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Based on review of medical records, staff interviews, and review of policies and procedures it was determined that the Governing Body failed to ensure that hospital policies and procedures related to the initiation of life-saving measures, and the effective communication of DNR statuses of patients were followed by Nursing Services for Patient #1 who expired on 8/21/2020.

Findings:

Cross refer-A-385 Nursing Services: The facility failed to promptly initiate life-saving interventions to Patient #1 on 8/21/20. Patient #1 was found by nursing services unresponsive. There was a delay in the initiation of cardiopulmonary resuscitation (CPR) between the time Patient #1 was found unresponsive and when a Code Blue was called and CPR initiated, due to nursing staff's failure to follow the facility's policy and procedure for initiating lifesaving measures. Patient #1 was pronounced deceased on 8/21/2020 at 4:21 am.

Medical Record Review:

A review of Patient #1's medical record revealed that she had been admitted into the facility on 7/12/20.

A review of the medical record for Patient #1 revealed that a physician's progress note that a Code Blue had been called after Patient #1 was found unresponsive.

A review of the medical record for Patient #1 failed to reveal documentation of the exact time Nurse AA found Patient #1 unresponsive, the time Charge Nurse II came in to the room to assess Patient #1 after Charge Nurse II was informed by RN AA that Patient #1 was unresponsive, and the time the on-call provider was called, prior to initiating CPR on Patient #1.

Despite cardiopulmonary resuscitation (performed when someone is not breathing or their heart is not beating) including emergency medications, Patient #1 did not have a return of spontaneous circulation. After approximately 20 minutes of resuscitation efforts, Patient #1 was pronounced deceased at 4:21 a.m. on 8/21/2020.

A review of the 'Code Blue Record' revealed that a Code Blue was paged at 4:01 a.m. CPR was in progress when the first Code Blue team member arrived at Patient #1's room at 4:02 a.m. and continued throughout the entire code. The Code Blue respiratory therapist and physician arrived at 4:04 a.m. Patient #1 did not have a pulse when the first team member arrived. Patient #1 was intubated (time illegible) and CPR continued. There was no change in Patient #1's assessment during the Code Blue. Resuscitation efforts were stopped at 4:21 a.m. and Patient #1 was pronounced dead.

Interviews:

An interview with Patient Safety Coordinator (Safety) HH took place via telephone on 8/27/20 at 2:00 p.m.
Safety HH stated that Nurse AA explained to Safety HH that when Nurse AA found Patient #1 unresponsive, Nurse AA was unsure of the patient's resuscitation status or the facility's protocol.
Safety HH explained that when a patient is a 'Do Not Resuscitate' (DNR- an order written to direct staff not to perform CPR if the patient is not breathing or has no pulse), this information is in the patient's medical record.
Safety HH explained that a staff debriefing took place with all of those on the unit after Patient #1 expired.
An interview with Nurse Practitioner (NP) JJ took place on 8/28/20 at 4:30 p.m. NP JJ recalled that on 8/21/20 she received a page from the Charge Nurse (CN) CC concerning Patient #1. NP JJ stated that she responded via phone call immediately. NP JJ recalled that CN CC told her regarding Patient #1, 'I think she has passed'. CN CC explained to NP JJ that Patient #1 had been found not breathing. NP JJ explained that she inquired about Patient #1's DNR status and CN CC responded that Patient #1 was not a DNR.
Simultaneously, NP JJ was reviewing Patient #1's electronic medical record. NP JJ asked CN CC if a Code Blue had been called, and CN CC responded 'no'.
NP JJ instructed CN CC, 'you need to call a code'. A Code Blue announcement was heard over the hospital intercom. NP JJ recalled that she was making her way to Unit 51 at that time.
When Patient #1 did not respond, the physician at the bedside pronounced her deceased.
After the Code Blue was over, NP JJ and the responding physician spoke with RN AA and CN CC. NP JJ recalled that she explained to both CN CC and RN AA that the protocol for responding to the patient being found unresponsive was not followed, and an incident report would be filed.
NP JJ explained that when patients have a DNR order, that information is found in the patient's electronic medical record, in the patient's paper record, and a specific colored dot is placed on the patient's identification band. NP JJ was not close enough to visualize Patient #1's armband after she arrived at the bedside. NP JJ explained that a 'dot' would not have been found on Patient #1's identification band as she was not a DNR.

An interview with Nurse Manager (Manager) II took place on 8/27/20 at 3:00 p.m.

