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Based on clinical record review, staff interviews and review of facility policies it was determined the registered nurse did not evaluate the continued nursing care for 1(#2) of 10 patients sampled.

Findings include-


1. A review of the facility policy " Patient Care Acuity levels (Assessments/Reassessments) " , policy # 780.06/P-18, dated 5/10, documented that all patients presenting to the Emergency Department (ED) are assessed rapidly to determine the severity of the presenting chief complaint. Acuity is assigned to each patient during the initial assessment. The acuity determines the time to treatment goals and the amount of time the patient can safely wait to be seen by a primary nurse and physician when no beds are available or caregivers are immediately available. A review of page 2 of 5, section I., paragraph C. Triage Acuity Category, revealed the acuity is determined by triage criteria which is stability of vital functions and potential for life, limb or organ threat, the risk for short-term complications and the amount of patient or family suffering. The facility uses the Canadian Triage Acuity Scale (CTAS) to indicate the patient ' s severity of illness or injury and the potential for complications related to the illness or injury.
The continued review of the policy, page 5 of 5, section III, paragraphs A &B; Reassessments revealed the following schedule for reassessment of the ED patients.
A.
1. -Level 1- Resuscitative - will be preformed continuously and documented per code/trauma hospital policies and procedures.
2.-Level 2- Emergent- will be documented at a minimum of hourly and more frequently if condition warrants.
3. - Level 3- Urgent- will be preformed and documented every 2 hours as condition dictates.
B. Reassessments should be done anytime there is a change in patient ' s status, vital signs and condition.


2. A review of the reference aid for Modified CTAS, used by the ED for reference and training of staff revealed the following triage assessment process. Assign minimum acuity level by definition, ask corresponding physiological status question to confirm minimum acuity level, and consider discriminators to escalate acuity. The minimum acuity level by definition lists-
a. Level 1- Resuscitation - an immediate threat to life or limb (or imminent risk of deterioration) requiring immediate aggressive interventions to save life. Patients who require immediate, continuous and/or resuscitative care; shock, unresponsive (unconscious) patients, cardiovascular and/or pulmonary arrest, severe respiratory distress requiring immediate intervention and major trauma.
b. Level 2 -Emergent - conditions that are a threat to life, limb, or function, requiring rapid medical intervention or delegated
c. Level 3 - Urgent- Conditions that could potentially progress to a serious problem requiring emergency intervention, May be associated with significant discomfort or may affect ability to function at work or in activities of daily living, frequent reassessment is imperative.

The Physiological Status definitions according to CTAS are resuscitation - life-saving intervention is needed, unstable- abnormal vital signs, appearance, and work at breathing or circulation, potentially unstable- normal or near normal vital signs with high risk for deterioration without intervention.


The guidelines for the different levels assigned for Hemodynamic stability according to CTAS are as follows;
a. Level 1- evidence of severe end -organ hypo perfusion: marked pallor, cool skin, diaphoresis, weak or thread pulse, hypotension, postural syncope, significant tachycardia or bradycardia, ineffective ventilation or oxygenation and decreased level of consciousness. Could also appear as flushed, febrile, toxic, as in septic shock. Signs of shock with evidence of inadequate tissue perfusion or progressive deterioration.
b. Level 2- Evidence of borderline perfusion: pale, history of diaphoresis, unexplained tachycardia, postural hypotension by history or suspected hypotension. Abnormal vital signs.
c. Level 3- Vital signs at the upper and lower ends of normal as they relate to the presenting complaint.

The definitions of a High-Risk patient according to CTAS are patients with a history of previous high risk medical events, those with multiple disease processes (comorbidity), and those with multiple risk factors. A high Risk medical history consists of Heart valve replacement, status post organ transplants, renal dialysis, insulin dependent diabetes and coagulation or clotting disorder.


