HospitalInspections.org

Based on medical record (MR) review, document review and interview, the facility failed to meet the emergency needs of patients. Specifically, the facility's emergency department (ED) staff failed to identify and provide cardiopulmonary resuscitation (CPR) when agonal respirations (a distinct abnormal pattern of breathing and brainstem reflex) required continuous resuscitation measures. Failure to recognize the need for continuous resuscitation measures resulted in a premature declaration of death of a patient (Patient #1). Additionally, ED nursing staff did not document an assessment including vital signs (V/S) on a patient (Patient #1) who resumed ROSC (return of spontaneous circulation) and did not ensure that recorded cardiac rhythm strips for patients who required CPR were retained in the MR according to the hospital's policy and procedure (P&P) and current standards of practice. These failures were identified in 2 of 3 MRs reviewed (Patient #1 and Patient #2). These failures may result in serious adverse outcomes to patients. The facility's failure to document a patient assessment, V/S and cardiac rhythm strips could lead to the inability to identify a patient's changing condition and the sequence of events during a resuscitative event (cardiac and/or respiratory arrest).

Findings include:

-- Review of MRs of two patients requiring CPR revealed 1) the facility's ED staff failed to identify that agonal respirations noted during a medical emergency required continuous resuscitative measures resulting in the premature declaration of a patient's death. 2) Lack of a documented assessment and V/S in the MR on a patient who resumed ROSC. 3) Lack of recorded cardiac monitor strips obtained during resuscitative measures were retained in the MR according to the hospital's policy and procedure (P&P) and current standards of practice. Consequently, Patient #1, with agonal respirations requiring continuous resuscitative measures was not identified by ED staff resulting in premature declaration of death. Additionally, Patient #1's MR lacked documentation of an assessment and V/S when the patient resumed ROSC and cardiac rhythm strips obtained during both resuscitative measures were not included in the MR. Patient #2 lacked recorded cardiac rhythm strips obtained during CPR in their MR.

See Tag C1116.

Based on observation, document review and interview, the hospital did not ensure emergency equipment was readily available for treatment of pediatric emergency cases. Specifically, the Broselow Bag (a nylon pack with seven color-coded pouches inside for organizing pediatric trauma supplies according to the measured length of pediatric patients) contained expired equipment, i.e., endotracheal tubes (ETT) and stylets (wire designed to be inserted into the endotracheal tube to make the tube conform better to the upper airway) or lacked equipment indicated on enclosed list (i.e., intubation stylets). Additionally, the hospital did not have a policy and procedure (P&P) that instructed staff to monitor contents of the Broselow bag for expired or missing items. This could cause the hospital to not be prepared for a pediatric emergency situation.

Findings include:

-- During a tour of the Emergency Department (ED) on 7/6/2021 at 12:45 pm, the Broselow Bag was noted to have the following expired and/or missing items.

- Pink/Red bag - Intubation stylet (expired 6/2021)
- Purple bag - No intubation stylet (2.5 - 4.5 millimeter [mm])
- Green bag - ETT 6.5 (expired 3/15/2021), intubation Stylet 5-7 mm (expired 3/2021)
- Blue bag - ETT 5.5 (expired 10/2020, enclosed list indicated it should be a size 5.0)
- White bag - ETT 5.0 (expired 6/2021)

-- Review of the hospital's P&P titled, "Code Blue - Adult and Pediatric Resuscitation," last reviewed 6/2020, indicated the ED registered nurse (RN) should take the Broselow Resuscitation Bag to all pediatric codes in ancillary departments (it does not address the monitoring of contents or expiration dates of supplies).

-- Review of the form titled "Gouverneur Hospital Nightly Crash Cart Checks," indicated to open cart and check for outdates every Monday (documentation did not specify checking of the Broselow bag). The form contained sections to document that all necessary equipment for resuscitation was checked and available for use (i.e., Ambu bags [adult and pediatric], monitor paper, defibrillator pads, oxygen and suction). There was a section to document the the lock number on the Broselow bag. Documentation of the lock number for the Broselow bag revealed from 2/1/2021 - 6/6/2021 the lock had not been changed and therefore the bag had not been opened. Staff A, ED, RN confirmed the findings at the time of observation.

