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Based on interview and record review, the hospital failed to ensure that nursing services were provided by competent staff, knowledgeable regarding their roles and equipment function during resuscitation, when Patient 1 required resuscitation, and he and four staff members inadvertently received an electrical shock from a defibrillator (a machine that delivers a therapeutic dose of electrical shock to the heart to allow the body's natural pacemaker to establish a normal rhythm when a patient has a life threatening cardiac rhythm) that was not clinically indicated. This failure resulted in prolonged injury of staff and may have contributed to Patient 1's death. This had the potential to also result in an immediate life threatening heart rhythm in both Patient 1 and the four staff members. This failure further placed patients whose condition declined to the point of needing resuscitation at risk for an ineffective clinical response that could result in patient death.


An Immediate Jeopardy (IJ) situation was declared on 3/5/14 at 3:15 pm with the Chief Executive Officer, Chief Medical Officer, the Chief Nursing Officer (CNO), and the Director of Risk Management. A plan to address the immediate safety of patients was presented by the CNO and accepted on 3/5/14 at 5 pm. The IJ was abated on 3/6/14 at 2:45 pm with the CNO.

The cumulative effect of these systemic problems resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation for Nursing Services.

Based on interview and record review, the hospital failed to ensure that adequate nursing services were provided for the resuscitation of Patient 1 by staff who were knowledgeable of their roles and the proper use of the defibrillator (a machine that delivers a therapeutic dose of electrical shock to the heart to allow the body's natural pacemaker to establish a normal rhythm when a patient has a life threatening cardiac rhythm) when Patient 1 required resuscitation, and he and four staff members (Respiratory Therapist (RT) H, Registered Nurse (RN) G, Nurse Practitioner (NP) I, and Emergency Room Technician (ERT) J inadvertently received an electrical shock from a defibrillator that was not clinically indicated.

An Immediate Jeopardy (IJ) situation was declared on 3/5/14 at 3:15 pm with the Chief Executive Officer (CEO), Chief Medical Officer (CMO), the Chief Nursing Officer (CNO), and the Director of Risk Management (DRM). A plan to address the immediate safety of patients was presented by the CNO and accepted on 3/5/14 at 5 pm. The IJ was abated on 3/6/14 at 2:45 pm with the CNO.

This failure resulted in prolonged injury of staff and had the potential to contribute to Patient 1's death. This failure had the potential to also result in an immediate life threatening heart rhythm in both Patient 1 and the four staff members. This failure further placed patients whose condition declined to the point of needing resuscitation at risk for an ineffective clinical response that could result in patient death.

Findings:

On 3/5/14, Patient 1's record was reviewed. Patient 1 was a 78 year old male, admitted on 2/22/14, for abdominal discomfort and chest pain. Patient 1's record contained nursing notes, dated 3/2/14 at 9:16 am, which indicated that Patient 1 had a low blood pressure for which he was receiving additional intravenous fluids (IV) when Patient 1 stated he needed the bathroom. Patient 1 was asked to wait until the IV fluids were completed and his blood pressure had improved. A short while later Patient 1 was found unresponsive, and partially out of bed. A Code Blue (resuscitation) was called at 9:34 am. Patient 1 was transferred to the intensive care unit at 9:54 am and the Code Blue continued until Patient 1 was pronounced dead at 10:35 am.

During an interview, on 3/5/14 at 10:30 am, CNO and DRM related unusual events during Patient 1's Code Blue. The code team and Physician E responded to Patient 1's room with CPR (cardiopulmonary resuscitation) in progress. Patient 1 was not yet connected to the monitor and pads were placed on Patient 1. DRM further stated that an unknown person charged the defibrillator (to enable it to provide an electrical shock) even though Patient 1 was not in a shockable rhythm and a shock had not been ordered by Physician E. The defibrillator was making a sound consistent with it being charged for a shock and Physician E requested it be turned off. RN F went to turn off the machine and inadvertently hit the red shock button. A shock was delivered to Code Blue team members: RT H, RN G, NP I, and ERT J; and Patient 1. DRM stated that they were unable to to determine who had charged the defibrillator.

