HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the patient's family member was informed when one of five sampled patients (Patient 1) was admitted to the hospital, coded, and expired for as per the hospital's P&P. This failure posed the risk of the patient's family member not being involved in decision-making process for the patient care.

Findings:

Review of the hospital's P&P titled Code Blue dated 2/11/22, showed the Responsibility of Staff to Code Blue section showing the following:

- Code Team Lead Physician: functions as the code team leader, clearly delegates tasks to the Code Blue team, manages the airway, orders medications and ancillary testing, communicates with the patient's attending and family members as indicated, and debriefs with the Code Blue team members as soon after the code as feasible possible based on patient needs.

- Nursing House Supervisor: maintains crowd control, cares and notifies the patient's family, facilitates in patient transfer as applicable, and ensures a staff person is assigned to remain with family member who desires to be present during the code.

- Pastoral Care or Social Work: responds if available, provide support to families of patients either directly or indirectly involved with Code Blue.

Review of the hospital's P&P titled Handling of Expired Patient and Property dated 4/12/22, showed the purpose is to establish a procedure and consistent guidelines for the proper management of an expired patient and his or her personal property. All expirations require pronouncement of death by a physician or authorized Department Director/Charge Nurse/Nursing Supervisor/RN. The hours of death will be the time of the official pronouncement. The physician should contact the next-of-kin.

On 12/30/24, review of Patient 1's closed medical record was conducted with the Accreditation and Regulatory Compliance Supervisor.

Review of the Emergency Department History and Physical dated 1/19/24 at 0227 hours, showed Patient 1 was brought to the ED on 1/19/24, with cardiac arrest. Patient 1 arrived to the ED and was intubated with CPR in progress. The CPR was resumed in the ED.

Review of the Patient Care Timeline dated 1/19/24, showed Patient 1 had survived at 0258 hours.

Review of the Emergency Department History and Physical dated 1/19/24 at 0227 hours, showed Patient 1 was admitted to ICU from the ED at 0516 hours.

Review of the Critical Care Communication Progress Note dated 1/19/24 at 0410 hours, showed to continue full code. Patient 1 was unresponsive. Patient 1's family member was unavailable.

Review of the Critical Care Communication Progress Note dated 1/19/24 at 0643 hours, showed Patient 1 was unstable and likely to have another cardiac arrest. Patient 1's pupils were fixed and dilated. Patient 1 was unresponsive and off sedation. Patient 1 would be made DNR as it would be medically futile, and the medical staff was unable to reverse the causes. No family contact information was available at that time.

Review of Critical Care Death Pronouncement Note dated 1/19/24 at 0705 hours, showed Patient 1's time of death occurred on 1/19/24 at 0703 hours.

Review of the nurse's End of Shift Summary dated 1/19/24 at 0739 hours, showed Patient 1 continued to decline. The intensivist changed Patient 1's code status to DNR. Patient 1 became asystolic. The intensivist was at bedside. Patient 1's family member was unable to reach.

Review of the LCSW note dated 1/19/24 at 0856 hours, showed the LCSW located the number for the next-of-kin. The LCSW located four phone numbers listed in Patient 1's previous record, possibly from Patient 1's family members. The LCSW updated the Charge RN and RN with these phone numbers.

Further review of Patient 1's medical record showed no documented evidence showing Patient 1's family member was notified during the resuscitation, after the resuscitation, and when Patient 1 expired on 1/19/24.

On 12/30/24 at 1402 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the LCSW. When asked about the process of notifying a patient's family member, the LCSW stated she searched for Patient 1's next-of kin, found the contact numbers of Patient 1's family members, and provided them to the RN and Charge RN. When asked who would contact the patient's family member at night, the LCSW stated the House Supervisor, the physician, or the nurse could have contacted the patient's family member; the nurses or House Supervisor were able to find the contact information of the patient's family member from the previous admission. When asked who called the patient's family member after the LSCW gave the contact numbers of the patient's family members to the RN and Charge RN, the LCSW stated she was not sure who called Patient 1's family member. The LCSW stated she would contact the family during the resuscitation, but Patient 1 had already passed, and she gave the contact numbers to the nurses to call the coroner.

On 12/31/24 at 1013 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the VP of Nursing Operation and the Accreditation and Regulatory Compliance Supervisor. The VP of Nursing Operation stated at night, the on-call CM in ED would contact the patient's family, and the ED team including the House Supervisor and physician were also involved. If the CM was not available, the ED team would facilitate to locate the patient's family. The VP of Nursing Operation and the Accreditation and Regulatory Compliance Supervisor confirmed there was no documentation showing Patient 1's family member was contacted.

On 12/31/24 at 1055 hours, an interview was conducted with the complainant. The complainant stated when the complainant could not find Patient 1, the complainant called all the hospitals in the area, jails, and coroners' offices and found Patient 1 12 hours after Patient 1 had passed. The complainant confirmed one of four phone numbers was the phone number of Patient 1's Family Member 1, but Patient 1's Family Member 1 had not received the phone call from the hospital.

Based on interview and record review, the hospital failed to ensure the RN supervised and evaluated the nursing care for one of five sampled patients (Patient 2) as evidenced by:

1. The nursing staff did not monitor and document Patient 2's vital signs every four hours as per the hospital's P&P.

2. The nursing staff did not perform a focused patient assessment for Patient 2 every four hours as per the hospital's P&P.

These failures created the increased risk of poor health outcomes to the patient with the potential to cause death due to aspiration.

Findings:

On 12/30/24, review of Patient 2's closed medical record was initiated. Patient 2 medical record showed the patient was admitted to the hospital on 10/27/24 at 0719 hours.

1. Review of the hospital's P&P titled Frequency and Reporting of Vital Signs, and Intake and Output dated 3/20/23, showed for Medical/Surgical/Telemetry units, routine vital signs are taken every four hours.

On 12/30/24 at 1300 hours, an interview and concurrent interview of Patient 2's medical record was conducted with the Patient Safety Lead RN.

Review of Patient 2's vital sign flowsheet showed Patient 2's vital signs was documented on 10/27/24 at 1200 hours.

The Patient Safety Lead RN was unable to locate documentation of the patient's vital signs for 10/27/24 at 1600 hours. The Patient Safety Lead RN acknowledged that vital signs should be taken and documented every four hours.

On 12/30/24 at 1530 hours, an interview was conducted with CNA 1. CNA 1 acknowledged the vital signs should be completed every four hours and was not sure why Patient 2's vital signs were not taken on 10/27/24 at 1600 hours.

On 12/31/24 at 1310 hours, the Accreditation and Regulatory Compliance Supervisor and Patient Safety Lead RN were notified and acknowledged the above findings.

2. Review of the hospital's P&P titled Department Scope of Service dated 11/4/24, showed for the 8 west Oncology, assessment and reassessment timeframes is "Unless otherwise ordered or indicated, timeframes are as followed: Head-to-toe assessment every shift with focused reassessment q4H."

On 12/31/24 at 0830 hours, and interview and concurrent review of Patient 2's medical record was conducted with the Patient Safety Lead RN.

Review Patient 2's medical record showed the head-to-toe assessment was completed on 10/27/24 at 0849 hours.

The Patient Safety Lead RN was unable to locate any additional assessments prior to 10/27/24 at 1846 hours.

On 12/31/24 at 1310 hours, the Accreditation and Regulatory Compliance Supervisor and Patient Safety Lead RN were notified and acknowledged the above findings.