-- During interview of Staff B, Vice President of Nursing, on 7/8/2021 at 10:00 am, he/she indicated there had been a shortage of supplies for the Broselow bag due to the COVID pandemic. The ED kept the expired supplies to ensure something would be available in case of a pediatric emergency. Staff B was not aware that the expired supplies were ETT tubes and intubation stylets which he/she indicated were available in the ED.

Based on medical record (MR) review, interview and document review, the facility failed to meet the emergency needs of patients. Specifically 1) in 1 of 3 MRs (Patient #1) the facility's emergency department (ED) staff failed to identify that agonal respirations (a distinct abnormal pattern of breathing and brainstem reflex) noted during a medical emergency required continuous resuscitative measures. 2) Emergency department nursing staff did not document an assessment including vital signs (V/S) on a patient (Patient #1) who resumed ROSC (return of spontaneous circulation). 3) In 2 of 3 MRs (Patient #1 and Patient #2) ED staff did ensure cardiac rhythm strips recorded during resuscitative measures were retained in the MR per the hospital's policy and procedure (P&P) and current standards of practice. Failure to recognize agonal respirations led to a premature declaration of death. Additionally, the lack of an assessment, V/S and cardiac rhythm strips could lead to the inability to identify a patient's changing condition and the sequence of events during a resuscitative event (cardiac and/or respiratory arrest).

Findings related to 1) include:

-- Review of Patient #1's MR (9 month-old female) revealed on 7/3/2021 at 2:12 pm, she presented to the ED via emergency medical services (EMS) with cardiopulmonary resuscitation (CPR) in progress. Patient #1 had been found face down in a kiddie wading pool at her home for unknown duration of time. She was intubated prior to arrival, went into ventricular fibrillation (an abnormal cardiac rhythm) and defibrillated (stopping fibrillation of the heart by administering a controlled electric shock in order to allow restoration of the normal rhythm) once, received 6 doses of epinephrine (cardiac medication) and 1 dose of amiodarone (cardiac medication) enroute to the facility. The ED "Cardiac Arrest Record," form indicated CPR had been in progress approximately 30-35 minutes prior to arrival in the ED. Patient was in PEA (pulseless electrical activity), no pulse palpable upon arrival to the ED. Patient remained in PEA throughout the code, no pulse palpable or auscultated at any time, no spontaneous respirations. Temperature was 84.6 degrees Fahrenheit (F) rectally at 2:33 pm and 84.9 degrees F at 2:40 pm. The patient was on an Ohio warmer with warm blankets underneath her for entirety of the code. The providers, laboratory staff and RNs (registered nurses) were unable to obtain arterial blood gases and labs. Suctioning was applied to nasogastric tube at 2:27 pm with approximately 50 ccs (cubic centimeters) of reddish bile colored contents obtained from stomach. Endotracheal tube suctioned with red frothy secretions obtained. Warm intravenous (IV) fluid boluses administered. Blood sugar was 239 mg/dL (milligrams per deciliter) on arrival. Temperature at 2:50 pm was 84.7 degrees F. At 2:52 pm (47 minutes later), the code was terminated and the patient was pronounced dead.

At 3:30 pm (38 minutes after the death was declared) the ED provider documented "no pulse but occasional agonal respirations noted." There was no documentation that resuscitative efforts were resumed at this time.

The attending pediatrician documented in his/her "Draft" consultation (dictated on 7/3/2021 at 4:53 pm), after approximately 25 minutes of resuscitative efforts in the ED with (no) response from the child, I spoke with the family indicating the likelihood of success now was very low. They seem to understand and agreed that it was time to stop resuscitative efforts. This was done at 2:52 pm. No pulse was noted. The child exhibited intermittent agonal respirations thereafter. There was never any pulse palpable or perfusion noted. Time of death 2:52 pm.

