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Based on document review and interview, the facility failed to ascertain advance directives/resuscitation status from the patient's guardian/power of attorney for 1 (#7) of 8 patients reviewed for advance directives/resuscitation status from a total sample of 15, resulting in the potential for not meeting the patient's wishes in refusing additional life-saving measures. Findings include:

Review of patient #7's medical record with Staff J, on 5/30/18 at approximately 1400, revealed that the patient was a 61 year-old male who had a history of recent esophageal rupture with esophagectomy, was treated for ventilator dependent respiratory failure with sepsis, debility, encephalopathy, and multiple co-morbidities. The patient had been in and out of the acute care hospital and long-term acute care facility since prior to August 2017 and was admitted to the present facility 12/7/17 - 1/9/18. It was noted in the "Interdisciplinary Plan of Care dated 1/3/18" that the Case Manager had documented that the "daughter was the guardian." Interview with Case Manager K, on 5/30/18 at 1320, revealed that he believed "the daughter or wife was the guardian" and he would get a copy of the guardianship papers if they were on file. Interview with Case Manager K, again on 5/31/18 at approximately 1105, revealed that he could not find the guardianship paperwork.

Further review of patient #7's medical record with Staff B, on 5/31/18 at approximately 1115 - 1145, revealed that the "Case Management Additional Information Note dated 12/8/17 at 1545" revealed that the wife was the guardian, not the daughter. The daughter had signed the form "Acknowledgement of Advance Directive for Health Care dated 12/8/17 at 6:30," and had documented BOTH that "The patient has a written Advance Directive for Health Care" and "The patient does NOT have an Advance Directive for Health Care."

On 5/31/18 at 1200, review physician progress note dated 12/8/17 documented that the patient had been a "No CPR (no resuscitation), however may intubate if needed." Also, review of a physician note dated 1/9/18 at 0624 revealed, the patient had "desaturation to 76%, fluid on lungs... stat transport to Harper ED...Unclear code status (resuscitation) per notes. Called patient's daughter twice and left voicemail with callback numbers."

On 5/31/18 at 1230, review of patient orders with Staff B revealed that the patient's resuscitation status was designated "Full Resuscitation" dated 12/9/17 (two days after admission) by the attending physician. Phone interview with Attending Physician N, on 5/31/18 at 1250, revealed that s/he had designated that status "Because I know that Doctor O always makes his patients full code." There had been no additional conversations or notes regarding discussions with the patient, family, or guardian. Phone interview with Admitting Physician O, on 5/31/18 at 1300, revealed that he had not discussed full resuscitation status or life saving measures with the patient, family, or guardian either.

On 5/31/18 at 1500 the following policies were reviewed:

Policy titled "Advance Directives, # 1 CLN 003, effective 3/15/16" documented "A properly designated Patient Advocate shall have the authority to make treatment decisions calculated solely to forego life-sustaining treatment only if the express grant of that authority is incorporated into the patient's Durable Power of Authority; and, with the concurrence of the attending physician...

Policy titled "Resuscitate/Do not Resuscitate (DNR) Orders, # 1 CLN 009 dated 3/9/18" documented, "The attending physician or designee must discuss with the patient the reasons and recommendations for or against a DNR order..." If the patient has executed a Durable Power of Attorney for Health Care...the signed form must be placed in the patient's medical record... A Patient Advocate may make a decision to withhold or withdraw treatments which allow a patient to die..."

Based on interview and document review the facility failed to provide all the necessary medical information during a transfer for 1 (#7) of 7 patients reviewed for discharge planning from a total sample of 15, resulting in the potential for negative outcomes. Findings include:

On 5/30/18 at approximately 1400 a review of the electronic medical record (EMR) for Patient #7, with staff C the Nursing Educator, documented he was a 61 year old male who was admitted to the rehabilitation hospital on 4/10/18 and transferred to a skilled nursing facility on 4/24/18 at 2251. Further review of the EMR documented a case manager initial discharge planning assessment on 4/11/18 that documented the plan for post hospital discharge care was to a skilled nursing facility.

On 5/30/18 at 1530 and on 5/31/18 at 1415 the case manager lead, staff K was interviewed regarding the transfer of patient #7 on 4/24/18. Staff K stated a contingent case manager had handled patient #7's referral and transfer. Staff K stated once a skilled nursing home had accepted the patient and the family agreed on the placement a completed packet of information was sent to the accepting facility on 4/20/18 at 1310 that included a complete history of the patients stay. Staff K stated on the day of discharge an updated informational packet was prepared by the case manager and sent to the unit where patient #7 was currently residing. Staff K stated at the time of discharge the discharging nurse adds "Depart summary" with the current medications and discharge instructions. Staff K stated the following day he received a call from the nursing home staff stating they did not receive the discharge instructions or current medications list and he found that Depart summary was not sent with patient #7 at the time of his discharge because the EMR system was down. He stated the discharge instructions and medications list was faxed on 4/25/18. Copies of the faxed documents and fax transmission log were reviewed with the surveyor at the time of the interview.

On 5/31/18 at 1445 staff R the registered nurse who discharged patient #7 on 4/24/18 at 2251 was interviewed regarding the transfer. Staff R stated she was informed of the planned transfer during shift report and given the packet of transfer paperwork. Staff R stated the ambulance was a few hours late. When queried about what information was included in the packet, staff R stated she did not look, but had assumed everything needed was in the packet because the day shift nurse generally has it ready. Staff R stated she called the nursing home and gave them a verbal report before the transfer and that they were expecting patient #7. Staff R stated she only heard after the fact that the Depart summary was not included in the packet sent at the time of discharge. Staff R stated it is the nursing portion of the discharge summary and includes the current medications and any discharge instructions. Staff R stated she did not go over the discharge medications with the patient or family because she assumed the day shift nurse had done it.

On 5/31/18 at 1540 the following facility policies were reviewed:

Policy 3 RIM PMR 8013 titled Depart Process, dated 12/1/16 documented the following: ". . .To provide a smooth transition from discharge from (name of facility) to home or other facilities for continuity of care. . .The Depart process in the EMR is to be utilized for all discharges to home and/or other facilities other than acute care. It is a patient's discharge instructions. . .The nursing sections are completed by the RN. 7. On the day of discharge the RN signs and prints the Depart summary and reviews it with the patient/responsible party."

Policy 3 RIM PC 8021 titled Patient Discharge Process, dated 1/31/17 documented the following: ". . .To provide guidelines for the discharge of the patient from (facility name). . .The assigned Registered Nurse is responsible for overseeing the discharge of the patient from the nursing unit. . .C. The RN views the Depart form to verify that the patient has received handouts/teaching materials relevant to his/her situation including medication teaching materials. . ."

Policy 1 EMR 001 titled EMR: Downtime Procedure, dated 12/1/13 documented the following: ". . .To describe procedures used when the Electronic Medical Record (EMR) is inaccessible for use. . .Manual processes are employed for physician orders, consults, diagnostic test results, online documentation, medication administration and patient movement during downtime. . .All documentation currently online will be done using downtime forms. . ."