HospitalInspections.org

Based on interview and record review, the facility staff failed to follow its policies and procedures in the provision of nursing services regarding patient wishes for their code status for 2 of 10 patients reviewed for code status (Patient (Pt.) #4 and Pt. #5) and failed to investigate an adverse incident for 1 of 1 patients (Pt. #4) who did not receive Cardiopulmonary Resuscitation (CPR) as ordered per facility policy.

The facility staff failed to provide cardiopulmonary resuscitation to patients who did not have a do not resuscitate (DNR) order for 1 of 10 patients reviewed for code status (Patient #4). See C-1046.

The facility staff failed to clarify resuscitation status and get physician orders for the DNR status of 1 of 10 patients reviewed for code status (Patient #5). See C-1046.

The facility failed to follow their quality improvement policy and adverse event reporting policy when they did not review and investigate an adverse event for 1 of 1 patients (Patient #4) who did not receive CPR as ordered and per the patient wishes when the patient was found breathless and pulseless. See C-1309.

Based on record review and interview the facility failed to provide cardiopulmonary resuscitation (CPR) to patients who were full code for 1 of 10 patients reviewed (Patient #4) and failed to clarify and get physician orders for the DNR status of 1 of 10 patients reviewed (Patient #5) in a sample of 10 records reviewed.

Findings include:

Review of facility policy titled, "Cardiopulmonary Resuscitation (CPR)," last reviewed 08/2020 stated, "In the event a patient is found to be without discernible pulse and/or respirations, the Cardiopulmonary Resuscitation (CPR) Policy shall be instituted ... ...Hospital staff must recognize the need for and know how to activate the hospital's resuscitation team. Healthcare professionals shall be trained and evaluated at frequent intervals by monitoring performance and retrained as necessary in the skills of basic life support (BLS). Healthcare professionals who are primary members of the hospital's resuscitation team shall be skilled in emergency cardiac care and advanced cardiac life support (ACLS) .... An ACLS trained and experienced patient care unit RN or Critical Care RN shall manage the CPR (Also known as Code Blue or Code) in the event of any delay in the arrival of a qualified physician. The critical care ACLS nurse shall be responsible for evaluation of the patient's condition regarding cardiac status and need for definitive therapy, and continue CPR following current ACLS algorithms until a qualified physician arrives and assumes responsibility .....Nursing Staff (RNs) ... ...shall be trained on an (sic) biannual basis for Basic Cardiac Life Support ....CPR Procedure ....Primary Nurse, Primary responsibility: finds the patient requiring code, assess patient for ABCs (Airway, breathing, circulation), Initiate CPR, Call Code Blue."

Review of facility policy titled, "Cardiac Emergencies, Protocol for Registered Nurses in the absence of a Provider, last reviewed 07/01/2021 stated, "In the absence of a Provider, the Registered Nurses (RN) may initiate the following protocol while waiting for a Provider to arrive and provide further medical treatment. Procedure: 1. Concurrently notify Provider, Lab, Radiology, Anesthesia, and other care personnel of emergent situation by paging overhead or phone. 2. Activate Code Blue emergency. 3. Initiate treatment following American Heart Association (AHA), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) protocols."

Review of facility policy titled, "Do Not Resuscitate orders/EMTs (Emergency Medical Technician) and ER (Emergency Room) Services, last revised 05/2016 stated, "Only the attending physician can issue a DNR order .....Resuscitation is defined to mean the full range of cardiopulmonary resuscitation, including cardiac compression, advanced airway management, defibrillation and cardiac resuscitation medications."


Patient #4:

On 03/30/2022 at 12:40 PM, Review of Patient (Pt.) #4's medical record revealed Pt. # 4 was a full code and was found pulseless and breathless on 01/24/2022 at 2:20 PM and there is no documentation present of CPR being provided. This was confirmed during interview by Medical Practice/compliance officer staff I on 03/30/2022 at 12:40 PM when asked if this was correct, Staff I stated, "There is no CPR flow sheet completed."

On 03/30/2022 at 12:40 PM review of RN note, completed by RN C in Pt.#4's medical record, dated 01/24/2022 at 5:11 PM stated, "At 2:20 PM this nurse entered room to administered (sic) approved Tramadol (pain medication) and found patient deceased. Alerted charge nurse, nurse manager and director of nurses as well as Dr. (Name). Followed death protocol procedures."

In an interview on 03/29/2022 at 10:55 AM with RN C when asked what the process is for CPR/Code Blue, RN C stated, "We yell code blue and start CPR, we call ER, and everyone comes to help and offers whatever help they can." When asked would you ever not provide CPR to someone who was a full code, RN C stated, "Yes this happened once, I didn't call a code, it happened 3-4 months ago, I should have called a code because the patient didn't have a DNR order and I didn't, I came in the room and the patient was cold and hard ...I was told after that, no matter what you start a code when they are a full code. I don't remember (his/her) name, I called the family to tell them. I learned a very valuable lesson."


Patient #5:

On 03/30/2022 at 12:45 PM, review of Pt.#5's medical record revealed Pt.#5 was a full code, No DNR orders were present in the record. Pt.#5 admitted on 01/03/2022 with a small bowel obstruction and continued to decline throughout his hospitalization and was placed on comfort cares and expired on 01/10/2022 at 11:20 AM.

