HospitalInspections.org

Based on medical record review, document review, interview, and in one (1) of four (4) medical records reviewed, the facility failed to get approval from the appropriate patient representative before discontinuing CPR.
(Patient # 1).

Findings include:

The facility staff failed to verify the correct patient and contact the appropriate patient family member while CPR (cardiopulmonary resuscitation) was in progress.

See Tag A-0117

Based on medical record review, document review, interview, and in one (1) of four (4) medical records reviewed, the facility failed to get approval from the appropriate patient representative before discontinuing Cardio-Pulmonary Resuscitation (CPR) (Patient # 1).


Findings include:

Review of the hospital policy and procedure titled "Patient Verification (P111)," dated 3/23 states.
"Purpose: To describe the processes for verifying the correct patient prior to rendering care, treatment or services and matching service or treatment to that patient. The verification process is applicable to all employees and providers i.e., physicians, NP's (Nurse Practitioner), PAs (Physician Assistant) who interact with patients or deal with patient information. This includes verbal and telephone conversations.

Policy:
1.Two unique identifiers must be used to verify that the correct patient has been identified prior to receiving any care, treatment, and services. This includes, but not limited to:
Administration of medication
Administration of breast milk
Administration of blood or blood products.
Specimen collection
Tests or procedures
Venipuncture
Transport of patients

2.The two unique identifiers must also be used in situations where patient information is being transmitted over the phone or in person. This includes, but is not limited to, scheduling procedures, requesting patient transport, and reporting test results.

3.Room number or other location is never used to identify a patient."

Review of the medical record for patient #1 revealed: that patient #1 was admitted to the facility on 4/24/2024. The patient was identified as a full code as per the advanced directives. A health care proxy was not completed. The family contact information was documented in the medical record. Patient # 1 was in the Medical Intensive Care Unit (MICU) and was treated for lactic acidosis (a buildup of lactic acid in the blood stream), pleural effusion, and atelectasis (a condition where all or part of the lung collapses), metapneumovirus pneumonia, cancer of the prostate, adenocarcinoma of the left lung, liver metastasis (cancer that spreads from the liver from another part of the body), bleeding from left chest tube drain, decreased blood pressure, and was intubated (insertion of a tube to keep the airway open to help with breathing).

On 5/14/2024 at 12:55 AM, Staff D, Medical Resident, documented that a code was called to the bedside as patient #1 had no activity on the monitor. CPR was initiated, and during CPR, a physician called the patient's family who requested discontinuation of compressions.

On 5/14/24 at 2:57 AM, a medical resident documented, "After a code, patient's son was called. However, after further discussion with family and amongst our team, the wrong family was called during the CAT (cardiac arrest team). The family of [Patient #2] was called instead. Patient #1 sons came in the MICU (Medical Intensive Care Unit) to discuss what happened during the code. I explained an error was made and we had called the wrong family during the code and received instructions to stop CPR (cardiopulmonary resuscitation). I apologized on behalf of our team and answered any questions patient #1's son had. They had no other questions and asked for time with their father."

During the interview on 11/7/2024 at 10:38 AM, Staff F, Medical Director (MICU) was asked, how a staff is instructed to call the family. Staff F stated a physician is instructed verbally to notify the family; it is preference for a physician who knows the patient to make the call to the family. The physician who is given the instruction to make the call to the family, is given the patient's name and must verify who the patient representative is before making the call. When asked why was the wrong family was called? Staff F responded that all physicians are trained on patient and family identification in the electronic medical record. The length of time to continue a code is determined by several factors such as the patient medical history, diagnosis, comorbidities, cardiac and respiratory response to cardiopulmonary resuscitation. The code stopped after the staff member spoke with the family.


During the interview on 11/7/2024 at 11:45 AM, Staff D, Medical Resident, PGY1 (post graduate year1) who was present during the code, stated. "After the first two minutes of compressions, the patient was reassessed, and CPR continued. Their focus was continuing the code and monitoring the patient's response. They were not aware who made the request for a resident, who responded to the code announcement, to notify the family of the patient's status. The resident returned and informed the team that they spoke with the patient's spouse, who requested to cease code operations. The fellow agreed to stop code. The code was in effect for about eight minutes and the patient did not respond, the fellow agreed to stop the code. The length of a code is determined by multiple factors, each case is different. A code can last for minutes to about an hour. Patient # 1 had blood loss, and prognosis was poor. There were discussions with the family about the patient's general condition, and prognosis. One of the patient's sons is a doctor and the physicians taking care of the patient had conversations with the son about the patient's condition. The family did not want to sign a Do not Resuscitate/ Do not intubate (DNR/DNI) document because of religious reasons. The son stated he wanted a "soft code" compressions and airway management."


During the interview on 11/7/2024 at 4:05 PM, with Staff C, Medical Attending stated, 'it is uncertain if the intern that called the family verified the patient and contact information prior to initiating the call to the wrong family. The intern returned after speaking with the family and informed the team that the patient's wife requested to stop the code. He was present at the code and stated that the staff had decided to stop CPR. It was a reasonable to stop the code which lasted 8 to 10 minutes. The patient would not have survived with continuing the CPR. The patient's prognosis was poor."

The intern that called the family is no longer at the facility.


The facility provided an IJ removal plan to survey staff 11/13/2024 at 9:15 PM. The plan included:

a) An education online module will be developed to educate all attending physicians (i.e. attendings, residents, fellows), and advanced practice providers (i.e. physician assistants and nurse practitioners) who are privileged to practice at New York Presbyterian Queens. The module will emphasize key information available in the below policies as they pertain to patient verification and patient rights:

-Patient Rights and Responsibilities Q P120 (Policy and Procedure)
-Patient Verification P111 (Policy and Procedure)
-Advanced Directives Q A163 (Policy and Procedure)

b) The education training to begin on November 13th, 2024.


The IJ was removed on 11/14/2024 at 2:30 PM after an onsite verification of the online education module training on the policy and procedures, staff interviews and verification of staff education attendance.

100% (22/22) of staff that were interviewed had received the online training for Patient's Rights and Responsibilities, Patient Verification, and Advanced Directives.

As of 11/14/2024 at 2:30 PM hospital staff were trained were as follows:
11/14/24 Overnight staff trained:
Attendings = 16/16 (100%)
Residents = 16/16 (100%)
Fellows = 1/1 (100%)
Physician Assistants = 24/24 (100%)
Nurse Practitioners/ CRNAs = 3/3 (100%)
Total number of overnight trained 60/60 = 100%

11/14/24 Day Shift trained:
Attending = 159/163 (97.5%)
Residents = 94/96 (97.9%)
Fellows = 10/11 (90.9%)
Physician Assistants = 70/70 (100%)
Nurse Practitioners/ CRNAs = 18/18 (100%)
Total number of day shift trained 351/358 = 98%