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Based on interview and record review, the hospital failed to ensure the hospital's P&P for code blue was followed for one of three sampled patients (Patient 2). This failure had the potential for the patient not to receive the timely and effective care needed during the critical situation.

Findings:

Review of the hospital's P&P titled Resuscitation of Patient dated December 2020 showed the following forms will be completed for each resuscitation: Code Blue records, evaluation of Code Blue, Event Notification, and EKG monitoring strips. The Director/ Charge Nurse/Administrative House Supervisor will take responsibility for, or delegate completion of the record and other facilities designated forms.

Review of Patient 2's medical record was initiated on 10/14/24 at 1050 hours with the Quality Manager.

Patient 2's medical record showed the patient was admitted as an inpatient to the hospital on 10/1/24.

Review of Patient 2's Code Blue note dated 10/10/24 at 1015 hours, showed Patient 2 was found to have agonal respirations and desaturations overnight. Patient 2 was also found to be hypotensive and was started on Levophed (a medication used to treat low blood pressure). Patient 2 was intubated with a 7.5 cm cuffed tube at 24 cm and had equal breath sounds bilaterally. Patient 2 tolerated the procedure well with no immediate complications.

On 10/14/24 at 1415 hours, an interview was conducted with the Quality Manager. The Quality Manager stated debriefing after Patient 2's code blue event was not done. The Quality Manager stated she was unable to find the EKG monitoring strips that were done during Patient 2's code blue event in Patient 2's medical records.

On 10/14/24 at 1534 hours, the above findings were shared and acknowledged by the Quality Manager.