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Based on record review, review of the Hospital's Policy and Procedures, review of the Plan of Correction and staff interviews, the Hospital failed to ensure an effective, ongoing, quality assessment and performance improvement program for 1 patient (Patient #11), in a total sample of 11 patients.

Findings included:

1.) The Hospital failed to develop and implement a ongoing QAPI program to address identified compliance failures in the area of Patient's Rights.

2.) The Surveyor reviewed the Plan of Correction, dated 4/4/14, on 5/18/14. The Plan of Correction indicated physician training on advanced directives and code status classification was completed by the Medical Director by 5/1/14.

For Patient #11, a patient who was designated as full code status, the Attending Physician failed to provide any resuscitation efforts when Patient #11 was found to have no vital signs on 4/30/14.

Based on record review, review of the Hospital's Policy and Procedures, staff interviews, the Hospital Plan of Correction, the Hospital failed to ensure an effective, ongoing, quality assessment and performance improvement program to ensure the Rights of the Patient.

Findings included:

The Surveyor reviewed the Plan of Correction, dated 4/4/14, on 5/18/14. The Plan of Correction indicated physician training on advanced directives and code status classification was completed by the Medical Director by 5/1/14.

For Patient #11, a patient who was designated as full code status, the Attending Physician failed to provide any resuscitation efforts when Patient #11 was found to have no vital signs.

The Surveyor interviewed the Attending Physician at 2:15 P.M. on 5/15/14. The Attending Physician said she had ordered full code status on Patient #11. The Attending Physician said Patient #11 was debilitated and experiencing a slow decline. The Attending Physician said Patient #11's full code status remained unchanged. The Attending Physician said she was stopped in the hallway when Patient #11 was first identified as having no vital signs and went to Patient #11's room where she had no doubt that Patient #11 was dead and she felt she would be resuscitating a dead person.

The Primary RN caring for Patient #11 was an agency nurse, who no longer works at the Hospital. The initial interview conducted by the Hospital, dated 5/1/14, indicated the Primary Nurse said he found Patient #11 unresponsive. The Primary Nurse said he waved a second RN #2 into Patient #11's room and they evaluated and assessed Patient #$11. The Primary RN said RN #2 went to the doorway and motioned the Attending Physician into Patient #11's room.