On 3/5/14, the hospital policy, titled, "Code Blues/Code Whites Occurring in Patient Care Areas: Response/Responsibilities," last approved on 8/2009, read, "Pages over head announce ... "Code Blue"... An Emergency Department (ED) physician responds...the nurse in charge remains at bedside, pharmacists, EKG tech, lab, and respiratory care practitioners respond ... a minimum of two critical care RNs and/or ED RNs respond... house supervisor responds... In the absence of a qualified physician, RNs possessing current Advance Life Support Cards may implement appropriate protocols..." The policy outlined duties of the team leader (physician or RN) and the house supervisor. Other Code Blue team members did not have defined roles in the policy or methods to determine who would respond or if all practitioners were to respond to a Code Blue.

During a survey conducted by the California Department of Public Health on 2/18 to 2/21/14, the hospital had identified deficiencies with several Code Blue practices including the incorrect use of the defibrillator by nurses responding to codes and inaccurate interpretation of cardiac rhythms. On 3/5/14 at 12:50 pm, CNO stated that they had taken actions to educate nurses during each shift starting on 2/19/14 and ongoing on the correct use of the defibrillator with a return demonstration. CNO confirmed that all of the nurses who responded to Patient 1's Code Blue had this training. CNO stated the medical staff, nurse practitioners and physician's assistants were not included in this training. CNO further reported that mock Code Blues had been performed on several units as part of the hospital's plan of correction for the survey ending on 2/21/14. CNO stated education on cardiac rhythm recognition was under way for all ACLS (Advanced Cardiac Life Support) certified nurses. CNO reported that some nurses were sharing the answers to the test. Subsequently, the cardiac rhythm recognition test was reconfigured and all the nurses were in the process of retaking the test to ensure competency. CNO stated that many nurses were required to have additional training because they were not able to pass the test. When asked what actions she had taken in light of the above event involving Patient 1, CNO stated that she had not yet taken any further actions to protect patients since Patient 1's Code Blue on 3/2/14, three days earlier.

A review of the five mock Code Blue evaluations conducted on 2/20, 2/25, 2/26, 2/27, and 3/3/14, noted lessons learned included: staff needed to be familiar with the crash cart and connecting the patient to the monitor, staff needed to be empowered to speak up if unfamiliar or disagree with the assessment/treatment, staff needed to be assigned roles during the Code Blue, staff not following the ACLS (Advanced Cardiac Life Support) procedures, and communication needed to be improved.

On 3/5/14 from 12:30 to 3 pm, staff involved in Patient 1's code were interviewed (Admin Nurse A, RN G, RN L, RN M, and Physician E) and had similar accounts of the above events involving patient 1. Four of these five interviews indicated that there were too many people responding to the Code Blues causing it to be loud and crowded, and complained of a lack of defined roles for the responders. RN M recalled the training she had received on the defibrillator recently and stated it did not include charging or removing a charge as indicated in the administrative education plan. None of these interviews disclosed who had charged the defibrillator without a physician's order or that a shockable rhythm was present. Physician E stated that shocking staff and patients when it was not clinically indicated could result in a lethal arrhythmia (heart rhythm).

On 3/5/14 at 3:15 pm, an Immediate Jeopardy situation was declared with CEO, CMO, CNO, and DRM due to widespread competency issues identified for Code Blue Response and the failure of the administrative staff to take immediate action to prevent patient and/or staff harm stemming from the failure to accurately identify cardiac rhythms and implement the appropriate ACLS protocol, and the failure to use the defibrillator accurately. On 3/5/14 at 5 pm, a plan of correction was presented by the CNO and accepted by CDPH (California Department of Public Health) which immediately implemented assigned Code Blue Team members with specific roles. These Code Blue Team members were restricted to well experienced intensive care nurses that were ACLS certified performing in the role of using the defibrillator and giving medications. A communication plan was developed to inform all staff, including members of the medical staff, of the above plan of correction. On 3/6/14 from 1:30 to 2:45 pm, observations of a mock code and staff interviews revealed that the plan of correction was effectively implemented and the IJ was abated at 2:45 pm.