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.


Based on review of 42 Code of Federal Regulations (CFR) 489.102, policy review, medical record review and interview, the hospital failed to inform the patient's representative of the patient's rights in advance of discontinuing patient care for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of 42 CFR 489.102 revealed, "...Hospitals...must maintain written policies and procedures concerning advance directives with respect to all adult individuals receiving medical or through the provider and are required to...Provide written information to such individuals concerning...An individual's rights under State make decisions concerning such medical care...The written policies of the provider or organization respecting the implementation of such rights, including a clear and precise statement of limitation if the provider cannot implement an advance directive on the basis of conscience. At a minimum, a provider's statement of limitation should...(A) Clarify any differences between institution-wide conscience objections and those that may be raised by individual physicians; (B) Identify the state legal authority permitting such objection; and (C) Describe the range of medical conditions or procedures affected by the conscience objection..."

2. Review of the hospital's "Advance Directives" policy revealed, "...If the attending physician cannot honor an Advance Directive, he/she should make every effort to transfer the patient to a physician who is able to honor the patient's wishes..."

Review of the hospital's "Patient Rights" policy revealed, "...PURPOSE...Ensure that all patients receiving care and/or patient representatives are informed of their rights...Ensure that this policy is in alignment with federal, state and local regulations ..."

3. Medical record review for Patient #1 revealed an admission date of [DATE] with diagnoses which included Severe Sepsis with Septic Shock, End-Stage Renal Disease on Dialysis, Chronic Tracheostomy/Ventilator, Persistent Vegetative State, Diabetes Mellitus, Chronic Respiratory Failure, [DIAGNOSES REDACTED], Decubitus Ulcers, Anemia and Congestive Heart Failure.

The "ADVANCE CARE PLAN" dated 11/20/17 revealed, "...I, [Patient #1's name], hereby give these advance instructions on how I want to be treated by my doctors and other health care providers when I can no longer make those treatment decisions myself...Agent: I want the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my agent must follow my instructions below...Name: [Patient #1's son]...Quality of Life: By marking "yes" below, I have indicated conditions I would be willing to live with if given adequate comfort care and pain management...[box checked "yes"]...Permanent Unconscious Condition...[box checked "yes"]...Permanent Confusion...[box checked "yes"]...Dependent in all Activities of Daily Living...[box checked "yes"]...End-Stage Illnesses...Treatment...By marking "yes" below, I have indicated treatment I want...[box checked "yes"]...CPR (Cardiopulmonary Resuscitation)...[box checked "yes"]...Life Support/Other Artificial Support...[box checked "yes"]...Treatment of New Conditions...[box checked "yes"]...Tube feeding/IV [intravenous] fluids..."

The physician's note dated 11/2/18 revealed, "...I [Physician #1] believe care is inappropriate and unethical at this time...I am going to stop dialysis...I believe she [Patient #1] should be hospice/comfort care only...I will discuss with son [Patient #1's Power of Attorney (POA) for Healthcare Decisions] when he arrivves [arrives] later today...Addendum 1: 11/02/18 0823 [8:23 AM]...SPOKE WITH SON BY PHONE...INFORMED SON THAT WE ARE STOPPING CARE AS WE FEEL IT IS UNETHICAL/FUTILE..."

There was no documentation the hospital provided Patient #1's POA for Healthcare Decisions written information concerning the written policies which included a clear and precise statement of limitation if the provider cannot implement an advance directive on the basis of conscience.

4. During an interview in the Ethics and Compliance Office on 12/10/18 at 2:45 PM, the Quality Improvement Manager stated she did not believe the hospital gave patients or their representatives the written policies for advance directives.