patient Experience" that the facility had notified Patient #1's family that the patient had passed away; however, the facility misidentified the family. The timeline stated that apologies were expressed to the patient and family and that the Chief Nursing Officer and Compliance staff were aware.

Interview with Patient #1's Family Member (Family Member #1) on 11/21/17 at 1:15 PM, revealed on 09/21/17 at approximately 10:00 AM, Social Worker #1 and Registered Nurse (RN) #5 approached Patient #1's family without identifying the family, and notified them that Patient #1 had expired. Social Worker #1 and RN #5 stated the patient had a "sudden turn during the night" and had expired. Family Member #1 stated approximately 30 minutes later RN #5 approached the family and stated, "I think there has been a mixup. [Patient #1] is not dead." At that time, Family Member #1 stated she observed Patient #1 in the hallway with facility staff. Subsequently, Family Member #1 stated the family verbalized a complaint to the facility's Patient Advocate #1 on 09/21/17, regarding being misinformed that their family member was deceased . Family Member #1 stated she wanted to ensure an incident like that did not happen again and did not feel that speaking to the advocate would result in resolution of her concern. In addition, after speaking to the Patient Advocate, Family Member #1 stated she made a public post on social media and "tagged" the facility to further call attention to the seriousness of the incident and to prompt the facility to take her complaint seriously. However, Family Member #1 stated she had never received any written communication from the facility and had never been informed of any action taken by the facility to ensure action had been taken to prevent a similar incident from occurring.

Interview with Patient Advocate #1 on 11/27/17 at 4:10 PM, revealed she visited with Family Members #1 and #2 on 09/21/17, regarding the misreporting of Patient #1's death. Patient Advocate #1 stated that she felt like the complaint had been resolved at the bedside and discussed the family's concerns with Senior Management, who agreed the complaint was resolved.

Interview with the Risk Manager on 11/21/17 at 1:15 PM, revealed that Family Member #1's complaint was not viewed as a formal grievance because they determined it was resolved when apologies were offered to the family; therefore, the grievance policy was not applicable.

2. Further review of Patient #1's medical record revealed an Inpatient and Outpatient Condition and Consents document (four pages) dated 09/20/17, that contained 15 conditions/consents for consideration by the patient, which included consent to medical procedures, responsibility for loss of articles, consent to wireless telephone calls, and Patient Rights and Advance Directives. Further review of the Patient Rights and Advance Directive section on page 3, revealed specific questions regarding Advance Directives was left blank, and no documentation that the facility determined whether the patient had an Advance Directive or was interested in more information regarding an Advance Directive. The patient signed the document on the fourth page indicating that all 15 conditions/consents were addressed with the patient.

A review of Patient #1's physician's orders dated 09/20/17 at 12:45 PM, revealed an order to "Allow Natural Death/Do Not Attempt Resuscitation."

Continued interview with Family Member #1 on 11/21/17 at 1:15 PM, revealed on 09/22/17 at approximately 5:32 AM, RN #1 contacted her and stated that Patient #1's heart rate had dropped and the family needed to come to the facility. Family Member #1 stated she asked the RN what was being done for the patient and requested that the patient be sent to the critical care unit. Family Member #1 stated that RN #1 informed her that Patient #1 "had signed a DNR order and nothing further would be done." However, Family Member #1 stated she told the RN that the patient had not signed a DNR, and demanded that treatment be provided for the patient. Patient #1's Family Member stated RN #1 called back minutes later and stated the patient had passed away. Further interview with Family Member #1 revealed she had contacted the facility multiple times after the patient's death because she was adamant that Patient #1 had never expressed wishes to not be resuscitated and the facility had made no effort to resolve the family's grievance.

Interview with RN #1 on 11/27/17 at 12:15 PM, revealed the RN called the patient's emergency contact (Family Member #1) on the morning of 09/22/17, to notify her of the change in Patient #1's condition. The RN stated she informed the family member that the patient's heart rate was low and requested that the family come to the facility. The RN stated the family member asked what was being done for the patient, and RN #1 reported to the family that the patient "had a signed DNR order and nothing would be done." Further interview revealed the family stated the patient was not a DNR and the RN needed to "do something." The RN stated Patient #1 expired minutes later and life-saving interventions were not performed.

Continued review of the facility's timeline revealed on 10/02/17, Family Member #1 contacted the facility to request medical records for Patient #1, and the timeline revealed a discussion regarding the DNR status of Patient #1 occurred. According to the timeline, the facility conducted a review of Patient #1's medical record and determined that the record contained a Do Not Resuscitate Physician Order for Patient #1. On 10/04/17, 10/11/17, and 10/12/17, the facility conducted interviews with facility staff who were involved in Patient #1's care during his/her hospitalized from [DATE] through 09/22/17. However, there was no evidence the facility implemented their grievance policy.

Further review of the timeline provided by the facility revealed on 10/10/17, Family Member #1 requested a meeting with Patient #1's providers, including the staff that notified her that the patient passed away, and requested a copy of the facility's DNR policy. In addition, on 11/07/17, the facility received a letter from a patient advocate reiterating the family member's concerns that the facility misinformed the family that Patient #1 had passed away on 09/21/17, and concerns that the patient had a physician's order to provide no resuscitation when this decision was not discussed with the patient/family and subsequently CPR was not provided for Patient #1 on 09/22/17.

