HospitalInspections.org

Based on interview and document review, the facility failed to ensure staff competence to implement protocols for life-saving procedures for 1 of 1 patient (P1). This resulted in an immediate jeopardy (IJ) for P1 who died from a cardiopulmonary arrest. Additionally, the facility failed to ensure appropriate suicide precautions and interventions were assessed and in place for 1 of 10 sampled resident (P10) reviewed.

The IJ began on 11/1/18 when staff failed to implement protocols for life saving procedures. The IJ was identified on 12/21/18 and the hospital administration were informed of the IJ at 4:30 p.m. 12/21/18. The immediate jeopardy was removed on 12/24/18 at 1:45 p.m..

Findings include:

A complaint was received by the Minnesota Department of Health related to hospital staff not providing adequate or timely treatment to a patient (P1) awaiting transfer to another hospital. The staff's delayed treatment response time needed for lifesaving measures resulted in death.

Review of the medical record for P1 revealed he was admitted to the emergency room on 11/1/18 at 11:53 p.m. with complaints of anxiety and left arm pain for most of the day. P1's weight at admission was 122.2 kilograms (kg) (269 pounds, 6.4 ounces). An electrocardiograph (EKG) was performed at that time. The EKG showed P1 was having a ST-segment elevation myocardial infarction (STEMI). Staff immediately placed 2 large bore intravenous (IV's) access and defibrillator (machine to give shock in emergency) pads were applied to P1's chest. Aspirin (ASA) and nitroglycerin were started per the facility's standing orders for STEMI protocol. Laboratory values were drawn and an X-ray was obtained. The documentation indicated emergency medical services (EMS) staff arrived onsite after they were called and had arrived within 2 minutes. The notes further indicated the EMS crew had arrived and were in a room alone with P1, readying him for transport, when P1 had gone into a dangerous cardiac rhythm, ventricular fibrillation (V-fib), at approximately 12:15 a.m. followed by cardiac arrest.

The medical record logs described the sequence of events as follows:
(1) 12:22 a.m. (11/2/18), P1's initial defibrillating shock was administered and compressions commenced.
(2) 12:26 a.m., RSI began with the administration of etomidate (anesthetic agent with an onset of less than 1 minute, limited to 1 dose lasting 5-10 minutes) 20 milligrams (mg) IV push (IVP). Dosing is between 0.2 mg to 0.4 mg/kg. (Based on P1's weight, he should have received 24 mg to 49 mg.)
(3) 12:27 a.m., Succinocholine (succs, a muscle relaxer with an onset of 45-60 seconds lasting 5-10 minutes) 100 mg IVP was given. Dosing is 1 to 1.5 mg/kg. (Based on P1's weight, his dose should have been 122 mg to 183 mg.)
(4) 12:29 a.m. an additional 50 mg dose of succs was given IVP.
(5) 12:30 a.m., 1 mg of epinephrine (epi) was administered IVP, 8 minutes after the first initial shock.
(6) 12:31 a.m., a 3rd dose of succs, 50 mg IVP was given.
(7) 12:33 a.m., a second dose of etomidate was given, 20 mg IVP, seven minutes after the 1st dose. There was no indication why a second dose of anesthetic was required as it is recommended limited to one dose.
(8) 12:35 a.m. P1 received a second shock, 12 minutes after the initial shock.
(9) 12:37 a.m., P1 was finally intubated.
(10) 12:40 a.m., P1 was given 300 mg of amiodarone, 18 minutes after the first shock was given and an nasogastric (NG) tube was placed, along with a suctioning endotracheal (ET) tube.
(11) 12:41 a.m. P1 received his second dose of epi 1 mg IVP, 11 minutes after the first dose.
(12) 12:45 a.m. Time of death was called. Documentation indicated the code lasted approximately 1/2 hour. There was no mention of the hospital's STEMI protocol being completed prior to P1's arrest.

