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Based on a review of facility documentation and policies and procedures, patient records, staff interviews, the facility failed to ensure that a Rapid Response Team patient intervention was documented, including time called, time ended, assessment of the patient, primary physician name, time notified, recommendations, and interventions according to facility policy and nursing standards of practice.

Findings were:

Review of the record for 1 out of 10 patient records, Patient #1, revealed that a Rapid Response Team was called for a patient who was decompensating at 0645 on 7/21/13. Patient #1 was subsequently transferred to the intensive care unit at 0700 on 7/21/13. However there was no documented evidence in the medical record of the Rapid Response Team form and no documentation about the patient ' s condition during the Rapid Response Team intervention.

Review of facility Nursing Department policy, Rapid Response, last approval date, 1/22/08, stated, in part, "The purpose of a Rapid Response Team is to support the primary nurse, perform a critical assessment, and provide rapid intervention in order to promote improved outcomes such as reduction in hospital mortality, stabilization of the patient's condition, or timelier transfer to a higher level of care ...SBAR (Situation, Background, Assessment, Recommendation) will be a standard form of communicating and receiving information about the patient ' s condition. The completed form will be available for the physician to review upon arrival at the patient bedside. The Primary nurse will initiate the SBAR form completion is by (sic) the primary nurse with assistance from the Rapid Response Team."

Review of a blank copy of the Scenic Mountain Medical Center Rapid Response Team Record revealed the documentation required when a Rapid Response Team is called, which includes items such as, location, time called, arrival called, time ended, Situation, background, assessment of the patient (vital signs, acute mental/neurological status change, acute significant bleed, seizures, failure to respond, etc.), primary physician name, time notified, recommendations and interventions (O2, suctioning, oral airway, bag mask, nebulizer treatment, ABG, etc.), primary nurse signature, respiratory signature, critical care nurse signature, and MD signature.

Review of the Rapid Response Team training PowerPoint provided by Staff #6, Med/Surg Director the afternoon of 10/23/13, revealed no mention of completing the Rapid Response Team form or any type of documentation required when the Rapid Response Team is initiated. Review of the Rapid Response Team quiz revealed no mention of completing the Rapid Response Team form or any type of documentation required when the Rapid Response Team is initiated.

In a telephonic interview with Staff #7, LVN at 11:39 am on 10/23/13 on speaker phone with the Chief Nursing Officer, Staff #7 stated, "I don't believe I documented on a Rapid Response form. I didn't know there was a Rapid Response form." When asked, Staff #7 stated that the Rapid Response Team was called and an emergency room physician came, an ER nurse came, a respiratory therapist, and the night shift ICU nurse came as part of the Rapid Response Team.

Review of the Texas Nurse Practice Act ?217.11. Standards of Nursing Practice, states, in part,
"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...
(D) Accurately and completely report and document:
(i) the client ' s status including signs and symptoms;
(ii) nursing care rendered; ...
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status."

In an interview with the Chief Nursing Officer the morning of 10/23/13 in the facility conference room, she confirmed that a Rapid Response Team form was not completed after the Rapid Response Team was called the morning of 7/21/13 for Patient #1 and that the documentation required by policy and in accordance with nursing standards was not completed for Patient #1.