HospitalInspections.org

Based on interview with staff and review of documents, it was determined the hospital does not allow patients with capacity to formulate advance directives in naming a medical decision maker in the event they become incapacitated during the admission. This has the potential to negatively affect each patient's rights during an admission to the hospital by not promoting and protecting each patient's right to formulate an advance directive.

Findings include:

1. Review of the policy "Advance Directives", last reviewed 5/05, revealed the policy states "If the patient has not completed an advance directive and requests information a referral will be made to the Social Services Department...Upon receipt of a referral the Social Services Department shall provide the patient with a packet of information regarding Living Will and Medical Power of Attorney...The Social Workers will be able to witness in the event the patient wishes to execute during the hospital stay, after conferring with the attending physician regarding the decision making capacity of the patient...The Social Workers are also notaries and can notarize the documents. However, a Social Worker will not act as a witness and a notary."

2. The Director of Case Management was interviewed on 9/25/2012 about 2:15 p.m. She stated that although the current policy states a patient will be assisted in formulating an advance directive while they are an inpatient, the current practice is that the hospital does not provide that service. She stated there are no Social Workers on staff and all social services are provided by Registered Nurses. She stated none of the nurses are able to legally assist the patients in notarizing documents pertaining to assigning a Medical Power of Attorney. She stated the patients are advised that if they lose capacity during an admission, a surrogate will be assigned as decision makers for the patient under State law. She stated the patients are also advised to complete any Medical Power of Attorney documents after they are discharged from the hospital.

Based on review of medical records and interview with staff it was determined the hospital failed to ensure the Registered Nurse adequately supervised and evaluated the care being provided in accordance with specific physician orders to three (3) of ten (10) cases reviewed (records #1, 2 and 9). This has the potential to negatively affect the quality of nurse care provided to all patients.

Findings include:

1. Review of the medical record for patient #1 revealed that at the time of admission on 7/29/2012, physician orders included an order to check the vital signs every four (4) hours. Review of the documentation in the record revealed the vital signs, including blood pressure were checked on 7/29/2012 at 4:40 p.m. The next recorded blood pressure was at 6:00 a.m. on 7/30/2012.

2. The record was reviewed with the Nurse Manager of the patient's nursing unit on 9/24/2012 at about 3:00 p.m. She concurred with the findings.

3. Review of the medical record for patient #2 revealed there were physician orders dated 8/2/2012 that included orders to do "strict intake and output" recordings and to check the patient's weight daily. Review of the record revealed these were not documented as ordered.

4. The Nurse Manager reviewed the record on 9/26/2012 at about 10:00 a.m. She concurred with the findings.

5. Review of the medical record for patient #9 revealed there was a physician order dated 8/10/2012 for "strict intake and output" recordings. Those were not documented as ordered.

6. The record was reviewed with the Director of Nursing at about 3:45 p.m. on 9/26/2012 and she concurred with the findings.

Based on review of medical records, documents and interview with staff it was determined the hospital failed to include documentation of an initial discharge planning evaluation in the medical records for ten (10) of ten (10) records reviewed. This has the potential to negatively affect the quality of the discharge planning for all patients.

Findings include:

1. Review of the medical record for patients #1 through 10 revealed there was no initial screening documented for potential discharge planning needs. The only documentation of discharge planning activities by the Case Management Department were in response to physician orders for specific post-hospital needs.

2. Review of the hospital's "2012 Utilization/Case Management Plan", dated 5/2012 revealed the plan includes Case Management/Discharge Planning policy/procedure. The policy states "The Case Manager screens all patients to assess their potential post-hospital needs...The Case Manager assesses discharge planning needs within one working day of the patient's admission and initiates discharge planning when post-acute care needs are identified..."

3. The Director of Case Management reviewed the record for patient #1 during interview on 9/25/2012 at about 2:15 p.m. She concurred there was no initial discharge planning screening documented in the record. She also stated there would be no documentation in any record, as that is done on a "worksheet" which is not filed with the medical record. She also stated that Case Managers may not screen patients within "one working day" of admission as the policy states, and that patients are routinely screened on the third day of admission to assess for post-discharge needs.

4. The Case Manager for patient #1 was interviewed on 9/26/2012 at about 3:15 p.m. She stated she did not screen the patient during the twenty-four (24) hour admission for discharge planning needs in accordance with hospital policy. She also stated patients are routinely screened "by the third day of admission."