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Based on observation, interview, and record review the facility failed to maintain an accurate and complete medical record for 3 out of 3 patients review for code blue documentation. (Patient #1, #4 and #5)


Findings include:

Record review documented that Patient #1 was admitted to the facility on 5/9/2023 with the following diagnoses: Neck pain and herniated cervical disc.

Review of the medical record documented that Patient #1 had a anterior cervical discectomy and fusion ( ACDF) on 5/9/2023.
Review of the Adult Emergency Intervention and Medical record form with no date reads, " Time event recognized 2341 ( 11:41 PM), Rapid response arrival time 2343 ( 11:43 PM), Provider arrival time 2343 (11:43 PM).Start time of chest compressions 2341(11:41 PM) , time of defib ( defibrillation) pads applied 2343 ( 11:43 PM) . No cardiac rhythm was documented beginning at 2342 ( 11:42 PM), 2343 ( 11:43 PM comments No pulse, no cardiac rhythm documented. 2347 ( 11:47 PM) comments Narcan 2 mg, no route documented, 2348( 11:48 PM) comments 1 liter bolus, no drug or route documented, 2350 ( 11:50 PM) comments: Vecuronium 10mg, no route documented, 2352 ( 11:52 PM) comments Levo ( Levophed) drip start, no amount or route documented, May 10: 0000 ( 12 midnight) Bicarb ( Sodium Bicarbonate) 50 meq ( milliequivalents) no route documented, 0002 ( 12:02 Am) comments: Levo ( Levophed)/Epi ( epinephrine) drips continue, there are no amounts or routes documented, 0010 ( 12:10 AM) comments: Vecuronium 10mg, no route documented, 0013 ( 12:13 AM) comments: Bicarb 50 meq no route documented, 0017 ( 12:17 AM) comments: Calcium 1 gram no route documented, 0020 ( 12:20 AM) comments: Bicarb 50 meq no route documented,0021 ( 12:21 AM) comments: Calcium 1 gram no route documented and there were no attempts at intubation documented.

Review of the Code Blue Event Report dated 5/10/2023 reads, Post code note. Reason code was called respiratory failure, PEA ( pulseless electrical activity), initial rhythm pulseless electrical activity,
Airway management being bagged on arrival, multiple attempts to secure airway during code
chest compressions in process upon arrival, Comments code blue event please refer to codes physical documentation for timesheet and specific details. During the early hours of 5/10/2023 the ICU responded to an emergent code blue broadcast. On arrival healthcare members already performing CPR CardioPulmonary Resucitation) via compressions and valve bag mask. Initial rhythm of PEA ( Pulsess Electrial Activity). After 2 rounds and one dose of epinephrine ROSC was achieved with patient blood pressure 140s over 80s. By this time both respiratory therapy and advanced practitioner were not able to secure airway given significant neck and airway edema. Minutes later patient again in PEA and CPR restarted. Intensivist attempting to secure airway, ROSC ( Return of Spontaneous Circulation) achieved, but patient again pulseless minutes later. After unsuccessful attempt to obtain and endotracheal intubation, cricothyrotomy was attempted, Also unsuccessful given significant edema and tracheal displacement. Further attempts for endotracheal intubation with different ET sizes, blades, stylets without success."

Review of the medical record documented that Patient #4 was admitted on 4/5/2023 with the following diagnoses: Acute ST elevation Myocardial Infarction ( heart attack), Diabetes type 2, acute metabolic acidosis, Renal failure and hyperkalemia.

Review of the Adult Emergency Intervention and Medical record form reads, " 4/5/2023 at 0044 ( 12:44 AM) Calcium, no dosage or route documented, 0049 ( 12:49 AM) comments: BIcarb no dosage or route documented and 0053 ( 12:53 AM) comments 1 G Mag ( Magnesium) no route documented."

Review of the medical record documented that Patient #5 was admitted on 4/10/2023 with the following diagnoses: COPD Chronic Obstructive Pulmonary Disease), diabetes, hypertension, hyperlipidemia, tardive dyskinesia, schizoaffective disorder, bipolar disorder, OCD (Obsessive- Compulsive Disorder) , anxiety, recurrent hyponatremia, bilateral pneumonia and bilateral pleural effusions.

Review of the Adult Emergency Intervention and Medical record form dated 4/14/2023 reads," Date 4/14/2023, Time event recognized 2213 ( 10:13 PM) , Start of chest compressions 2213 ( 10:13 PM), Time defib pads applied 2213 ( 10:13 PM) . No other details are documented on the sheet except the times of 2213 ( 10:13 PM) and 2214 ( 10:14 PM). No comments, no rhythm, no blood pressure. Time rescue event ended was documented as 2230 ( 10:30 PM). "

During a telephone interview on 5/25/2023 at 8:00 AM Medical Doctor #1 stated, " When I arrived he ( Patient #1) was blue and you know he was not breathing and he was blue. CPR( CardioPulmonary Resucitation) was being done and we were having a hard time bagging him. The NP ( nurse practitioner) was lead in the code, when I arrived, the NP tried to get the airway initially, but his neck was swollen. He was post ACDF, his neck was swollen, tried can't get the blade into his mouth initially, he was inflexible and somehow his mouth was restricted. We couldn't see anything, due to swelling, but we continued CPR. We attempted Nasal trumpets and couldn't get any type of airway to mouth. He was very difficult to bag, we attempted multiple times to intubate and get an airway during the interruption of CPR to pulse check. I tried, my first attempt, I struggled , nothing could be seen with glide scope, I believe we attempted, probably tried a total of 4-5 attempts, after 5 attempts or so the patient remained purple and I attempted the cricothyrotomy ( an incision made into the neck to place a tube into the trachea) , but his neck was so swollen, need landmarks, need to feel the Adams apple. I suspected deviated trachea, did not believe that his trachea was midline due to the swelling and inability to visualize cords ( Vocal cords) when attempting to intubate him. I did not document the times or number of attempts that I made, or the team made to intubate him so I can't tell you the exact amount of times. We should have an accurate record, that should have been documented."



During an interview on 5/25/2023 at 9:16 AM Staff A, Registered Nurse( RN) stated, "The patient ( Patient #1) was having CPR ( cardiopulmonary resuscitation)in progress when we got to the room, his skin was mottled and blue and there was heavy edema in his neck. There was a large dressing covered in blood, and the whole dressing was saturated. He had trismus ( lockjaw, restricted mouth opening) and his airway management was a BVM. We had difficulty obtaining an airway with multiple attempts by the physician and nurse practitioner. I did complete the code sheet and should have documented attempts at intubation and any other treatments, how they are delivered and how much. When a code is called as the RRT ( rapid response team) nurse, we will document the code events. I do not see that any cardiac rhythm was documented , when the Levo and epi drips were hung or at what rate they were hung. These should be documented. "

During an interview conducted on 5/25/2023 at 11:05 AM the Director of Patient Safety stated, " The code blue documentation should be completed with cardiac rhythm, the route and dosage of medications. There is no documentation of attempts at intubation or at the attempt to cric the patient ( Patient #1)."

Request for a policy and procedure for Code Blue documentation was not provided to the survey team prior to exit from the facility.