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Based on interviews, policy review, and record review, the facility failed to immediately initiate appropriate interventions for Patient #1 in a Code Blue (an emergency situation in which a person has stopped breathing or has no pulse) for one of one Code Blue record reviewed. The facility nursing administration failed to keep staff prepared for Code Blue situations through education and drills so that when an event occurred the response was appropriate and immediate. Please see A 0395 for details.

The cumulative effect of this systemic failure resulted in the facility's non compliance with 42 CFR 482.23 Condition of Participation (COP): Nursing Services. This failure had the potential for harm to all patients within the facility also known as Immediate Jeopardy (IJ). The facility census was 20.

As of 12/22/16, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Immediate education of all staff in patient care areas on Basic Life Support (BLS) skills, utilization of phone system, utilization of emergency call lights in patient rooms, and calling a rapid response/Code Blue;
- Mock codes will be performed and competency evaluated prior to each coworker working their next shift;
- Mock code drills will include competency in BLS skills, Cisco phone system, use of emergency call lights, and calling a rapid response/Code Blue;
- Mock Codes will continue on each shift until patient care staff demonstrate competency at 100%, then daily on alternating shifts and locations until staff demonstrate expected competencies, then weekly for four weeks, and if at 100%, monthly for six months

Based on interviews, policy review, and record review, the facility failed to immediately initiate appropriate interventions for Patient #1 in a Code Blue (an emergency situation in which a person has stopped breathing or has no pulse) for one of one Code Blue record reviewed. The facility nursing administration failed to keep staff prepared for Code Blue situations through education and drills so that when an event occurred the response was appropriate and immediate. The facility census was 20.

Findings included:

1. Record review of the facility's policy titled, "Code Blue," dated 04/06/15, showed that the standard of care for all resuscitation (patient not breathing or no heart beat) incidents is rapid intervention and that the staff member that discovered the patient not breathing or with no heartbeat (cardiac arrest) will immediately summon help by calling 45555 or pressing a Code Blue button, if one is present in the area, and start resuscitation procedures.

2. Record review of Patient #1's medical record showed:
- The patient was a 73 year old male, who was admitted to the hospital on 12/12/16 for surgery due to colon cancer.
- During the surgery and subsequent tests it was determined that the cancer had spread to other organs in his body.
- On 12/13/16 the surgeon documented that the patient was doing great.
- On 12/14/16 the surgeon documented that the patient was upset because he soiled himself but tolerated a regular diet and, "May go home tomorrow".
- On 12/15/16 the surgeon documented that the patient felt, "Too weak to go home today but will go home tomorrow".
- On 12/15/16 at 7:30 PM, Staff F, Registered Nurse, (RN), documented a full assessment of patient.
- On 12/15/16 at 9:05 PM Staff F documented that Staff G, Certified Nurse Assistant (CNA), came into another patient's room and asked her [Staff F] to come quickly to Room 106. When Staff F arrived, she found the patient in the bathroom with a belt around his neck that was tied to the shower bar. She told Staff G to call a Code Blue, removed the belt from around his neck and shower bar; checked for a heartbeat and started to do chest compressions (pushing on chest to replace heart beats);
- At 9:20 PM Staff F documented that the code was in progress, Emergency Department (ED) physicians were present, medications were administered;
- At 9:25 PM Staff F documented that the code continued, the patient had been intubated (tube placed in throat to assist with breathing), additional medications were administered but no spontaneous (unassisted) breathing or heartbeats were present;
- At 9:27 PM Staff F documented that the physician stated to discontinue interventions and staff stopped all efforts to resuscitate (bring back to consciousness) the patient.

3. Record review of event timeline based on video recorded on 12/15/16 from a camera in the Nurses Station:
- At 9:12 PM Staff G entered room 106 (Patient #1's room);
- At 9:13:03 PM Staff G exited room 106 to notify Staff F;
- At 9:13:17 PM Staff G returned to room 106;
- At 9:13:21 PM Staff F entered room 106;
- At 9:14:49 PM an additional CNA entered room 106;
- At 9:15:24 PM Crash Cart (Emergency Medical Cart with medications and equipment) arrived at room 106;
- At 9:15:37 PM Additional staff arrived (responded to Code Blue).

4. Record review of facility provided spreadsheet showed as of 12/21/16
there had been 45 "Code Blue" events in 2016.

During a telephone interview on 12/21/16 at 1:15 PM Staff F stated that:
- She was the nurse for Patient #1 on 12/15/16 at the time of his death;
- She was in another room when the CNA came to the door and asked her to come to Room 106;
- On entry she found the patient with a belt around his neck, tied to the shower bar;
- She told the CNA to call a code, got the belt off the patient, and began Cardio Pulmonary Resuscitation (CPR- chest compressions);
- She didn't know why the CNA did not immediately call a code and start CPR. She stated that maybe she was in shock to see a patient like that.

During a telephone interview on 12/21/16 at 2:30 PM Staff G stated that:
- When you find a patient that is not responsive, you should shake the patient, ask if he is alright, if not, start CPR;
- She was doing vital sign rounds on 12/15/16 around 9:00 PM and the patient was not in bed, she knocked on the bathroom door and called his name but there was no answer. She peeked in but he was not on the toilet. She saw the patients' hand from under the shower curtain. She thought he had fallen, pulled the shower curtain back and saw he had hung himself with a belt around his neck and tied around the handrail;
- Staff G stated that she was aware of the emergency call button in the bathroom, but she was just so shaken, she went to get the nurse;
- She stated that the hospital did not hold mock (practice) codes and she had never done chest compressions in an actual code.

During a concurrent interview on 12/21/16 at 2:50 PM Staff C, Executive Director of Nursing, Staff B, Director of Clinical Services, and Staff D, Quality Manager, stated that:
- An investigation into this event was initiated and statements were taken as recently as today;
- The hospital had not done a mock code in over a year;
- The delay in initiation of CPR was probably because the CNA was in shock;
- We have a Root Cause Analysis (RCA- formal review of event to determine what caused the situation and what could have been done better) for 12/27/16;
- No process improvements or education were identified as a result of their investigation.

5. Record review of facility report, "Time Detail" showed that Staff G worked on the medical unit on 12/19/16 and 12/20/16 for 12 hours on each shift (education related to this event was not started until 12/21).

During an interview on 12/22/16 at 3:12 PM Staff C stated, "This was definitely a wakeup call for us."