Manager II learned that RN AA went in Patient #1's room and found her unresponsive. RN AA immediately left the room to get the charge nurse because she (RN AA) thought that Patient #1 was a DNR. Manager II explained that a patient's DNR status was on the 'status bar' of the patient's medical record and posted in the patient's room next to the whiteboard. Manager II explained that RN AA was an agency nurse, and this was her first shift on this unit. Manager II explained that staffing was supplemented with agency nurses from time to time. She explained that agency nurses were either assigned to the system-wide float pool or to a specific unit. System-wide float pool nurses were deployed to different hospitals throughout the healthcare system. RN AA was assigned to the system-wide float pool. Manager II explained that nurses on the medical/surgical unit are required to have Basic Life Support (BLS - training in CPR) certification.

A telephone interview with RN AA took place on 8/27/20 at 3:30 p.m. RN AA explained that she was employed by a staffing agency and had been assigned to the healthcare system for three weeks.
RN AA explained that she had system orientation and shadowed a nurse for one shift. RN AA did not recall receiving training on responding to patient emergencies or Code Blue. RN AA recalled that Patient #1 had been alert and answered questions earlier in the shift.
RN AA recalled that she went in Patient #1's room to check on her feeding and found her with her eyes open. RN AA checked for a pulse and respirations and found that Patient #1 did not have a pulse and was not breathing.
RN AA stated that she called for CN CC, who responded immediately.
RN AA explained that she did not immediately call a Code Blue or begin resuscitative efforts because she thought the patient was 'already dead'. RN AA explained that she is still assigned to the healthcare system and has a current BLS.

A telephone interview with Charge Nurse (CN) CC took place on 8/27/20 at 4:45 p.m. CN CC recalled that RN AA came to her at approximately 3:45 a.m. to 3:50 a.m. on 8/21/20 and reported that Patient #1 didn't look well. CN CC and RN AA immediately proceeded to Patient #1's room and observed Patient #1 to be pale with no visible movement. CN CC checked Patient #1 for a pulse and found that she did not have a pulse and was 'lifeless'. CN CC explained that she 'was thinking' that the patient was a DNR and called the provider on call. RN AA told CN CC that she was unsure of Patient #1's code status. NP JJ responded via telephone at 3:51 a.m. and after hearing of Patient #1's assessment, instructed CN CC to call a code and start CPR. CN CC recalled that she immediately began CPR and RN AA called for a Code Blue after receiving instructions from the on-call provider. The Code Blue record revealed that CPR was initiated at #:55 a.m. and Code Blue was called at 4:01 a.m. CN CC stated that during shift report, the code status of each patient was discussed but sometimes was sometimes overlooked.
If a patient is a DNR, that information would be in the medical record.



Policies:

A review of the facility's policy titled 'Code Status (DNR/Limited DNI), effective 11/28/18 revealed that resuscitative measures were initiated for any patient who experienced cardiac and/or respiratory arrest, unless a code status of DNR (Do Not Resuscitate, a physician's order that specified withholding of all basic life support and advanced life support treatments), Limited DNR (a code status that was less than a full code but not a DNR), Limited DNI, or Limited. If unable to immediately determine the patient's code status, hospital staff initiated full resuscitative efforts while team members accessed the medical record. Code status had no impact on medical decisions prior to the absence of respirations and/or loss of a pulse. Any code status other than Full Code was designated by the placement of a purple armband on the same arm as the identification band.

A review of the facility's policy titled 'Code Blue-Resuscitation', effective date: 3/22/19 revealed that a 'Code Blue' could be called when there was a need for additional personnel or equipment to respond to an immediate life-threatening condition in adult and pediatric patients, visitors, or staff.
Resuscitative measures were initiated per current American Heart Association guidelines for any person experiencing cardiac and/or respiratory arrest, unless a do-not-resuscitate (DNR) order was written in accordance with the hospital Code Status policy and found in the patient's record. Full resuscitative measures were attempted when the status was not immediately known.

Continued review of the policy revealed that when a staff member felt, in his/her best judgment, an immediate life-threatening condition may exist, that person activated the Emergency Response System by calling the appropriate emergency number for the facility and giving the building, floor, location, and room number. If it was decided that the Emergency Response System would not be activated, identified resources not present were notified immediately. It was the responsibility of the unit/department directors to ensure appropriate training to staff to function in appropriate roles in a Code Blue response.