Review of P1's 11/2/18, ED (emergency department) provider note written by nurse practitioner (NP)-A revealed NP-A had called the [transfer hospital cardiac catheterization (cath) lab] at 12:15 a.m.. The note further indicated: [P1] had a sudden arrest on the bed with staff and ambulance crew in the room. Immediate CPR began and a shock was given. CPR continued. Medications for RSI prepared and given along with epi and amiodarone as recorded. Pt (patient) was intubated using glidescope (video equipped intubation). Another shock was given per recording. P1 was unresponsive to any treatment and attempts at resuscitation and was pronounced dead at 12:45 a.m. his wife was contacted immediately and arrived while staff was working on patient. She was informed of the death and declined to see P1. She called family and left for home.

Review of P1's EKG revealed it was taken at 12:03 a.m. and signed by the provider at 12:09 a.m.. The EKG showed P1's heart rate was 98 and he was in normal sinus rhythm with ST elevation.

Review of the August 2018 Fast Track STEMI Work Aid revealed:
(1) STAT 12 lead EKG, BRIEF HISTORY AND EXAM.
(2) Call [transfer hospital]. They will connect ED with cardiologist and assist in arranging transport.
(3) Fax EKG to [transfer hospital].
(4) If onset over 2 hours give Heparin (blood thinner) infusion and administer Plavix (blood thinner).
(5) Transfer patient directly to [transfer hospital]. P1's record did not include any mention as to whether heparin or Plavix were given by the STEMI protocol, provided as a standing order by the receiving hospital.

Review of P1's 11/2/18, Physician Certification of Transfer revealed P1 was being transferred as he was over level of care and required testing that was not performed at the facility. P1 was deemed at risk for deterioration from or during transport. P1 required advanced level transport. P1 signed the consent at 12:15 a.m. on 11/2/18.

During observation of the ED, the ED director (ED)-A and medical director (MD)-B were interviewed. On 12/19/18 at 12:30 p.m., the ED was observed to consist of 2 trauma bays (1 pediatric and one adult). Inside the adult trauma bay was a crash cart, placed directly behind the bed. Medications contained inside the cart were listed on the outside of the cart for easy access. ED-A stated nursing staff were trained upon hire, annually and as needed and an orientation checklist was reviewed with staff upon hire and completed before they would work independently [without a mentor]. MD-B said a concern regarding care had been brought to his attention in November 2018. MD-B said the concern had been reported by NP-C who had reported P1's wife had advised her she didn't think the ED staff had made attempts long enough to revive P1 following a cardiac arrest. MD-B stated both he and ED-A had reviewed P1's medical record and had spoken with staff. MD-B and ED-A said they'd made the determination staff had responded appropriately, in a timely manner, and identified no concerns.

During interview on 12/21/18 at 11:00 a.m., registered nurse (RN)-A stated she'd been a nurse at the facility for almost 2 years, an had 11 years of experience working in an ED. RN-A stated the other RN on duty with her 11/2/18, was RN-B who was a new nurse to the ED with 1-2 years at the facility. RN-A stated, "Prior to that, he worked at a nursing home for 1 year after receiving his RN degree." RN-A stated P1 had arrived at the facility on 11/1/18 just before midnight, and had presented with STEMI type symptoms so an EKG was preformed. NP-A was sleeping in the physician call room. RN-A woke NP-A up and NP-A immediately went to the ED. EMS happened to be onsite across the hall from the ED. Once it was decided to transfer P1, both RN's were out at the nurses' station copying information for the EMS crew and transfer facility. NP-A was on the phone with the cardiologist.
RN-A stated while she and RN-B were at the nurses' station, the cardiac monitor alarm sounded. RN-A said P1 had gone into cardiac arrest and both ED nurses ran back into the room. EMS had been present in the room when P1 went into cardiac arrest and had also yelled for staff. The crash cart was closest to RN-B on the left side of the bed so he would hand RN-A medication. RN-A recalled giving 1 shock to P1, but stated she was concentrated on giving medications from the right (R) side of the bed. RN-A did all the RSI medications and ACLS medications. RN-A said RN-B was quite nervous and inexperienced, and that this incident was only the second code blue situation he'd ever been part of. RN-A described RN-B, "He was frantic, unsure, and fairly new at that time." RN-B had grabbed a bottle of some type of liquid from either the cart or cupboard and tried drawing up the medication from the vial. RN-A told him that was the wrong medication. RN-A could not recall what medication RN-B was attempting to draw up. RN-A told RN-B to get the prefilled syringes of epi. RN-A had to retrieve the prefilled syringes of epi from the cart as RN-B could not find them. RN-A stated she'd had to give RN-B a lot of direction. Further, RN-A confirmed she did not call a code blue. She said 3 medical-surgical nurses arrived in the emergency room around the same time and lab and X-ray were at the ED already.

