HospitalInspections.org

Based on review of facility documents, credential files (CF), medical records (MR) and interview with staff (EMP), it was determined the privileges granted were not commensurate with the physician's qualification, experience and present capabilities for pediatric patients for one of one medical record reviewed (MR1).

Findings include:

Review on March 29, 2011, of the "Credentialing Policy of Jersey Shore Hospital," approved by the Board of Directors April 30, 2009, revealed "2.C. Application 2.C.1. Information: (a) Applications for appointment and reappointment shall contain a request for specific clinical privileges and shall require detailed information concerning the individual's professional qualifications. The applications for initial appointment and reappointment existing now and as may be revised are incorporated by reference and made a part of this Policy. ... (b) In addition to other information, the applications shall seek the following: ... (4) current information regarding the applicant's ability to safely and competently exercise the clinical privileges requested. (c) The applicant shall sign the application and certify that he or she is able to perform the privileges requested and the responsibilities of appointment."

Review on March 29, 2011, of the "Jersey Shore Hospital Emergency Services Delineation of Privileges" form revealed no requirement for Pediatric Advanced Life Support (PALS).

Interview with EMP3 and EMP17 at 11:00 AM on March 31, 2011, confirmed that emergency department (ED) physicians were not required to have PALS certification to work in the ED.

Review of the Jersey Shore Hospital's "Nursing Standards - Emergency Department," last revised July 2010, revealed "I. Organization, Management, Authority and Accountability of the Emergency Department ... B. Objective and Purpose The Jersey Shore Hospital Emergency Department offers emergency health care service to anyone presenting to the ER requiring/requesting emergency care."

Interview with EMP2 on April 25, 2011, at 1:00 PM confirmed that the Jersey Shore Hospital ED provided services to pediatric and adult patients.

Review on March 10, 2011, of a listing of the number of pediatric patients presenting to and treated in the Jersey Shore Hospital's ED January 23, 2011, to March 9, 2011, revealed 438 pediatric patients (patients ages 18 and under) were seen in the Jersey Shore Hospital ED. This listing was provided by EMP3.

Review of MR1 on March 10, 2011, revealed the patient presented to the ED on January 24, 2011, in respiratory distress. MR1 became unresponsive; a code was called; and cardiopulmonary resuscitation (CPR) was initiated. During the code, MR1 required endotracheal intubation (used to maintain a patient's airway when they are unable to breathe on their own). CF1 was unable to perform the endotracheal intubation. The emergency medical service (EMS) was called to provide care to the patient in the Jersey Shore Hospital's ED.

Request was made on March 10, 2011, for the PALS certification for CF1. This was not provided on March 10, 2011. Review on March 31, 2011, of CF1 revealed privileges were granted for emergency services. CF3's PALS certification had expired in 2005. CF1 provided care to a pediatric patient in the Emergency Department on January 24 and January 25, 2011.

Cross Reference 485.635(b)(4) Direct Services

Based on review of facility documents, medical records, and interview with staff (EMP), it was determined the facility failed to ensure emergency procedures by facility staff were provided for one of 15 emergency department records reviewed (MR1).

Findings include:

Review of the Jersey Shore Hospital's "Nursing Standards - Emergency Department," last revised July 2010, revealed "I. Organization, Management, Authority and Accountability of the Emergency Department ... B. Objective and Purpose The Jersey Shore Hospital Emergency Department offers emergency health care service to anyone presenting to the ER requiring/requesting emergency care."

Interview on April 25, 2011, at 1:00 PM confirmed that the Jersey Shore Hospital Emergency Department provided services to pediatric and adult patients.

Review of MR1 on March 10, 2011, revealed the pediatric patient presented to the Emergency Department (ED) on January 24, 2011, in respiratory distress. MR1 became unresponsive; a code was called; and cardiopulmonary resuscitation was initiated. Review of the Nurses' Notes revealed an entry dated February 1, 2011, "Late entry to chart for date 1/24/11". This revealed a medic from an EMS station was called. The medic arrived and placed an endotracheal tube to support respirations and an intraosseous site to administer fluids and medication. Review of the physician progress notes revealed an addendum note dated January 25, 2011, 1:06 AM. This revealed the paramedic intubated MR1.