A review of the facility policy titled 'Agency and Traveler Usage', effective 1/23/18 revealed that the purpose was to identify when and how agency health care providers and travelers are temporarily used to assist staffing when needs cannot be met through employed healthcare staff. Department directors were responsible for the oversight of services provided by any agency employee or traveler. Only system approved agencies were utilized. Prior to the designated start date, agencies, or agency and travelers must present the following:
current license and/or certification, skills checklist outlining competency in applicable area and recent performance evaluation, current BLS/ACLS were appropriate, current health screen and evidence of PPD, and vaccines, evidence of N-95 fit testing where appropriate, dates of successful drug screen and criminal background check, dates that the competency guidelines of The Joint Commission or other accreditation agency have been met.

A review of the temporary staffing agreement between RN AA's employer agency and the Healthcare system revealed that the agreement was signed on 9/12/19 and was in effect for five years thereafter. The scope of services included temporary, short-term clinical staff including nursing and allied health professionals. Continued review of the agreement revealed that the staffing agency provided the healthcare system with qualified individuals in their employment upon request. The staffing agency warrants that staff are fully authorized and licensed in the State of Georgia to perform the services, have not been convicted of a felony in the past seven years, will comply will applicable federal and state regulations governing licensing, conduct with applicable standards of practice and with policies and procedures of the client (facility or healthcare system). A quality assurance program will be maintained to monitor services. The staffing agency agrees to ensure the following credential requirements are met prior to confirming a staff assignment: current license, background check, education verification, references, job description, drug screening, regulatory education, basic cardiac life support from AHA, Advanced Cardiac Life Support as applicable, basic medication administration test, specialty area testing.

Review of regular facility staff new employee orientation revealed that the clinical topics presented included but were not limited to: an overview of National Patient Safety Goals, how to call an emergency code including Code Blue, intentional rounding, restraints, DNR, Do Not Intubate (DNI), and consents. A presentation on Code MET and Code Blue included the objectives of understanding the process of caring for patients with medical emergencies, difference between Code MET and Code Blue, documentation on Code MET form. A presentation on clinical emergencies included steps involved in Code MET and Code Blue.

A review of the meeting minutes from the Clinical Effectiveness Executive Oversight Committee (CEEOC) revealed that meetings were held on: 1/21/20, 2/11/20, 2/18/20, 3/17/20, 4/21/20, and 5/19/20. Data reported included but was not limited to: catheter associated urinary tract infections, incidence of clostridium difficile, central line associated infections and other required regulatory measures.
A review of the Process Improvement Projects grid revealed multiple projects in progress spanning all hospital departments. Projects included but were not limited to patient satisfaction, daily readiness huddles, supply management, and perioperative scheduling.

Based on a review of medical records, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to provide nursing care in a safe, and efficient manner according to acceptable standards for 1 (Patient #1) of 5 sampled patients' medical records reviewed. This failure resulted in the failure of staff to identify Patient #1's code status and initiate life-saving measures for Patient #1, who was found unresponsive and without a pulse or respirations on 8/21/2020.

Findings:

Medical Record Review:

A review of Patient #1's medical record revealed that she had been admitted into the facility's Intensive Care Unit (ICU) after being seen in the emergency department on 7/12/20. Patient #1's admitting diagnoses were hemorrhagic shock (shock caused from loss of blood), gastrointestinal bleeding (bleeding in the gut), symptomatic anemia (a condition where blood doesn't have enough red blood cells), diarrhea, and Crohn's Disease (a disease that causes inflammation of the intestines).

A review of Patient #1's vital signs for twelve (12) hours preceding the Code Blue revealed:
On 8/20/20 at 4:02 p.m.: Temperature (T) - 36.7 degrees Celsius (normal was 37.0 degrees); heart rate (HR) - 43 beats per minute (bpm) (normal was 60-100 bpm); respiratory rate (RR) - 18 breaths per minute (normal was 12 to 20 breaths per minute); blood pressure (B/P)-155/81 (normal was 120/80); oxygen saturation (O2) - 100%.
A review of laboratory results of blood glucose levels for eight (8) hours preceding the Code Blue revealed the following:

8/20/20 at 8:31 p.m.
181 mg/dl (normal was 65-100 mg/dl)
8/20/20 at 11:55 p.m. 338 mg/dl

A review of the medical record for Patient #1 revealed that the last documented nursing assessment before a code blue was called on Patient #1 was performed on 8/20/20 at 8:00 p.m. and included the following findings: Patient #1 had a normal pulse in both wrists and both feet, regular respirations, did not complain of respiratory symptoms, the abdomen was soft, not swollen, and not painful, skin was warm and dry, mucous membranes (areas lining body cavities and tunnels that are connected to the outside of the body) were moist and pink.
Review of 'Interventions' for the eight (8) hours preceding the Code Blue revealed that Patient #1 repositioned herself to her back when reminded to do so.