Continued interview with RN-A revealed, 1 med-surg nurse assisted with intubation, 1 nurse was doing compressions with the EMS crew, and 1 nurse was writing code information down. Normally, ED staff would have called a code. No other MD or provider was in the emergency room. The facility does have a Hospitalist available daily. RN-A was unsure why shocks were delayed at 12/13 min apart. She was trying to shock and give medication at the same time as giving RN-B orders. RN-A also had to insert P1's NG-tub. RN-B was deemed independent to work without a mentor along side him as he had passed orientation. Staff are given a checklist to complete. No competencies are done to ensure staff are able to perform duties independently. RN-A felt RN-B was too new to ED to work independently. Heparin was not given per standing order as NP-A gave direction to hold off until she spoke with the cardiologist in the cath lab at the transferring facility. There was no documentation in P1's medical record indicating why the heparin was not started according to protocol. Once the heparin would be started, EMS would take the patient away to the transferring hospital. She agreed that delayed P1 from leaving the facility timely with EMS.

Interview on 12/21/18 with RN-B regarding the events surrounding P1's cardiac arrest revealed upon P1's arrival to the facility, RN-B hooked P1 up and preformed an EKG. After the EKG, when staff knew P1 was to be transferred, RN-B was assisting RN-A at the desk gathering and faxing P1's medical information to the transfer facility. RN-B saw P1 "code". RN-B ran into the room. EMS began CPR on P1. RN-B remembers attempting to place the backboard under P1 to use the automated Lucas compression machine. RN-B felt P1 was too large in size for the Lucas. After staff began the initial CPR, RN-B tried to administer P1 ACLS medication but had forgotten where the medication was as that was only his second time he had been involved with a code blue. RN-B located a bottle of epi, but RN-A told him that was the wrong medication. RN-A then grabbed the prefilled epi medication from the crash cart and administered the medication. RN-A was administering medications on P1's right side. RN-B had not felt comfortable performing the ACLS protocol independently so he waited for all instruction from RN-A. RN-B verified RN-A had a difficult time placing P1's NG-tube. RN-B remembered 1 nurse was suctioning and RN-A had delivered the second dose of epi as well. RN-B said he felt comfortable being the 2nd nurse and being told what to do, but had not felt comfortable performing on his own independently with the team. RN-B was worried about what to do from lack of experience. RN-B has not had another code blue happen since that day

Review of RN-B's employee file revealed he began employment in early September, 2017. RN-B's orientation checklist revealed he had 3 classifications to his orientation. 1 was having been exposed to the information, 2., performing with assistance and 3., performing without supervision. With regard to critical areas of cardiac and respiratory arrest and RSI, RN-B was exposed to the information 9/20/17. Areas of performing with assistance that were left blank included defibrillating, cardioversion, and pacing of a patient's heart rhythm, airway management, and code blue documentation. RN-B could perform those duties independently without supervision 2/2/18. There is no indication how RN-B was determined to work independently in a life-threatening situation.