At approximately 5:00 pm nursing documented "this writer noted increased agonal respirations ..." The ED provider documented that at 5:00 pm the coroner was at the hospital to retrieve the body and the patient was breathing regularly. The attending pediatrician was in attendance and attached Patient #1 to a cardiac monitor revealing a heart rate of 58 to 62 beats per minute (bpm) and attached her to a bag-valve-mask (BVM) to provide assisted respirations. Oxygen saturation 78 percent, skin slightly warmer than previously. Capillary refill 3 to 4 seconds. Core temperature 91.7 degrees F. Resuscitation measures were resumed. Patient #1 was transferred to a higher level of care via flight EMS on 7/3/2021 at 8:23 pm.

-- During interview of Staff C, RN, Nursing Supervisor, (provided care to Patient #1) on 7/6/2021 at 1:00 pm and 7/8/2021 at 10:25 am, he/she revealed details of the Code Blue initiated on 7/3/2021 at 2:05 pm. Resuscitative measures ended with Patient #1's time of death (TOD) at 2:52 pm. No one in the room during the code said the baby still had a pulse and/or was breathing. The attending pediatrician asked everyone in the room 2-3 times if anyone had any concerns or anything to add and no one responded. After Patient #1 was pronounced, Staff C was in the room while the ED RN cleaned the baby and wrapped her in a warm blanket which took 10-15 minutes. There was no pulse or respirations noted during this time. Staff C offered Patient #1's mother a lock of the baby's hair. During this time the family did not indicate anything going on with the baby. Staff C then left the room to tend to other responsibilities. After some time (time unknown) Staff C re-entered the ED room and noticed an agonal respiration, nothing regular. Staff C asked the ED provider to go into the room and look things over and the ED provider went into the room, but Staff C did not hear anything after that. Staff C was called back to the ED by staff informing him/her that when the ED nurse took the baby into another room for the coroner, the baby was unwrapped from the blanket and noted to have more spontaneous respirations and a faint pulse was detected. Resuscitative measures were resumed. He/she revealed Patient #1's cardiac monitor showed a sinus rhythm of 70 - 80 bpm with a palpable pulse. Staff C had never seen anything like this before. The baby received strong rescue measures, he/she did not have any concerns with how the ED provider and pediatrician provided care during the code.

-- During interview of Staff D, Attending Pediatrician, (provided care to Patient #1) on 7/6/2021 at 1:45 pm and 7/7/2021 at 4:10 pm, he/she revealed details of the Code Blue called on 7/3/2021 at 2:05 pm. The baby had a low heart rate on the monitor but he/she couldn't feel a pulse. Staff D recalled the cardiac tracing showed moderately narrow complex bradycardia not a wide complex pattern. Pulseless electrical activity (PEA) indicates no pulse, no ventricular outflow for perfusion. Patient #1's heart rate never went above 60 bpm. After approximately 40 minutes of resuscitative measures with no response, Staff D called the regional hospital (who provides a higher level of care) for recommendations and was told if nothing was working, resuscitative measures with no response from the child, that the chance of recovery was essentially zero, the code should probably be stopped. The baby's parents agreed to stop the code. The child continued to have intermittent agonal respirations approximately 4 per minute. It is not uncommon to have cardiac electrical activity after pronouncing a patient. There was some electrical activity on the monitor but no pulses. The family held the baby. The pediatrician stated no one voiced any concerns to him/her that the baby was alive. The pediatrician stated a rhythm strip was not done especially with PEA as there is electrical activity so it's not helpful. Staff D was then called out of the room to speak with law enforcement.

At approximately 5:00 pm, Staff D went to check on the baby with the coroner. The baby was noted to have spontaneous respirations and a femoral pulse. The baby was breathing but was assisted with the BVM. The baby's temperature came up some, Staff D stated maybe to 95 degrees F. The baby was marginally perfused, mottled, sometimes better with slow capillary refill. Pupils were smaller and unresponsive, later were mid-sized and the pediatrician thought still unresponsive. Staff D reported they did not give more doses of epinephrine only started an epinephrine drip.

Staff D reported they do not have many pediatric codes at GH. Since merging with the other 2 hospitals they have even less. Since the event, Staff D has spoken with the regional hospital's Pediatric ICU (Intensive Care Unit) attending physician who indicated that they see this (ROSC) happen every once in a while. Due to so much medication (epinephrine) administered, it could stimulate electrical activity and breathing. Staff D felt the code team and the paramedics were spectacular.

