HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the patient and/or the patient representative had the right to make informed decisions regarding their care. This deficient practice is evidenced by the hospital 1) failing to ensure its policy on informed consent included the process of how to manage informing of rights when the patient has a medical power of attorney in place, 2) failing to notify a patient's legal representative of changes in the patient's condition and 3) failing to obtain informed consent from the medical power of attorney for 1 of 5 patient records reviewed (Patient #1).
Findings:

Review of the closed medical record for Patient #1 revealed he was transferred to this hospital from another hospital on 06/13/17. Review of the admit physician orders revealed the patient was a full code. Review of the History and Physical dated 06/14/17 revealed the patient was admitted with diagnoses including respiratory failure, status post tracheostomy, pneumonia, heart failure, PEG tube placement and revolving septic shock. The History and Physical further revealed that the patient was admitted on a mechanical ventilator and was sedated.

Review of a form titled, VA Advance Directive/Living Will and Durable Power of Attorney for Healthcare, revealed that the patient's friend was listed as POA for healthcare and the patient's brother was listed as POA for healthcare if his friend could not make decisions for the patient. Further review of the form revealed that the patient did not want life-sustaining treatments should he have an incurable or irreversible condition. The form was dated 02/03/05.

Review of the admit papers/consents revealed that the wife of the patient's medical Power of Attorney (POA) signed them as the "patient representative". Further review of the patient's medical record revealed documentation that the wife of the patient's medical POA gave informed consents for a jejunostomy procedure (06/15/17), blood administration (06/20/17), peripherally inserted central venous catheter placement (06/27/17) and thoracentesis (07/12/17 and 07/21/17).

Review of a form titled, Physician Order Form-Resuscitation/Do Not Resuscitate, revealed that the wife of the patient's medical POA signed this form (dated 06/20/17) indicating that Limited Resuscitation was to be performed, with the boxes checked for emergency cardiac/vasoactive medications and defibrillation/cardioversion to be initiated only. Review of the form, Physician Order Form-Resuscitation/Do Not Resuscitate, dated 08/05/17, revealed that the POA's wife signed this form indicating that the patient was now a DNR (do not resuscitate).

Review of the case management notes dated 08/11/17, written by S1Case Manager, revealed that she received a call from the patient's brother informing writer that the wife of patient's POA has been misrepresenting herself as POA. The notes further revealed that the brother sent a copy of the current POA, living will and his drivers license. Copies of these were placed on chart. The notes further revealed that S1Case Manager notified the patient's physicians of the brothers wish for the patient to be terminally weaned from the ventilator.

Further review of the patient's record revealed that multiple attempts were made to wean the patient from the ventilator with no success. There was no documentation that the patient was ever responsive. The patient remained on the ventilator from admit until 08/17/17 at 3:50 p.m., when the patient was removed from the ventilator and his tube feeding. The notes further revealed that the patient was pronounced dead on 08/18/17 at 7:20 p.m.

On 09/06/17 at 10:15 a.m., interview with S1Case Manager revealed that since admit, the wife of the patient's medical POA stated that she was the patient's POA. S1Case Manager stated that she believed her and did not request legal documentation indicating this. She further stated it was not normal procedure to request the documentation if someone says that they are a patient's POA. She further confirmed that the POA's wife signed informed consents and code status changes for the patient. When asked when the hospital realized that she was not the patient's POA, S1Case Manager stated that the patient's brother who lived out of town called her on 08/11/17. He stated that the patient's pastor had sent him pictures of the patient on the ventilator. The patient's brother informed S1Case Manager that the POA's wife was misrepresenting herself and that her husband was actually the legal POA. S1Case Manager stated that the patient's brother also informed her of the patient's advanced directive documentation and emailed them to her that day. She further stated that the patient's brother stated that the patient would not want to live that way and he requested to have the patient removed from the ventilator. When asked if she had ever seen or talked to the patient's legal POA, she stated no.

On 09/06/17 at 2:00 p.m., interview with S2Director of Quality revealed that the hospital did not have a policy/procedure that addressed the process of managing informing of rights when a patient had a medical POA. She further stated that there was no system in place to ensure that individuals who claim to be medical POA are actually legally delegated to do this. She confirmed that there was no documented evidence that the patient's legal POA for medical was notified of changes in condition or the need for informed consent for procedures.