3. A review of the ambulance run sheet for patient #2, dated for 12/2/10 revealed vitals at 1:17 p.m. of blood pressure 92/56, pulse 86 and at 1:27 p.m. blood pressure was 113/56, pulse 83. A review of the narrative revealed the patient was complaining of pain and swelling in the right arm. The patient ' s upper right extremity was observed to be swollen. The staff at the Hemodialysis unit stated that when they put the needle in to begin Hemodialysis treatment, the patient ' s arm immediately started to swell and the patient was complaining of pain. The patients past medical history was listed as end-stage renal disease, diabetes, hypertension, chronic obstructive pulmonary disorder, double by-pass surgery, pace maker and congestive heart failure. A review of the patient ' s clinical record nursing documentation revealed the patient presented to the Emergency Department (ED) on 12/2/10 at 1:30 p.m. per ambulance for the complaint of right arm swelling and pain. The patient had been transported from a dialysis unit where s/he was preparing to receive a dialysis treatment. The patient was triaged by the ED nurse at 1:46 p.m., with the chief complaint as upper extremity pain and injury. The subjective assessment stated the patient was 15 minutes into the dialysis treatment when s/he started to have severe pain and swelling to right upper extremity. The nurses objective assessment stated the patient has swelling, extensive bruising to right upper arm and unable to move right extremity. The patient was crying in pain, and listed the pain level as 10 out of 10 on a scale of 0-10 with 10 being the worst. The patient ' s vital signs were temperature 99 degrees, pulse 78, respirations 18, blood pressure 85/40 and oxygen saturations of 99% on supplemental oxygen. The patient was assigned an acuity level of 3- which is considered urgent per facility ' s policy. At 2:36 p.m., the ED nurse documented an assessment of the upper extremity which revealed the extremity was edematous with decreased range of the motion. The movement distal to injury was limited and the skin color was dusky, mottled and bruised. The patients vital signs were the same vital signs documented at time of triage. An entry made at 3:00 p.m. in the nursing ED notes that the patient was sitting in blood with extensive bleeding coming from right upper arm. A pressure dressing was applied and the ED physician was at the bedside to assess the patient. An ED nursing reassessment was documented at 3:28 p.m., which revealed the skin color of the upper extremity was dusky and ashen. The patient ' s vitals at this time were temperature 98 degrees, pulse 74, respirations 18, blood pressure 94/57 and oxygen saturations of 99% on supplemental oxygen. The circumference of the right upper extremity was measured at this time and was 34 centimeters (cm). An entry in the Nursing ED notes at 4:15 p.m. revealed the surgeon who placed the Fistula in right upper arm had arrived to the ED to assess the subject. The nurse advised the surgeon of the patient ' s blood loss, of the patient being hypotensive and that the right upper arms circumference measured 31 cm down from 34 cm measured earlier. At 4:40 p.m., the medic advised the nurse the subject was now unresponsive and not breathing. The subject was moved to another room and a " code blue " was called.

4. A telephone interview was conducted on 12/23/10 at 10:40 a.m. with the patient's ED nurse. The patient's ED nursing documentation was reviewed with the nurse. The nurse verified that the patient's right upper arm was mottled, dusky and bruised. When the nurse was informed that the ED physician did not agree with the nurse's assessment of the arm the nurse responded that she had seen the patients arm when the patient first arrived in the ED not the physician. The nurse was adamant that she had assessed the arm correctly. When the nurse was questioned concerning the patients blood pressure, the nurse stated she was not concerned about the blood pressure being low because the family stated it was always low after dialysis. The nurse stated she did not report it to the ED physician but did report it to the patients surgeon. When the nurse was questioned concerning the patients assigned triage level, she responded that in hindsight she should have assigned the patient a higher triage level.

