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Based on medical record review and policy review, the facility failed to ensure one patient (Patient #1) was reassessed for an abnormal respiratory rate and an abnormal oxygen saturation reading. This had the potential to affect all of the facility's 134 active patients.

Findings include:

The medical record review for Patient #1 showed Patient #1 had a respiratory rate of eight breaths per minute and a pulse oximeter reading of 18% on 07/25/15 at 7:15 AM. The next documented readings were on 07/25/15 at 7:30 AM and were 16 breaths per minute with a pulse oximeter reading of 100%. The medical record did not contain documentation on 07/25/15 from 7:15 AM to 7:30 AM to show interventions were being conducted to stabilize Patient #1's respiratory rate and oxygen saturation levels.

The facility's GN-12-Nursing Standards of Care: Intensive Care Unit (ICU) policy was reviewed. The policy stated reassessments will be completed every eight hours and as indicated with change in condition.

Based on medical record review, policy review and interview, the facility failed to ensure respiratory therapy services were conducted in accordance with the facility's policy for one (Patient #1) of 10 medical records reviewed. This had the potential to affect all of the facility's 134 active patients.

Findings include:

The medical record review for Patient #1 contained a Code Blue sheet from 07/25/15 at 6:54 AM. The code blue sheet contained a box to indicate ETCO2 (end tidal carbon dioxide, the level of carbon dioxide released at the end of an exhaled breath) Confirmation. The box was not checked to indicate the ETCO2 had been confirmed.

On 10/15/15 at approximately 5:20 PM, Staff A verified the medical record of Patient #1 did not contain an ETCO2 during or after the code blue was called. Staff A confirmed ABGs (arterial blood gas, measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery) were not ran during or immediately following the code blue on 07/25/15 at 6:54 AM.

The facility's 11.2-Code Blue: Cardiopulmonary Resuscitation policy was reviewed. The policy stated members of the code team are notified of a "Code Blue" by pager with location information of the floor and patient care unit. See attachment A for members of the Code Team and their responsibilities. Attachment A listed respiratory therapy responsibilities as assisting with intubation, verifies intubation using ETCO2 detector and other established parameters and runs ABG results.