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Based on observation, interview and record review, the facility failed to ensure a patient's right to participate in a medical discussion for plan of care regarding code status (a patient's predetermined medical instructions regarding the type of life-saving measures they wish to receive if they stop breathing or their heart stops).

This failure resulted in the patient being resuscitated (revived from apparent death or from unconsciousness) against her current preferences regarding life sustaining care.

FINDINGS:

During a review of the Electronic Medical Record (EMR) for Patient 1 (P1), titled, "Emergency Department (ED) Physician Note", dated 9/16/25, 7:28 p.m., P1 arrived to ED by ambulance from a rehabilitation hospital and was assessed as alert upon arrival, with worsening shortness of breath and a medical history of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently), and atrial fibrillation with rapid ventricular response (A-fib with RVR, a irregular and fast heart rhythm disorder, resulting in shortness of breath, chest pain, fatigue, dizziness or palpitations) and was admitted to the hospital.

During review of P1's EMR, the rehabilitation hospital's transfer report titled, "Transfer/Discharge Report," the report indicated, "CODE STATUS: NO CPR [cardiopulmonary resucsitation, a combination of chest compressions and rescue breathing used when someone's heart or breathing stops] ... (REFER TO POLST)."

During review of P1's EMR titled, "Physician Orders for Life-Sustaining Treatment (POLST)" form, signed by P1 and dated 8/30/25, the form indicated the patient's wishes as, " ...if no pulse and is not breathing, Do Not Attempt Resuscitation / DNR (Allow Natural Death),... [and] Comfort-Focused Treatment ...Do not intubate [place breathing tube in throat] .....Generally avoid intensive care."

During review of P1's EMR physician medical order, titled, "Code Blue: Selective DNR, Palliative Consult," dated 9/17/25, 12:13a.m., the order indicated, "All reasonable efforts of resuscitation will be employed in the event of a cardiopulmonary [heart-lung] arrest ... Not Yet Discussed with Patient." The EMR indicated a unit staff nurse validated the order on 9/17/25 at 3:59 a.m.

During review of P1's EMR, titled, "Code Blue Note," dated 9/18/25, 4:23 a.m., the note indicated, "Rapid Response called as patient became acutely bradycardic and progressed to asystole. Nursing staff confirmed patient full code per electronic medical record (EMR) ... cardio-pulmonary resuscitation (CPR) performed ... Patient initially pronounced [dead] at 3:36 a.m." The Code Blue note indicated at 3:45 a.m., P1's heart began to beat on its own again and an endotracheal tube (ETT, tubing that keeps the airway open so oxygen can be delivered to the body) was inserted into the P1's airway and connected to a ventilator (a machine that controls breathing and oxygen delivery to a patient's body). The note indicated the Intensive Care Unit (ICU) charge nurse arrived at the bedside around the same time noting P1's, "paper medical chart had a DNR/DNI POLST form signed and dated on 8/30/25."

During an interview on 11/4/25 at 10:25 a.m., with the ICU supervisor (ICUS), ICUS stated a patient paper copy chart is put together upon arrival to the admitting unit so paper copies of medical records accompanying the patient can be accessible to health care team. ICUS stated nurses are expected to communicate POLST information to physicians to ensure a physician Code Blue Order aligns with patient's current preferences for life-sustaining treatment. ICUS stated this is to occur at the time of admission or as soon as possible.

During an interview on 11/5/25 at 10:55 a.m., with the Telemetry and Med-Surgical Unit Manager (TNM) and Telemetry and Med-Surgical Service Director (TMSD), TMSD stated if a patient is admitted to the unit with paper copies of a POLST form, indicating "Do Not Resuscitate- Do Not Intubate (DNR/DNI), the nurse is expected to contact physician immediately to ensure Code Blue Order aligns with patient's current preferences for life sustaining care.

During an interview on 11/5/25 at 2:21 p.m., with the Chief Medical Officer (CMO), CMO stated he expects physicians to have the code blue discussion with patients in real-time during a patients' initial assessment at admission; however if not feasible due to patient not medically stable, patient not capable of having a decision-making conversation with physician, or if the designated family decision-making person is not present, then discussion has to happen as soon as feasible and as soon as possible.

During a review of the facility's policy and procedure (P&P), titled, "Patient Rights and Responsibilities," dated 1/23/2024, P&P indicated, "You [the patient] have the right to effective communication and to participate in the development and implementation of your plan of care."

During a review of the facility's P&P, titled, "Physician Orders for Life Sustaining Treatment (POLST)," dated 6/1/2017, P&P indicated when patient is admitted to the hospital with a completed POLST form, "the admitting physician will document the existence of the POLST Form, and confirm with patient, if possible, or ...patient's legally recognized health care decision-maker, that the POLST Form in hand has not been voided or superseded by a subsequent POLST Form. P&P indicated, "Discussion about revising or revoking the POLST should be documented in the medical record and dated and timed ...documentation should include the essence of the conversation and the parties involved in the discussion."