Review of the 2011, American Heart Association, Advanced Cardiac Life Support provider manual revealed:
(1) On page 21, "Not only should everyone on the team know his or her limitations and capabilities, but the team leader should also be aware of them. During the stress of an attempted resuscitation, do not practice or explore a new skill. If you need extra help, request it early."
(2) On page 26, "Successful resuscitation following cardiac arrest requires an integrated set of coordinated action. Immediate recognition of cardiac arrest and activation of the emergency response system, early CPR with emphasis on chest compressions, rapid defibrillation, and effective advance life support. To improve care, leaders must assess the performance of each system component. Only when performance is evaluated can participants in a system effectively intervene to improve care."
(3) On page 31, "The best way to improve a patient's chance of survival from cardiorespiratory arrest is to prevent it from happening. The majority of cardiorespiratory arrests in hospitals should be classified as 'failure to rescue' rather than an isolated, unexpected random occurrence. Actions and interventions need to be proactive with the goal of improving rates of morbidity and mortality rather than reacting to a catastrophic event."
(4) On page 61, Adult cardiac arrest steps are as follows:
a. Activate the emergency response system.
b. If the rhythm is shockable (ventricular fibrillation or tachycardia), deliver a shock.
c. Perform CPR for 2 min.
d. If rhythm is shockable, shock, and administer epinephrine every 3-5 minutes while considering an advanced airway.
e. If the rhythm is shockable after another 2 minutes of CPR, deliver another shock followed by administering amiodarone.
f. If rhythm shockable, shock, and administer epinephrine every 3-5 minutes.
g. Continue the process.
(5) On page 77, an EKG should be performed to identify those patients with a STEMI. Once identified, EMS personnel should transport these patients to a facility that reliably provides cardiac reperfusion (medical treatment to restore blood flow, either through or around blocked arteries, typically after a heart attack, with surgery or drugs).

Interview on 12/21/18 at 12:30 p.m., with ED-A regarding the events surrounding P1's cardiac arrest revealed the expectation for staff to be deemed competent is passing their orientation. There were no competencies performed on staff to ensure they were capable of handling the life-threatening situation. RN-B had attended ACLS classes and worked with a mentor only during orientation. After completion of orientation, RN-B was expected to perform independently. ED-A was unsure why the ACLS protocol for cardiac arrest was not followed. It was her expectation it should have been and staff were competent in that task.

Review of the March, 2018 Code Blue policy revealed staff were to immediately activate an overhead page of "code blue." Licensed staff were to immediately implement ACLS standards. All staff, trained in CPR should attend codes to ensure sufficient response. The on-duty charge nurse from Med-Surg and other available licensed staff shall respond to the code blue location.

Review of the October 2018, Job Description Emergency Room Registered Nurse policy revealed the RN was to recognize and intervene when pertinent patient changes occurred, and was able to perform in crisis or complex situations grasping the problem and managing team work.

Review of the current Bylaws of the Medical Staff of Rivers Edge Hospital and Clinic revealed there was no mention of how the facility was ensuring staff competence.

Review of P10's medical record indicated P10 arrived by EMS on 10/23/18 at 8:17 a.m.. P10 was found outside down by a pond. P10 responded only to pain. EMS found an empty pill bottle and 1/2 liter of vodka. P10's family member was called, P10 had a history of suicide attempts x 2. P10's parents were out of town. P10 was taking antidepressants and sleep medication. P10 had eyes open with verbal responses at 10:08 a.m. P10 stated he needed to use the bathroom, but was informed he had a urinary catheter in place. P10 was drowsy but awake and verbal at that time. There was no mention in the medical record what steps were implemented to keep P10 safe while in the ED until his discharge at approximately 120 minutes after arrival per documentation. P10's diagnoses were hypothermia, drug overdose, intentional self harm, toxic effect of alcohol, and history of major depression, suicide attempt. There was no documentation to support a suicide assessment had been performed, or 1:1 observation was performed.

Review of the March, 2018, Care of Psychiatric Patient policy revealed, should the patient be suicidal, the ED staff will provide 1:1 coverage to prevent any harm and keep the patient safe on a temporary basis until transfer arrangements had been made.

The IJ which began on 11/1/18, was removed on 12/24/18 at 1:45 p.m., when it could be verified through observation, interview, and document review, the facility had reviewed hospital protocols, took steps to re-educate staff and verify competencies for rapid sequence intubation (RSI), advanced cardiac life support (ACLS) and code blue policies, and had developed measures to verify ongoing competence.