HospitalInspections.org

Based on interview and record review, the facility failed to uphold the rights of 6 of 10 sampled patients and /or his /her representative to be involved in plan of care and to request or refuse treatment (Patient ID # 4 ,6, 7, 8, 9, 10).

Findings include:

TX 00287913

Review of facility policy titled "Patient Rights & Responsibilities", dated 11/14. read:"... As a patient...you have the right to:...4.....participate in ethical questions...including issues of...withholding resuscitative services or withdrawal or withholding life-sustaining treatment. 5. Make decisions regarding medical care and ..proposed treatment or procedures...6. Request or refuse treatment to the extent permitted by law..."

Record review on 07-18-18 of a facility pre-printed form titled "DO NOT RESUSCITATE/ CODE STATUS ORDERS". The form had 2 sections:

Section l. titled "Code Status Decision Reached by": choices included:"competent adult patient; qualified adult patient via documented directive; person designated in directive or Durable Power of Attorney; , legal guardian; family member on behalf of incompetent adult; adult spouse; ethic committee review..";

Section ll. titled "Code Status Ordered By The Physician" : choices included: Full Code; Modified Life Support/DNR (modified life support was defined); Comfort Measures Only/DNR (comfort measures were defined).

Space was provided for "Special Instructions" and signature of attending physician, date, and time. At the bottom of the form it read: "Code status must be renewed every seven (7) days."

Record review of 10 sampled patient records revealed the following issues related to "Do Not Resuscitate (DNR) / Code Status Orders".

1. Missing code status orders: Patient# 4 , # 9.

2. Code Status Order not dated and /or timed: Patient 6, # 8, # 10.

3. Code Status Order incomplete: Patient # 8: failed to indicate if: "full code"; "modified life support/DNR" or "comfort measures only/DNR".

4. Code Status Order by physician assistant (PA) was not co-signed by MD: Patient # 7.

Interview on 07-18-18 at 10:15 a.m. with staff Registered Nurse (RN) # 7 she said every patient should have a DNR/Code Status Order in their record.

Interview on 07-19-18 at 1:45 p.m. with Chief Nursing Officer (CNO) # 2 she stated the DNR/Code order for Patient # 8 should have been completely filled out. She went on to say all DNR/code orders should be signed, dated, and timed by the physician.

Review of facility policy titled "Do Not Resuscitate", dated 05/2016, revealed it was not consistent with the current DNR/ Code Status Order form being used. This policy read: "The DNR order....should be reviewed as often as medically appropriate." The code status form currently in use states:"codes status must be renewed every 7 days.

Review of facility Medical Staff Rules & Regulations, dated January 2018, read: ...Medical Records & Orders:...3. The attending practitioner must sign or must read, edit and countersign all orders...when they have been recorded by....a physician assistant....11. All orders, including telephone orders, must be dated, timed, and signed by the ordering practitioner..."

Based on interview and record review, the facility failed to uphold the rights of 1 of 10 sampled patients to care in a safe setting ( Patient ID # 9).

The facility failed to investigate an incident per policy in which security was called when Patient # 9 was found missing from her room.

Findings include:

Record review of facility policy titled " Incident Event Reporting & Follow-Up", dated 1/18, read:"...Event investigation and Follow-Up..Each department director or manager is responsible for review of all events in their respective area...this will include...investigations..It is the responsibility of each director to review, investigate and follow-up on all incidents within their department with 7 to 10 days of the event..."

Record review of Patient # 9's History & Physical Examination revealed she was a 47 year old female admitted on 06-08-18 with diagnosis of Bacteremia and a history of HIV, malnutrition, and hypertension. Patient # 9 had documented second degree heart block but could not have a pacemaker inserted until the infection was resolved.

Further review of Patient # 9's clinical record revealed a nurses note, dated 6-21-18 (time written over--appeared to be 0300 with 450 written over / illegible) that read: "Due to round not found (sic) Patient not in room. After an hour (illegible word) she isn't come back (sic). Notify supervisor...security but was unable to reach family...patient unable to reach her to (sic) Will continue to monitor..."

