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Based on record review and interview the facility staff failed to have an effective system in place in which medical staff respond to medical emergencies in a timely manner and ensure patient safety in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed.

Findings Include:

The facility staff failed to have an effective system in place in which medical staff respond to medical emergencies in a timely manner and ensure patient safety . See tag A-0145

Based on record review and interview the facility staff failed to have an effective system in place in which medical staff respond to medical emergencies in a timely manner and ensure patient safety in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed.

Finding Include:

Review of policy and procedure #71507 titled, "Medical Emergencies Policy" last revised 04/15/2024 revealed:
1. "The Rapid Response Team (RRT) is available 24 hours daily to support the healthcare provider in the care of an inpatient...who is experiencing a change in condition."
2. "Reasons for mobilization of the RRT includes, but are not limited to: 1. Staff member is concerned or worried about a patient...3. Acute or significant changes in vital signs such as respiratory rate, heart rate, hypotension or hypertension, and acute oxygen desaturation. 4. Acute Respiratory distress, change in breathing pattern, difficulty speaking or threatened airway..."

Review of Attachment A of the "Medical Emergencies Policy" revealed that the Rapid Response Team includes the following: the Hospitalist, Intensive Care Unit (ICU) Registered Nurse (RN), Emergency Department (ED) RN, Patient's Primary RN, Public Safety, Respiratory Therapist, Nurse Supervisor, Lab Personnel. The ED physician is not included in this list.

Review of Attachment F of the "Medical Emergencies Policy" titled, "Who Do You Call for Help?" revised 08/15/2024, revealed that the Code Team is called when a patient is pulseless, not breathing, unresponsive, and lethal rhythm change. Per Attachment F, the Responders include the following: ED Physician, Hospitalist, ED RN, ICU RN, Respiratory Therapist, House Supervisor, Public Safety, and Chaplain.

Review of the Medical Staff Bylaws approved 11/05/2024 revealed, "Upon the granting of Staff Membership and Clinical Privileges, the applicant agrees to: (a) provide or arrange for continuous care to his/her patients at the professional level of quality and efficiency... (b) delegate in his/her absence the responsibility for diagnosis and care of his/her patient to a qualified Practitioner who possesses the Clinical Privileges necessary to assume care of such patients.

Review of Pt #1's medical record revealed Pt #1 was admitted to the Medical Surgical unit on 10/18/2024 at 6:19 PM and transferred to ICU on 10/18/2024 at 7:54 PM.

Review of Family Medicine History and Physical Examination progress note dated 10/20/2025 at 10:13 AM revealed, Pt #1 was a "64 year old...with PMH (past medical history) of throat cancer, DM (Diabetes Mellitus), anemia, HTN (hypertension) presents for altered mental status, fever, throat/neck pain...shortly after admission to the floor his tachycardia (fast heart rate) was noted to be worsening, he was noted to have increased work of breathing. RN called with concern of worsening clinical status. He was subsequently transferred to the ICU...shortly after being transferred to the ICU he had a rapid response and then a medical emergency (Code) called due to respiratory distress...Code efforts were reported to last approximately 20 minutes. He did achieve ROSC (return of spontaneous circulation)."

Review of Pt #1's Safety Event incident #SE-24-0292000, Event date 10/18/2024 at 8:25 PM revealed, "The patient was transferred to the ICU and shortly began experiencing a decline in respiratory status...Charge RN (K) called ED to notify them that the patient was likely going to require intubation (insertion of breathing tube) so that ED would be aware of the situation and could respond accordingly...No Intensivist (ICU Physician) was on site at the time and this information was relayed to (ED RN M)...At 8:25 PM an RRT was called for the patient's increasing respiratory distress...(Physician L) (Hospitalist) at bedside. (ED RN M) called the ICU on behalf of the ED providers to question why they had to come down to intubate the patient when an Intensivist is supposed to be here. (ED RN) was informed a second time that no Intensivist was on site and the patient was requiring emergent intubation...(Physician L)...requested to talk to the (ED) provider(s) himself...where he then explained the situation and requested that an ED physician come down to perform the intubation. The RRT escalated into a Code at 8:32 PM...ED team (ED Provider J, ED Provider B...) arrived at 8:33 PM (8 minutes after RRT was called)...The patient went into asystole (no heart rhythm) at 8:38 PM, compressions started..." Per Safety Event documentation after the Code was completed, ED Provider J informed Charge RN K that the "Intensivist is to be on call until 11:00 PM and any issues arising prior to that time should be directed to the Intensivist."