Interview on March 10, 2011, at approximately 6:00 PM with EMP3 confirmed that the EMS crew was called to provide care to MR1 in the Jersey Shore Hospital's emergency department. EMP3 also confirmed that the paramedic who inserted the endotracheal tube and intraosseous line was not an employee of the Jersey Shore Hospital.

Interview on May 5, 2011, at 4:15 PM with OTH1 confirmed the emergency medical service (EMS) crew who responded to the 911 call on January 25, 2011, was not an employee of the Jersey Shore Hospital. OTH1 confirmed the EMS was not under a written agreement or contract for providing care and services to the patients at Jersey Shore Hospital.

Cross Reference 485.618 Emergency Services

Based on review of facility documents, medical records, and interview with staff (EMP), it was determined the recorder during a code failed to ensure accurate information was recorded on the Jersey Shore Hospital's Cardiac Arrest Data Sheet for one of one medical record reviewed (MR1).

Findings include:

Review on March 30, 2011, of the facility's policy "Cardiac Arrest Data Sheet," last reviewed April 2010, revealed "Form Instructions for: Cardiac Arrest Data Sheet Expected Outcomes: To document patient care during a Code 99. Description of Form: These forms are supplied in every crash cart to be used in each Code 99. The patient addressograph is to be stamped in the upper right corner of the page. This form remains a permanent part of the record. ... When to Use This Form: In the event of a cardiac/respiratory arrest. Responsibility: The Code Team "Recorder" is responsible for the accurate recording of information on the Data Sheet."

Review of MR1 on March 10, 2011, revealed the patient presented to the Emergency Department (ED) on January 24, 2011, in respiratory distress. MR1 became unresponsive; a code was called; and cardiopulmonary resuscitation (CPR) was initiated. During the code, MR1 required endotracheal intubation (used to maintain a patient's airway when they are unable to breathe on their own). The facility staff was unable to perform the procedure. An emergency medical service (EMS) was called to provide care to the patient in the Jersey Shore Hospital's ED. MR1 was transferred to a tertiary care center for continued care. Review of MR1 revealed a Cardiac Arrest Data Sheet. The area on page 2 of the Cardiac Arrest Data Sheet for Recorder Signature/Initials was completed by EMP13.

Interview with EMP13 on March 31, 2011, at 7:20 AM revealed EMP13 was assigned to be the recorder for codes on the night of January 24-25, 2011. EMP13 went to the ED when the code was announced. EMP13 stated they grabbed some paper and wrote down what the staff told EMP13 to record. EMP13 recorded onto a regular sheet of paper not on the Cardiac Arrest Data Sheet (code sheet). EMP13 stated that the patient's RN transcribed he recorder's notes onto the code paper. EMP13 stated they signed the code sheet prior to their notes being transcribed onto the sheet. EMP13 did not review the completed sheet after their notes were transcribed by the RN. EMP13 stated their training to be a recorder during a code consisted of someone telling them to write down what they tell you to write.

Cross Reference 485.638(a)(2) Records Systems

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the patient's medical record was incomplete for one of 15 emergency medical record reviewed (MR1).

Findings include:

Review on March 29, 2011, of the Jersey Shore Hospital's "Medical Staff Rules and Regulations," revised June 25, 2009, revealed "... 17. Medical Records: The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current. This record shall include identification data, chief complaint, personal history, family history, history of present illness, physical examination, special reports such as consultations, clinical laboratory and radiology services and others, provisional diagnosis, medical or surgical treatment ... "

Review of MR1 on March 10, 2011, revealed the patient presented to the Emergency Department (ED) on January 24, 2011, in respiratory distress. MR1 became unresponsive; a code was called; and cardiopulmonary resuscitation was initiated. MR1 was intubated. A chest x-ray completed following the intubation revealed "Indications: Intubated. Technique: An AP portable view of the chest was performed and compared with January 23, 2011. Interpretation: The cardiomediastinal silhouette is within normal limits. There has been interval placement of an endotracheal tube with its tip approximately 4 cm below the level of the clavicles. The tip of the endotracheal tube is at or near the carina. The costophrenic angles are clear bilaterally. The lungs are well aerated and clear. Impression: 1. Status post endotracheal tube placement. The endotracheal tube tip is near the carina and should be withdrawn by approximately 2-3 cm." Continued review of MR1 revealed no documentation that the endotracheal tube was withdrawn.

