HospitalInspections.org

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Based on interview, document review, and review of hospital policy and procedures, the hospital failed to ensure that staff took appropriate emergent action to respond to patient needs for 1 of 1 patients reviewed (Patient #1).

Failure to ensure staff take appropriate immediate action to respond to a patient's emergency medical needs risks delays in activating the hospital emergency response system and initiation of treatment.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Cardiopulmonary Resuscitation Code Blue," PolicyStatID 16028862, approved 07/24, showed that:

a. The purpose of the policy is to ensure the immediate provision of basic life support (BLS) and advanced cardiac life support (ACLS) by trained caregivers in the event of cardiopulmonary arrest anywhere on the hospital grounds of PeaceHealth Southwest Medical Center.

b. The first responder will call for help and code team activation and will initiate basic life support (BLS) for the patient.

c. All Code Blue documentation will be completed within the electronic medical record (EMR) by the Rapid Response Nurse (RRT).

Document review of the hospital policy titled, "Cardiac Arrest (Code Blue) Procedure," showed that the first responder will identify that the victim is unresponsive, breathless or pulseless, call for assistance and initiate BLS protocol.

2. On 11/14/24 at 10:55 AM the investigator and the Clinical Risk Management Director (Staff #1), a Risk Manager (Staff #2), the Chief Nursing Officer (Staff #3), the Surgical Services Director (Staff #4), the Surgical Services Manager (Staff #5), and the Rapid Response Team Manager (Staff #6) reviewed video footage recorded in the hospital's main lobby on 09/11/24.

The review showed:

a. At 11:20 AM, Patient #1, sitting in a wheelchair accompanied by her mother and a staff member (Staff #8).

b. At 11:21 AM, Patient #1's body posture became limp, her head slumped backward, and her eyes closed. Patient #1 appeared to be unresponsive. Staff #8 did not assess Patient #1 for airway, breathing, or circulation (ABC), as prescribed by Basic Life Support (BLS) protocol.

c. At 11:22 AM, Patient #1 briefly opened her eyes and straightened her head before her body posture again became limp with closed eyes and her head slumping to the side. Staff #1 did not perform an ABC assessment for Patient #1.

d. At 11:24 AM, Patient #1's still appeared unresponsive. Patient #1's father came through the hospital entrance doors, looked at Patient #1, appeared to say something, and rushed away. Staff #8 did not perform an ABC assessment for Patient #1.

e. At 11:26 AM, two unidentified staff members pushing a code cart (cart containing emergency resuscitation supplies) arrived. No staff member performed an ABC assessment for Patient #1. Two unidentified staff members pushed Patient #1 in the wheelchair out of the hospital entrance as rapid response team members appeared on scene.

3. On 11/14/24 between 9:30 AM and 11:00 AM, the investigator conducted a group interview with the Clinical Risk Management Director (Staff #1), a Risk Manager (Staff #2), the Chief Nursing Officer (Staff #3), the Surgical Services Director (Staff #4), the Surgical Services Manager (Staff #5), and the Rapid Response Team Manager (Staff #6). The interview showed:

a. Staff #1 had current Basic Life Support (BLS) certification.

b. It is an expectation that BLS certified staff perform ABC assessments for unresponsive patients in emergent situations.

c. It is an expectation that the Code Blue team respond to patient emergencies in the hospital main lobby. It was unclear which staff member called for a rapid response rather than a Code Blue (emergent response for any person who might be experiencing cardiac arrest).

d. There was no documentation of the Rapid Response or Code Blue event prior to Patient #1's arrival in the Emergency Department.

e. The hospital does not hold Code Blue drills for public areas.

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Based on interviews, document review, and review of hospital policy and procedures, the hospital failed to implement its policies and procedures to ensure that post-anesthesia care (PACU) registered nurses (RNs) documented a full set of vital signs prior to discharge for 1 of 4 same day surgery patients (Patient #1) reviewed.

Failure to ensure that staff follow approved policies and procedures for patient discharge risks unsafe discharge and patient harm.

Findings included:

1. Review of the hospital document titled, "PeaceHealth Nursing Care Standards (NCS) 2024," no #, no date, showed that RNs will assess and document patients' blood pressure, heart rate, respiratory rate, SpO2 (oxygen saturation), and temperature prior to discharge.

2. The investigator reviewed Patient #1's medical record created on 09/11/24. The review showed that Patient #1 had no respiratory rate documented prior to discharge.

3. On 11/14/24 at 2:30 PM, the investigator interviewed the Surgical Services manager (Staff #4), who confirmed the missing information and stated that taking and documenting a full set of patient vital signs prior to discharge is a department expectation.

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