Per Safety Event incident #SE-24-0292000, "Suggestions for Error Prevention" revealed "We need a better plan in place for what to do when no Intensivist is on site. ED was pre-notified that they were going to be needed for an intubation d/t no Intensivist present, and there was still pushback and a delay in care despite that notification."

Per interview with Charge RN K on 12/13/2024 beginning at 11:54 AM, Charge RN K stated that she was the Charge RN on duty during Pt #1's RRT and Code. RN K stated that Pt #1 was in respiratory distress and needed to be intubated and the Intensivist was not on site and was not answering calls. Charge RN K stated that she reached out to the ED Provider to request intubation of Pt #1 and then called a RRT. RN K stated that the ED providers do not typically respond to RRT calls unless requested. Charge RN K stated that the ED providers did not come to assist until a Code was called despite notifying the ED providers a head of time. Charge RN K stated the Physician L was present, however he was not trained to intubate. Charge RN K stated that it is common for Intensivist to not always be on site and immediately available, so Charge RN K tends to page ED providers first when there are emergent concerns with patients. Charge RN K stated that to her knowledge, the Intensivist should be on site until 7:00 PM and on call until 10:00 PM. Charge RN K stated that the ED Providers are responsible for on site emergencies after that time. Charge RN K stated that there was a delay in care due to the ED Providers not immediately responding to the request for help when the RRT was called.

Per interview with ICU Medical Director I on 12/12/2024 at 10:09 AM, ICU I stated that an Intensivist is typically not immediately available on site from 7 PM to 7 AM but an Intensivist is on call 24 hours a day, and should be called in to assist in emergencies. ICU I stated that the ICU Provider rounds on patients and if work is done "they are not tied to the place" and can leave the building and come back if an emergency arises. ICU I stated that an ED provider is responsible for emergencies on site until the Intensivist arrives to the hospital. ICU I stated that it could take the ICU Provider 30 to 45 minutes to get to the hospital depending on where they live. ICU I stated that ICU N was the Intensivist on call during Pt #1's RRT and Code and was called to come in, but never showed up to the hospital. ICU I stated that this process pulls the ED Provider from providing care to the patients in the ED, so Intensivist should be "on route" to relieve the ED Providers in these emergency situations. ICU I stated he recognizes an area of "weakness" and stated there is currently no action plan in place yet to address these concerns.

Per interview with ED Medical Director J on 12/12/2024 at 10:55 AM, ED J stated that he and ED B were the 2 ED physicians that responded to Pt #1's Code on 10/18/2024. ED J stated that he was made aware that Pt #1 was on the medical floor and being transferred to the ICU potentially needing emergency interventions. ED J stated that there should be an Intensivist on at all times to manage ICU patients, however this was not the case. ED J stated that a RRT was called but the ED Providers do not typically respond to RRT unless specifically requested (staff did request). ED J stated that the ED is available to assist with patients needing emergent airway response if the Intensivist is not available. ED J stated that he is not aware when the Intensivist is on or off site so that ED Provider knows when he/she is responsible for covering ICU emergencies. ED J stated that typically after 1:00 AM there is only 1 ED Physician staffing a busy 21 bed ED and the ED Physician is required to respond to RRT requests and Codes in the ICU because there is no ICU physician immediately available on site, potentially causing concerns with safe care in the ED and ICU. ED J stated that no new changes to this process have been implemented in response to Pt #1's Safety Event on 10/18/2024.