5. A review of the patients Code Blue Documentation Record, dated 12/2/10 revealed the patient was found at 5:06 p.m. At 5:07 patient was in pulseless electrical activity (PEA) and was given epinephrine, no vital signs were documented. At 5:08 p.m. the patient was still in PEA and was given Calcium Carbonate, no vital signs documented. At 5:10 p.m. the patient was in sinus tachycardia and was given Sodium Bicarbonate, no vital signs documented. At 5:18 p.m. the patient was in sinus tachycardia and was given 2 liters of Normal Saline and 150 mg of amiodarone, no vital signs documented. At 5:30 p.m. the patient was in sinus tachycardia and was given 2 units of blood and the vital signs were blood pressure of 81/44, pulse 65, respirations 22, and oxygen saturations of 74% on ventilator. It should be noted that the patient was intubated ( time not documented) with a #8 ET tube and marked at 22 inches. Further review of the code blue documentation record failed to reveal any further documentation. An interview with the Charge Nurse on duty at the time of the patients presentation to the ED was conducted on 12/23/10 at 10:30 a.m. The Charge Nurse verified the Code Blue documentation record and the only set of vital signs documented at end of code at 5:30 p.m.

Based on staff interviews, review of clinical records, policies and procedures it was determined that the facility failed to properly assess 1 (#2) of 10 sampled patients causing a delay in treatment for a patient who presented to the Emergency Department (ED) from a End Stage Renal Disease (ERSD) Dialysis Clinic with an injury to the extremity due to a puncture to the Arterial/Vein fistula and was hypotensive, continued use of this practice has the potential for loss of limb and/or life.


1. The facility failed to ensure, in 1(#2) of 10 sampled patients reviewed and any patients presenting to the ED, to follow policies and procedures approved by the Medical Staff, to ensure the continued monitoring and stabilization of the ED patient, to ensure timely treatment by the ED physician of the hypotensive, injured ED patient, and an accurate acuity assessment by nursing and the notification of a change in condition of a injured, hypotensive patient to the ED physician.

2. The facility failed to ensure care in the ED is integrated with the Quality Assurance Performance Improvement program due to the lack of tracking of ED cardiac and respiratory codes to ensure consistent safe and therapeutic care of hypotensive patients whose condition deteriorated to a code situation in the ED (refer to A1103).

Due to the seriousness and combination of these systematic problems, the Condition for Participation for Emergency Services was determined to be out of compliance.

Based on clinical record review, facility policies and staff interviews it was determined the facility failed in 1(#2) of 10 sampled patients reviewed and any patients presenting to the ED, to follow policies and procedures approved by the Medical Staff, to ensure the continued monitoring and stabilization of a Unstable ED patient, to ensure timely treatment by the ED physician of the hypotensive, injured ED patient, and accurate acuity assessment by nursing and the notification of a change in condition of a injured, hypotensive patient to the ED physician.

Findings include-

1. A review of the facility policy " Patient Care Acuity levels (Assessments/Reassessments) " , policy # 780.06/P-18, reviewed on 5/10 documented that all patients presenting to the Emergency Department (ED) are assessed rapidly to determine the severity of the presenting chief complaint. Acuity is assigned to each patient during the initial assessment. The acuity determines the time to treatment goals and the amount of time the patient can safely wait to be seen by a primary nurse and physician when no beds are available or caregivers are immediately available. A review of page 2 of 5, section I., paragraph C. Triage Acuity Category, revealed the acuity is determined by triage criteria which is stability of vital functions and potential for life, limb or organ threat, the risk for short-term complications and the amount of patient or family suffering. The facility uses the Canadian Triage Acuity Scale (CTAS) to indicate the patient ' s severity of illness or injury and the potential for complications related to the illness or injury.
The continued review of the policy, page 5 of 5, section III, paragraphs A &B; Reassessments revealed the following schedule for reassessment of the ED patients.
A.
1. -Level 1- Resuscitative - will be preformed continuously and documented per code/trauma hospital policies and procedures.
2.-Level 2- Emergent- will be documented at a minimum of hourly and more frequently if condition warrants.
3. - Level 3- Urgent- will be preformed and documented every 2 hours as condition dictates.
B. Reassessments should be done anytime there is a change in patient ' s status, vital signs and condition.
2. A review of the reference aid for Modified CTAS, used by the ED for reference and training of staff revealed the following triage assessment process. Assign minimum acuity level by definition, ask corresponding physiological status question to confirm minimum acuity level, and consider discriminators to escalate acuity. The minimum acuity level by definition lists-
a. Level 1- Resuscitation - an immediate threat to life or limb (or imminent risk of deterioration) requiring immediate aggressive interventions to save life. Patients who require immediate, continuous and/or resuscitative care; shock, unresponsive (unconscious) patients, cardiovascular and/or pulmonary arrest, severe respiratory distress requiring immediate intervention and major trauma.
b. Level 2 -Emergent - conditions that are a threat to life, limb, or function, requiring rapid medical intervention or delegated
c. Level 3 - Urgent- Conditions that could potentially progress to a serious problem requiring emergency intervention, May be associated with significant discomfort or may affect ability to function at work or in activities of daily living, frequent reassessment is imperative.

