HospitalInspections.org

Based on review of the facility policy, medical record review, and interview, the facility failed to maintain an accurate medical record for 1 patient (#1) of 4 medical records reviewed.

The findings included:

Review of facility policy, Patient's Rights, last revised on 5/2013, revealed "...You have the right to formulate advance directives and to have those directives followed..."

Medical record review revealed patient #1 was admitted to the facility on 1/5/16 with diagnoses including Hypoxic Respiratory Failure, Multi-Organ Failure, and Management of Respiratory Failure and Ventilator Weaning.

Medical record review of a physician's Hiistory and Physical dated 1/5/16 revealed "...POA [Power of Attorney]...consistent in wishing for the patient to be a Full Code [Cardiopulmonary Resuscitation will be performed in the absence of pulse and/or breathing]..."

Medical record review of a physician's order dated 1/5/16 revealed "...Full Code..."

Medical record review of a Pulmonary Physician's Consultation note dated 1/6/16 revealed "...Condition was discussed with the [POA] and code status was changed to Do Not Resuscitate [DNR], however, the son wanted to continue full care otherwise..."

Medical record review of a physician's order dated 1/6/16 at 4:50 PM revealed "...DNR..."

Medical record review of a physician's order dated 1/7/16 at 12:30 PM revealed "...Pt [patient] is a Full Code..."

Interview with the Chief Nursing Officer (CNO) on 1/13/17 at 8:15 AM, in the CNO's office, revealed "...code status being changed was a misunderstanding between the son and the physician..."Continued interview confirmed the patient's code status was changed for less than 18 hours.

Telephone interview with Chief Executive Officer (CEO) on 1/23/17 at 2:26 PM, in the conference room, confirmed the facility failed to maintain an accurate medical record for patient #1.