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Based on staff interviews, medical record reviews, and policy/procedure review, the facility failed to ensure a complete and accurately documented medical record was maintained for one (1) of three (3) medical records reviewed on two (2) of two (2) days of survey; Patient #1.

Findings Include:

Interview with Chief Quality Officer, Risk Manager, and Assistant Chief Nursing Officer on 01/18/2022 at 4:45 p.m. confirmed there is no documented evidence in Patient #1's medical record of the nurse documentation of the "Code BLUE" intervention on form "Emergency Cardiopulmonary Record" for Patient #1 that was performed on 01/02/2022.

Review of the medical record for Patient #1, revealed there was no documented evidence of the facility form, "Emergency Cardiopulmonary Record" for the "Code BLUE" incidence that occurred on 01/02/2022 at 10:20 a.m.

Review of the "Code BLUE" - "Cardiac/Respiratory Arrest Policy", Policy # 601; effective date 01/1992 and reviewed/revised 09/2019 states at " ...7. c. The patient's attending nurse or designee will ...document and sign as appropriate actions during the Code BLUE on the Emergency Cardiopulmonary Record ...".

During Exit conference on 01/19/2022 at 3:00 p.m., survey findings were discussed, and no further documentation was submitted for review.