-- During interview of Staff E, ED provider, Nurse Practitioner (NP) (provided care to Patient #1) on 7/6/2021 at 2:25 pm and 7/7/2021 at 3:35 pm, he/she revealed details of the Code Blue initiated on 7/3/2021 at 2:05 pm. The cardiac monitor showed sinus rhythm, bradycardia with 40-50 bpm, no pulses, PEA. Pulseless electrical activity is when the heart is having semi-normal electrical impulses but no corresponding mechanical action from the heart and can last an extended period of time (20-30 minutes). The cardiac monitor could look as if it is a normal rhythm but no pulses are palpable. The monitor continued to show bradycardia, CPR continued. Staff E listened to the chest of Patient #1 and did not hear any heart tones. He/she never saw asystole (cessation of electrical and mechanical activity of the heart, no heartbeat) on the monitor. The decision to end the code was based on the fact that CPR had been in progress for over an hour with no response to CPR and medications. There were no signs of life, no spontaneous respirations, eyes were rolled up and not reactive and the baby didn't react to anything staff did to her. The code was called and the baby pronounced dead at 2:52 pm. There was no pulse or spontaneous respirations at the time of death (TOD) and the family came into the room. Staff E observed the baby while the nurse cleaned her and did confirm no respirations or pulse. The baby was cool and mottled and clinically expired. Staff E talked to staff involved in the code and said they did everything they could do. Staff E stated no one had any concerns. The baby received good quality CPR, equipment and medications were available and on hand. Everything went smoothly and by the book.

-- During interview of Staff F, ED Registered Nurse (RN) (provided care to Patient #1) on 7/6/2021 at 3:15 pm and 7/7/2021 at 3:00 pm, he/she revealed details of the Code Blue initiated on 7/3/2021 at 2:05 pm. Resuscitation measures were performed for at least one hour. At time of death (TOD) the cardiac monitor was showing 60 - 70 bpm but the baby didn't have a pulse. Staff F stated Patient #1 was having questionable agonal respirations and trying to gurgle. Staff F cleaned the baby, wrapped her in a blanket and let the family come in. Staff F didn't notice anything else and no one voiced any concerns about the baby to him/her at the time.

Findings related to 2) include:

-- Review of Patient #1's MR (9 month-old female) revealed she presented to the ED on 7/3/2021 at 2:12 pm in cardiopulmonary arrest and was triaged as a Level 1 - Resuscitation (using the Emergency Severity Index; Level 1 is resuscitation and Level 5 is non-urgent). The ED "Cardiac Arrest Record" indicated she was in PEA, no pulse palpable throughout the code. The code was terminated at 2:52 pm and Patient #1 was pronounced dead. The ED provider documented at 3:30 pm "no pulse but occasional agonal respirations noted." At approximately 5:00 pm nursing documented "this writer noted increased agonal respirations ..." The ED provider documented that at 5:00 pm the coroner was at the hospital to retrieve the body and the patient was breathing regularly. The attending pediatrician attached Patient #1 to a cardiac monitor revealing a heart rate of 58 to 62 bpm. Attached to BVM and respirations assisted. Oxygen saturation 78 percent, skin slightly warmer than previously. Capillary refill 3 to 4 seconds. Core temperature 91.7 degrees F. Resuscitation measures were resumed. There was no documentation in the MR of an assessment and V/S after ROSC.

-- Review of the hospital's P&P titled Patient Triage/Initial Assessment," last reviewed 4/2020, indicated patients should be designated a triage priority and monitored consistent with that priority category. The initial evaluation should include a brief history, a determination of possible allocation of hospital resources and if indicated by triage level, V/S. For a Level 1 triage level V/S are measured, cardiac monitor applied and interpreted. Vital signs and neurological checks if applicable should be monitored at least every 5 minutes or as ordered by the ED provider.

