HospitalInspections.org

Based on record review and staff interview, it has been determined that the hospital failed to meet the Condition of Participation of Patient's Rights relative to care in a safe setting for 1 of 1 sample patient, ID #1.

Findings are as follows:

1. The hospital failed to implement the Code Blue Emergency Response and provide procedural sedation in accordance with the approved medical staff policies and procedures.

Refer to A-0144.

Based on record review and staff interview, it has been determined that the hospital failed to implement the Code Blue Emergency Response and provide procedural sedation in accordance with the approved medical staff policies and procedures for 1 of 1 sample patient, Patient ID# 1 who suffered a complication/cardiac arrest during a cardiac catheter procedure.

Findings are as follows:

Review of the hospital's policy titled "Procedural Sedation" last approved in 9/2019, states in part:

"Levels of Sedation/Anesthesia

- Moderate sedation/analgesia ("conscious sedation"): A drug-induced depression of consciousness during which patients respond purposely to verbal commands, either alone or accompanies[sic] by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Sedation /analgesia is generally achieved when there is slurred speech, but the patient is arousable, able to respond, and retain the ability to independently maintain a patent airway ...

2. Nursing competency requirements ...
2.2. Patients requiring procedural or deep sedation will be monitored by an RN who meets the following criteria: ...
-f. Satisfactory completion of the sedation education program annually
-g. Demonstrate competency in the delivery of medications used for sedation including the effects of the medication, potential side effects of the medication, contraindications of the medication and proper doses and routes of administration of the medication.
-h. Recognizes emergency situations and institutes emergency procedures.
-i. Completes the procedural sedation learning module including a test on approved medications with a passing score of 100%...
3. Physicians and Registered Nurses who participate in procedures managed with these sedation medications must pass the competency and be certified in BLS (basic life support) ..."

Review of the Hospital Policy titled "Code Blue: Cardiopulmonary Arrest" last approved in 11/2019, states, in part:

PURPOSE:

1. To provide a standard and consistent method to initiate the process of artificial ventilation and circulation to those patients, visitors and employees with sudden cardiovascular collapse or arrest.
2. To provide a response protocol for the professional staff responding to a code blue.

PROCEDURE:

1. Any hospital staff member may call a "Code Blue" by pressing the Code Blue button when available or dialing 2222 to inform the switchboard of the event of a code and the patient's room number or location...
12. Code Team Members:
- 12.1 Hospitalist, Intensivist, or ED (Emergency Department) Physician (in ED)
- 12.2 Critical Care Registered Nurse (RN) or ED RN (in ED)
- 12.3 Respiratory Therapist
- 12.4 Administrative Nursing Supervisor..."

Record review for Patient ID# 1 revealed the patient was admitted for a voluntary cardiac catheterization (insertion of a narrow tube into the heart through an artery to examine how well the heart is functioning) in January 2020.The patient was transported to the cardiac catheter lab and placed on the exam table. The nurse administered 1 milligram of Versed and 25 micrograms of Fentanyl at 7:22 AM.

The physician arrived at the catheter lab at 7:24 AM and administered the contrast dye at 7:28 AM. At 7:36 AM the patient's heart rate was 58 and his/her blood pressure was 124/100. This began a steady decompensation. At 7:41 AM the patient's oxygen saturation was 46% and the heart rate was 36; the monitor was unable to detect a blood pressure. Respiratory was paged at 7:44 AM and arrived with Bipap (a device to help you breathe) at 7:47 AM; At 7:49 AM CPR was initiated. Anesthesia was called at 7:52 AM and arrived at 7:55 AM. At 7:49 AM the hospital failed to initiate a code blue requiring all code team members including the Hospitalist or Intensivist, Critical Care Registered Nurse and Administrative Nursing Supervisor to immediately respond.

Review of the nurses note written following the incident stated "during the procedure patient became bradycardic in 30's. Patient unresponsive even after several strong sternal rubs. Patient snoring loudly becoming diaphoretic. ACLS (advanced cardiac life support) protocol started. Anesthesia and respiratory paged STAT to the Cath lab".

On 2/11/2020 at 12:38 PM, during surveyor interview with the cardiologist performing the procedure (Staff ID #2), he acknowledged that when the catheter was inserted in the left side of the heart, approximately 7:36 AM, the patient was noted to be "snoring, apneic and fighting for air." Staff ID #2 acknowledged that when anesthesia arrived, they had trouble with the intubation. The "summary of course of events during cardiac catheterization" written by Staff ID #2 reveals that the patient's jaw was hard to open, and medication had to be administered to release the jaw for intubation, which took approximately 10 minutes to achieve. The patient subsequently required three cardioversions (medical procedure to convert an abnormally fast heart rate to a normal rhythm using electricity or drugs).

Further record review revealed once stabilized in the catheter lab the patient underwent another cardiac catheterization by an interventional cardiologist, Staff ID #3, to evaluate heart patency. The patient was subsequently transferred to the Intensive Care Unit where s/he remained unresponsive; a CT scan of the patient's brain indicated s/he suffered from a hypoxic brain injury. The patient was breathing on his/her own but did not have a gag or corneal reflex (blink reflex). S/he was transitioned to comfort care and passed away.

Record review revealed Staff ID #1 is a Registered Nurse and was directly involved with this procedure.

Review of his education transcript failed to reveal current evidence of annual sedation education, per the hospital requirement.

Record review revealed Staff ID #2 is a Physician and was directly involved with this procedure. Review of his credentialing file failed to reveal evidence of a current BLS certification, per the hospital requirement.

During an interview on 2/12/2020 at 9:51 AM with the Director of Risk Management and the Director of the Cath Lab they acknowledged that a Code Blue had not been activated for this patient as per policy.

During an interview on 2/12/2020 at 10:08 AM with the Directors of the Intensive Care Unit and Cath Lab they could not provide evidence to support that Staff ID #1 completed the required sedation training annually, as per policy.

During an interview with the Director of Performance Improvement on 2/12/2020 at approximately 11:00 AM, she acknowledged that Staff ID #2 was not certified in BLS.