On 8/21/20 at 12:02 a.m. vital signs were:
HR-46 bpm,
RR-18
BP-94/64
O2-91%
On 8/21/20 at 1:07 a.m. vital signs were:
HR-45 bpm
BP-91/65

A review of the medication administration record for the eight (8) hours preceding the Code Blue included:
8/20/20 at 9:19 p.m. - Protonix by mouth (medicine given for gastrointestinal problems)
8/20/20 at 9:19 p.m. - Mesalamine suppository (used to treat Crohn's Disease)
8/20/20 at 9:32 p.m. - Latanoprost eye drops to both eyes (medicine for glaucoma)
8/20/20 at 9:38 p.m. - insulin Lispro 2 units injection
8/21/20 at 1:00 a.m. - insulin Lispro 7 units injection (helps reduce high blood glucose)
Review of the 'Progress Notes' on 8/21/20 at 6:26 a.m. revealed a note by a physician that a Code Blue had been called after Patient #1 was found unresponsive.
A review of the 'Code Blue Record' revealed that a Code Blue was paged at 4:01 a.m. CPR was in progress when the first Code Blue team member arrived at Patient #1's room at 4:02 a.m. and continued throughout the entire code. The Code Blue respiratory therapist and physician arrived at 4:04 a.m. Patient #1 did not have a pulse when the first team member arrived. Patient #1 was intubated (time illegible) and CPR continued. There was no change in Patient #1's assessment during the Code Blue. Resuscitation efforts were stopped at 4:21 a.m. and Patient #1 was pronounced dead.

Interviews:
An interview with Patient Safety Coordinator (Safety) HH took place via telephone on 8/27/20 at 2:00 p.m. Safety HH explained that she had been in her current role since 11/18. Safety HH explained that her duties included monitoring the safety events entered via the online system. Safety HH recalled that a safety event had been entered after Patient #1 expired in the early morning hours of 8/21/20. The safety report was entered as a delay in code blue. Safety HH received the initial safety report after she reported for work on 8/21/20. She recalled that she immediately reviewed Patient #1's medical record and began building a timeline of events. Safety HH facilitated a meeting of the executive team to discuss the event at which time it was decided that a report be filed with the State agency.
Safety HH explained that she initiated an investigation into the incident and is currently in the interview phase. She will interview all staff members who had contact with Patient #1 on the night that Patient #1 expired. Safety HH stated that she had interviewed Nurse AA who was caring for Patient #1 and the Charge Nurse (CN) CC that was working that shift.
Safety HH stated that Nurse AA explained to Safety HH that when Nurse AA found Patient #1 unresponsive, Nurse AA was unsure of the patient's resuscitation status or the facility's protocol.
Safety HH explained that when a patient is a 'Do Not Resuscitate' (DNR- an order written to direct staff not to perform CPR if the patient is not breathing or has no pulse), this information is in the patient's medical record.
Safety HH explained that a staff debriefing took place with all of those on the unit after Patient #1 expired. Since the incident took place, unit staff are presented with 'just in time' education at shift huddles consisting of a refresher on the facility's Code Blue policy.
An interview with Nurse Practitioner (NP) JJ took place on 8/28/20 at 4:30 p.m. NP JJ explained that she usually works at night and part of her responsibilities was to assess patients as needed and field calls from nurses with questions and concerns for patients admitted to the hospital under the hospital service (general medicine). NP JJ explained that she had been familiar with Patient #1 because she was briefed on all assigned patients when she reported to work each evening. NP JJ recalled that Patient #1 had been in the hospital for a long time and had many comorbidities. NP JJ recalled that on 8/21/20 she received a page from the Charge Nurse (CN) CC concerning Patient #1. NP JJ stated that she responded via phone call immediately. NP JJ recalled that CN CC told her regarding Patient #1, 'I think she has passed'. CN CC explained to NP JJ that Patient #1 had been found not breathing. NP JJ explained that she inquired about Patient #1's DNR status and CN CC responded that Patient #1 was not a DNR.
Simultaneously, NP JJ was reviewing Patient #1's electronic medical record. NP JJ asked CN CC if a Code Blue had been called, which CN CC responded 'no'.
NP JJ instructed CN CC, 'you need to call a code'. A Code Blue announcement was heard over the hospital intercom. NP JJ recalled that she was making her way to Unit 51 at that time.
NP JJ recalled that when she arrived at Patient #1's bedside, several members of the hospital code team were at the bedside starting resuscitation procedures. When Patient #1 did not respond, the physician at the bedside pronounced her deceased.
NP JJ was not sure how long Patient #1 had been 'down' before resuscitation efforts were started. NP JJ explained that she was not sure if the outcome would have been different if resuscitation efforts had been started as soon as Patient #1 was found unresponsive.
After the Code Blue was over, NP JJ and the responding physician spoke with RN AA and CN CC. NP JJ recalled that she explained to both CN CC and RN AA that the protocol for responding to the patient being found unresponsive was not followed, and an incident report would be filed.
NP JJ explained that when patients have a DNR order, that information is found in the patient's electronic medical record, in the patient's paper record, and a specific colored dot is placed on the patient's identification band. NP JJ was not close enough to visualize Patient #1's armband after she arrived at the bedside. NP JJ explained that a 'dot' would not have been found on Patient #1's identification band as she was not a DNR.