-- Review of the hospital's P&P titled "Code Blue - Adult and Pediatric Resuscitation," last reviewed 6/2020, indicated interventions, treatments and the patient's status should be documented frequently during a code and in post-ROSC period.

-- During interview of Staff C (provided care to Patient #1) on 7/6/2021 at 1:00 pm and 7/8/2021 at 10:25 am, he/she indicated the pediatrician and he/she stayed with the family for about a half an hour after the baby was pronounced dead. Staff C offered Patient #1's mother a lock of the baby's hair. During this time the family did not indicate or note anything going on with the baby. Staff C then left the room to tend to other responsibilities. After some time (time unknown) Staff C re-entered the ED room and noticed an agonal respiration, nothing regular. Staff C asked the ED provider to go into the room and look things over and the ED provider went into the room, but he/she did not hear anything after that. Staff C was called back to the ED by staff informing him/her that when the ED nurse took the baby into another room for the coroner, the baby was unwrapped from the blanket and noted to have more spontaneous respirations and a faint pulse was detected. Resuscitative measures were resumed. He/she revealed Patient #1's cardiac monitor showed a sinus rhythm of 70 -80 bpm with a palpable pulse. Staff C stated he/she had never seen anything like this before.

-- During interview of Staff D (provided care to Patient #1) on 7/6/2021 at 1:45 pm and 7/7/2021 at 4:10 pm, he/she recalled law enforcement or the coroner stated the baby was breathing with 20-25 breaths per minute and a pulse. Resuscitative measures were resumed.

-- During interview of Staff E (provided care to Patient #1) on 7/6/2021 at 2:25 pm and 7/7/2021 at 3:35 pm, he/she revealed 1 to 1 1/2 hours after the TOD was declared (approximately 5:00 pm) law enforcement and the coroner came to the ED and stated the baby was breathing. The baby had a pulse of 70 bpm and blood pressure of 80/50 with respirations of 16 -20 per minute. Resuscitative measures were resumed. Staff E stated he/she has seen a similar situation to this 25 years ago.

-- During interview of Staff F (provided care to Patient #1) on 7/6/2021 at 3:15 pm and 7/7/2021 at 3:00 pm, he/she revealed when the coroner arrived in the ED (doesn't recall what time this occurred) he/she went to get the baby from the family member. Staff F laid the baby on the stretcher and heard her gurgle a couple of times. He/she said something to the attending pediatrician who went to check the baby and said the baby had a pulse. Resuscitation measures were resumed. Staff F stated he/she was not able to document in the MR at that time as he/she was at the bedside assisting Patient #1 with ventilations.

Findings related to 3) include:

-- Review of Patient #1's MR (9 month-old female) dated 7/3/2021 at 2:12 pm, she presented to the ED via EMS with CPR in progress. Resuscitative efforts continued until 2:52 pm, when the code ended and the patient was pronounced dead. At approximately 5:00 pm, Patient #1 had ROSC and resuscitation measures were resumed. There were no recorded cardiac rhythm strips documented in the MR during either resuscitation efforts.

-- During interview of Staff C (provided care to Patient #1) on 7/6/2021 at 1:00 pm and 7/8/2021 at 10:25 am, he/she revealed that during the code Patient #1 was in PEA with no palpable pulse and a rhythm in the low 100's. Towards the end of the code the cardiac monitor ran out of tracing (strip) paper. Staff C switched out the paper and couldn't get it to print, he/she is unsure if the paper was jammed or the door to the paper wouldn't/didn't close properly. Staff C is not sure what happened to the initial recorded cardiac strips that were printed. Staff C does not recall printing a cardiac rhythm strip after Patient #1 resumed ROSC.

-- During interview of Staff F (provided care to Patient #1) on 7/6/2021 at 3:15 pm and 7/7/2021 at 3:00 pm, he/she stated he/she would usually print a cardiac rhythm strip at the end of a code.

-- During interview of Staff G, RN (provided care to Patient #1) on 7/6/2021 at 3:50 pm, he/she recalled initially cardiac rhythm strips on the EMS and ED side were printing out. Towards the end of the code the cardiac rhythm strips weren't printing out but doesn't know why they weren't printing. At the end of the code the cardiac rhythm strips went to the Nursing Supervisor and Staff G went back to his/her assigned unit.

