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Based on interview and record review, the facility failed to check placement of airway emergently placed in an infant to ensure its efficacy and safety. This failed practice exposed the infant to potentially lethal harm and unnecessary discomfort. The findings are:

A. On 05/05/15 at 9:15 am during interview, the complainant reported the following:
1. The family arrived at the facility Emergency Department (ED) at 5:00 pm on 03/16/15 with a traumatized 4-month-old infant with a possible bleed in the head from a fall caused by a cow on the family farm.
2. A flight crew prepared to transport the infant by air at 8:30 pm to a hospital in Albququerque that could provide a higher level of care, and the flight crew requested placement of a breathing tube in the infant.
3. The ED physician failed to insert a breathing tube (intubate) on his first attempt and asked the Respiratory Therapist (RT) to insert it.


B. Record review of documents from the hospital in Albuquerque (the receiving hospital) indicated the following:
1. Chest x-rays and a Magnetic Resonance Imaging (MRI) (a more detailed scan) confirmed the child upon arrival had a bleed in her head, a pneumothorax (a collapsed lung) and air in the abdomen created by a misplaced airway (the tube was in the esophagus, which sent the air into the stomach, not the lungs). The most common cause of a collapsed lung from barotrauma is from mechanical ventilation; the lung collapses due to excessive force in bagging (mechanically breathing) the infant (Critical Care Nursing, Mosby).
2. The receiving facility RT correctly placed it and confirmed placement by first listening to lung sounds on both sides of the chest and then taking a chest x-ray. The x-ray confirmed the placement of the tube in the airway.
3. Clinical documentation provides no explanation for the the collapsed lung in view of the prior erroneous placement of the breathing tube in the stomach; no reference is made to the actions of the receiving hospital staff or to posssible actions by other personnel prior to the arrival of the infant that would account for the collapsed lung.

C. Record review of documentation of the sending facility (the facility that is the subject of this investigation) indicated no use of a carbon monoxide detector or chest x-ray to confirm both the placement of the breathing tube in the airway and the depth of the tube.

D. On 06/05/15 at 12:15 pm, during interview, the Director of Operations and the Director of Quality of the sending facility confirmed that a chest x-ray was neither ordered nor done. The Director of Operations also agreed that a chest x-ray could have confirmed the presence or absence of the collapsed lung reported later by the receiving facility.