HospitalInspections.org

Based on document review and interview, the facility staff failed to have a complete and accurate medical record for 3 patients, Patients #1, 2 and 3. ADL (Activities of Daily Living) Assessment Forms were completed for Patient #1, 2 and 3 for the evening shift (3-11 P.M.) at 11:30 A.M. and Patient #2 had a DNR (Do Not Resuscitate) form that was incomplete.

The findings include:

On 12/8 & 9/14 the medical records of Patient's #1, 2 and 3 were reviewed along with a log book containing the ADL Assessment Forms for each patient. Patient #1, 2, and 3's ADLs for 12/8/14 were reviewed at approximately 11:30 A.M. and all three noted the individual patients (Patient #1, 2 and 3) had received their HS (Hour of Sleep) snack and their dinners.

Patient #2's medical record contained a DNR with a date of 11/1/13 which was signed by the mother of Patient #2 and the physician. The first paragraph of the form reads: I, the undersigned, state that I have a bona fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that her/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respirator arrest.

The DNR contained two sections to be addressed.

The first section reads: I further certify (must check 1 or 2). This section contains two boxes one of which should be checked.

Number 1 reads: the patient is capable of making an informed decision about providing, withholding or withdrawing specific medical treatment or course of medical treatment.

Number 2 reads: the patient is incapable of making informed decision about providing, withholding or withdrawing specific medical treatment or course of medical treatment because the patient is unable to understand the nature, extent or probable consequences of the proposed medical decision or make a rational evaluation of the risks and benefits of alternatives to that decision.

The next section of the form reads: If you checked 2 above, check A, B, or C below. None of the boxes were checked.

The total form did not have any boxes checked directing the healthcare providers on what to do in the event Patient #2 went into cardiac and/or respiratory arrest.