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Based on 5 of 6 medical records reviewed (MR #2, #3, #22, #23, and #24) of patients with advanced directives, staff interview, and review of facility policies and procedures, it was determined that the facility failed to implement the policy and procedure for Advance Directives.

Findings include:

Reference: Facility policy and procedure titled 'Advance Directives' states, "POLICY ... The receipt of the advanced directives will be documented on the medical record. ... Procedure ... Admission Department 1. ... Advance Directive status is documented on the Advance Directive Acknowledgement Form (attached), and signed by the patient/or representative. 2. ... If an Advance Directive has been executed, but the patient/resident does not have a copy at the time of admission, the patient/representative will be instructed to bring a copy to ---- hospital as soon as possible. ... Case Management/Social Service 1. To ascertain whether or not the patient's Advance Directive has been brought to the facility. If a copy has not been provided to the facility, Case Management will provide the patient with an opportunity to develop a new Advance Directive. ... Nursing ... 3. If a copy of advance directives is received after admission: a. it will be placed on the chart and the date received documented on the Advance Directive Acknowledgement form..."

1. Review of Medical Record #2 revealed the following:

a. The History and Physical (H&P) with a dictation and transcription date of 7/6/11 stated, "The patient wishes to be do not resuscitate and do not intubate, and there is a copy of the living will on the chart."

b. There was no evidence of an advance directive in Medical Record #2 as indicated in the H&P. This was confirmed by Staff #11 on 7/12/11 at 12:15 PM.

c. A physician order dated and timed 7/6/11 at 6 PM indicates a DNR/DNI [do not resuscitate and do not intubate] order.

d. The Interdisciplinary Assessment completed by the nurse on 7/6/11, indicates the patient requests no CPR, no ventilatory support, and no tube feedings.

e. A 'Case Management Addendum' note dated and timed 7/7/11 at 2:45 PM indicates in the 'Follow -up Advance Directives/living Will/Guardianship/DPOA:' section that the patient is "DNR/DNI."

f. Review of a handwritten physician note in Medical Record #2, dated and timed 7/6/11 at 6 PM states in the 'PLAN' section that the patient is a "Full code" and no living will is on the chart.

2. Without the evidence present in Medical Record #2 of the patient's Advance Directive, it could not be determined what status the patient has requested regarding resuscitation efforts to be carried out or not.

a. There was no evidence that Case management provided Patient #2 with an opportunity to develop a new Advance Directive, as per the policy stated above.

5. Review of Medical Record #3 on 7/12/11 indicated in the 'Social History' section of the H&P that the patient "... has an advance directive and he is do not resuscitate level of resuscitative effort."

a. A physician order dated and timed 7/1/11 at 5 PM circled 'Yes' next to 'Advance Directive' and 'Do Not Resuscitate' was checked off ordered and did not include to whom this directive was confirmed by.

b. The DNR was renewed by a telephone order dated and timed 7/8/11 at 5 PM.

c. Review of a Case Management Addendum note dated and timed 7/2/11 at 11:15 AM stated in the 'Follow -up Advance Directives/living Will/Guardianship/DPOA:' section that the patient, "does not have a living will, but does have a Power of Attorney (POA)."

d. There was no evidence of an Advance Directive in Medical Record #3.

6. Review of Medical Record #22 indicated in the 'Code Status' section of the H&P that the "Patient requests do not resuscitate. She states she has lived "long enough." She does not want CPR. She wants to be DNR. she has a living will and a grandson is the healthcare representative."

a. There was no living will in Medical Record #22, as indicated in the H&P. Staff #7 found Patient #22's Health Care Directive and Appointment of Health Care Representative in the file from the sending hospital.

i. Review of the Health Care Directive and Appointment of Health Care Representative indicates that the patient's son and daughter-in-law are the designated healthcare representatives. There was no evidence that the patient's grandson is his/her healthcare representative as stated in the H&P.

7. A review of Medical Record #23 indicated a handwritten physician progress note dated and timed 7/8/11 at 5:30 PM that states "DNR requested."

a. Review of a Case Management Addendum note dated and timed 7/8/11 at 1515 indicated in the 'Follow -up Advance Directives/living Will/Guardianship/DPOA:' section that the, "patient states he has executed a living will."

b. The physician's admission orders indicate an order dated and timed 7/8/11 at 5:30 PM that circles 'Yes' next to Advance Directive, and a checkmark next to 'Do Not Resuscitate.'

c. There was no evidence of an advance directive in Medical Record #23. As per interview with Staff #7 on 7/13/11, the sending hospital did not send a copy with the patient.

8. Review of Medical Record #24 indicated a physician note dated and timed 7/1/11 at 5 PM that states the, "patient wants DNR."

a. Review of an H&P with a dictation and transcription date of 7/2/11 also indicates the patient requests DNR and that she has a living will with a health care representative.

b. The physician's admission orders indicate an order dated and timed 7/1/11 at 5:30 PM that circles 'Yes' next to Advance Directive, and a checkmark next to 'Do Not Resuscitate'.

c. There was no evidence of an advance directive in Medical Record #24. As per interview with Staff #7 on 7/13/11, the sending hospital did not send a copy with the patient.

9. There was no evidence that the facility pursued obtaining a copy of the patient's advance directives.

a. The facility policy and procedure referenced above states "... Advance Directive status is documented on the Advance Directive Acknowledgement Form (attached), and signed by the patient/or representative." There was no of a 'Advance Directive Acknowledgement Form' attached to the policy or found in any of the medical records referenced above.