Continued review of same nursing note read: (6-21-18) "06:15 a.m. pt walk in the room at this time. Transportation here to take the pt. D/C (discharge) processed. PICC (percutaneous intravascular central catheter) line (illegible word) and sent patient home..."

Review of facility form titled "Occurrence/Incident Report", dated 6-22-18 for Patient # 9 revealed indication "patients leaves AMA /Elopement"; narrative provided brief description of patient not being in room, notification of security, supervisor, etc...and unable to reach family.

All of the following areas on the back of the form were left blank:

"Department Supervisor Investigation & Follow-Up Actions"
"Level of Harm"
"Follow Up Actions"
"Supervisor /AFF Follow Up"
"Mandatory Investigations"

There were no signatures of supervisor or Director of Quality to indicate review of the incident.

Interview on 7-19-18 at 1:35 p.m. with Chief Nursing Officer (CNO) # 2 she stated she remembered hearing Patient # 9 had left with a friend and was riding around and later came back. She went on to say the front door would have been locked but it can always be exited. There was a stairwell exit that opened to a non-secured area. CNO # 2 stated she was unsure which door the patient had exited or how long she had been gone. CNO # 2 said the time on the nursing note was difficult to read, illegible because as it had been written over. She went on to say the incident should have been investigated and documented.

Based on interview and record review, a Registered Nurse (RN) failed to supervise and evaluate the care of 1 of 10 sampled patients (Patient #6):

RN failed to accurately document neurological (neuro) assessments as ordered by physician.

RN failed to ensure accurate documentation of percentage of meal intake as ordered by physician.

Findings include:

TX 00287913

Review of the clinical record of Patient # 6 revealed she was a 44-year-old female admitted to the facility on 06-18-18 for status post pulmonary embolism, deep vein thrombosis, and weakness. The patient was placed on fall precautions on admission.

Review of the fall data reports revealed Patient # 6 fell on 6/20/18; 06/22/18; 6/23/18 and 07-13-18. The clinical record was reviewed in-depth with Chief Nursing Officer (CNO) # 2. Each of the 4 falls was reviewed including post-fall nursing assessments, physician notification; timeliness of diagnostic orders; fall prevention measures, etc. ...

Continued review of the medical record for Patient # 6 revealed the following three (3) physician orders:

1. 06/20/18 (1900); every 2-hour neuro checks x 4 hours"

2. 06/22/18 (8:54 a.m.): "neuro checks every 2 hours x 24 hours"

3. 07/13/18 (2200) "neuro checks tonight every 4 hours x 24 hours"

Four (4) forms, each labeled: "Glasgow Coma Scale-use PRN and for neuro patients" had Patient #6's ID label at bottom right of the form. The forms had completed neuro assessment data documented at various times.

One of the forms was dated 6/22/18; one was dated 06-23-18. The remaining two (2) neuro check forms had no date to indicate when they were completed.

None of the four (4) neuro check assessment forms were signed by a Registered Nurse (RN) or signed by anyone.

During an interview on 07-19-18 at 2:30 p.m. CNO # 2 said all nursing assessments, to include neuro checks, entered in the medical record must be dated, timed, and signed.

She went on to say it looked like medical record department had separated the neuro check forms from the daily nursing notes when the patient was discharged. CNO reported the facility had adapted this neuro check form from the ICU flowsheet that was a connected trifold. She said as they had been working to address the neuro check process; the lack of signature & date space on this form was not noticed.

Additional review of Patient #6's record revealed a physician order dated 07/01/18 that read: "record % meal intake on graphic sheet." Review of the graphic sheets for Patient # 6 revealed four (4) days lacked recorded percentage of meal intake: July 3, 8, 11, & 14, 2018.

Review of facility policy titled "Medical Records Content", dated July 2017, read:"...10. Nurses Notes: Nursing notes and entries by non-physicians that contain pertinent, meaningful observations and information are recorded and authenticated.."