HospitalInspections.org

Based on personnel file review, review of facility job descriptions, review of Medical Staff certifications, review of P&P, and interview with staff, in 2 of 12 ED staff ACLS certifications reviewed (G and Y) the facility failed to ensure all staff are trained and qualified for the positions they are assigned per policy at time of hire. In 8 of 10 ED MD's (N, O, Q, LL, MM, NN, OO and PP) the facility failed to ensure Medical Staff are certified for ACLS and/or PALS per facility requirements.

Findings include:

Per review on 9/27/12 at approximately 10:00 AM, of the Emergency Department Job Description for Registered Nurse states under Education, Training and Experience, dated 6/01, "...CPR Certification, ACLS Required..."

Per review on 9/27/12 at approximately 2:00 PM, of the Department of Nursing Advanced Cardiac Life Support (ACLS) Certification, dated 7/12, states under Policy : 1. "All registered Professional Nurses working the following areas or positions shall obtain ACLS Certification. Emergency Room, Operating Room, Post-Anesthesia Room...3. Registered Nurses hired for Medical/Surgical Unit are encouraged to obtain their ACLS within one year of service."

Examples in personnel files:

ED RN G's personnel file reviewed on 9/27/12 at approximately 10:00 AM revealed RN G was hired 5/12, there is no evidence of current ACLS certification. This is confirmed in interview with RN L on 9/27/12 at approximately 2:00 PM.

Review of additional CPR and ACLS training on 10/2/12 in the AM, ED RN Y, hired 11/11, does not have ACLS certification. This is confirmed with RN L 10/29/12 at 2:59 PM via email.

Per email from MCS AA on 10/2/12 at 4:46 PM, the Medical Staff By-Laws require ACLS and PALS for the ED staff, and do not require CPR for any medical staff.

The following was confirmed 10/2/12 at 4:46 PM with MCS AA.

Per review of CPR certification for medical staff, provided by MCS on 10/2/12 at 4:46 PM, the following ER MDs are not certified with CPR: MD N, MD O, MD Q, MD LL, MD MM, MD NN, MD OO and MD PP.

The following ED MDs are not current with PALS: MD Q and MD MM.

In 2 of 3 ED MRs the facility failed to ensure the ED is staffed continuously when patients are present in the ED and failed to provide access ED services 24/7. See Tag C201.

In 1 of 1 interview the facility failed to ensure coordination with EMS services to provide optimal emergent Pt care. See Tag C209.

The cumulation of these deficiencies directly affect Pts 1,2, 3, 4, and all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Based on review of MR, review of staffing guidelines, review of P&P, and interview with staff, in 2 of 3 ED MRs (3 and 4) the facility failed to ensure the ED is staffed continuously when patients are present and provide ED access 24/7.

This deficiency potentially affects all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Findings include:

Per review of facility policy on 10/2/12 in the PM titled Medical Record Documentation Requirements, Standards, Guidelines and Ownership, dated 11/11, it states under Purpose "The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and results accurately..." Under 8. "When emergency care is provided, the following additional information is records in the medical record: a. Pertinent history of the illness or injury, b. Emergency care provided to the patient prior to arrival c. Time and means of arrival d. Diagnostic and therapeutic orders e. clinical observations, including results of treatment f. Reports of procedures, tests and results g. diagnostic impression h. conclusion and determination of evaluation/treatment including final dispositions, in the patient's condition on discharge/transfer...j. documentation of a patient's decision to refuse treatment or leave against medical advice (AMA), if applicable."

Facility staffing guidelines (no title and no date), reviewed on 9/26/12 at approximately 11:30 AM revealed there is to be 2 RNs on the M/S department with the second RN to cover the ED as a second RN.

On 8/9/12 between 2:30 AM and 5:30 AM there were 10 patients in the M/S department, 1 documented ED patient (Pt #3), and 1 undocumented ED patient (Pt #4). Nurse staffing for the entire hospital included 2 RNs and 1 CNA in M/S; 1 RN and 1 LPN in the ED.

On 8/9/12, two Pt codes were called in the M/S department. The first code was called at approximately 3:30 AM regarding Pt #1, and the second code for Pt #2 (also hospital employee RN X) was called between 3:45 AM and 4:00 AM.

Pt #3's MR review on 9/30/12 at 12:15 PM revealed Pt #3 arrived in the ED on 8/9/12 at 2:23 AM. The MR indicates Pt #3 had fallen and had a head injury.

