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Based on record review, staff interview and review of policy and procedures, the facility failed to ensure accurate and timely documentation in the medical record for 1 of 10 (Pt 10) sampled patients. Patient 10 had an anaphylactic reaction to a blood product (platelets) resulting in a Rapid Response Team (RRT-a team to respond to a deterioration in a patients condition) that progressed to a code blue. Documentation during the RRT failed to show vital signs, pulse oxygen level readings, cardiac monitoring strips and a chronological progression of events. The facility census was 261.

Findings are:

A review of Pt 10's medical record revealed the 58 yr old was admitted on 9/3/20 for further evaluation of diabetes, and cancer metastasis (spread) resulting in 2 surgical procedures and passed away on 9/10/20. On 9/5/20 the patient received 2 units of platelets, and developed an anaphylactic reaction (a severe life-threatening allergic reaction). The patient experienced a rash, severe swelling of lips, severe swelling of tongue and upper extremities. Pt 10 was having stridor (An abnormal, high-pitched, musical breathing sound caused by a blockage in the throat or voice box.) and snoring respirations. The patients nurse RN A notified the physician immediately and provided intravenous (IV) Benadryl (antihistamine given for allergic reaction) and IV Solumedrol (a steroid given for severe allergies) and racemic epi (medication given for relief of shortness of breath). An RRT was called.

Review of the RRT documentation on 9/5/2020 at 2145 (9:45 PM) revealed:
-Upon entering the room, "The patient was in bed, tongue severely swollen. Pt was lethargic (very tired), maintaining oxygen saturations of 96-99% on 3L/NC (liters per nasal cannula)."
-RT (respiratory therapist) had an oral airway (a device that is curved and prevents the tongue from blocking the airway) placed with some difficulty.
-The RRT called the Pulmonary Nurse Practitioner (NP) to the bedside for assistance. The NP called the Pulmonologist (Dr M) that was in house to assist, and arrived at bedside within 5 minutes. Dr M verbalized the need for intubation (the process of inserting a tube, called an endotracheal tube (ET), through the mouth and into the airway.)

Review of Dr M's progress note dated 9/5/20 at 22:44 (10:44 PM) revealed:
-"Called to see patient stat (immediately) because of severe angioedema (swelling of the skin and mucous membranes) after platelet infusion with marked swollen lips, swollen tongue, swollen upper extremities, stridor and needing acute airway."
-"The patient had severe airway edema. The airway edema was so severe could not even see the opening of the trachea. Cannot visualize the vocal cords."
-Dr M attempted to use a fiberoptic bronchoscope (lighted tube to visualize airway) and a glidescope (device to visualize the larynx) to pass the ET tube,
unsuccessfully.
-"A code was called and the patient had bradycardia (low heartrate) and at one point loss of pulse, and had to have CPR (cardio pulmonary resuscitation) initiated."
-Code Blue initiated at 22:22 (10:22 PM) on 9/5/20 and pulse returned and the code blue event ended at 22:40 (10:40 PM) on 9/5/20.

Review of the Emergency Department Dr's (ED Dr) progress note dated 9/5/20 at 23:48 (11:48 PM) revealed:
-"A medical emergency was called overhead and (ED Dr) responded to the room. On arrival the patient was found to be unresponsive and hypoxic. Dr M was at the head of the bed attempting intubation with a glide scope, but this was unsuccessful. I called for a bougie (a long stiff plastic wand incerted to help guide the ET tube) and a cric kit (tools needed in an emergency to make an incision through the skin in the neck to establish an airway). There was significant airway swelling, but was able to pass a bougie with some difficulty. An ET Tube was passed over the bougie and the airway was secured."

An interview on 11/17/20 at 2:20 PM with the NP revealed that the RRT called for assistance, when arrived at the bedside (Pt 10) was awake and having stridor and dyspneic (not breathing or difficult to breathe), could follow commands. The pt had received medications, needed to be intubated, had staff call (Dr M), which happened to be in the house. The patient had swollen lips and airway which made it very difficult to intubate. Dr M tried several times (6-7) using different methods. The patient would desaturate (oxygen level would go very low) and become hypoxic (low oxygen). (The Pt) became pulseless and CPR was initiated. The ER Dr responded to the code blue and was able to intubate the pt with some difficulty.

Review of the documentation of the events that occurred during the RRT and Code Blue showed a lack of vital signs, pulse oxygen level readings, cardiac monitoring strips and a chronological progression of events (times of attempted intubations).

A review of the Discharge Summary revealed that Patient 10 was managed on the ventilator and critical care medicine following the 9/5/20 event. The patient showed significant encephalopathy (injury to the brain that alters the brain function) which was consistent with anoxic brain injury (lack of oxygen to the brain during a cardiac arrest/code where the brain cells die). Consultation with neurology (specialist that treats disease of the brain) and palliative care (specialist that assesses and treats end of life) discussed the prognosis with the family. It was decided to perform compassionate extubation and comfort cares (removal of the ventilator to alleviate suffering while avoiding the prolongation of death) on 9/10/20 surrounded by loved ones.

Review of the Policy and Procedure dated 10/18 titled "Documentation of Pt Care" revealed, "The Medical Record shall serve as the primary means for providers to communicate among themselves, and with other patient care providers about the patient's status and to document information necessary for continuity of care to include the patient's care, treatment, and services provided. Clinical information related to patient assessment, patient problems, interventions provided, and patient outcomes shall be considered a permanent part of the patient's medical record."