HospitalInspections.org

Based on a review of Hospital policy, record review and staff interview it was determined in 1 of 1 (Pt. #1) medical records reviewed, the Hospital failed to ensure resuscitative management policies were followed to provide prompt response and actions to changes noted in patient's physical condition.
Findings include:

1. The Hospital policy revision date of 8/12 titled, "Resuscitative Management (formerly Code Blue and Express Team) was reviewed on 7/1/13. The policy indicated under "Resuscitative Management: Express Team Procedure: The Express Team's purpose is to enhance patient outcomes by providing early and rapid interventions...to the deteriorating patient...without cardio pulmonary arrest."

2. The medical record of Pt. #1 was reviewed on 7/1/13. Documentation indicated Pt. #1 was admitted on 5/22/13 through the ED with diagnoses of Psychosis NOS and Right Foot Pain. Documentation indicated on 5/27/13 Pt. #1 was in the dining room in a w/c. Pt. #1 stated he was not feeling well and slid out of w/c onto the floor. Pt. #1 was asked to get back into w/c, but was unable to without assistance of 2 staff members. Documentation indicated Pt #1 was perspiring and a nurse attempted to take blood pressure but was unable to hear. Documentation indicated the nurse called for the Charge Nurse and the ED was called to transport Pt. #1. ED physician stated he would come to the unit. Documentation indicated the ED physician called a "Code Blue" after arriving to the unit. There was no documentation in the medical record to indicate an "Express Team" was called to the unit to assess Pt. #1.

3. During an interview with the ED physician on 7/1/13 at 1:55 PM, the ED physician confirmed a Code was called after arrival on the Psychiatric unit. During an interview with the VP on 7/1/13 at 2:15 PM, the VP indicated the Express Team was not called by the staff but a Code Blue was called by the ED physician after arrival to the Psychiatric Unit.