HospitalInspections.org

Based on interview, record review and policy review, the facility failed to ensure that the hospital staff requested and obtained 2 of 6 sampled patients (Patient's 1 and 6) executed advance healthcare directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated).

This failure had the potential for all patients that had executed an advance healthcare directive to not have their wishes honored during their hospitalization.

Findings:

1. On December 17, 2012, Patient 1's medical record was reviewed with Registered Nurse (RN) 1 and the Nurse Manager. Patient 1 was admitted to the facility on December 15, 2012 with a diagnosis of acute renal failure (inability to filter the blood).

A review of the Patient's Rights, signed and dated December 15, 2012 by the patient was conducted. The statement numbered 18, indicated that the patient shall have the right to formulate advance directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf.

A review of the signed "Advance Directive Acknowledgement," dated December 15, 2012 was conducted and revealed that the patient had an executed Advance Directive. Additionally, the patient had a designated Power of Attorney.

A review Patient 1's medical record failed to show evidence that a copy of the patient's executed Advance Directive/Power of Attorney was obtained by the hospital staff. There was no documentation in the medical record to show that the RN requested that the patient bring in a copy. RN 1 and the Nurse Manager confirmed the finding.

On December 17, 2012 at 4:25 PM, an interview was conducted with RN 1 and the Nurse Manager, they stated that the patient's executed advance directive should have been contained in the patient's medical record.

2. On December 18, 2012, Patient 6's medical record was reviewed with the Chief Nursing Officer (CNO). Patient 6 was admitted to the facility on October 19, 2012 with a diagnosis of chest pain.

A review of the Patient's Rights, dated October 19, 2012 was conducted. The statement numbered 18, indicated that the patient shall have the right to formulate advance directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patient's rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf.

A review of the signed "Advance Directive Acknowledgement," dated October 19, 2012 was conducted and revealed that the patient had an executed Advance Directive. Additionally, the patient had a designated Power of Attorney.

A review Patient 6's medical record failed to show evidence that a copy of the patient's executed Advance Directive/Power of Attorney was obtained by the hospital staff. There was no documentation in the medical record to show that the RN requested that the patient bring in a copy. The CNO confirmed the finding.

On December 18, 2012 at 9:15 AM, an interview was conducted with the Patient Access Manager (PAM). The PAM reviewed the hospital's current policy that indicated that the hospital shall comply with Health Care Decisions Law, the staff shall ask patients 18 years and older upon admission, if they have executed an Advance Directive. Procedure 4., showed that when a patient is admitted and does not have a copy of his/her existing Advance Directive, the Registered Nurse (RN) shall request a copy of the existing Advance Directive be brought in, if possible. The PAM acknowledged that the Advance Directive Acknowledgement form did not contain a request section. She stated that the document should have contained a request section to show that the RN initiated the process and that a follow-up request may be necessary to ensure that the patient's healthcare wishes were honored.