The Physiological Status definitions according to CTAS are resuscitation - life-saving intervention is needed, unstable- abnormal vital signs, appearance, and work at breathing or circulation, potentially unstable- normal or near normal vital signs with high risk for deterioration without intervention.
The guidelines for the different levels assigned for Hemodynamic stability according to CTAS are as follows;
a. Level 1- evidence of severe end -organ hypo perfusion: marked pallor, cool skin, diaphoresis, weak or thread pulse, hypotension, postural syncope, significant tachycardia or bradycardia, ineffective ventilation or oxygenation and decreased level of consciousness. Could also appear as flushed, febrile, toxic, as in septic shock. Signs of shock with evidence of inadequate tissue perfusion or progressive deterioration.
b. Level 2- Evidence of borderline perfusion: pale, history of diaphoresis, unexplained tachycardia, postural hypotension by history or suspected hypotension. Abnormal vital signs.
c. Level 3- Vital signs at the upper and lower ends of normal as they relate to the presenting complaint.
The definitions of a High-Risk patient according to CTAS are patients with a history of previous high risk medical events, those with multiple disease processes (comorbitity), and those with multiple risk factors. A high Risk medical history consists of Heart valve replacement, status post organ transplants, renal dialysis, insulin dependent diabetes and coagulation or clotting disorder.


3. A review of the ambulance run sheet for patient #2, dated for 12/2/10 revealed vitals at 1:17 p.m. of blood pressure 92/56, pulse 86 and at 1:27 p.m. blood pressure was 113/56, pulse 83. A review of the narrative revealed the patient was complaining of pain and swelling in the right arm. The patient ' s upper right extremity was observed to be swollen. The staff at the Hemodialysis unit stated that when they put the needle in to begin Hemodialysis treatment, the patient ' s arm immediately started to swell and the patient was complaining of pain. The patients past medical history was listed as end-stage renal disease, diabetes, hypertension, chronic obstructive pulmonary disorder, double by-pass surgery, pace maker and congestive heart failure. A review of the patient ' s clinical record nursing documentation revealed the patient presented to the Emergency Department (ED) on 12/2/10 at 1:30 p.m. per ambulance for the complaint of right arm swelling and pain. The patient had been transported from a dialysis unit where s/he was preparing to receive a dialysis treatment. The patient was triaged by the ED nurse at 1:46 p.m., with the chief complaint as upper extremity pain and injury. The subjective assessment stated the patient was 15 minutes into the dialysis treatment when s/he started to have severe pain and swelling to right upper extremity. The nurses objective assessment stated the patient has swelling, extensive bruising to right upper arm and unable to move right extremity. The patient was crying in pain, and listed the pain level as 10 out of 10 on a scale of 0-10 with 10 being the worst. The patient ' s vital signs were temperature 99 degrees, pulse 78, respirations 18 blood pressure 85/40 and oxygen saturations of 99% on supplemental oxygen. The patient was assigned an acuity level of 3- which is considered urgent per facility ' s policy. At 2:36 p.m., the ED nurse documented an assessment of the upper extremity which revealed the extremity was edematous with decreased range of the motion. The movement distal to injury was limited and the skin color was dusky, mottled and bruised. The subjects vital signs were the same vital signs documented at time of triage. An entry made at 3:00 p.m. in the nursing ED notes that the patient was sitting in blood with extensive bleeding coming from right upper arm. A pressure dressing was applied and the ED physician was at the bedside to assess the patient. An ED nursing reassessment was documented at 3:28 p.m., which revealed the skin color of the upper extremity was dusky and ashen. The patient ' s vitals at this time were temperature 98 degrees, pulse 74, respirations 18, blood pressure 94/57 and oxygen saturations of 99% on supplemental oxygen. The circumference of the right upper extremity was measured at this time and was 34 centimeters (cm). An entry in the Nursing ED notes at 4:15 p.m. revealed the surgeon who placed the Fistula in right upper arm had arrived to the ED to assess the subject. The nurse advised the surgeon of the patient ' s blood loss, of the patient being hypotensive and that the right upper arms circumference measured 31cm down from 34 cm measured earlier. At 4:40 p.m., the medic advised the ED nurse the patient was now unresponsive and not breathing. The patient was moved to another room and a " code blue " was called.
A review of the " Code Blue " documentation record revealed the patient was found at 5:06p.m., in pulseless electrical activity (PEA) on the cardiac monitor. Resuscitation was initiated at 5:06 p.m. and ceased at 5:30 p.m., the patients vitals were blood pressure 81/44 and pulse 65. The patient ' s next set of vitals documented at 5:20 p.m. revealed a blood pressure of 103/50 and a paced heart rate of 63. The vital signs at 6:39 p.m. were blood pressure of 94/60 and pulse of 63. The vitals at 7:21 p.m. were blood pressure 80/45 and pulse of 64.

