HospitalInspections.org

Based on review of facility policy and procedures, medical records (MR), and staff interview (EMP), it was determined the facility failed to implement and adhere to safety measures for one of 20 medical records reviewed. (MR1)

Findings include:

Review of facility policy and procedure on November 1, 2016, at approximately 1:00 PM revealed, "Revised/Reviewd 7/09...Purpose: To provide immediate medical and nursing treatment for life-threatening situations...Procedure: 1. Check Code status a. Green: Full Code...c. Purple: Do Not Resuscitate (Check chart for confirmation of DNR[Do not Resuscitate] status) 2. Initiate BLS [Basic Life Support] based on Code Status. 3. Use nearest phone and dial 85. Announce "Code Blue" and state the location of the emergency three times. Hang up receiver. 4. Contact Physcian for notification and orders, then emergency medical services (9-1-1) if ordered.

Review of facility document on November 1, 2016, at approximately 10:30 AM revealed, "HealthSouth Polices on Demand...Patient Privacy...July 2016...Purpose The purpose of this policy is to comply with federally required Patient Privacy and Patient Rights Applicable to the inpatient Rehabilitation Facility patient Assessment..."

1. Review of MR1 on November 1, 2016, revealed that the patient was admitted to the facility on June 3, 2016. The Interdisciplinary Assessment dated June 3, 2016, at 8:00 PM revealed that the Advance Directive section had a box that was checked for CPR..."
Continued review of MR1 on November 1, 2016, revealed a "Daily Progress/Narrative" dated September 29, 2016, which indicated, "0200 Pt found lying in bed 02 NC [Oxygen Nasal Canula]...Body found...Assessed Cortaid, no pulses no heart beat...No reaction to pupils. No femoral pulses..."
There was no evidence of a DNR order or advanced directives in the patient's medical record.
During an interview on November 2, 2016, at approximately 7:20 AM, EMP8 confirmed that the facility full code policy was not followed for MR1, and stated, "If it happened again I would call the code and start CPR."

During an interview on November 2, 2016, at approximately 7:30 AM, EMP6 confirmed that if there is not a DNR, CPR should be started..."

During an interview on November 2, 2016, at approximately 1:00 PM EMP1 confirmed that CPR should have been initiated for MR1. "..People come here for rehabilitation and are then going home..., but now everyone is aware of what to do..."