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Based on record reviews and interviews, the hospital failed to ensure the patient or his/her representative had the right to make informed decisions regarding his/her care as evidenced by failing to have documented evidence of a discussion with a patient, the family member legal representative, or agent and/or his/her family regarding the DNR order and the decision to have the DNR order written in accordance with hospital policy for 1 (#2) of 2 (#1, #2) patient records reviewed with an order for DNR from a sample of 5 patients.
Findings:

Review of the policy titled "With-holding Lifesaving Procedure / DNR" revealed in part the hospital recognizes the right of the patients to make medical decision, including the right to accept or refuse medical interventions that include palliative care and the use of extraordinary procedures and treatments. The purpose is to define the role of physicians and nursing personnel regarding patient decision of refusal of life sustaining treatment. To provide documentation guidelines for the patient's medical record of the decision of the patient patient's family, and physician not to resuscitate the patient in the event of respiratory or cardiac arrest.
All patients shall be presumed as having consented to cardiopulmonary resuscitation unless there is documentation in the medical record indicating the contrary.
Physician responsibilities as it relates to DNR orders: The attending physician shall give a written or telephone order for a DNR after making the decision with the patient, the appropriate family member(s) or the patient's agent ...If the patient is incompetent and /or not able to understand his or her medical condition or where a patient is in an irreversible coma, the following persons in the following order of priority may make health care decisions for the patients who are unable to consent: ...6. Any parent, whether adult or minor, for his child; 7. The patient's sibling ...
Entries in the patient's medical record include but are not limited to: 1. A description of the factors utilized in making the medical determination that the patient's condition is terminal, or that the patient is in an irreversible coma or that any further medical treatment will only prolong the act of dying; 2. Reference to the mental status of the patient, including, if relevant, the determination that the patient is unable to comprehend his or her medical condition; 3. Reference to discussion held with the patient, the family member legal representative, or agent, including specific reference to the authorization of the patient or family member, legal representative, or agent (if patient is unable to understand his or her medical condition) and/or consultations with the Ethic's Committee.

Patient #2
Review of Patient #2's medical record revealed she was 54 years old and admitted on 10/17/2018 with a diagnosis of Acute Respiratory Failure status post tracheostomy 09/14/2018. Hospitalized for ventilator weaning. Further review revealed a history of seizure disorder; psychosis; and moderate intellectual disability. Review of his physician orders revealed a "Resuscitation Order" on 10/17/2018 written as "DO NOT RESUSCITATE; NO CODE BLUE per records 09/17/2018" by S9NP. Review of the nursing notes dated 05/21/2019 at 8:30 p.m. stated, "Patient lying in bed small amount of blood noted on the left side of her mouth, no respirations, no pulse detected, respiratory therapist notified, charge nurse notified." Review of the Record of Death stated Patient #2 died on 05/21/2019 at 8:50 p.m.

Review of the entire medical record revealed no documented evidence of a discussion by S9NP with the patient and/or family explaining what DNR means and agreement by the patient and/or family for the DNR.

In an interview on 02/18/2020 at 1:30 p.m. with S1DQRM, she verified there was no documentation in the medical record of Patient #2 which stated there was a discussion between the physician/nurse practitioner and the patient and/or family regarding the DNR status.

In an interview on 02/19/2020 at 8:35 a.m. with S4MD, he revealed that he did not think it was documented they spoke to the family of Patient #2 about the DNR. He further stated the hospital was able to wean Patient #2 off of the vent and he stated when she does not have a pulse, they are not to do anything and this is why they did nothing.

In an interview on 02/19/2020 at 8:45 a.m. with S6NP, she stated she started her employment in April 2019 and she did not speak to the Patient #2 or the family about the DNR.

In an interview on 02/19/2020 at 11:00 a.m. with S7RT, she stated on 05/21/1019, the nurse called her to see Patient #2. "The patient was not moving. I auscultated her and she was not breathing. She was already dead so we did not suction her or anything and she was a DNR."