A review of the patient ' s Hemodialysis clinical records dated from 10/09/10 through 11/20/10 revealed the following laboratory results and previous blood pressures. The patient ' s hemoglobin and hematocrit on 10/09/10 was 11.7/38.1, on 10/16/10 it was 10.2/33.2, on 10/23/10 it was 10.0/32.7, on 10/30/10 it was 10.5/34.1, on 11/06/10 it was 11.6/39.7, on 11/13/10 it was 10.6/34.7, and on 11/20/10 it was 10.4/33.2. The patients post dialysis blood pressures are as follows, prior to presenting to the ED on 12/2/10 was on 11/30/10 of 129/63. The patient ' s blood pressures at the Hemodialysis center on 12/2/10 at 12:25 p.m. were 120/59. After the arterial/vein fistula needle was removed due to infiltration, the patient ' s blood pressure was 116/78.
An interview with the Assistant ED director on 10/22/10 at approximately 11:30 a.m. revealed the ED staff is trained on the Canadian triage acuity scale for assigning acuity to the ED patients. After reviewing the patients initial triage notes with the Assistant director, he responded that according to CTAS the patient should have been assigned a level 1 or 2 acuity level based on being hypotensive, co morbidities, and description of injury of the right upper arm.
A telephone interview was conducted on 12/23/10 at 10:40 a.m. with the patient's ED nurse. The patient's ED nursing documentation was reviewed with the nurse. The nurse verified that the patient's right upper arm was mottled, dusky and bruised. When the nurse was informed that the ED physician did not agree with the nurse ' s assessment of the arm the nurse responded that she had seen the patient's arm when the patient first arrived in the ED not the physician. The nurse was adamant that she had assessed the arm correctly. When the nurse was questioned concerning the patients blood pressure, the nurse stated she was not concerned about the blood pressure being low because the family stated it was always low after dialysis. The nurse stated she did not report it to the ED physician but did report it to the patient's surgeon. When the nurse was questioned concerning the patient's assigned triage level, she responded that in hindsight she should have assigned the subject a higher triage level.

The ED staff failed to follow the policy for Patient Care Acuity Levels, to determine by triage criteria which are stability of vital functions and potential for life, limb, or organ threat. The ED staff failed to follow the guidelines provided by the CTAS for evaluation of the ED patient, taking into account all the determining factors affecting the ED patient. Thus assigning the patient with a lower than required acuity level, resulting in a lack of urgency for continued reassessments and vital signs at a higher acuity level and delay in treatment by the ED staff. The ED staff nurse failed to report to the ED physician that the patient was hypotensive throughout their stay in the ED. There was no documentation of an intravenous (IV) line being ordered and/or started by nursing, although at 2:48 p.m. the patient received IV pain medications.

