HospitalInspections.org

Based on policy review and staff interview, the facility failed to assure the policies and procedures of the CAH were reviewed annually. This failed practice had the potential to affect all patients of the facility. There were 517 inpatients, 683 surgical patients and 1,876 Emergency Department (ED) patients at the facility for Fiscal Year Ending 2023.

Findings are:

A. Review of the following policies and procedures revealed:

-Anesthesia Standards of Care last reviewed on 7/22/2020
-Anesthesia Safety Program last reviewed on 4/12/2019
-Anesthesia Scope of Service last reviewed on 4/12/2019
-Anesthesia Policy last reviewed on 4/30/2019
-Surgery Department Policy last reviewed on 7/22/2020
-Sterile Gowning and Gloving Procedure last reviewed on 7/1/2019
-Aseptic Technique last reviewed on was left blank
-Surgical Hand Scrub Technique last reviewed on 7/2/2019
-Sterile Processing Department Policy last reviewed on 12/18/2020
-Surgery Turnover Cleaning Procedure last reviewed on 7/2/2019
-Surgical Count Policy last reviewed on 5/24/2019
-Acceptable Operating Room Attire Policy last reviewed on 4/3/2019.

B. Interview with Surgery Manager and Quality Specialist (5/8/2024 at 10:22 AM) confirmed that above policies and procedures were not reviewed annually, and Quality Specialist stated, "These policies have not been reviewed in a long time."

Based on policy review, medical record review, Advanced Cardiovascular Life Support (ACLS) algorithm review and staff interview the facility failed to ensure that 1 of 2 expiration medical records (Patient 19) reviewed had complete documentation of a code (medical emergency where the patient has no pulse and/or is not breathing, requiring life sustaining intervention). This failed practice has the potential to cause harm or death to all patients who present to the CAH. There were 517 inpatients, and 1,876 Emergency Department (ED) patients at the facility for Fiscal Year Ending 2023.

Findings are:

A. Review of policy titled Code Blue (last approved on 5/26/2022) revealed the recorder role in a code is to, "record assessment and interventions on the code blue record and reviews the record for completeness and obtains appropriate signatures as the completion of the code."

B. Review of Patient 19's medical record (5/9/2024 at 10:27 AM) revealed an inpatient admission on 2/5/2024 - 2/7/2024 for Shortness of Breath (difficulty breathing) and Influenza B (viral lung infection). Review of the entire medical record lacked evidence of a complete documented recorded timeline and interventions of the 2/7/2024 1:00AM code. The facility documented Patient 19 time of death as 2:03AM.

C. Review of the Adult ACLS algorithm from the facility inpatient crash cart revealed the timeline of interventions to follow during a code. Review of the entire medical record lacked evidence of a complete documented recorded timeline and interventions of the 2/7/2024 1:00AM code.

D. Interview with the Chief Nursing Officer (CNO) (5/9/2024 at 11:11 AM) confirmed patient 19's medical record lacked evidence of a complete documented timeline and interventions of the 2/7/2024 1:00AM code.