HospitalInspections.org

Based on document review and interview, the facility failed to ensure the patient was involved and participated in decisions related to his/her care (code status) by following policy and procedure in one (1) instance. (Patient # 10)

Findings include:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", policy number BE 3, indicated the patient has the right to "exercise rights while receiving competent, considerate care or treatment in a safe setting". The patient has the right to participate in decisions about their care. This policy was last reviewed in 04/2018.

2. Review of the hospital policy titled "Do Not Resuscitate/Limited Intervention", policy number BE 5, indicated "the attending physician must record in the progress notes" the discussion with the patient, family and staff and the justification for the Do Not Resuscitate (DNR). No aspect of medical care shall be discontinued or limited without the express agreement and authorization of the patient if capable, or of the health care decision maker. This policy was last reviewed in 03/2019.

3. Review of the "Medical Staff Rules and Regulations", indicated on page fourteen (14) section three (3) number one (1) the MR shall contain sufficient information...to justify the treatment furnished...number three (3)..."Its contents shall be pertinent and current."

4. Review of the closed MR (medical record) for patient # 10 indicated the patient was a 83 y/o (year/old) who was admitted to H # 1"s (Rehabilitation Center) on 10/17/2019. The patient's medical history included, but were not limited to, atrial fibrillation, hypertension, pulmonary hypertension, dysphagia, acute on congestive chronic diastolic heart failure and possible pneumonia.
A. The original History and Physical (H&P) dated 10/17/2019 at 3:55 pm (date of service 10/18/2019 at 12:40 pm) by MS # 2 (Attending Physician), indicated the patient's code status was a DNR (Do Not Resuscitate). The second edited H&P dated 10/18/2019 at 12:55 pm by MS # 2, indicated the patient's code status changed to a Full Code. The third edited H&P dated 10/18/2019 at 4:57 pm by MS # 2, indicated the patient was a DNR again.
B. The MR lacked any documentation in the history/physical and/or progress notes where the attending physician had discussed the code status (DNR) with the patient/family/staff and/or documented the justification. The first DNR order was entered on 10/17/2019 at 8:31 pm and electronically signed by MS # 2 on 10/18/2019 at 9:01 am. The patient was transferred to H # 3 (Acute Care Hospital) on 10/21/2019 and the DNR order was canceled in the system at approximately 3:57 pm. The patient returned to H # 1 on 10/22/2019 early am and at that time was a Full Code in the system. MS # 1 (Internal Medicine Physician) gave a verbal DNR order on 10/22/2019 at 11:00 am.
C. The MR contained an "Appointment of Health Care Representative" dated 12/20/2016, which indicated the patient had authorized his/her family member to make decisions concerning withdrawal of health care if at any time the patient was unable to give consent for health care.
D. The Nursing Progress Note dated 10/22/2019 at 11:55 am, indicated the patient had put on the call light at approximately 10:30 am and complained with shortness of breath (SOB). MS # 1 and Respiratory Therapy (RT) were notified. Orders were received by MS # 1 to administer Lasix. MS # 1 was in room during administration of medication. MS # 1 left room and the patient became agonal and cyanotic. Oxygen (100%) was administered by Ambu bag. The patient passed at 11:04 am. The family was called and "notified". MS # 2 called and notified.
E. The Physician Progress Note dated 10/22/2019 at 11:17 am by MS # 1, indicated MS # 1 had been called early by nursing "concerning worsening breathing". I went to see the patient and he/she had regular rate and rhythm and crackles on lung examination. Upon leaving the room the patient became agonal and cyanotic. "Patient was DNR." No further pulse on auscultation nor carotid pulse found. Time of death 11:04 am. Family member "informed over the telephone".
F. The Care Plan on 10/22/2019 indicated the patient was a "Full Code".

5. In interview on 01/09/2020 at approximately 1:50 pm with administrative staff member A # 4 (Manager System/Quality), confirmed that the DNR was canceled in the system on 10/21/2019. There was no order in the system for a DNR at the time the patient was experiencing problems breathing. The staff did not initiate CPR.

6. In interview on 01/09/2020 at approximately 2:20 pm with MS # 1, indicated the patient was unresponsive. At that time "I went to assess the patient" and the patient was unresponsive. "I then asked the nurse the patient's code status." The nurse indicated the patient had been a DNR prior to being sent to H # 3 on 10/21/2019. "I gave a verbal order for a DNR".

Based on document review and interview, the facility failed to ensure the patient's medical record (MR) was accurately written and promptly completed for one (1) of eight (8) closed patient MR's reviewed. (Patient # 10)

Findings include:

1. Review of the hospital policy titled, "Patient Expiration/Post Mortem Care", policy number CSRC PCS 16.17, indicated the MR should have the following documentation...completed Release of Deceased Form...time of transportation to the funeral home and/or morgue. This policy was dated 08/2019.

2. Review of the Patient # 10's "Release of Deceased Form", lacked released by name, date/time, acknowledgement of receipt of the remains and the date/time the funeral home picked up the deceased patient.

3. In interview on 01/09/2020 at 9:20 am with administrative staff member A # 4 (Manager System/Quality), confirmed the "Release of Deceased Form" had not been filled out completely for Patient # 10.