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Based on medical record review and interviews with hospital staff, it was determined that in one of one medical record in which documentation reflected the withdrawal of life support treatment, medical record # 1, the hospital failed to ensure that the medical record contained documentation of the results of the physician's and case manager's consultations with Patient # 1's family members related to withdrawal of life support treatment. Findings:

The following hospital policy and procedure was reviewed: Vibra Specialty Hospital Portland No. ERR 7.0 entitled Withdrawal of Life Support Treatment. The procedure required the hospital Care Manager to provide a complete set of supporting documents demonstrating the validity of the request to discontinue life support to the hospital Administrator and Director of Quality Assurance. The procedure identified that supporting documentation should include, but was not limited to, the following:
A copy of physician progress notes where discussions regarding the termination of life support with the patient or family are documented; and
Information about a patient's family members and whether such family members agree with the decision to withdraw life support and/or treatment.

Medical record # 1 was reviewed. Documentation reflects that Patient # 1 had a history of a continuos prolonged period of hospitalization that included the provision of care at three hospitals between 10/08/2009 and 02/11/2010. Patient # 1 had multiple medical problems that included a progressive deterioration in respiratory function and increased ventilator dependence. Interviews with hospital staff revealed that consultations occurred between physicians, case management, and Patient # 1's representative/family. The consultations reportedly addressed the appropriateness of continued ventilator support versus the withdrawal from life support. The medical record contained only minimal documentation of the consultations with family. The medical record lacked the documentation required by hospital policy. The lack of documentation failed to ensure the consultative findings were available to all health care providers involved in the care and treatment of Patient # 1.

Documentation reflects Patient # 1 was a 44 year old individual who was admitted to the Emergency Department at Hospital C on 10/08/2009 in acute respiratory distress. Documentation reflects Patient # 1 had a prolonged hospitalization at Hospital C, 10/08/2009 through 11/23/2009. Patient # 1 was diagnosed to have H1N1 pneumonia followed by Adult Respiratory Distress Syndrome (ARDS) and acute on chronic respiratory failure requiring tracheostomy and continuous ventilator support. Patient # 1 developed deep vein thrombosis, a pulmonary embolism, and urinary tract infections during his/her H1N1 hospitalization. An indwelling Foley catheter and percutaneous enterostomal gastrostomy (PEG) feeding tube were inserted and maintained. Patient # 1 had a history of obesity and hypothyroidism. The admitting physician's History & Physical dated 10/08/2009 stated that Patient # 1 had a history of "fairly significant Down Syndrome with marked development delay".

Documentation reflects that Patient # 1 was transferred from Hospital C to Vibra Specialty Hospital on 11/23/2009 for rehab and ventilator weaning. Documentation reflects that Patient # 1 evidenced a failed response to ventilator weaning and, despite treatment, evidenced increased ventilator needs while hospitalized at Vibra between 11/23/2009 and 01/01/2010. On 01/01/2010 Patient # 1 was transferred to Hospital D for evaluation, bronchoscopy, and a pan CT scan. Patient # 1 remained hospitalized at Hospital D until 01/10/2010 due to hypoxia and hypotension. The same group of pulmonologists cared for Patient # 1 at Vibra and at Hospital D. Patient # 1 was transferred from Hospital D back to Vibra on 01/10/2010. The same group of pulmonologists continued to care for Patient # 1 at Vibra.

Patient # 1's Attending Hospitalist at Vibra was interviewed at 1355 hours on 04/05/2010. Patient # 1's Case Manager at Vibra was interviewed at 1630 hours on 04/05/2010. The Hospitalist reported that Patient # 1 had no capacity to consent to medical treatment. Patient # 1's mental capacity was that of a "7 year old child" at baseline. Patient # 1's mental capacity was "further diminished as a result of [his/her] prolonged illness". Patient # 1 evidenced no understanding of [his/her] illness and was unable or unwilling to participate in [his/her] care, i.e., physical and occupational therapy. As a result, Patient # 1 became increasingly debilitated which further weakened his/her respiratory status.

The Attending Hospitalist reported that s/he had a number of discussions with Patient # 1's family. Discussions revolved around Patient # 1's progressive decline in overall quality of life and Patient # 1's poor prognosis with the projected outcome that Patient # 1 would get sicker and sicker and would never be ventilator free. The Attending Hospitalist reported that s/he made him/herself available to the family at the hospital and through e-mails. S/He kept the family informed of Patient # 1's status, was open to the family's requests, and accommodated their schedules. The Attending Hospitalist and family made the decision to withdraw the ventilator. The Attending Hospitalist reported that all family members were in agreement with the plan to withdraw the ventilator. The Attending Hospitalist reported that s/he did not document details of the family meetings. The medical record lacked documentation of the details of the family meetings with the physician, i.e., the date and time of the meetings, who attended, what was discussed, and what decisions were made. The physician's progress notes were limited to identification that a family conference was planned or that a conference had occurred, but progress notes provided no detail.

The Case Management notes were also limited and provided no detail. The Case Management notes dated 01/12/2010 timed 0940 hours reflect the following: "Met with patient and spoke with [patient representative]-patient is not able to participate in communication plan-plan to arrange care conference when parents return from Hawaii".
Case Management notes dated 01/22/2010 timed 1300 hours reflects the Case Manager "spoke with mom and dad to update treatment plan if able to get off vent".


-These findings also reflect noncompliance with the following Oregon Administrative Rule (OAR) for Hospitals:

333-505-0030(3) Organization, Hospital Policies, A hospital shall adopt, maintain and follow written patient care policies.