Undocumented ED Pt #4, was also roomed in the ED and had been given a urine cup for sample by ED RN G, just prior to ED RN G being called onto the M/S to help with patient codes.

Per interview with ED RN G on 9/26/12 at 11:49 AM, RN G confirmed being in the ED on 8/9/12. When the first code was called on the M/S unit, LPN H who was assigned to staff the ED, left the ED to respond to the M/S department. ED RN G stated when the second code was called 30 minutes later for M/S, she "felt comfortable" leaving the ED, allowing Pt #3, (and FM I to Pt #3), as well as the undocumented Pt #4, to stay alone in the ED without any hospital personnel.

Interview with ED MGR J on 9/26/12 at 9:30 AM, revealed she arrived at the facility at approximately 4:25 AM on 8/9/12, in response to an emergent call from the hospital, to report in to handle hospital coverage. ED MGR J stated upon her arrival in the ED, she first assessed Pt #3, who needed pain medication and had nausea, then left the ED to report to the M/S floor and answered patient call lights. ED MGR J confirmed taking over care and documentation in Pt #3's ED record at 4:30 AM.

Interview with Pt #3's, FM I, on 9/26/12 at approximately 10:30 AM, FM I stated she offered to ED RN G that "I'll watch the desk" in the ED, and then RN G left the ED. Per FM I in interview, "somewhere in there", undocumented Pt #4 left the ED, leaving the urine specimen and a note on the ED nurse counter for staff.

Pt #3 was in the ED between 3:48 AM and 4:30 AM with no facility staff present to address her needs, and Pt #4 was not seen or examined.

Based on interview, review of MRs and interviews, in 2 of 2 interview (M and P) the facility failed to ensure coordination with EMS services, and failed to document their system to ensure on-call staff are reached to provide optimal emergent Pt care. This deficiency potentially affects all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Findings include:

Per interview with EMS Dir P on 10/1/12 at 12:20 PM, he stated Edgerton is not a level I or II trauma hospital. Dir P stated Pts have a choice on where they would like to go, if it is not a situation where bypassing a hospital would be life threatening to that Pt. Dir P stated there are reports, the ED staff turn down the communication radio volume, or turn off the EMS pager, limiting contact with EMS staff during runs. Additional concerns presented by the EMS Dir P, is staff in the ED usually have the EMS staff run Pt codes (direct staff with what to do).

Per review of Pt #1 and Pt #2's MRs on 9/26/12 at 7:00 PM and 1:00 PM respectively, there is documentation in Pt #1's MR that MD BB, "on call" for the inpatients, was called. There is no time documented for this call. The code for Pt #1 was called at approximately 3:30 AM, the code for Pt #2 was between 3:40 AM and 3:55 AM. There is no hospital record indicating phone calls were made to extra staff to report in to help with the codes. The hospital obtained staff's personal cell phone information, on 10/1/12, to document when calls were made on 8/9/12. This is confirmed with QA Dir M on 10/1/12 at approximately 3:15 PM.

Based on review of staffing schedules and census reports, and interview with staff, in 6 of 6 interviews (A, G, I, J, P and M) the facility failed to ensure the facility is staffed to ensure safe patient care per facility guidelines.

Findings include:

In 10 of 22 staff records reviewed the facility failed to ensure staff is trained for emergencies per facility policy. See Tag 200.

In 2 of 3 ED MRs reviewed the facility failed to ensure the ED is staffed 24/7. See Tag 201.

In 30 of 116 night shift schedules the facility failed to ensure the M/S department is staffed to ensure safe patient care per facility guidelines. See Tag 253.

The cumulation of these deficiencies directly affect Pts 1,2, 3, 4, and all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Based on review of staffing schedules, review of complaints, review of staffing guidelines and interview with staff, in 30 of 116 night shift schedules the facility failed to ensure the M/S department is staffed to ensure safe patient care per facility guidelines. This deficiency potentially affects all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Findings include:

Per facility staffing guidelines reviewed on 9/26/12 in the PM, with no title and no date, the night shift (6:00 PM to 6:00 AM) is to have 2 RNs for 7 Pts or less, 2 RNs and 1 CNA for 7-11 Pts, 3 RNs and 1 CNA for 12-18 Pts. The guide includes "Minimal staffing of 2 RNs to cover the ED as second RN."