Continued review of the facility's timeline revealed on 11/10/17, Family Member #1 sent an e-mail to facility corporate staff requesting that the facility respond to the patient advocate's letter. On 11/15/17, the patient advocate e-mailed the facility and asked that the facility address the issues of the confusion surrounding Patient #1's family being notified on 09/21/17 that the patient died , "only to find out that [Patient #1] was alive a mere 30 minutes later" and the family's claim that the patient never consented to a DNR status and that despite a physician's order, no signed consent to DNR existed in the patient's medical records.

Interview with the facility's Risk Manager on 11/21/17 at 1:15 PM, revealed she was aware Family Member #1 was upset and had been communicating with the facility regarding her concerns that transpired during Patient #1's hospitalization . However, there was no evidence the facility implemented the facility's grievance policy and reviewed the family member's complaint and upon completion of the review, sent a letter indicating the results of the review and actions taken on their behalf.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure rights were protected for one (1) of ten (10) patients (Patient #1) during the decision-making process related to life-sustaining measures. Furthermore, the facility failed to develop a clear policy that ensured the staff was knowledgeable of the facility's expectations of when to perform Cardiopulmonary Resuscitation (CPR).

The findings include:

Review of the facility's policy titled "Do Not Resuscitate," (DNR) dated 04/19/17, revealed the physician and others involved in the decision should consider the patient's medical prognosis, the possibility of extending life under humane and comfortable conditions, and the patient's attitude toward sickness, suffering, and death. The physician should be active in the decision-making process by making specific recommendations and defining reasonable alternatives before obtaining the decision of the patient, family, and/or other designated surrogate regarding a DNR. In addition, the policy stated that a DNR order may be considered when a patient capable of making health care decisions has expressed his/her wishes either directly or through an advance directive or acceptable surrogate. According to Section I of the policy, in addition to the actual order, the physician should document his/her opinion of the competency of the patient at the time the decision was made. However, Section II of the DNR policy appears to be in conflict with Section I as the first sentence of Section II again refers to a competent patient; however, subsequent language references family and surrogate situations.

Review of the facility policy titled "Patient Rights and Responsibilities," revised 02/02/17, revealed the patient or patient's surrogate has the right to make informed decisions regarding care, including being informed of the patient's health status; being involved in care planning and treatment; being able to request or refuse treatment to the extent permitted by law; and being informed of the medical consequences of the patient's actions.

Review of Patient #1's record revealed the patient arrived at the Emergency Department on 09/20/17 at 9:29 AM with complaints of abdominal pain, diarrhea, and dry heaving.

Review of Patient #1's physician orders dated 09/20/17 at 12:25 PM, revealed Physician Assistant (PA) #1 wrote an order for a "Conditional Code" for Patient #1, while the patient was in the Emergency Department. The order stated to "Allow Natural Death/Do Not Attempt Resuscitation."

Review of Patient #1's History and Physical, dated 09/20/17, revealed the patient's code status was discussed with the patient and family. Further review revealed it was documented that Patient #1 would like medicinal treatment, but did not desire chest compressions, code drugs, or mechanical ventilation.

Further review of Patient #1's medical record revealed no evidence that the facility documented that the patient was incurable, terminal, and further intervention would be futile as required by the facility's policy. However, review of the DNR policy revealed that the policy was unclear as to whether this section referred to a competent patient's decision or family/surrogate's decision.

Interview with PA #1 on 11/22/17 at 12:20 PM revealed Patient #1's conditional code status was discussed with the patient in the Emergency Department on 09/20/17, while family members were present. The PA stated that in her opinion Patient #1 was competent to make decisions regarding care and treatment; therefore, no further justification for the code status was required for the conditional code order to be written.

Interview with Family Member #1 on 11/21/17 at 1:15 PM and Family Member #2 on 11/27/17 at 1:58 PM revealed they were present in the Emergency Department when PA #1 spoke with Patient #1. Family Members #1 and #2 denied that PA #1 ever discussed the patient's code status with the patient or the family that was present. Subsequently, Family Member #1 stated that when Registered Nurse (RN) #1 contacted her on 09/22/17 at approximately 5:32 AM, she expected the facility to provide all life-saving measures possible for Patient #1. When RN #1 told the Family Member that Patient #1 had signed a request for no CPR, Family Member #1 stated at that time she specifically requested that the resident receive life-saving measures and had the expectation that it would be provided because she was the patient's family member.

Interview with RN #1 on 11/27/17 at 12:15 PM revealed on the morning of 09/22/17, she informed the family member that Patient #1's heart rate was low and requested that the family come to the facility. The RN stated the family member asked what was being done for the patient and she reported to the family that the patient "had a signed DNR order and nothing would be done." Further interview revealed the family stated the patient was not a DNR and the RN needed to "do something." However, RN #1 stated she had not been trained on what to do in the event that a patient's family member requested CPR for a patient who had an order for no resuscitation.

Interviews on 11/27/17 with RN #2 at 2:45 PM, RN #3 at 2:55 PM, RN #4 at 3:45 PM, and a facility House Supervisor at 1:35 PM, revealed that to their knowledge, a family member's wishes would supersede a DNR or conditional code order, and they would provide life-saving interventions at the request of the family despite the patient's wishes when the patient did not have an Advance Directive.

Interview with the Chief Nursing Officer (CNO) on 11/21/17 at 3:40 PM, revealed the expectation for facility nursing staff was to follow physician orders. However, the CNO also stated that "the least the facility could do was to ensure a patient's wishes were followed."

The above five (5) staff interviews revealed an inconsistent understanding of when a patient's wishes versus a family member's wishes regarding DNR status should be followed.