HospitalInspections.org

Based on observation during tour, review of hospital policies/procedures, documents and staff interviews, it was determined the hospital failed to require that in the case of an emergency (code blue) that the procedure/equipment used is maintained in working order. This deficient practice poses a high risk for injury or death in case of emergency if staff is unsure of the procedure, which system to use, and that the system is functional.

Findings include:

Observation on tour 6/08/2016 through 6/17/2016 revealed that units of the hospital use different methods of calling "codes". Radiology / Computerized Tomography (CT) / Magnetic Resonance Imaging (MRI) use the "red phone"on wall, "code button" blue button on wall, leave the patient to "yell out door", and/or call the emergency room from the office area of the department. Intensive Care Unit uses code "button" on the wall in the patient's room, if no response call overhead. The Inpatient unit uses overhead paging system.

Hospital policies require the following:

Code Blue Procedure, 1014, PolicyStat ID: 1683869, (last revised 01/06) requires: " ...code should be called according to the hospital's pre-established code procedure...."

Cardiopulmonary Resuscitation Emergency Treatment, 1016, PolicyStat ID: 1683867, (last revised 1/06) requires: "...Stay with the patient! 'Code Blue' will be called over the intercom by the Unit Secretary for the Emergency Department (ED), after s/he has been notified by department personnel...."

Cardiac Arrest - Code Blue, 1249, PolicyStat ID: 1628807 (last revised 1/08) revealed: "...All cardiac arrests within the Intensive Care Unit...the staff will overhead page 'Code Blue' and indicate room number...."

Cardiac Arrest - Code Blue, 2200, PolicyStat ID: 1602067, last revised 1/2015 revealed: "...All cardiac arrests with the Emergency Department...will...overhead page 'Code Blue'...."

Participation in Emergency Department's Code Blue, 5004, PolicyStat ID: 2019031, last revised 3/2016 revealed: "...respiratory care practitioners will take following steps in calling a CODE BLUE...by using the 'CODE/fire' button on the hospital telephone and announcing code blue...."

The (Department) Guidelines for Design and Construction of Hospital and Health Care Facilities 2001 requires: "...A staff emergency assistance system for staff to summon additional assistance...shall annunciate visually and audibly...at the nursing station of the nursing unit with backup to another staffed area from which assistance can be summoned...."

The ED is built in a square configuration with 18 patient bays encircling the nurses' station. The nurses' station contains multiple computers, monitors, and desk phones. In addition to the desk phones, the desk phone nearest the telemetry monitors on the counter is designated to receive emergency calls from the red phones. Also there is a gray metal panel with a simple phone receiver resting on top of the panel (located nearest the CT room) that was equipped with multiple visual indicators (buttons) that lit up when a code arrest was called from the blue code arrest button on the wall in CT (no button identified for ICU).

CT/MRI/X-Ray Technician #10 confirmed during interview 6/8/2016 at 1030, that the red phone in the CT room is used with the code button on the wall, and "yelling out door". Tech #10 demonstrated the code call process on 6/8/2016 at 1040, for the purpose of confirming the process for the surveyors, as follows:

In the event of a code arrest in CT, the staff will pick up the red phone on the wall and push the blue code button. The surveyor observed that the phone handset was taped to the cradle on the receiver. The staff indicated that when the receiver is lifted, this "triggers" a blinking light and a ring on the designated phone in ED.

The surveyor observed that the designated phone in the ED blinks but does not ring and the ED staff were not aware and did not respond. In addition the designated phone in ED is not manned. The surveyor confirmed that the Code Blue button quietly sounded (beeped) in the ED at the gray metal panel. The surveyor observed that multiple ED staff members to be "wondering" what the beeping indicated and attemping to turn off the sound. The gray metal panel is not manned.

The Plant Operations Manager #48 confirmed that the designated phone did not ring, only flashed, and that the ED staff did not respond to the phone.

CT/MRI/X-Ray Technician #10 confirmed that if a patient is in the MRI room the staff leaves the patient - unattended - to go to the MRI control room to use the phone to call the ED for assistance and then return to patient.

The hospital does not maintain a working emergency assistance call system, as described in the Guidelines for Design and Construction of Hospital and Health Care facilities 2001 (architectural requirements) effective at the time of initial licensure and remains the current Department requirements for this hospital.