-- During interview of Staff E (provided care to Patient #1) on 7/6/2021 at 2:25 pm and 7/7/2021 at 3:35 pm, he/she indicated nursing staff should be responsible to obtain rhythm strips during a code.

-- Review of Patient #2's MR (56-year-old male) revealed on 6/30/2021 at 10:00 am, he presented to the ED via EMS with CPR in progress provided by the Lucas device (device that maintains chest compressions during transport to advanced lifesaving therapies). He was intubated prior to arrival and had received 2 doses of epinephrine enroute. The ED provider documented on arrival the patient was in asystole (cessation of electrical and mechanical activity of the heart, no heartbeat). Two doses of epinephrine 1 milligram (mg) were given and the patient resumed ROSC at 10:10 am. There were no recorded cardiac rhythm strips during the resuscitation efforts documented in the MR.

-- Review of the hospital's P&P titled "Code Blue - Adult and Pediatric Resuscitation," last reviewed 6/2020, indicated the ED RN functioning as the recorder should manage and monitor defibrillation and rhythm strips and communicate electrocardiogram (ECG) findings to the physician. The completed code documentation and the rhythm strips should be placed in the patient's MR.

-- During interview of Staff M, Risk Management and Regulatory Affairs Director, on 7/8/2021 at 3:00 pm, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, in 3 of 3 MRs (Patient #1, Patient #2 and Patient #3) the facility's "Cardiac Arrest Record" lacked signatures of the specific staff members who participated in the resuscitative measures (e.g., recorder, ED provider, physician, etc.) according to the hospital's policy and procedure (P&P). This could lead to the hospital being unable to adequately review medical care provided during a resuscitative event (cardiac and/or respiratory arrest) and does not accurately portray which staff provided care to the patient.

Findings include:

-- Review of the hospital's P&P titled "Code Blue - Adult and Pediatric Resuscitation," last reviewed 6/2020, indicated the recorder, code team provider and all members present should review and sign the Code Blue Documentation ("Cardiac Arrest Record") form.

-- Review of Patient #1's MR (9-month-old female) revealed on 7/3/2021 at 2:12 pm, she presented to the ED via emergency medical services (EMS) with cardiopulmonary resuscitation (CPR) in progress. Resuscitative efforts continued until 2:52 pm, when the code ended and the patient was pronounced dead. The form titled "Cardiac Arrest Record," lacked the signatures of the recorder, ED provider, physician and other staff members who participated in the code.

-- Review of Patient #2's MR (56-year-old male) revealed on 6/30/2021 at 10:00 am, he presented to the ED via EMS with CPR in progress provided by the Lucas device (device that maintains chest compressions during transport to advanced lifesaving therapies). He was intubated prior to arrival and had received 2 doses of epinephrine enroute. The ED provider documented on arrival the patient was in asystole (cessation of electrical and mechanical activity of the heart, no heartbeat). Two doses of epinephrine 1 milligram (mg) were given and the patient resumed ROSC (return of spontaneous circulation) at 10:10 am. The form titled "Cardiac Arrest Record," lacked the signatures of the ED provider, physician and other staff members who participated in the code.

-- Review of Patient #3's MR (68-year-old female) revealed on 3/26/2021 at 8:57 am, she presented to the ED via private vehicle with her husband after she became unresponsive while riding in the car. Upon arrival to the ED she was noted to be in PEA (pulseless electrical activity) and unable to oxygenate herself. Provider documentation revealed the patient was intubated and CPR was in progress. She was transitioned to the electronic CPR machine. Atropine and epinephrine were given. The "Cardiac Arrest Record" indicated the code ended at 9:57 am, the patient had no pulse and eyes were fixed and dilated. The patient never had ROSC. The "Cardiac Arrest Record" was signed by the recorder and the ED provider but lacked the names and signatures of all other staff who participated in the code.

-- During interview of Staff M, Risk Management and Regulatory Affairs Director on 7/8/2021 at 3:00 pm, he/she acknowledged the above findings.