Review of Pt. #5's medical record Provider progress note documented by a PA-C (Physician Assistant-Certified), dated 01/08/2022 at 7:35 PM, stated, "(Name) is not doing well, (he/she) told (his/her) PCP (Primary Care Provider) (he/she) did not want intubation or resuscitation if needed, (his/her) (wife/husband) and (daughter/son) are both registered nurses and at this point still wanted a full code. Today his wife visited and discussed with charge nurse that (he/she) would be DNR/DNI."

Review of Pt.#5's medical record revealed a code status change log from a full code on 01/08/2022 at 11:04 AM to a DNR/DNI on 01/08/2022 at 1:35 PM, verified by RN C, No DNR order was documented in the medical record by the medical provider.

In an interview with compliance officer Staff I on 03/30/2022 at 12:45 PM when asked about where the provider order was for the DNR/DNI or discussion between the RN and MD regarding the code status change for Pt.#5, Staff I stated, "There is no MD order for DNR/DNI, just what the nurse documented on the code status change log and the provider note."

Based on record review and interview the facility failed to follow their Quality Improvement policy and Adverse event reporting policy for 1 of 10 patients reviewed for code status (Patient #4) in a sample of 10 records reviewed.

Findings include:

Review of facility policy, titled, "Quality Improvement Policy," last reviewed 07/13/2021, stated, "(Facility Name) Medical Center is committed to all care and services throughout the hospital ... ...The goal of the organization is to continuously improve patient experience/outcomes in all areas of care .....In order to provide a consistent approach to performance improvement, (Name) has adopted the Focus- PDCA(Plan, Do, Check, Act) model. This step-by-step, systematic approach guides teams in continuous quality improvement. 1. Plan- set goals based on patients needs. 2. Do- work as a team to implement your goals. 3. Check-analyze what happened. 4. Act-make sure improvement is permanent!"

Review of facility policy, titled, "Patient/Visitor Incident Report Policy and Procedures," last reviewed 07/13/2021 stated, "It is the policy of (Facility Name) Medical Center to require that an incident report be completed for each event (as defined below) that occurs involving a patient .....which is not consistent with the routine activities of the (Facility Name) Medical Center or care of a patient .....Adverse event: Any occurrence or situation not consistent with the routine operations of (Facility Name) Medical Center, .....The event report shall be completed for, but not limited to, the following ....8. Unexpected death ....12. Any practice inconsistent with the normal practices of the facility ....The following actions shall be taken when an incident or near miss occurs: ... ...2. The employee involved or the one with the most knowledge of the event will complete the event report. The manager is notified of the event ....3. Adverse events will be investigated in collaboration with directors, department managers, supervisors and the risk manager. 4. The completed event report will be forwarded to the risk manager for tracking and trending within 24-48 hours. 5. Corrective actions are implemented and documented to prevent reoccurrence .....E. Event Report Processing: 3. a. All managers will receive and review quality incident information ....b. Managers will review the data with their employee and ensure that patient/resident safety issues are addressed from educational, human resource and performance improvement perspectives as necessary."

Review of email sent by Quality Manager G sent to CNO A on 03/29/2022 at 11:30 AM stated, "We have 0 adverse events besides one medication.....I have no formal complaints of nursing for the floor since 03/2021.....I have no incident reports of a complaints (sic) by a patient on the floor either."

In an interview on 03/30/2022 at 10:05 AM with CNO A when asked what was done following the event on 01/24/2022 with RN C, when Pt. #4 was found pulseless and breathless, CNO A stated, "Talked to the RN involved and asked why, (he/she) was shell shocked, no incident report was completed, we did a Mock Code shortly after the incident." Review of Mock code documentation revealed a mock code was conducted on 03/16/2022. (Almost 2 months after this event). When asked if there were other instances where this type of situation has happened, CNO A stated, " I'm not aware of any other instances where this has happened." When asked what the expectation is for providing CPR to a full code patient, CNO A stated, "It is an expectation that CPR should be started if a patient is found breathless and pulseless if a full code."

In an interview on 03/30/2022 at 1:55 PM with Quality Manager G, when asked about the event with Pt. #4 on 01/24/22 if this would have been considered an incident, Manager G stated, "Yes it should have been written as an incident report, I would have expected it to be completed, the provider then has to review the event. I wouldn't know unless an incident report was completed. There is no incident report on this. If there was no incident report then no review would have been done."

In an interview on 03/30/2022 at 2:00 PM with CNO A, when asked what was done as far as follow up to ensure this type of event didn't happen again, CNO stated, "I wasn't here at the time and (name) nurse manager figured it out the next day. When writer asked who decided not to call a code, CNO A had no response. Writer asked CNO A again if an incident report should have been filled out, CNO A stated, Yes, and meeting with the nurse involved, the manager would have done." CNO A confirmed during interview that no follow up was completed and no education was done. CNO A stated, "This hasn't happened before." When asked how CNO A knew this type of event hadn't happened before, CNO A stated, I don't know." When asked what education or follow up was done between 01/24/2021 and mock code on 03/16/2022, CNO A stated, "There was no education or follow up completed."