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Based on record review and interview, the CAH (critical access hospital) failed to ensure equipment and supplies commonly used in life saving procedures were available for use during cardiopulmonary resuscitation. This deficient practice was evidenced by failure of the CAH to ensure all personnel, including respiratory therapy personnel, were familiar with the type and location of equipment and supplies commonly used in infant/pediatric life-saving procedures in the hospital's emergency department.

Findings:

Review of Patient #2's medical record revealed the patient was a 6 month old infant who had been brought into the hospital's emergency department in full cardiopulmonary arrest on 10/19/17.

Further review of Patient #2's medical record revealed an entry documented by S6MD on 10/19/17 at 8:23 a.m. The entry revealed in part: Attempted intubation (but we did not have the right size for a 6 month-old and the blade would not fit). Attempted with finger but unable to do secondary to rigor mortis and stiff jaw and neck. Two attempts at needle cricothyrotomy but unable to thread cath. Bagging was continued and CPR (cardiopulmonary resuscitation) continued. Crico (cricothyrotomy) cut down was attempted; blade dull not cutting well. No small forceps on pediatric cart plus crico kit was for an adult. Patient was pronounced at 08:43 a.m.

Review of S4RT's personnel record revealed no documented evidence of orientation to the emergency equipment and supplies available in the hospital's emergency department. Further review revealed no documented evidence of training on the hospital's pediatric code blue policy.

In an interview on 11/16/17 at 6:59 a.m. with S6MD, he confirmed he had coded Patient #2 (a six month old infant who had been brought into the CAH ED in full cardiopulmonary arrest) on 10/19/17. He reported Patient #2 was coded and during that code he had been handed the wrong size blade for intubation of the 6 month old infant. He further reported he had needed a Miller size 0 blade and he had been handed a blade that was too large. S6MD also reported he had requested a pediatric cricothyrotomy kit and he had been handed an adult kit by a respiratory therapist.

In an interview on 11/16/17 at 11:54 a.m. with S4RT she indicated she had worked at the hospital for approximately 1 ½ years. S4RT confirmed she had participated in Patient #2's code. S4RT reported S6MD had requested a blade for intubation of Patient #2 and she had handed him either a Miller size 1 or a Miller size 2. She also reported when S6MD requested a pediatric cricothyrotomy kit she had handed him an adult sized kit because that was first cricothyrotomy kit she had seen. She indicated she had told S6MD maybe you can use some of the equipment in this kit (the adult kit). S4RT confirmed she had basic life support certification and did not have current training in pediatric advanced life support protocol.

In an interview on 11/16/17 at 3:35 p.m. with S2DON, she confirmed the hospital treated infant/pediatric patients in the ED. She also confirmed pediatric codes sometimes occurred in the ED. She agreed all staff participating in an infant/pediatric code should be trained and familiar with the pediatric advanced life support protocol. She indicated the pediatric advanced life support protocol was located in the policy binder in the ED. S2DON reported she could not be sure if the hospital's respiratory therapy staff had been trained on the hospital's pediatric advanced life support protocol.

In an interview on 11/16/17 at 3:53 p.m. with S5RTDirector, she reported the hospital's respiratory therapy staff had basic respiratory therapy training, such as bagging and obtaining blood gases. S5RTDirector indicated the respiratory therapy staff was shown the contents of the crash carts and resuscitation equipment in the ED, but there was no orientation check off list or any type of orientation documentation. S5RTDirector reported that the hospital had not had that many pediatric codes.