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Based on record review and staff interviews it was determined the hospital failed to ensure patient #1 had a right to participate in her plan of care by not respecting her wishes to be a full code in the event of respiratory or cardiac failure in one (1) of two (2) death records reviewed. This failure has the potential for all patients who request a full code to be denied the right for cardiopulmonary resuscitation that would result in the patient's death. (See tag A 131 and A 144)

A. An immediate jeopardy to the supervision of nursing care to ensure physician's orders are followed to allow a patient to be a full code in the event of cardiac or respiratory failure was called on 02/28/19 at 8:40 a.m.

B. Harm or Potential Harm: Patient #1 requested to be a full code on 04/06/17 at 7:45 a.m. and ordered by the physician. On 4/11/17 at 8:20 p.m. the patient had no heartbeat and minimal respiratory effort. Nurse #2 declared the patient was a Do Not Resuscitate and no cardiopulmonary resuscitation was performed as requested by the patient and ordered by the physician.

C. Immediacy: An adverse event was completed by the hospital on 4/11/17. The adverse event states in part: "Patient DNR...No further follow up needed."

D. Culpability: An interview was conducted with the Director of Quality/Risk Management on 2/28/19 at 8:10 a.m. When asked if the adverse event showed any errors on the part of the hospital she stated in part: "No, we did not catch it. If we had we would have fixed the error with retraining."

E. An immediate Plan of Correction was received and sent to the State Agency Program Directors. It was accepted and the facility abated on 02/28/19 at 1:25 p.m.

Based on record review and staff interviews it was determined the Director of Nursing failed to supervise the Registered Nurse (RN) to ensure patient #1's wishes were respected to be a full code in the event of respiratory or cardiac failure in one (1) of two (2) death records reviewed. This failure has the potential for all patients who request a full code to be denied the right for cardiopulmonary resuscitation that would result in the patient's death. (see tag A 395)

A. An immediate jeopardy to the supervision of nursing care to ensure physician's orders are followed to allow a patient to be a full code in the event of cardiac or respiratory failure was called on 02/28/19 at 8:40 a.m.

B. Harm or Potential Harm: Patient #1 requested to be a full code on 04/06/17 at 7:45 a.m. and ordered by the physician. On 4/11/17 at 8:20 p.m. the patient had no heartbeat and minimal respiratory effort. Nurse #2 declared the patient was a Do Not Resuscitate (DNR) and no cardiopulmonary rescusitation was performed as requested by the patient and ordered by the physician.

C. Immediacy: An adverse event was complete by the hospital on 4/11/17. The adverse event states in part: "Patient DNR...No further follow up needed."

D. Culpability: An interview was conducted with the Director of Quality/Risk Management on 2/28/19 at 8:10 a.m. When asked if the adverse event showed any errors on the part of the hospital she stated in part: "No, we did not catch it. If we had we would have fixed the error with retraining.

E. An immediate plan of correction was received and sent to the State Agency Program Directors. It was accepted and the facility abated on 02/28/19 at 1:25 p.m.

Based on record review and staff interviews it was determined the hospital failed to ensure patient #1 had a right to participate in her plan of care by respecting her wishes to be a full code in the event of respiratory or cardiac failure in one (1) of two (2) death records reviewed. This failure has the potential for all patients who request a full code to be denied the right for cardiopulmonary resuscitation that would result in the patient's death.

Findings include:

A. An immediate jeopardy to the supervision of nursing care to ensure physician's orders are followed to allow a patient to be a full code in the event of cardiac or respiratory failure was called on 02/28/19 at 8:40 a.m.

B. Harm or Potential Harm: Patient #1 requested to be a full code on 04/06/17 at 7:45 a.m. and ordered by the physician. On 4/11/17 at 8:20 p.m. the patient had no heartbeat and minimal respiratory effort. Nurse #2 declared the patient was a Do Not Resuscitate (DNR) and no cardiopulmonary resuscitation was performed as requested by the patient and ordered by the physician.

C. Immediacy: An adverse event was completed by the hospital on 4/11/17. The adverse event states in part: "Patient DNR...No further follow up needed."

D. Culpability: An interview was conducted with the Director of Quality/Risk Management on 2/28/19 at 8:10 a.m. When asked if the adverse event showed any errors on the part of the hospital she stated in part: "No, we did not catch it. If we had we would have fixed the error with retraining."

