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Based on record review, review of the Hospital's Policy and Procedure, and interviews, the Hospital failed to ensure that the rights of 4 patients (Patient #1, Patient #2, Patient #6 and Patient #8) in a total sample of 10 patients, were protected and promoted.
Findings included:

1.) The Hospital failed to ensure that Patient #1 and Patient #2 had their healthcare wishes determined in a timely manner. Patient #1 suffered a cardiac arrest and was resuscitated against his/her wishes. Family members had to make the decision to withdraw life support.

Please refer to A-130.

2.) The Hospital failed to ensure that four incapacitated patients (Patient #1, Patient #2, Patient #6 and Patient #8 ) had their Health Care Proxy invoked, according to State Law. This action failed to promote the patient's rights to designate the person to make healthcare decisions for the patient when deemed physically or mentally incapacitated.

Please refer to A-131.

Based on review of the medical records and the Hospital's Policies and Procedures, and staff interviews, the Hospital failed to take reasonable steps, in a timely manner, to determine a patient's healthcare wishes, for 2 patients (Patient #1 and Patient #2) in a total sample of 10 patients.
Findings include:

1.) Patient #1's History and Physical (H&P), dated 12/13/2013, indicated Patient #1 had a previous Do Not Resuscitate (DNR, no code, a designation of a patient not to undergo cardio-pulmonary resuscitation) prior to admission to the Hospital. The H&P indicated the Attending Physician called the family member/significant other to re-address this issue but was unable to reach him/her and left a message. Eight days after Patient #1 was admitted to the Hospital, Patient #1 suffered a cardiac arrest and was successfully resuscitated (restored heartbeat and facilitated breathing).

The Surveyor interviewed the Attending Physician at 10:25 A.M., on 2/12/14. The Attending Physician said she always validates the DNR status of her patients when they are admitted to the Hospital. The Attending Physician said she called the family member/significant other to discuss the status of the DNR and left a message for the family member/significant other to return the call. The Attending Physician said she did not hear back from the family member/significant other and a DNR order was not entered into Patient #1's medical record.

Patient #1's Expiration Summary, dated 12/22/2013, indicated Pt #1 suffered a cardiac arrest on 12/20/2013, eight days after admission, and was successfully resuscitated.

The Surveyor interviewed Family Member #1 at 1:15 P.M. on 2/10/14. Family Member #1 said Patient #1 was made a DNR after a long hospitalization at another hospital, prior to his/her arrival to Hospital #2. Family Member #1 said during Patient #1's eight day hospitalization, family members were involved in Patient #1's care and visited Patient #1 daily. Family Member #1 said Patient #1's family felt fully accessible during Patient #1's hospitalization. Family Member #1 said during a family visit with Patient #1 during the evening of 12/20/13, Family Member #1 became increasingly concerned about Patient #1's respiratory status and asked the Respiratory Therapist to meet with the physician, but was told Patient #1's physician had left the Hospital.

Family Member #1 said after Patient #1 was successfully resuscitated the family was left with the unfortunate and difficult task of withdrawing life support.

2.) Patient #2's History and Physical (H&P), dated 2/08/2013, indicated Patient #2 had an existing (out-of-State) advanced directive (living will) declining life sustaining treatment. The H&P indicated Patient #2 would remain a full code (using emergency drugs and procedures to resuscitate a patient) until Patient #2's spouse was contacted to discuss the code status.

The Surveyor reviewed Patient #2's medical record at 9:00 A.M. on 2/13/14. Patient #2 remained a full code and Pt #2's Attending Physician's Progress Notes, dated 2/9/13 and 2/10/13, did not indicate Patient #2's Attending Physician attempted to clarify Patient #2's status for resuscitation with Patient #2's spouse.

Based on record review and staff interview, the Hospital failed to activate the health care proxy (HCP) for four incapacitated patients (Patient #1, Patient #4, Patient #6, and Patient #8); failed to comply with the Hospital's policy on informed consent for two of three dialysis patients (Patient #4 and Patient #5), in a total sample of ten patients and the Hospital failed to provide a policy to guide staff on compliance with the State law on Health Care Proxy.


Findings include:

1. Under the Health Care Proxy (HCP) Law (Massachusetts General Laws, Chapter 201D), when a patient unable to make or communicate health care decisions, the doctor determines, in writing, that a patient lacks the ability to make health care decisions and activates the HCP to make decisions on behalf of the patient.

The Surveyor reviewed the Hospital's Consent for Admission and Treatment form on 2/11/14. According to this consent form, the hospitalized patient was consenting to laboratory or diagnostic procedures; x-ray exams; medical or surgical treatment, procedures, observations; medications; infusions; transfusions of blood and blood products; anesthesia; placement of prosthesis within a patient's body; or radiation therapy.

a. For Patient #1, a patient with ongoing unresponsiveness, the Hospital failed to activate the health care proxy in writing. Patient #1's Consent for Admission and Treatment, dated 12/13/14 and informed consent for blood products, dated 12/14/14, was signed by a family member who was not the designated HCP.

b. For Patient #4, the patient had a diagnosis of dementia and required ongoing hemodialysis. Patient #4's Consent for Admission and Treatment, dated 1/4/14 was signed by Patient #4's HCP, however, the Hospital failed to activate the health care proxy in writing. The Surveyor interviewed Patient #4 at 3:00 P.M. on 2/11/14, with the Assistant Administrator present. Patient #4 was found to be confused, denying he/she was a patient in the Hospital and saying he/she was a Hospital visitor.

c. For Patient #6, a patient requiring ventilator support, the Hospital failed to activate the health care proxy in writing. Patient #6's Consent for Admission and Treatment, dated 12/13/14, was signed by a family member as the HCP, but this family member was the alternate HCP to the alternate HCP, so third in line for healthcare decision making.

d. For Patient #8, a patient with end-stage liver disease, the Hospital failed to determine the family members who should be involved in healthcare decision making. The Admission Face Sheet indicates that Patient #8 was single. Patient #8's Consent for Admission and Treatment, dated 1/19/14, was signed by a spouse (initials PV) and an informed consent was obtained by telephone consent from a spouse (initials PS).


2. The Hospital failed to comply with their policy on Informed Consent for 2 of 3 dialysis patients (Patient #4 and Patient #5).

The surveyor reviewed the Hospital Policy titled Informed Consent on 2/12/14. The Policy required a current, signed informed consent form prior to initial and subsequent dialysis treatments.

a. Review of the clinical records of Patient's #4 and #5, indicated informed consent for dialysis was not obtained, as required by Hospital Policy, prior to dialysis treatments. Patient #4 was admitted on 1/3/14 and Patient #5 was admitted on 2/7/14, both patients were on a dialysis treatment schedule of three times weekly.


3. The Hospital failed to provide a policy to guide staff to meet compliance with the State Health Care Proxy (HCP) Law (Massachusetts General Laws, Chapter 201D).

The Surveyor reviewed the Hospital Policy titled Ethics and Healthcare Decision Making on 2/12/14. The Policy neither included directions to comply with the HCP law nor instructions on how a HCP was activated.

a. The Surveyor interviewed Patient #1's Attending Physician at 10:25 A.M., on 2/12/14. The Attending Physician said if she needed to invoke a patient's healthcare proxy, she would need to consult with the Hospital's administration.