HospitalInspections.org

Based on 1 (Patient #1) of 12 records reviewed, Hospital policies, and interviews, the Hospital failed to ensure that Patient #1's right to not be resuscitated was implemented.

Findings include:

1.) The Surveyor interviewed Nurse Manager #1 on 6/1/15 at 9:00 A.M. Nurse Manager #1 said Registered Nurse #1 found Patient #1 unresponsive on 5/27/15. Nurse Manager #1 said Registered Nurse #1 called the emergency resuscitation team and resuscitation attempts were started.

2.) The Hospital policy titled Patient's Bill of Rights, dated 12/15/14, indicated that Patients have the right to make decisions about their plan of care prior to and during the course of treatment, to refuse treatment and this included resuscitative and limitation of life-sustaining treatment.

3.) The Surveyor interviewed Registered Nurse #1 on 6/3/15 at 9:00 A.M. Registered Nurse #1 said she found Patient #1 unresponsive and not breathing at approximately 6:00 A.M. on 5/27/15. Registered Nurse #1 said the Nursing Worksheet (patient specific, computer-generated worksheet, developed by the electronic medical record system) she used, showed Patient #1 as a Full Code Status (all resuscitation efforts were to be implemented) and she started Patient #1's resuscitation.

4.) The Code Blue Arrest Record, dated 5/27/15 at 5:55 A.M., indicated that Patient #1 was found unresponsive, received chest compressions, epinephrine (emergency cardiac medication) three times, and an intraosseus (in the bone) line was established. The Code Blue Arrest Record indicated Patient #1 received one electrical shock to his/her heart. The Code Blue Arrest Record indicated Patient #1's resuscitation stopped at 6:13 A.M. (a total of 18 minutes of resuscitative efforts).

5.) The Surveyor interviewed Physician #1 at 11:50 A.M. on 6/3/15. Physician #1 said that he was the Resuscitation Leader and he reviewed Patient #1's medical record and discovered that Patient #1 had a Modified DNR physician order and stopped the resuscitation efforts. Physician #1 said there was confusion about Patient #1's Code Status during the resuscitation because Registered Nurse #1 said Patient #1 was a Full Code according to her Nursing Worksheet and Patient #1's medical record indicated Patient #1 as a Modified Code Status.

6.) Physicians Orders, dated 5/21/15 at 11:29 A.M., indicated Patient #1's Code Status as a Modified Do-Not-Resuscitate (DNR) and that it was appropriate to intubate (insert a breathing tube).

7.) The Hospital policy titled Code Status Orders, dated August 2013, indicated that a Modified Code Status included that the patient (or agent or surrogate decision-maker) desired some resuscitation efforts. The policy indicated that the specific resuscitative efforts were written in Physicians Orders and a yellow bracelet indicated a Modified Code Status.

8.) Nurse Manager #1 said that the Hospital Vice President for Operations/Director of Nursing (VP/DON) was notified of the confusion in Patient #1's Code Status on 5/27/15.

9.) The Surveyor interviewed the VP/DON on 6/1/15 at 1:15 P.M. The VP/DON said the Hospital became aware of Patient #1's Code Status confusion issue early on the morning of 5/27/15. The VP/DON and Physician #1 said that Patient #1 had on a yellow DNR bracelet. The VP/CNO said that there was confusion about Patient #1's Code Status because Registered Nurse #1's Nursing Worksheet indicated Patient #1 as a Full Code Status. The VP/DON said the Hospital did not know if the confusion was a computer "cross-over" (computer generated formation that moves form the Physician Order computer system to the Nurses Worksheet computer system) issue and the Hospital was in the process of reviewing this computer issue.

10.) Registered Nurse #1 said that her Nursing Worksheet for Patient #1 was printed when either Patient #1 was admitted, on 5/21/15, to the Hospital or another shift she cared for Patient #1. Registered Nurse #1 said she hand wrote patient care plan updates and changes on the Nursing Worksheet and did not print a new Nursing Worksheet.