E. An immediate Plan of Correction was received and sent to the State Agency Program Directors. It was accepted and the facility abated on 02/28/19 at 1:25 p.m.

1. Review of the medical record for patient #1 revealed in part that the patient was admitted to the hospital on 04/05/17 at 8:20 p.m. and signed her consent for treatment, privacy and Medicare rights. On 04/05/17 at 8:20 p.m. a resuscitative status form was signed by the patient's cousin and witnessed by a nurse. On 04/06/17 at 7:45 a.m. physician #1 completed a history and physical that stated in part: "Patient is alert and interactive, pleasant and cooperative ...Code Status Full. This is reviewed with patient. Will continue to honor wishes ..." Further review of the medical record revealed no order for a DNR or Medical Power of Attorney MPOA).

2. Review of the policy titled Patient Rights and Responsibilities with a last review date of 01/29/19 revealed in part: "Patients will be given a written statement upon admission."

3. An interview was conducted with physician #1 on 02/28/19 at 7:20 a.m. When asked if he remembered patient #1 and if so, please explain her cognitive during her hospitalization. He stated in part: "I reviewed her chart and yes I remember her and her family was frequently at the hospital and her son would communicate by telephone because he lived out of state. She was a pleasant lady who would answer appropriately and would ask questions appropriately." When asked if he remembered a discussion with the patient regarding her wishes for a full code or a DNR and if he felt the patient had capacity at the time of the discussion, he stated in part: "Yes, I completed my assessment of the patient so I had talked with her for awhile and then we went over the resuscitation form to see if she wanted to be a DNR. She wanted to be a full code and that is why I did not sign the paper to make it an order. I believe she had capacity and that is why I didn't accept the DNR and we also did not have MPOA papers to honor any wishes of a family member if she did not have capacity." When asked if he had ever given an order for a DNR he stated no.

4. An interview was conducted with the Director of Quality/Risk Manager on 02/28/19 at 8:10 a.m. and she concurred with the above findings.

5. An interview was conducted with the Chief Nursing Officer on 02/28/19 at 2:00 p.m. She concurred there was no physician's order for the patient to be declared a DNR.

Based on record review and staff interviews it was determined the hospital failed to ensure care was given in a safe setting for one (1) of two (2) death records reviewed (patient #1) by failing to follow an order for full code in the event of respiratory or cardiac failure. This failure has the potential for all patients who have an order for a full code to be denied the right for cardiopulmonary resuscitation that would result in the patient's death.

Findings Include:

1. Review of the medical record for patient #1 revealed in part that the patient was admitted to the hospital on 04/05/17 at 8:20 p.m. and signed her consent for treatment, privacy and Medicare rights. On 04/05/17 at 8:20 p.m. a resuscitative status form was signed by the patient's cousin and witnessed by a nurse. On 04/06/17 at 7:45 a.m. physician #1 completed a history and physical that stated in part: "Patient is alert and interactive, pleasant and cooperative ...Code Status Full. This is reviewed with patient. Will continue to honor wishes ..." Further review of the medical record revealed no order for a Do Not Resuscitate (DNR) or Medical Power of Attorney (MPOA).

2. Review of the policy titled Patient Rights and Responsibilities with a last review date of 01/29/19 revealed patients will be given a written statement upon admission.

3. An interview was conducted with physician #1 on 02/28/19 at 7:20 a.m. When asked if he remembered patient #1 and if so, please explain her cognitive during her hospitalization. He stated in part: "I reviewed her chart and yes I remember her and her family was frequently at the hospital and her son would communicate by telephone because he lived out of state. She was a pleasant lady who would answer appropriately and would ask questions appropriately." When asked if he remembered a discussion with the patient regarding her wishes for a full code or a DNR and if he felt the patient had capacity at the time of the discussion, he stated in part: "Yes, I completed my assessment of the patient so I had talked with her for a while and then we went over the resuscitation form to see if she wanted to be a DNR. She wanted to be a full code and that is why I did not sign the paper to make it an order. I believe she had capacity and that is why I didn't accept the DNR and we also did not have MPOA papers to honor any wishes of a family member if she did not have capacity." When asked if he had ever given an order for a DNR he stated no.

4. An interview was conducted with the Director of Quality/Risk manager on 02/28/19 at 8:10 a.m. and she concurred with the above findings.

5. An interview was conducted with the Chief Nursing Officer on 02/28/19 at 2:00 p.m. She concurred there was no physician's order for the patient to be declared a DNR.

