HospitalInspections.org

Based on interview and record review, the hospital failed to ensure nursing staff followed the hospital's policies for one (Patient 1) of 30 patients when:

1. The Code Blue sheet was incomplete and there was no evidence of attached rhythm strips (electrical activity of the heart traced on paper) documenting the events of the code blue (medical emergency - cardiac [heart] or respiratory [breathing] arrest [stoppage or sudden cessation of motion]).

2. The order for Rhythm strip was not implemented.

These failures had the potential to affect the health and safety of the patient.

Findings:

1. During a review of Patient 1's medical record, dated 2/5/23, Patient 1 arrived in the emergency department (ED) on 2/5/23 at 4:05 a.m. for chest pain. Patient 1 was triaged at 4:25 a.m., given a priority of ESI 3/ Urgent (emergency severity index, a tool that stratifies patients into five groups based on acuity and resource needs). Patient 1 was treated in the ED and admitted to a monitored bed at 9:30 a.m. Patient 1 remained in the Emergency Department, in the hallway on a portable monitor waiting for a room assignment. At 12:29 p.m. Patient 1 complained of chest pain. At 12:38 p.m. Patient 1 was found unresponsive by the physician. When the nurse checked the patient, the cardiac monitor showed ventricular fibrillation (a life threatening heart rhythm that results in a rapid heartbeat), he was moved into an Emergency Department room and resuscitated (brought back to life).

Review of Patient 1's "Code Blue Resuscitation Sheet", dated 2/5/23, indicated incomplete and missing documentation including but not limited to: "Time of arrest, initial vital signs, procedures performed: intubation, ventilation, SBAR of event, signatures for medication RN, Respiratory therapist, and transfer to information".

During a concurrent interview and record review on 3/7/23 at 1:17 p.m. Patient 1's medical record was reviewed with the Director, Emergency Services (DES), the DES stated she "would expect the code blue record to be completed", the DES acknowledged Patient 1's Code Blue record was incomplete". The DES also acknowledged there was no evidence of rhythm strips or code summary recorded.

Review of the facility's policy "Code Blue Initiation and Resuscitation Procedures of an Adult", revision date 12/22, indicated "The Code Blue resuscitation record must be completed on all resuscitations". "Within 30 minutes of code termination, the Code Blue resuscitation record is completed ...", "Records of events of Code Blue to include ... EKG rhythm." " ... Attaches rhythm strips to the appropriate form".

2. During a concurrent interview and record review, on 3/7/23 at 9:00 a.m., with the Director, Advanced Clinicals (DAC), Patient 1's medical record, dated 2/5/23 was reviewed; there was no evidence a EKG Rhythm strip was obtained while Patient 1 was in the emergency department. The DAC stated the ED did not need an order for monitoring or obtaining a Rhythm strip, "it is standard of care".

During an interview on 3/7/23 at 12:22 p.m. with the Director, Emergency Services (DES), the DES stated, "it is not routine to print a rhythm strip." During the same interview the EDD stated, "portable cardiac monitors do not show up on the central monitoring and are not capable of printing Rhythm strips".

During an interview on 3/8/23 at 1:52 p.m. with Registered Nurse (RN) A, RN A stated Patient 1 was admitted and waiting a room in the ED hallway on a portable monitor. RN A stated she observes the portable monitor whenever doing vital signs. RN A stated she does not print Rhythm strips.

Review of Patient 1's medical record dated 2/5/23 indicated vital signs were completed in the ED at 6:24 a.m., 6:35 a.m., 6:40 a.m., 7:22 a.m., 8:20 a.m., 9:17 a.m., 10:00 a.m., 11:00 a.m., and 12:00 a.m.

Review of Patient 1's physician orders dated 2/5/23 at 4:44 a.m. indicated an order for an "EKG Rhythm strip", and at 4:46 a.m. an order for "Cardiac Monitor".

Review of Patient 1's Physician Orders dated 2/5/23 at 9:31 a.m. indicated "Admit Order, medical reason: chest pain, level of care Medical/surgical: telemetry (continuous monitoring of a patient's heart rate and rhythm, respiratory rate and oxygen levels)."

Review of Patient 1's Physician order dated 2/5/23 at 9:31 a.m. indicated "Telemetry Monitoring" duration: 48 hours, indication: Chest pain, Telemetry management: no removal of telemetry".

Review of patient 1's Physician order dated 2/5/23 at 9:31 a.m. indicated "Telemetry notification ...call ... for the following new onset atrial flutter, ventricular tachycardia, Ventricular fibrillation ... any change in rhythm".

Review of the facility's policy "Cardiac Telemetry Monitoring", revision dated 1/9/2023, indicated "Patients being monitored on continuous telemetry will be observed by a telemetry technician or nurse ...", "Rhythm changes, life-threating arrhythmias, .... will be responded to in an immediate manner". "Rhythm changes and/or life-threating arrhythmias must be assessed and responded to immediately to assure the safety of the patient and ensure prompt treatment of a problem".