HospitalInspections.org

Based on policy review, record review, and interview the Critical Access Hospital (CAH) failed to ensure health care services were provided in accordance with updated written policy for 3 (Patient ' s 1, 2, and 7) of 7 sampled patients. Failure to update or follow appropriate written policy places patient at risk for negative outcomes and unmet care needs.

Findings Include:

Review of the CAH policy titled, "CODE BLUE MANAGEMENT" last reviewed 02/03/25, showed "Code blue team roles are assigned by the House Supervisor at the beginning of the shift. This is subject to change as other staff arrives. ... The Team Leader of the code will be the most experienced Registered Nurse available. ... The electronic code blue record will be completed by the patient ' s nurse. The House Supervisor can assist if needed. ... Code blue critiques will be distributed to all staff involved in the code blue and returned to the ER supervisor."

Patient 1

Review of Patient 1 ' s medical record showed a 55-year-old admitted to the emergency room (ER) on 06/11/25 at 4:23 AM with a primary diagnosis of a code blue (no breathing or pulse). The record showed the code blue was ended by physician bedside order on 06/11/25 at 4:39 AM with no return of spontaneous circulation (ROSC) achieved. Patient 1 ' s body was released to the mortuary on 06/11/25 at 5:20 AM. Patient 1 ' s record failed to show evidence of a designated code blue team or team leader during the code blue per hospital policy.

Patient 2

Review of Patient 2 ' s medical record showed a 61-year-old admitted to the ER on 06/11/25 at 9:49 AM with a primary diagnosis of code blue. The record showed the code blue was ended with no ROSC achieved on 06/11/25 at 10:28 AM. Patient 2 ' s body was released to the mortuary on 06/11/25 at 1:32 PM. Patient 2 ' s medical record failed to show evidence of a designated code blue team or team leader during the code blue per hospital policy.

Patient 7

Patient 7 ' s medical record showed an 18-year-old admitted to the ER on 08/30/25 at 10:06 AM with a primary diagnosis of code blue. The record showed the code blue was ended with no ROSC achieved on 08/30/25 at 10:32 AM. Patient 7 ' s body was released to the mortuary on 08/30/25 at 11:26 AM. Patient 7 ' s medical record failed to show evidence of a designated code blue team or team leader during the code blue per hospital policy.

During an interview on 10/08/25 at 11:45 AM, Staff H, RN, Paramedic, Director of Emergency Medical Services (EMS), stated that any code blue situations in the hospital the team leader is not always designated and could be one of the paramedics from EMS, the ER RN, or the ER physician depending on the situation.

During an interview on 10/08/25 at 12:00 PM, Staff C, registered nurse (RN) House Supervisor, stated that during any code blue situation the team leader for the code blue would be the primary ER nurse that is working that day. Staff C, stated that on 06/11/25 the team leader for the 2 code blue patients that occurred would have been the primary ER nurse present at the time who would be the most experienced RN. Staff C, stated that a specific code blue team or team leader is not designated at the beginning of each shift by the house supervisor.

'During an interview on 10/08/25 at 12:26 PM, Staff B, RN, Chief Nursing Officer (CNO), stated that in any code blue situation, any available clinical staff are to report to the code for assistance including EMS staff, ER staff, and house supervisors. Staff B, stated that the leader of the code blue should fall to the ER staff, EMS staff, or the physician. Staff B, stated that the house supervisor no longer makes a code blue team assignment and the procedure has changed since the beginning of the year but is not reflected on the current policy.

During an interview on 10/08/25 at 1:20 PM, Staff D, RN, ER Director, stated that in the past the house supervisor would often act as the lead in code blue situations, but the process has changed in the last year to have an ER RN as the lead in code blue situations. Staff D, stated that the ER staff have more experience with code blue scenarios and would be expected to lead a code blue if one should occur.

The CAH failed to update the code blue policy to reflect current practice of the hospital staff.