In an interview on 02/20/2020 at 9:00 a.m. with S10CI, he stated the family was aware Patient #2 was a DNR at "Hospital B" while she was in the ICU. He further stated they state they were not aware a DNR transferred and no one at "Hospital A" spoke with them about Patient #2 being a DNR.

Based on record review and interview, the hospital failed to ensure the RN supervised the care of each patient as evidenced by:
1) failure of the nursing staff to notify the physician for an acute change in a patient's blood pressure for 1 (#4) of 5 (#1 - #5) records reviewed for vital signs from a total sample of 5 records; and
2) failure of the nursing staff to document notification of the physician for a medication error for 1 (#4) of 2 (#4, #5) records reviewed for medication errors from a total sample of 5 records.
Findings:

1) Failure of the nursing staff to notify the physician for an acute change in a patient's blood pressure.

Review of the Rapid Response Team Policy presented as current policy revealed in part that a possible Rapid Response Team Event is a sudden change in systolic blood pressure (less than 90 or greater than 150) or any significant changes in blood pressure systolic or diastolic.
Rapid Response team members consist of on call physician, charge nurse, and respiratory therapist.

Patient #4
Review of the medical record revealed a 70 year old admitted on 07/08/2019 for antibiotics, and wound care. The nursing note dated 07/14/2019 at 12:47 p.m. nursing note stated, "Patient called stated feeling funny. Checked blood pressure low. All other are stable. Given drink put on O2 PRN 2 Liters and elevated the leg of bed. Continue to monitor." Review of the vital signs for 07/14/2019 revealed at 7:00 a.m. blood pressure was 136/57 and blood pressure at 1:00 p.m. was 96/40.

There was no documented evidence in the medical record that the physician or the Rapid Response Team was notified of the acute decrease in blood pressure.

In an interview on 02/18/2020 at 3:15 p.m. with S2IC, she verified there was no documentation in the medical record the nurse notified the physician or called a Rapid Response when the systolic blood pressure suddenly changed and the patient reported feeling funny.


2) Failure of the nursing staff to document notification of the physician for a medication error.

Patient #4

Review of the policy titled Medication Administration and Documentation revealed in part under Drug Administration to verify that there is no contraindication for administering the medication ....Drug administration errors, adverse or untoward drug reactions, and incompatibilities must be immediately reported to the attending physician (who ordered the drug), the facility's quality improvement program, and the pharmacy ....Further under Medication Administration Recording stated in part an entry of drugs administered (including drugs administered in error), adverse drug reactions, and omitted doses shall be properly documented in the patient's medical record as follows: ...When a medication is discontinued, either by a physician order or by automatic cancellation, the nurse is to draw a line through the medication on the MAR with a highlighter. Make a line in the remaining date columns.

Review of the incident report dated 07/18/2019 revealed Patient #2 had an order on 07/13/2019 at 5:40 p.m. for Cipro 500mg by mouth twice daily for 14 days; the patient's allergy to Cipro was noted and the medication was discontinued at 6:57 p.m. 2 doses of Cipro were given after the order was discontinued.

Review of the medical record revealed a 70 year old admitted on 07/08/2019 for antibiotics, and wound care. Further review revealed she was allergic to Cipro and Lasix.

Review of the physician order dated 07/13/2019 at 5:40 p.m. was for Cipro 500mg by mouth twice daily for 14 days; further review of the physician's orders revealed on 07/13/2019 at 6:57 p.m. an order read to discontinue Cipro (Allergy).

Review of the MAR revealed Cipro was administered on 07/13/2019 at 9:25 p.m. and on 07/14/2019 at 8:30 a.m.

There was no documented evidence in the medical record the physician was notified of the medication error.

In an interview on 02/19/2020 at 8:55 a.m. with S5NM, she verified there was no documentation in the medical record the physician was notified of the medication error.