Based on record review and staff interviews it was determined the Director of Nursing failed to supervise the Registered Nurse (RN) to ensure patient #1's wishes were respected to be a full code in the event of respiratory or cardiac failure in one (1) of two (2) death records reviewed. This failure has the potential for all patients who request a full code to be denied the right for cardiopulmonary resuscitation that would result in the patient's death.

Findings Include:

1. Review of the medical record for patient #1 revealed in part that the patient was admitted to the hospital on 04/05/17 at 8:20 p.m. and signed her consent for treatment, privacy and Medicare rights. On 04/05/17 at 8:20 p.m. a resuscitative status form was signed by the patient's cousin and witnessed by a nurse. On 04/06/17 at 7:45 a.m. physician #1 completed a history and physical that stated in part: "Patient is alert and interactive, pleasant and cooperative ...Code Status Full. This is reviewed with patient. Will continue to honor wishes ..." Further review of the medical record revealed no order for a Do Not Resuscitate (DNR) or Medical Power of Attorney (MPOA).

2. An interview was conducted with physician #1 on 02/28/19 at 7:20 a.m. When asked if he remembered patient #1 and if so, please explain her cognitive during her hospitalization. He stated in part: "I reviewed her chart and yes I remember her and her family was frequently at the hospital and her son would communicate by telephone because he lived out of state. She was a pleasant lady who would answer appropriately and would ask appropriately." When asked if he remembered a discussion with the patient regarding her wishes for a full code or a DNR and if he felt the patient had capacity at the time of the discussion, he stated in part: "Yes, I completed my assessment of the patient so I had talked with her for a while and then we went over the resuscitation form to see if she wanted to be a DNR. She wanted to be a full code and that is why I did not sign the paper to make it an order. I believe she had capacity and that is why I didn't accept the DNR and we also did not have MPOA papers to honor any wishes of a family member if she did not have capacity." When asked if he had ever given an order for a DNR he stated no.

3. An interview was conducted with the Director of Quality/Risk manager on 02/28/19 at 8:10 a.m. and she concurred with the above findings.

4. An interview was conducted with the Chief Nursing Officer on 02/28/19 at 2:00 p.m. She concurred there was no physician's order for the patient to be declared a DNR.

Based on record review and staff interviews it was determined the hospital failed to maintain an accurate medical record in one (1) of two (2) death records reviewed (patient #1) for a code status during a cardiac or respiratory failure. This failure has the potential for all patients admitted to the hospital to have an inaccurate medical record that may prevent them to have cardiopulmonary resuscitation (CPR) that may cause death to the patient.

Findings Include:

1. Review of the medical record for patient #1 revealed in part that the patient was admitted to the hospital on 04/05/17 at 8:20 p.m. and signed her consent for treatment, privacy and Medicare rights. On 04/05/17 at 8:20 p.m. a resuscitative status form was signed by the patient's cousin and witnessed by a nurse. On 04/06/17 at 7:45 a.m. physician #1 completed a history and physical that stated in part: "Patient is alert and interactive, pleasant and cooperative ...Code Status Full. This is reviewed with patient. Will continue to honor wishes ..." Further review of the medical record revealed no order for a Do Not Resuscitate (DNR) or Medical Power of Attorney (MPOA).

2. An interview was conducted with physician #1 on 02/28/19 at 7:20 a.m. When asked if he remembered patient #1 and if so, please explain her cognitive during her hospitalization. He stated in part: "I reviewed her chart and yes I remember her and her family was frequently at the hospital and her son would communicate by telephone because he lived out of state. She was a pleasant lady who would answer appropriately and would ask questions appropriately." When asked if he remembered a discussion with the patient regarding her wishes for a full code or a DNR and if he felt the patient had capacity at the time of the discussion, he stated in part: "Yes, I completed my assessment of the patient so I had talked with her for a while and then we went over the resuscitation form to see if she wanted to be a DNR. She wanted to be a full code and that is why I did not sign the paper to make it an order. I believe she had capacity and that is why I didn't accept the DNR and we also did not have MPOA papers to honor any wishes of a family member if she did not have capacity." When asked if he had ever given an order for a DNR he stated no.

3. An interview was conducted with the Director of Quality/Risk Manager on 02/28/19 at 8:10 a.m. and she concurred with the above findings.

4. An interview was conducted with the Chief Nursing Officer on 02/28/19 at 2:00 p.m. She concurred there was no physician's order for the patient to be declared a DNR.


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