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Based on interview and record review, the hospital failed to ensure the five-minute EKG strip was obtained for one of four sampled patients (Patient 1) as per the hospital's P&P. This failure had the potential for miscommunication among hospital staff.

Findings:

Review of the hospital ' s P&P titled Code Blue-Adult Cardiac/Pulmonary Arrest dated December 2020 showed the purpose is to provide an accurate chronological record of all data pertaining to the arrest and resuscitation efforts. The post CPR responsibilities include the Nursing Supervisor will complete code blue sheet with assistance of primary nurse, the Code Blue critique must be completed. The House Supervisor must obtain a five-minute strip print out from the Charge Nurse or Monitor Tech and make sure it is scanned into the Electronic Healthcare System. The Nursing Supervisor obtains the input from Code Blue team members for completion of the Code Blue Evaluation. A five-minute cardiac monitoring strip prior to code blue must be obtained and be included with the completed critique form.

An interview and concurrent review of Patient 1's closed medical record was conducted with the CNO on 8/28/24 at 1602 hours.

Patient 1 ' s medical record showed on 7/16/24 at 1310 hours, RN 4 noticed the patient's heart rate went from 90 to 75 beats per minute. The patient was unresponsive, pale, and agonal breathing. The Code Blue was called. At 1313 hours, the patient had no pulse and the chest compressions started. At 1319 hours, the Code Blue ended. The patient was intubated with a breathing tube and returned to a spontaneous circulation. However, Patient 1 ' s medical record did not include the EKG strip.

The CNO stated she was the recorder for Patient 1's Code Blue and responsible to retain the EKG strips, but she went to help another patient immediately and was not able to retrieve Patient 1's EKG strips for the CPR record.

Based on interview and record review, the hospital failed to ensure the nursing staff accurately conducted the integumentary assessment and took a wound photograph for one of four sampled patients (Patient 4) as per the hospital's P&P. This failure had the potential to result in poor clinical outcomes to the patient.

Findings:

Review of the hospital's P&P titled Skin Integrity dated December 2020 showed Photographed alterations in skin integrity and open wound are to be posted on the Wound Photograph Documentation Form in the patient's medical record or uploaded to the electronic medical record. Wounds are to be photographed upon discovery of a new wound. Any change in conditions on skin integrity will be reported to the primary physician and will be documented.

On 8/28/24 at 1455 hours, a medical record review for Patient 4 was initiated with the CNO, Director of Performance Improvement, and Director of Behavioral Unit.

Review of Patient 4's closed medical record showed Patient 4 was admitted on 8/20/24.

Review of the Nursing Note dated 8/22/24 at 1545 hours, showed Patient 4 was walking around unit in underwear and asked by the MHW to return to the room. The patient started to become agitated and yelling back on his way to his room "I can do whatever I want!" The patient was educated on the way back to his room of the unit rules, non-acceptant of the teaching. The patient was able to be escorted back to the room. About a minute later, the patient exited room yelling "Where is he" "Lets go then!" The patient rushed at the MHW swinging arms. The MHW and LVN were able to hold and restraint the patient. The unit staff was notified and the code gray was called. The staff notified the NP and the emergency medications were ordered.

Review of the Progress Notes dated 8/23/24 at 0945 hours, showed an event yesterday involved Patient 4, requiring to be physically restrained and code gray being called. Patient 4 hit the ground during the event, but no LOC. Patient 4 suffered a minor laceration to the forehead.

Review of the Default Flowsheet Data dated 8/22/24 at 2000 hours and 8/23/24 at 0900 hours, showed the RN had performed the integumentary assessment. The integumentary assessment showed "WDL."

Review of Patient 4's medical record failed to show documented evidence of the photograph was taken for the patient's minor laceration to the forehead as per hospital's P&P.

On 8/28/24 at 1506 hours, an interview and concurrent medical record review was conducted with the RN 4 in the presence of the Director of Behavioral Unit, Director of Performance Improvement, and CNO. RN 4 stated he was the primary RN for Patient 4 on 8/22/24. RN 4 stated he witnessed the incident that happened to Patient 4 at that time. RN 4 stated Patient 4 attacked the staff. RN 4 stated Patient 4 sustained injury from the incident, a small skin opening on his right eyebrow. RN 4 stated he performed an assessment of Patient 4's injury. RN 4 stated there was no documentation of the assessment of the wound, it should have been documented, but it was missed.

On 8/29/24 at 0912 hours, an interview and concurrent review of Patient 4's medical record was conducted with the Director of Behavioral Unit. The Director of Behavioral Unit stated it was not necessary to document the wound assessment. The Director of the Behavioral Unit stated the assessment of Patient 4's integumentary system was not accurate. The Director of the Behavioral Unit stated there was no photograph taken for Patient 4's laceration. The Director of Behavioral Unit reviewed the hospital's P&P and acknowledged the findings.

On 8/29/24 at 1300 hours, the CNO, Director of Performance Improvement, Director of ICU, and Director of Behavioral Unit were informed and acknowledged the findings.