NP JJ explained that all emergency codes were called by informing the hospital operator to call a Code Blue. The operator makes an overhead announcement that a Code Blue was being called along with the specific unit and room number. The operator repeats the overhead announcement several times. NP JJ explained that a Code Blue was called by calling the operator on a specified phone number. She explained that Code Blue buttons were generally no longer found in patients' rooms because they were often accidentally pushed.

An interview with Nurse Manager (Manager) II took place on 8/27/20 at 3:00 p.m.

Manager II was the manager of the medical/surgical unit (Unit 51) that Patient #1 was on when she expired.
Manager II explained that Unit 51 had a maximum of 50 patients. Manager II recalled that she was informed of Patient #1's death on 8/21/20 at 7:30 a.m.
She explained that she immediately began the investigative process and the goal was to learn what opportunities for improvement existed and how to prevent this type of event from happening again. Manager II explained that she had the opportunity to speak with RN AA on the morning of the incident. RN AA told Manager II that Patient #1 had been alert and oriented approximately one hour prior to finding her unresponsive. Manager II learned that RN AA went in Patient #1's room and found her unresponsive. RN AA immediately left the room to get the charge nurse because she (RN AA) thought that Patient #1 was a DNR. Manager II explained that a patient's DNR status was on the 'status bar' of the patient's medical record and posted in the patient's room next to the whiteboard. Following the incident, Manager II explained that all staff received education at shift huddles consisting of a refresher of the Code Blue policy, a reminder to call a Code Blue when unsure of DNR status, and a reminder that the emergency number is located in all patient rooms and should be called from the patient's room. Manager II explained that RN AA was an agency nurse, and this was her first shift on this unit. Manager II explained that staffing was supplemented with agency nurses from time to time. She explained that agency nurses were either assigned to the system-wide float pool or to a specific unit. System-wide float pool nurses were deployed to different hospitals throughout the healthcare system. RN AA was assigned to the system-wide float pool. Manager II explained that nurses on the medical/surgical unit are required to have Basic Life Support (BLS - training in CPR) certification.

A telephone interview with RN AA took place on 8/27/20 at 3:30 p.m. RN AA explained that she was employed by a staffing agency and had been assigned to the healthcare system for three weeks.
RN AA explained that she had system orientation and shadowed a nurse for one shift. RN AA did not recall receiving training on responding to patient emergencies or Code Blue. RN AA recalled that Patient #1 had been alert and answered questions earlier in the shift.
The report had been that Patient #1 had been refusing to eat and take medications. RN AA recalled that Patient #1 took medications during her shift with encouragement and had been receiving tube feedings. RN AA explained that patients were rounded every hour either by an RN or Nurse Tech (nursing assistant). RN AA recalled that she went in Patient #1's room to check on her feeding and found her with her eyes open. RN AA checked for a pulse and respirations and found that Patient #1 did not have a pulse and was not breathing.
RN AA stated that she called for CN CC, who responded immediately. CN CC called the provider on-call (NP) who instructed her to call a Code Blue.
RN AA explained that she did not immediately call a Code Blue or begin resuscitative efforts because she thought the patient was 'already dead'. RN AA explained that she is still assigned to the healthcare system and has a current BLS.