Per review of staffing schedules and patient census between 3/12/27 and 9/24/12, there are 30 days where the night shift is not staffed per facility guidelines.

Per M/S staffing schedules, reviewed on 10/1/12 in the PM and confirmed in interview with RM A on 10/1/12 at approximately 2:00 PM, the following was found:

On 3/12/12 there are 12 Inpt/ SB with 2 RNs and 1 CNA.

On 3/27/12 there are 11 Inpt/SB with 1 RN and 1 CNA.

On 4/3/12 there are 12 Inpt/SB with 2 RNs and 1 CNA.

On 4/4/12 there are 12 Inpt/SB with 2 RNs and 1 CNA.

On 5/12/12 there are 12 Inpt/SB with 2 RNs and 1 CNA.

On 5/22/12 there are 12 Inpt/SB with 2 RNs and 2 CNAs.

On 6/12/12 there are 12 Inpt/SB with 2 RNs and 2 CNAs.

On 6/25/12 there are 13 Inpt/SB with 2 RNs, 1 NT orientee, and 1 CNA.

On 6/26/12 there are 15 Inpt/SB with 2 RNs and 1 CNA.

On 6/27/12 there are 12 Inpt/SB with 3 RNs to 10:00 PM, 2 RNs with one RN orientee from 10:00 PM to 6:00 AM, and 2 CNAs.

On 6/28/12 there are 14 Inpt/BS with 3 RNs to 10:00 PM, 2 RNs from 10:00 PM to 6:00 AM and 2 CNAs.

On 7/21/12 there are 12 Inpt/SB with 2 RNs and 2 CNAs.

On 7/22/12 there are 12 Inpt/SB with 2 RNs and 2 CNAs.

On 7/23/12 there are 15 Inpt/SB with 2 RNs and 2 CNAs.

On 7/24/12 there are 17 Inpt/SB with 2 RNs and 2 CNAs.

On 7/25/12 there are 16 Inpt/SB with 3 RNs to 10:00 PM, 2 RNs from 10:00 PM to 6:00 AM and 2 CNAs.

On 7/26/12 there are 13 Inpt/SB with 2 RNs and 1 CNAs.

On 7/27/12 there are 12 Inpt/SB with 2 RNs and 2 CNAs.

On 7/28/12 there are 12 Inpt/SB with 2 RNs and 1 CNAs.

On 7/30/12 there are 13 Inpt/SB with 2 RNs and 2 CNAs.

On 8/4/12 there are 12 Inpt/SB with 2 RNs and 2 CNAs.

On 8/5/12 there are 13 Inpt/SB with 2 RNs and 2 CNAs.

On 8/6/12 there are 13 Inpt/SB with 3 RNs to 10:00 PM, 2 RNs from 10:00 PM to 6:00 AM, and 2 CNAs.

On 8/7/12 there are 13 Inpt/SB with 3 RNs to 10:00 PM, 2 RNs from 10:00 PM to 6:00 AM, and 2 CNAs.

On 8/11/12 there are 13 Inpt/SB with 2 RNs and 1 CNA.

On 8/12/12 there are 14 Inpt/SB with 2 RNs and 1 CNAs.

On 8/13/12 there are 15 Inpt/SB with 2 RNs and 3 CNAs.

On 8/14/12 there are 15 Inpt/SB with 3 RNs to 10:00 PM, 2 RNs from 10:00 PM to 6:00 AM, and 2 CNAs.

On 8/15/12 there are 13 Inpt/SB with 3 RNs to 10:00 PM, 2 RNs from 10:00 PM to 6:00 AM, and 2 CNAs.

On 8/16/12 there are 12 Inpt/SB with 2 RNs and 2 CNAs.

Per review on 9/27/12 in the AM, of complaints related to insufficient staffing dated 3/27/12, two were filed revealing there was only 1 RN and 1 CNA for 11 Pts over the night shift of 3/27/12 to 3/28/12. Two RNs had been scheduled, one called in ill, and there is no evidence a replacement was located. Per review of the complaint there is no indication it was investigated or action was taken. This is confirmed in interview with RM A on 9/27/12 at approximately 12:00 PM.

