HospitalInspections.org

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure that the medical record of Patient #1 contained documentation of a cardiac resuscitation response to cardiac arrest. One (1) of five (5) patients reviewed was affected.

Findings include:

Patient #1: Medical record review revealed that a nurse's note dated 11/30/2010 revealed the following information. At 11:22 a.m. The patient's blood pressure and heart rate began to drop. A code blue was called.

Registered Nurse (RN) #1 provided the following signed statement on 12/08/2010. "The monitor tech (technician) stated on the intercom that help was needed in bed ---. I went from the rooms where I was taking care of my patients. I picked up the marker and started recording the code on the dry erase board. I recorded times - start, in between, and ending time. I recorded rhythms, CPR, meds (medications) and amounts of meds given. I recorded the time the code was called. After the code was called I told the primary nurse (RN #3) that the code information was on the board and that I had to go to my patient's room. I then left the room."

RN #2 provided a signed statement on 12/08/2010 which contained the following information. "On 11/30/10 the RN caring for him called a code blue to room at 11:22 a.m." "She called for help and Dr. ------- and other staff members responded immediately. Dr. ------ and Dr. ------ both to bedside. CPR continued along with administration of medications. After no return of pulse, code was stopped per Dr. -------. Unable to locate Code Record." "I have talked with (RN#1) who wrote all medications on whiteboard in the patient's room and kept up with sequence of events. She stated she did not write on a paper document after code was over. (RN #3), primary nurse, does not recall if code record was completed or not. Pharmacy has provided a copy of the medication list they used to charge by at the end of code."

The discharge summary contained the following information. "Admitting Diagnosis: Acute chronic obstructive pulmonary disease exacerbation. Brief History: This is an 80-year-old male, who had known history of COPD (Chronic Obstructive Pulmonary Disease) and presented with increasing shortness of breath. Hospital Course: He was initially admitted to the progressive care unit where he underwent treatments with broad-spectrum antibiotics and IV (intravenous) steroids. His condition, however, declined and he ceased speaking. He never really was talking completely on admission, but this worsened and he began to drool. For this, CT of the head was done that revealed a left MCA ischemic stroke. He also had an MRI that confirmed that. He was found to have a mass and what looked like an endobronchial lesion on CT of the chest. He was seen in consultation by pulmonology. He underwent bronchoscopy with fine needle aspiration of the mass of which the results were pending. Nonetheless, on 11/29, he suffered acute respiratory failure with a hypercapnic respiratory failure. He was subsequently moved to the intensive care unit and intubated. He continued to decline. His blood pressure became labile, and on the morning of 11/30/10, he went into pulse-less electrical activity. ACLS protocol was initiated. However, it was unsuccessful in resuscitation. Patient expired. Dr. ------ was the pronouncing physician. The family was notified. Discharge Diagnoses: 1. Acute chronic obstructive pulmonary disease exacerbation. 2. Acute Cerebrovascular accident. 3. Acute respiratory failure. 4. Encephalopathy." The death certificate listed Acute Myocardial Infarction as the immediate cause of death.

The facility's In-House Resuscitation Policy, Reference #: S-RES/178.1, last revision review on 4/09, pages two (2) and three (3) contained the following requirements: Responsibilities of personnel: (4. b. 4.) revealed that the Primary Nurse was responsible for recording/documenting the events of the resuscitation. Responsibilities of personnel #6 "Review of CPR" contained the following requirement: "Each Record of CPR is initially reviewed at the time the event occurred. The Shift Coordinator collects the PI (performance improvement) tool 'In-house Resuscitation Performance Improvement Spread Sheet.' The information is then forwarded to the manager of Critical Care."