11.) The Surveyor interviewed Quality and Compliance Specialist #1 on 6/3/15 at 10:30 A.M. The Quality and Compliance Specialist said it was the Hospital's expectation that Registered Nurse #1 should have printed a new Nursing Worksheet each day.

12.) The VP/CNO said the Hospital referred Patient #1's case to Physician #1 for review of medical care, to the Code Committee for review however, the Code Committee Chairperson was deployed, and the Quality Department was going to review Patient #1's care. The VP/CNO did not provide dates for the medical, Code Committee or Quality Department reviews when asked by the Surveyor.

18.) Nurse Manager #1 said that no practice changes were implemented for staff providing direct patient care.

19.) The Surveyor interviewed 11 Registered Nurses, on 6/3/15, which represented all Hospital in-patient care units. The 11 Registered Nurses said that they printed a new Nursing Worksheet for every patient, every day for current updates and changes to patient care plans and discarded the Nursing Worksheet at the end of their shifts.

Based on observations and Hospital policy, the Hospital failed to ensure confidentiality of patient medical records.

Findings include:

1.) The Surveyor toured Patient Care Unit (PCU) #1 at 10:05 A.M. and PCU #2 at 12:15 P.M. on 6/1/15; and PCU #2 again at 9:30 A.M. on 6/4/15. The Surveyor observed 5 clip boards/computer screens, with patient Protected Health Information (PHI) visible to others (staff, visitors, patients) that did not need this information.

2.) The Hospital policy titled Patient's Bill of Rights dated 12/15/14, indicated that the patient has the right to privacy and confidentiality of all medical, financial, and other information related to care.

Based on review of the Restraint/Death Log, Hospital policy and interview the Hospital failed to:

1.) Report 1 of 2 (Patient #10) patient deaths associated with the use of restraint to the Centers for Medicare and Medicaid Services (CMS), and
2.) Include 2 of 2 (Patients #1 and #10) patient dates of birth in the Restraint/Death Log.

Findings include:

1.) The Surveyor interviewed Quality and Compliance Specialist #1 on 6/3/15 at 1:20 P.M. The Quality and Compliance Specialist said during the review of the death in restraint of Patient #1, the Hospital discovered that the death in restraint of Patient #10 was not reported to CMS. The Quality and Compliance Specialist #1 said the Hospital developed and implemented a Corrective Action Plan (CAP) for the Quality Department's identification and review or patient deaths in restraint, however the Quality and Compliance Specialist #1 said that the Hospital had not reported the death in restraint of Patient #10 to CMS.

2.) The Death Certificate Medical Certifier Worksheet, dated 4/26/15, indicated Patient #10's cause of death was pneumonia and died at 7:55 A.M.

3.) Doctors Orders, dated 4/25/15 at 1:18 P.M. indicated that Patient #10's types of restraints were all 4 side rails of the bed and mitts of both hands, for safety and pulling at lines and tubes.

4.) The Hospital policy titled Restraints, Non-Behavioral dated 10/2014, indicated that the Hospital used side rails to restrict a patient's freedom to exit the bed and the Hospital considered side rails restraint.

5.) The Hospital policy titled Safety Reporting, dated 4/23/13, indicated the Hospital reported each death that occurred while a patient was in restraint to the Centers for Medicare and Medicaid (CMS). The Safety Reporting policy indicated that each death that occurred within 24 hours after the patient was removed from restraint or seclusion was reported to CMS.

6.) The Restraint/Death Log indicated that the Hospital reported the death of Patient #1 to CMS on 5/28/15. The Restraint/Death Log did not indicate that the Hospital reported the death of Patient #10 to CMS.

7.) The Safety Reporting policy indicated that the Hospital must maintain a log (or other system) for deaths that occur while the patient was in soft-2-point wrist restraints. The Safety Reporting policy did not indicate that the Hospital maintained the log for patient deaths that occurred while in all types of restraint.

8.) The Hospital policy titled Safety Reporting indicated the log must include the patient's name, date of birth, date of death, and name of attending physician or practitioner responsible of patient care, medical record number, and primary diagnosis.

9.) The Restraint/Death Log did not indicate a date of birth for 2 of 2 patients (Patient's #1 and #10).