HospitalInspections.org

Based on clinical records and interviews with facility personnel for one of two sampled patients (Patient #1), the facility failed to ensure that documentation of a cardiac arrest was completed.

The findings include:

1. Patient #1 was transferred to the hospital from Hospital #1 on 3/8/10. After transferring the patient into a wheelchair, the patient slumped over and became unresponsive. Patient #1 was given cardio-pulmonary resuscitation and transferred to Hospital #3. Subsequently, Patient #1 expired on 3/8/10. Review of the clinical record failed to identify that documentation of the code was completed including medications and interventions given to Patient #1. Review of hospital policy identified that the recorder utilizes the medical emergency monitor form to record events of the emergency and the emergency medical patient record to record medications given and vital signs taken. Interview with the Director of Performance Improvement on 4/8/10 identified that the emergency monitoring form was not completed.