Interview on March 10, 2011, at 6:00 PM with EMP3 revealed that the endotracheal tube was adjusted by anesthesia when they arrived in the emergency department on January 25, 2011.

Interview on March 30, 2011, at 2:00 PM with EMP11 revealed when they arrived at the hospital on January 25, 2011, MR1 was already intubated. EMP11 listened to the patient's breath sounds, and there were sounds only on one side of the chest. EMP11 stated this finding indicated that the tube was too far down into the trachea. EMP11 then readjusted the endotracheal tube placement. After the adjustment, breath sounds were heard on both sides of the chest. EMP11 was not aware that a chest x-ray was performed. EMP11 stated that they utilize the physical examination to check for proper placement of endotracheal tubes.

Interview with EMP12 at 2:41 PM on March 30, 2011, revealed EMP12 was on call on the night of January 24-25, 2011. EMP12 received a call from the switchboard operator that they were needed stat for an intubation of a child in the ED. When EMP12 arrived, the patient was already intubated. EMP12 checked the ventilation bag and oxygen setting. The oxygen setting was at 100%. EMP12 listened to the patient's chest and heard bilateral breath sounds. EMP11 arrived in the ED after EMP12 and did an assessment of the patient. EMP12 stated that EMP11 then adjusted the endotracheal tube.

Interview with EMP2 at 11:00 AM on March 30, 2011, confirmed there was no documentation in MR1 indicating that EMP11 examined MR1 or adjusted MR1's endotracheal tube. The interview also confirmed there was no documentation in MR1 indicating that EMP12 examined MR1.

2) Review on March 30, 2011, of facility policy "Cardiac Arrest Data Sheet," last reviewed April 2010, revealed "Form Instructions for: Cardiac Arrest Data Sheet Expected Outcomes: To document patient care during a Code 99. Description of Form: These forms are supplied in every crash cart to be used in each Code 99. The patient addressograph is to be stamped in the upper right corner of the page. This form remains a permanent part of the record. ... When to Use This Form: In the event of a cardiac/respiratory arrest. Responsibility: The Code Team "Recorder" is responsible for the accurate recording of information on the Data Sheet. Standard Instructions: ... 9. Tubes ... d. Record any other tube inserted. 10. Outcome a. Record the time the arrest ended b. Check the box to indicate the status of the client c. Check the box to indicate why the resuscitation event was ended d. Obtain the signature and initials of the physician in charge 11. All participants involved with the arrest must sign their name, title ... and initials."

Review of MR1 on March 10, 2011, revealed the patient presented to the Emergency Department (ED) on January 24, 2011, in respiratory distress. MR1 became unresponsive; a code was called; and cardiopulmonary resuscitation (CPR) was initiated. During the code, MR1 required endotracheal intubation (used to maintain a patient's airway when they are unable to breathe on their own). The facility staff was unable to perform the procedure. An emergency medical services (EMS) was called to provide care to the patient in the Jersey Shore Hospital's ED.

Review of the Nurses' Notes revealed an entry dated February 1, 2011, "Late entry to chart for date 1/24/11". This revealed a medic from an EMS station was called. The medic arrived and placed an endotracheal tube to support respirations and an intraosseous site to administer fluids and medication. Review of the physician progress notes revealed an addendum note dated January 25, 2011, 1:06 AM. This revealed the paramedic intubated MR1.

Interview with EMP3 on March 10, 2011, at approximately 6:00 PM confirmed the paramedic from EMS inserted the endotracheal tube and intraosseous line.

Review of the Pennsylvania EMS Report noted a timeline of events. It was documented that an intraosseous pediatric line was inserted at 00:38 on January 25, 2011, by EMS. It was also documented that an orotracheal intubation was completed at 00:40 by EMS.

Review of MR1 revealed a Cardiac Arrest Data Sheet. Page two of the Cardiac Arrest Data Sheet contained an area for documentation of IV (intravenous) Sites, Tubes and Outcome. These areas were blank.

Interview with EMP2 at 11:30 AM on March 30, 2011, confirmed that the areas for documentation of IV (intravenous) Sites, Tubes and Outcome of the Cardiac Arrest Data Sheet were blank.


Cross Reference 485.638(a)(1) Records Systems