HospitalInspections.org

Based on document review and interviews, it was determined for 1 of 3 (PT #1) clinical records reviewed of patients that were coded and expired, the Hospital failed to ensure the Governing Body provided oversight in immediate activation of the emergency system, thus placing all patients in the Hospital at risk for ineffective life saving measures. Refer to deficiencies at A 093. As a result, it was determined that the Condition of Participation for Governing Body was not in compliance.

1. The Hospital failed to ensure timely activation of 911, the emergency transportation system. See deficiency at A 093.

Based on document review and interview, it was determined for 1 of 3 (Pt. #1) reviewed for the activation of 911, the Hospital failed to immediately activate the (911) emergency transport system.

Findings include:

1. Hospital policy PM & R (Physical Medicine and Rehabilitation) entitled, "Emergency Appraisals, Initial Treatment, and Referral for Additional Services," (revision date 05/15) required, "Policy ...It does not maintain an emergency department ... Procedure: A. Inpatients: 1. Appraisals. A. All patients are assessed by a registered nurse (RN) ...3. Referral for Additional Services: a. If it is determined that a patient should be transferred to an acute care hospital with advanced capabilities for further emergency management, the transfer will be made by calling the ambulance dispatch or 911 to activate the emergency transport system ..."

2. The clinical record of Pt. #1 was reviewed on 11/9/16 at approximately 1:00 PM. Pt. #1 was a 22 year old male admitted 8/31/16 with a diagnosis of intracranial hemorrhage. Pt. #1 was a full code (life support measures were to be initiated) and with a tracheotomy. Nursing documentation dated 9/28/16 at 3:32 AM entitled, "Final Report," included, "1:30 AM - Patient awake in bed ...Staff went for a break and patient still talking, not in distress. 2:15 AM - While doing the hourly round, found patient non responsive, code was called, no pulse, not breathing. Started CPR at 2:16 AM and ...While staff doing CPR - charge nurse started calling MD, ambulance and families. 2:38 AM (#A1) ambulance here ...3:48 AM - 911 ambulance here and pronounce dead..."

3. Pt. #1's ambulance report dated 9/28/16 included, "Dispatched at 2:23 AM; at scene at 2:38 AM; at patient at 2:39 AM; 911 arrived on scene at 2:48 AM; and in service at 3:01 AM." Further documentation included, "Crew requested #A1 dispatch to confirm with (Hospital) that CPR is in progress, if so, to call 911 for assistance ...Per staff Pt.#1 was found unresponsive at 2:15 AM, #A1 called at 2:25 AM."

4. On 11/9/16, at approximately 2:00 PM' the Hospital contacted the EMS Coordinator by phone regarding Pt. #1. The Coordinator stated, "The call came in at 2:40 AM (35 minutes after CPR initiated) on 9/28/16. The ambulance arrived on scene at 2:47 AM with 2 paramedics and a ladder company, arrived at the patient at 2:50 AM, and was cleared from the scene at 3:01 AM."

5. On 11/9/16 at approximately 2:30 PM Pt. #1's attending physician (MD #1) was interviewed. MD #1 stated, "If a patient is coding and in an emergency situation, I would expect 911 to be called first. If they are stabilized then it is OK to call a private ambulance. The patient was found unresponsive; therefore, 911 should have been called and transported to the nearest Hospital."

6. On 11/10/16, at approximately 5:15 AM a Registered Nurse (RN) (E #2) on duty on 9/28/16 was interviewed. E #2 stated, "I called the ambulance (#A1) when directed by the patient's nurse. They usually send a team when they are called. We always call #A1 at night for a code. Ambulance #A1 then called 911 when they arrived. I believe I called #A1 two times during the code."

7. On 11/10/16 at approximately 5:30 AM a RN (E #3) was interviewed. E #3 stated, "I can't remember how long it took the ambulance (#A1) to arrive. However according to the note the code started at 2:15 AM, and #A1 arrived at 2:39 AM and took over for the staff. The fire department (911) arrived 9 minutes after #A1. I don't know who called 911."

8. On 11/10/16 at approximately 5:40 AM Pt. #1's primary RN (E #4) was interviewed. E #4 stated, "I found the patient unresponsive at 2:15 AM, pushed the code button, and instructed someone to call the family, physician, and ambulance. At 2:15 AM CPR was started. The ambulance (#A1) was called by the charge nurse. It is our policy to call (#A1) first for codes. This is per our former CNO (chief nursing officer). They are close and respond quickly. According the report, CPR was started at 2:15 AM and (#A1) arrived at 2:38 AM (23 minutes after the code started). I would expect 10 - 20 minute response. At 2:40 AM, 911 arrived. I believe they were called by (#A1)."

9. On 11/10/16 at approximately 8:00 AM, the Charge Nurse (E #6) on duty on 9/28/16 was interviewed by phone. E #6 stated, "I called the ambulance (#A1). That's the one I was told to use by the old Director of Nursing. I had to recall #A1 after the ambulance did not arrive timely. They then arrived within 5 minutes. When they arrived they stated that 911 needed to be called because more manpower was needed. I don't remember who called, but they arrived within 2 to 3 minutes."

10. Instructions on who to notify for emergencies was presented by the Hospital 11/10/16 at approximately 8:30 AM. The instructions included, "Emergent/CODE BLUE transportation - call (#1) at ...If no response, then call 5911 (fire department) ..." The instructions did not include to call 911 first.

11. On 11/10/16, at approximately 11:30 AM, the Director of Quality (E #7) and the CEO (E #8) were interviewed. E #7 stated, "If a patient is coding the nurse should call the code first and initiate CPR and have someone start calling for an ambulance. 911 should be called. " E #8 stated, "Not calling 911 is never an option."