HospitalInspections.org

Based on document review and interview the hospital failed to insure the medical staff followed the rules and regulations as stated in the medical staff policies in 1 of 1 patient record reviewed.

On 3/5/2012 as 9:00 AM in the quality meeting room the medical record for patient #1 was reviewed and revealed following physician entries into the record:
-Pt #1 presented to the Emergency Department (ED) on 8/14/2011 at 1040 hours (hr) with a two (2) day history of nausea, vomiting and diarrhea .
-Pt #1's representative signed "No Advanced Directive" on Section 11 "Advanced Directive", of the Admission Patient Rights sheet dated 8/14/2011 at 9020 Hrs.
-Pt #1 had a history of significant alcohol use and had been drinking beer heavily.
-Upon evaluation in the ED, Pt #1 was found to be hypotensive with a blood pressure (B/P) of 90/60
-Pt #1 was given intravenous (IV) fluids in the ED for a total of three (3) liters.
-Pt #1 B/P stabilized in the ED.
-Pt #1 primary diagnosis upon admission was as follows:
-sepsis due to urinary tract infection
-presumed infectious gastroenteritis
-acute kidney failure
-Pt #1 secondary diagnosis upon admission were as follows:
-history of cardiomyopathy
-coronary artery disease
-history of hypertension
-history of colon cancer
-ED documented Pt #1 as full code status.

- 8/14/2011 1415 hr Pt #1 was admitted to the telemetry floor.
- 8/14/2011 1415 hr the telemetry unit physician's order indicated, by an "x", Pt #1 was code status Do Not Resuscitate (DNR)
-8/14/2012 1415 hr all other physician admission orders are documented by a check mark rather than an "x"
-8/14/2011 1415 hr Pt #1 was receiving IV antibiotics.
-4/15/2011 1257 hr physician's order for Pt #1 records clear liquid diet a tolerated
-4/15/2012 1823 hr physician orders record "charge nurse to pronounce pt"

Nursing documented the following:
-8/14/2011 2012 hr received report from previous shift. No complaints, no distress will monitor call light within reach.
-8/15/2011 0020 hr Respirations even and unlabored.
-8/15/2011 0423 hr Respirations even unlabored on 2 liters of oxygen, denies distress
-8/15/2011 0735 hr Tylenol for head ache/fever
-8/15/2011 1402 hr B/P 88/52 Doctor #11 notified of B/P, no further orders
-8/15/2011 1839 hr Pt very restless, change in mental status, increase oxygen to 5 L per nasal cannula charge nurse notified (documentation does not reflect physician was notified)
-8/15/20122 1842 hr code blue canceled due to DNR status, unable to get B/P and Doctor #11 notified, family here. Pt's daughter here refusing to talk with Doctor #11
-8/15/2011 1918 hrs Patient asystole, charge nurse pronounced Pt, Doctor #11 gave telephone order.

On 3/5/2012 at 10:00 AM in the quality meeting room policies were reviewed and revealed the following:
-Policy No 41. Death, Determination and pronouncing by Registered Nurses within the hospital.
-RN's may determine and pronounce patient death if ALL of the following criteria are met:
1. Death is expected
2. The physician had written a current "Do Not Resuscitate" order, AND there is documentation in the progress notes that the physician and family agree on the DNR status and
3. The patient is not on artificial life support.
A review of progress notes did not reveal any entry by the physician addressing the DNR status.

On 3/5/2012 at 2:15 PM in the quality meeting room an interview occurred with staff #3,# 4 and #5.
-The physician's were asked if the patient's death was expected.
-The consensus was no.
-The physician's were asked about the DNR order.
-After conversation regarding the DNR order, the policy was discussed and the lack of progress notation to support the DNR was brought to the attentionof the physician's.

On 3/5/2012 at 2:00 PM an interview with staff # 7 revealed the following:
-Staff #7 stated The family was involved but the children were demanding. The daughter was a registered pharmacy technician and wanted to know everything.
-Staff #7 stated the spouse had been at Pt #1 bed side all day.
-Staff #7 stated the daughter had very different expectations from what she understood the patient's desires were.
-Staff #7 stated the patient declined to have her B/P check frequently "she only wanted what she wanted"
-When staff #7 was questioned about the lack of documentation to reflect the patient's desire Staff #7 stated "we don't put it in the nurses notes because we are only going to do what the patient and Doctor want".

After review of documentation and interviews, the facility failed to insure physician documentation in a progress note indicating both he and the family had discussed and agreed upon a Do Not Resuscitate order. Without the progress note the patient remained a full code status. No resuscitation was attempted. Without the progress note the Registered Nurse could not pronounce the patient as dead. The facility did not follow policy #41.