4. A review of the facility ' s policy on EMTALA- Florida Medical Screening Examination and Stabilization, policy #Admin.10/LD.22, revised 4/22/10 was conducted. On page 9 of 15, Extent of the Medical Screening Examination, paragraph #5, states " the record must reflect continued monitoring according to the individuals needs and must continue until the individual is stabilized or appropriately transferred. "
A continued review of this policy, page 13 of 15, paragraph #7, states an emergency physician may contact the individual ' s physician, so long as this does not inappropriately delay services.

5. A review of the ED physician ' s record revealed the physician had assessed the patient at 2:15 p.m. The Physicians physical assessment of the right upper extremity was as follows; a healed right upper arm laceration, positive firm right upper arm with ecchymosis and moderate tenderness. The Neuro-vascular assessment stated normal sensation, motor, and tendon function. There is no vascular compromise and subject has good radial pulse.
A continued review of the ED physician ' s documentation under progress notes timed at 3:10 p.m. revealed the physician spoke with the patient's surgeon at 2:45 p.m., the surgeon was in the operating room. The surgeon recommended the ED physician to call his partner. The ED physician spoke with the surgeon ' s partner at 2:55 p.m., who recommended applying pressure and to consult Ortho/Hand surgeon if needed for compartment syndrome. The ED physician spoke with orthopedic surgeon on-call at 3:10 p.m. The Orthopedic surgeon on call does not have hand privileges and does not do fasciotomy procedures. If a fasciotomy needs to be done the ED physician would need to transfer the patient. The ED physician again spoke with the patients surgeon at 3:10 p.m., who stated would come to the facility to see the subject at 4:30 p.m. The ED physician wrote that due to the patient's coagulopathy therapy the plan was to admit the patient for compartment monitoring. A review of a second Emergency Physicians Record, revealed an entry by the ED physician at 6:00 p.m. The entry stated the patient ' s surgeon stopped by to see patient and opened right arm with incision to expel clots and blood. The patient at this time was complaining of shortness of breath. The patient went into respiratory failure and became unresponsive. The patient was in pulseless electrical activity (PEA) on the monitor with a heart rate in the 90 ' s. The patient was given epinephrine, bicarbonate, calcium and IV fluids. The patient was intubated for airway protection and given amioderone for abnormal wide complex rhythm. The patient was given 2 units of emergency uncrossed blood. No further entries were documented by the ED physician.

The ED physician failed to follow the facility ' s policy monitoring according to the individuals needs and must continue until the individual is stabilized or appropriately transferred for an ED patient who was unstable. Although the ED physician did consult the patient ' s physician, he waited until after that physician arrived to reassess the patient. This resulted in a delay in treatment placing the patient in severe distress from pain due to the increasing swelling in the patient ' s right upper arm and placing the patient ' s cardiovascular system under undue stress. The ED physician assessed the patient at 2:15 p.m. and not again until the patient coded at approximately 5:06 p.m. The ED physician did not order an IV started and/or IV fluids or medications to assist in stabilizing the patient ' s blood pressure. The ED physician did not take emergency measures to relieve the pressure in the right upper arm from the increasing swelling to help decrease the risk of the loss of that limb. There was no documentation from the ED physician on the patient being hypotensive or address the fact the patients hemoglobin had dropped from 10.4/33.2 at the Hemodialysis clinic to 9.4/29.9 at 2:40 p.m. in the ED until the patient coded at 5:07 p.m.