A telephone interview with Charge Nurse (CN) CC took place on 8/27/20 at 4:45 p.m. CN CC had been employed at the facility since February of this year. She explained that her unit orientation consisted of shadowing a staff nurse for two weeks followed by working with a Charge Nurse for four weeks. CN CC recalled that RN AA came to her around 3:45 a.m. to 3:50 a.m. on 8/21/20 and reported that Patient #1 didn't look well. CN CC and RN AA immediately proceeded to Patient #1's room and observed Patient #1 to be pale with no visible movement. CN CC checked Patient #1 for a pulse and found that she did not have a pulse and was 'lifeless'. CN CC explained that she 'was thinking' that the patient was a DNR and called the provider on call. RN AA told CN CC that she was unsure of Patient #1's code status. NP JJ responded via telephone at 3:51 a.m. and after hearing of Patient #1's assessment, instructed CN CC to call a code and start CPR. CN CC recalled that she immediately began CPR and RN AA called for a Code Blue. CN CC stated that during shift report, the code status of each patient was discussed but sometimes was sometimes overlooked.
If a patient is a DNR, that information would be in the medical record.

An interview with the System Business Manager for the float pool (Float Manager) GG took place on 8/28/20 at 10:00 a.m. Float Manager GG explained that her job role included oversight of the on-boarding and orientation process for float pool nurses including contract and agency nurses. She explained that due to COVID-19, completion of modules was done at home.

New staff were provided a list of required modules including: Contractor Orientation and Nursing Practice. Training on documentation took place in person. Unit orientation consisted of a 12-hour shift with another nurse. New staff were required to complete a unit orientation checklist, which may be completed after the 12-hour orientation shift. RN AA's staffing agency was responsible for regulatory compliance modules with topics such as safety, infection prevention, disaster preparedness and EMTALA. Float Manager GG stated that Code Blue and DNR's were not specifically covered in the facility's Contractor Orientation. All new staff were provided an Emergency Code pocket card that had all emergency codes including Code Blue.

Float Manager GG explained that RN AA's agency was contacted 8/21/20 regarding the incident with Patient #1. She stated that she planned to follow up with the agency today. She had not spoken with RN AA and their investigation was ongoing.


Review of regular facility staff new employee orientation revealed that the clinical topics presented included but were not limited to: an overview of National Patient Safety Goals, how to call an emergency code including Code Blue, intentional rounding, restraints, DNR, Do Not Intubate (DNI), and consents. A presentation on Code MET and Code Blue included the objectives of understanding the process of caring for patients with medical emergencies, difference between Code MET and Code Blue, documentation on Code MET form. A presentation on clinical emergencies included steps involved in Code MET and Code Blue.
A review of the Staffing Guide for Unit 51 revealed that a patient census of 48 patients required a Patient to RN ratio of 4:1 for all shifts.
A review of the staff schedule on Unit 51 for 8/20/20 revealed a sufficient staffing roster per facility guidelines.

A review of the patient assignments for Unit 51 on 8/20/20 from 7:00 p.m. to 7:00 a.m. revealed a total of 48 patients. Six RNs, including RN AA were assigned five patients each. Three RNs were assigned six patients each. There were three patient care technicians and a Charge Nurse.

A review of the meeting minutes from the Clinical Effectiveness Executive Oversight Committee (CEEOC) revealed that meetings were held on: 1/21/20, 2/11/20, 2/18/20, 3/17/20, 4/21/20, and 5/19/20. Data reported included but was not limited to: catheter associated urinary tract infections, incidence of clostridium difficile, central line associated infections and other required regulatory measures.
A review of the Process Improvement Projects grid revealed multiple projects in progress spanning all hospital departments. Projects included but were not limited to patient satisfaction, daily readiness huddles, supply management, and perioperative scheduling.
A review of four additional medical records (Patient #2, Patient #3, Patient #4, Patient #3) revealed that all had signed, or a representative signed a consent to treat and acknowledged receipt of Patient Rights. Monitoring and observation were documented in all records per facility protocol. No regulatory concerns were noted.
A review of six personnel files (RN AA, CNA BB, CN CC, RN DD, RN EE, RN FF) revealed that all had current license, if required, had completed an orientation checklist, had current BLS certification, and current mandatory education.