Based on medical record review, it was determined that the facility failed to implement its policy for medication reconciliation in 1 of 3 medical records reviewed (MR #29).

Findings include:

Reference: Facility policy and procedure Subject 'Reconciliation of Medication JCAHO: NPSG #8' states, "... POLICY: ... The process of reconciliation will occur at admission ... and at the time of discharge. ... Discharge Reconciliation Unless a transfer or a discharge occurs under emergent circumstances, staff will provide the patient with education and will review their current medications prior to discharge. ... c) Discharge to Home i. The Discharge Instructions Form ii. Discharge Prescriptions iii. Medication Information Teaching Sheets."

1. On 7/13/11 review of Medical Record #29 indicated that the patient was admitted 5/27/11 and discharged 6/4/11.

2. The 'Medication Reconciliation Worksheet' was completed by the nurse on 6/1/11 and listed the following medications the patient was taking at home:

a. Enbrel injection 1 time per week.

b. Methotrexate .04 injection one time per week.

c. Lopressor 50 milligrams 2 times per day.

d. Ambien 15 mg 1 time at hourly sleep.

e. Protonix 40 1 time per day.

3. The 'Medication Reconciliation Worksheet' was signed by the physician on 6/1/11 and in the 'Final Disposition' area of the form, the following medications to be discontinued and resumed were checked as follows:

a. Enbrel injection 1 time per week / Discontinued

b. Methotrexate .04 injection one time per week / Discontinued.

c. Lopressor 50 milligrams 2 times per day / Resumed.

d. Ambien 15 mg 1 time at hourly sleep / Resumed.

e. Protonix 40 1 time per day / Resumed.

4. Two prescriptions dated 6/3/11 were evident in the chart. The following medications were ordered:

a. Lopressor 50 milligrams by mouth twice a day times one month.

b. Prilosec 20 milligrams by mouth daily times one month.

c. KCL [Potassium Chloride] 10 milli-equivalents by mouth daily times one month.

d. Feosol 325 milligrams by mouth twice a day times one month.

e. Nucynta 50 mg tablets, one or two tablets by mouth every 4 hours as needed for pain.

4. The Medication list for discharge in Medical Record #29 was blank. This was confirmed by Staff #5 on 7/13/11 at 2:30 PM. Staff #5 stated that some of the nurses do not like to use this form. This form has columns to identify the medications and dosage, instructions, reason for taking the medication, and the last dose taken before discharge.

5. There was no evidence that Patient #29 was provided with instructions on his/her medications prior to discharge. There was no indication if the patient should resume his/her previous home medications of the Enbrel injection 1 time per week and the Methotrexate .04 injection one time per week both of which were discontinued by the physician on 6/1/11.

a. There was no indication of the newly prescribed Prilosec 20 milligrams by mouth, daily, times one month, was to replace the patient's Protonix 40, one time per day, that was previously taken at home and resumed in the hospital.

b. There was no evidence that the patient was provided with education on the newly prescribed KCL, Feosol or Nucynta, that he/she had not been prescribed prior to his/her hospital admission.

A. Based on document review and staff interview, it was determined that the facility failed to measure, analyze and track quality indicators related to the acute care hospital services and operations.

Findings include:

1. A review of the 'Plan of Correction' submitted by the facility to the Department and dated June 9, 2011, stated, "The Quality Metrics Report (QMR) is a new tool that was implemented in January 2011, replacing the prior trending reports. The Infection Control department, as well as most other departments, must report monthly QMR data..."

2. A review of the 'Pain Re-Assessment' indicator in the QMR 2011 report revealed the following:

a. "Calculation/Formula # of pain re-assessments documented after pain intervention administered/total # of pain interventions audited times 100."

b. "Sampling Instructions 30 per quarter; review one week per medical record."

c. The QMR report indicated that the facility was 65% compliant for April 2011 and 86% compliant for May 2011.

e. A review of the "Action Plans" in the QMR report for pain re-assessment stated, "LTC... (Long Term Care) education of float nurses..."

3. A review of the 'Healthsouth Rehabilitation Hospital Performance Improvement Report' for pain assessment dated April 2011 for the 'South Acute Unit' stated, "Sample Size 20...Is there a follow-up for effectiveness of medication...Findings 66%."

4. There was no evidence that the findings of 66% compliance for pain re-assessment with a sample size of 20 medical records, corresponded with the QMR report that stated 65% compliance for pain re-assessment based on 30 medical records.

5. Staff #5 and Staff #7 confirmed during interview on 7/14/11, that the data collected and reflected on the monthly QMR for pain re-assessment was for the 'Long Term Care Unit' only.

4. The facility was unable to provide quality data results on the day of the survey, 7/14/11, for all of the Acute Care Units regarding pain re-assessment.

B. Based on a review of the performance improvement process and quality indicators and staff interview, it was determined that the facility failed to track, analyze and measure data effectively to improve patient care.

Findings include:

1. A review of the 'Quality Metrics Report (QMR)' for the months of January 2011 through May 2011 revealed that the facility had combined the quality indicators and data collected from the Long term Care Units and Acute Care Units. There was no evidence that the information collected for performance improvement was separated for each individual provider within the hospital.

2. There was no evidence that the sampling size of the 'Healthsouth Rehabilitation Hospital Performance Improvement Report' matched the sampling instructions of 30 per quarter on the QMR report.

3. Upon request on 7/14/11, the facility was unable to provide quality data information for all of the indicators recorded on the QMR report, for all of the Acute Care Units.