6. A review of the patient's surgeon dictated consultation completed on 12/2/10 but dictated on 12/16/10 at 2:41 p.m. revealed the following. The reason for consultation was for a Hematoma in the right upper extremity. The surgeon dictated that the ED physician felt that the patient would need an emergency fasciotomy and hand care, and no hand surgeons are available at this facility. The surgeon stopped at the facilities ED and found the patient with a hematoma of the arm and contracture signs of expanding hematoma in the right upper arm where a very large hematoma was causing ischemia of the hand, which was quite cold and pale at the time. The surgeon requested an incision and drainage set and quickly drained the hematoma at that site and placed a compressive dressing with no further bleeding. The surgeon ' s impression was that the bleeding came from the posterior aspect of the vein, but was not a 100% sure. The surgeon also noted the patient was in great distress due to pain in the upper extremity , went into respiratory arrest and cardiac arrest followed by a code and the ED successfully resuscitated the patient. The surgeon listed the patient's past medical history as severe cardiac disease, diabetes mellitus type 2, hypertension, and coronary artery disease, end-stage cardiac and renal disease.

7. An interview was conducted on 12/23/10 at 10:10 a.m. with the ED physician who took care of the patient. The ED physician stated the patient complained of pain to right upper arm with occasional tingling. But the exam he completed revealed there were no pallor, no pulselessness, and no need for a fasciotomy. After he spoke with the patient's surgeon, the surgeon ' s partner and the orthopedic physician on call, his plan was to admit the patient to monitoring for compartment syndrome. The ED physician also stated he did not agree with the nursing assessment of the patient's arm when the patient arrived at the facility. The ED physician again reiterated that he felt there was no need for an emergency fasciotomy of the patient's right upper arm.

Based on review of 1(#2) of 10 clinical records , facility polices and staff interviews, it was determined the facility failed to integrate the ED with the facilities Quality Assurance performance Improvement program to ensure a mechanism for consistent , systematic evaluation of outcomes, processes and structures related to emergency department (ED) cardiac/respiratory codes to optimize and maintain the safety of the ED patients.

Findings Include:

A review of patient #2's ED clinical record, nursing documentation revealed the following entry was made on 12/2/10 at 4:40 p.m. the medic advised the subjects nurse that the patient was now unresponsive and not breathing. The patient was moved to another room and a "code blue" was called.

A review of the subjects Code Blue Documentation Record, dated 12/2/10 revealed the subject was found at 5:06 p.m. At 5:07 patient was in pulseless electrical activity (PEA) and was given epinephrine, no vital signs were documented. At 5:08 p.m. the subject was still in PEA and was given Calcium Carbonate, no vital signs documented. At 5:10 p.m. the subject was in sinus tachycardia and was given Sodium Bicarbonate, no vital signs documented. At 5:18 p.m. the subject was in sinus tachycardia and was given 2 liters of Normal Saline and 150 mg of amiodarone, no vital signs documented. At 5:30 p.m. the patient was in sinus tachycardia and was given 2 units of blood and the vital signs were blood pressure of 81/44, pulse 65, respirations 22, and oxygen saturations of 74% on ventilator. It should be noted that the subject was intubated ( time not documented) with a #8 ET tube and marked at 22 inches. Further review of the code blue documentation record failed to reveal any further documentation.

An interview with the Charge Nurse on duty at the time of the patients presentation to the ED was conducted on 12/23/10 at 10:30 a.m. The Charge Nurse verified the Code Blue documentation record and the only set of vital signs documented at end of code at 5:30 p.m.

An interview with the Quality Manager was conducted on 12/23/10 at 10:45 p.m. with concerns related to the lack of documentation on the Code Blue documentation record and time difference of 26 minutes that the nurse reports the medic found the patient unresponsive and the time the code sheet reports the subject being found . When questioned whether a quality assurance review was conducted on the patients clinical record and the Emergency room code sheet. The Quality manager responded she had not reviewed the patients clinical record due to the patients co-morbidities,the Emergency Department physicians assessment and treatment of the subject. When the Quality Manager was asked about the tracking and trending of the code blue records she responded that the clinical records are reviewed based on adverse incidents and outcomes, once a month. Further review of the Quality Assurance meeting minutes failed to produce any tracking or trending of code blue records for the Emergency Department. This clinical record was to be reviewed next month since this subject had passed away in December. The code blue documentation record is only reviewed if a problem exists.