On the night of 8/9/12 there were two patient codes called in the M/S unit. The first code called at between 3:30 AM and 3:40 AM involved Pt #1 who was a SB Pt with pneumonia that went into respiratory arrest. The 2 RNs and CNA from M/S responded, the LPN from the ED, and the MD on call for the ED. There was no other staff available to care for the other 9 Inpt/SB. When the second code was called between 3:45 AM and 4:00 AM, the remaining ED staff, RN G responded; leaving Pt #3 and #4 alone in the ED.

Based on review of P&P, review of MR and interview with staff, in 2 of 2 MR the facility failed to ensure a complete evaluation of Sentinel Events is conducted per facility policy.

Findings include:

In 2 of 2 MR the facility failed to ensure a complete evaluation of Sentinel Events is conducted per facility policy. See Tag C271.

In 1 of 1 interview the facility failed to ensure the CQI committee is fully informed and acts on recommendations related to Pt care and safety. See Tag C336.

In 1 of 1 interview the facility failed to ensure the facilty conducts a review of Pt events related to Pt safety. See Tag C337.

The cumulation of these deficiencies directly affect Pts 1,2, 3, 4, and all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Based on review of P&P, MR review, interview with staff, and email notes provided by staff, in 2 of 2 MR (1 and 2) the facility failed to ensure a complete evaluation of Sentinel Events is conducted per facility policy. This deficiency potentially affects all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Findings include:

Per review of facility policy on 9/26/12 in the PM titled Sentinel Event Policy and Procedure dated 7/12 it states under Definition "A Sentinel Event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof. Serious injury specifically incudes loss of limb or function The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant change of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. The subset of sentinel events that is subject to review includes any occurrence that meets any of the following criteria: The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition..." Under Procedure the policy states 2. "The Risk Manager will review the report and conduct the appropriate investigation, reporting and other action if deemed necessary following review by the Chair of th Quality Management." 3. If sentinel event review and analysis is indicated, the Chief of Staff and CEO will be notified. The Quality Improvement Council will appoint a multidisciplinary team consisting of medical staff and clinical services staff to conduct root cause analysis as a peer review activity...The root cause analysis, along with a proposed corrective action, will be reported to the Quality Improvement Council for approval. Upon approval of a corrective plan, the specified staff will implement it."

Pt #1's MR review on 9/26/12 at 7:00 PM, revealed Pt #1, had an unexpected cardiac and respiratory arrest on 8/9/12 between 3:30 AM and 3:40 AM. Pt #2's MR review on 9/26/12 at 1:00 PM revealed Pt #2 (also hospital employee RN X), who had participated in Pt #1's code, experienced an unexpected cardiac arrest sometime between 3:40 AM and 3:55 AM.

Per review on 9/27/12 in the PM, of the facility's internal Nursing Council & Patient Care Management Team meeting minutes dated 8/9/12, a nursing After Action Report was presented. This report included recommendations developed after reviewing the code for Pt #2. This is confirmed with OR RN MGR B on 9/26/12 at 8:55 AM, stating this was not a Root Cause Analysis, and Pt #1's record was not included in the After Action Report.

Per interview with VP C on 9/26/12 at 10:50 AM, no Root Cause Analysis has been done for either Pt #1 or Pt #2 as of 9/26/12.

Based on review of MR, review of P&P and interview with staff, in 2 of 5 MR (1 and 2) the faciltiy failed to ensure accurate medical record documentation to reflect the course of treatments and Pt care.

Findings include:

In 2 of 3 ED MRs the facility failed to ensure the ED MRs accurately document Pt care and include minimum information per facility policy. See Tag C201.

In 3 of 5 MR the facility failed to ensure the MR is accurately and completely documented and addendums are completed to clarify data, with no alteration to previous documentation. See Tag C302.

The cumulation of these deficiencies directly affect Pts 1,2, 3, 4, and all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Based on MR review, review of P&P and interview with staff, in 2 of 5 MR (1 and 2) the facility failed to ensure the MR is accurately and completely documented and addendums are to clarify, with no alteration to previous documentation. This deficiency potentially affects all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Findings include:

Per review of facility policy on 10/2/12 in the PM titled Medical Record Documentation Requirements, Standards, Guidelines and Ownership, dated 11/11, it states under Purpose "The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and results accurately..." Under Proper Authentication it states "No other individual shall be authorized to enter, delete, change, sign or authenticate documentation in the electronic medical record."

Pt #1's MR review on 9/26/12 at 7:00 PM revealed the MD notes for 8/8/12 indicated Pt #1 developed pneumonia while during the Swing Bed stay at the hospital. On 8/8/12 at 5:04 PM, an RN T, wrote " VS (vital signs) BP lower than usual and patient is concerned...Respiratory: rhonchi in all bases, finished. Left sided pneumonia... " There are no additional RN notes until 8/9/12 at 6:25 AM with a summary of events the night before when Pt #1 coded and died. The summary included only the time of death. Pt #1's MR does not include Life Pak 12 heart monitor strips which determine the heart rhythm during the code and to confirm asystole (no heart rate). This was confirmed in interview with RM A on 10/1/12 at 9:45 AM.

RT D confirmed in interview on 9/26/12 at 9:38 AM she was the scribe for Pt #1's code. RT D said she witnessed Pt #2 (also hospital employee RN X) giving a dose of medication, walking around the foot of the bed and collapsing between the bed and portable Xray machine. RT D stated Pt #2 (also hospital employee RN X) was then placed on the sofa by the MD and CNA, then RN G from the ED was called to help and move Pt #2 (also hospital employee RN X) to the next room. RT D stated in interview continued CPR on Pt #1 until 4:15 AM. At that time, RT D stated she obtained supplies for Pt #2's (also hospital employee RN X) code and began scribing Pt 2's (also hospital employee RN X) code at 4:40 AM, adding the documentation on Pt #2's code sheet prior to 4:40 was dictated to her by staff involved in the code.

Per interview with MD N on 9/26/12 at 2:30 PM confirmed Pt #2 collapsed, could not move her himself and required help to place her on the sofa. MD N stated compressions were going on with Pt #1, he returned to Pt# 1 and kept thinking "5 minutes" related to helping Pt #2.

Pt #2's MR review on 9/26/12 at 1:00 PM revealed Pt #2 is also RN X who gave the medication to Pt #1 at 3:45 AM or 3:50 AM. Per MD N's notes on 8/9/12 at 7:00 AM, Pt #2 "collapsed at 3:55 AM", during a code already in progress. (See Pt #1's MR) The notes include "initial rhythm asystole. Confirmed by checking pads and wire connectors."

Per interview with RN K on 9/26/12 at 11:49 AM, CPR was not started immediately on Pt #2, it was not started until Pt #2 was moved to the next room.

MR notes by RN K on 8/9/12 at 3:10 PM it states "called at home approximately 0400 (4:00 AM)...arrived shortly after call and responded to bedside. Tech obtaining EKG. Patient color dusky. Unable to see rhythm. combo pads in place and now attached to find patient in coarse V-fib (ventricular fibrillation). Defibrillated at 200j (joules) with response of sinus bradycardia (normal but slow heart rate)... Unsure of fluid resuscitation, possibly up to 3 liters 0.9NS (normal saline).

The code sheet in Pt #2's MR, written on a plain sheet of paper, revealed the following: "3:55 brought in, 4:00 started CPR, 4:05 Epi (Epinephrine)-1 mg (milligram), CPR, Analyzine[sic], Tachy Intubated, 4:09 -Epi 1 mg (AC), CPR, 4:25 drawing femoral blood, 4:30 V-fib, shock given 200, rhythm..."

Per interview with OR RN B on 9/26/12 at 8:55 AM, she was not involved in either Pt #1's or Pt #2's codes and took the code sheet and monitor strips to reconstruct the code documentation. On 8/14/12, RN B met with the RNs, LPN and CNA involved in Pt #2's code, to fill in the gaps. The reconstructed strips were written in the MR on 8/16/12 as an addendum to 8/9/12, and includes: "3:55 am Pt collapsed on floor between crash cart and bed, placed on sofa, agonal respirations, no pulse, unresponsive to calling out name. Carried by 3 people to next room due to code already in progress on another patient." The original code sheet states "3:55 AM brought in". The addendum has documentation of medications, heart rhythms and actions between 4:09 AM and 4:25 AM. The original code sheet has nothing documented between 4:09 AM and 4:25 AM.

Per interview with MD O on 10/1/12 at 10:45 AM, the heart monitor strips in Pt #2's MR at 4:03:12 and 4:13:07, indicated ventriclar fibrillation, and action should be taken. The strips timed at 4:03:21, 4:05:17, 4:11:54 and 4:12:52, 4:13:19 and 4:19:07, that are flat line, and "No Shock Advised", MD O confirmed they did not look like asystole (no heart rhythm), per the addendum to the code sheet. The code sheet indicates CPR was in progress at 4:00, 4:05, and 4:09 AM. This was confirmed in interview with MD O including there was no indication on the monitor strips that CPR was being done, again reflecting possibly the monitor was "not right". Per MR review and interview MD O, there are no monitor strips in Pt #1's MR, and Pt #2's MR contains conflicting documentation between original documentation, addendum, and monitor strips.

Based on review of CQI minutes, MR review, review of P&P and interview with staff, in 2 of 2 interviews ( O and R) the facility failed to ensure the CQI is appraised of Pt events, resulting recommendations and acts on said recommendations.

Findings include:

In 1 of 1 interview the facility failed to ensure the CQI committee is fully informed and acts on recommendations related to patient care and safety. See Tag 336.

In 1 of 1 interviews the facility failed to ensure the facility conducts a review of Pt events related to Pt safety. See Tag 337.

The cumulation of these deficiencies directly affect Pts 1,2, 3, 4, and all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Based on review of meeting minutes, and interview with staff, in 1 of 1 interview (R) the facility failed to ensure the CQI committee is fully informed and acts on recommendations related to patient care and safety. This deficiency potentially affects all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Findings include:

Per review on 9/27/12 in the PM, of the CQI meeting minutes dated 8/23/12, there is a statement under Department Reports, related to two Pts codes on 8/9/12, "1. Administrative Report/Patient Services Report/Joint Commission...Recently, 2 Medical Emergency Alert codes occurred at the same time in Med/Surg. Teams worked well but additional education is needed. All staff in patient care areas must be BLS trained. Staff need help in documentation. There are 2 RN's on the floor at all times...The 'Send Word Now' group was called in immediately...Mock Codes will begin in Med/Surg"

There is no documentation in the CQI minutes regarding specific actions to be taken related to meeting the recommendations noted above, setting of goals and timelines, and who is responsible to ensure the goals are met.

The Nursing Council & Patient Care Management Team dated 8/9/12 included the After Action Report related to the 2 medical codes that happened on 8/9/12. Recommendations from this report included a phone tree, Send Word Now up and running, 2 RNs at night in the ED, Check batteries/machines at the start of each shift, Crash cart experience-Mock codes, Skills Fair, RSI (emergency medication) kit in Med/Surg-in-service hospital wide, timeline."

Not all the recommendations listed in the After Action Report are mentioned in the 8/23/12 CQI report, and do not include a timeline for accomplishing the recommendations.

This is confirmed in interview with MD R, Chair of the CQI committee, on 10/2/12 at 11:35 AM.

Based on MR review, and staff interview, in 1 of 1 interviews (O) the facility failed to ensure the facility conducts a review of Pt events related to Pt safety. This deficiency potentially affects all 7 Inpt/SB Pts and 21 ED Pts treated on 9/26/12, 9 Inpt/SB Pts and 16 ED Pts treated on 9/27/12, and 10 Inpt/SB Pts and 18 ED Pts treated on 10/1/12 while surveyor is on site during survey.

Findings include:

Per interview on 10/1/12 at 10:45 AM with MD O, Dir of ED, Pt #1's and Pt #2's MRs were sent to an outside agency for code review. Per MD O, the summary of the review was received "last week". MD O stated the outside agency indicated there could be no review of Pt #1's code because no heart monitor strips were included with the MR, to determine the correct actions were taken during resuscitation, and if asystole (no heart rhythm) existed.

Review of Pt #2's MR with MD O on 10/1/12 at 10:45 AM, MD O stated the heart monitor strips, that were documented in the addendum notes as asystole looked like the monitor test strips or that the paddles/pads were not connected properly. There are two monitor strips stating "check patient" at 4:03:12 AM and 4:13:07 AM, showing what MD O interpreted as ventriclar fibrillation (rapid fluttering of the heart), and she would expect staff to take some action. There was no documentation the patient was checked, or action taken, on the code sheet or addendum, matching those times. Per interview with MD O on 10/1/12 at 10:45 AM, the summary of findings provided by the outside agency review, who determined the team responded "appropriately", did not match her findings on date of interview.

Based on this knowledge, the independent reviewer was not given heart monitor strips for Pt #1, and as of 10/1/12, has not completed a re-review of Pt #2's MR.