The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on clinical record review, observation and staff interviews, the Hospital failed to implement preventive action to address the root causes that had been identified on 08/28/14, relating to an adverse patient event occurrence of 08/09/14.

The findings include:

An interview was conducted with the hospital Risk/ Quality Manager on 09/08/14 beginning at 10:45 AM, to review an adverse patient event which occurred on 08/09/14 concerning Patient #1.
The manager stated a root cause analysis of the patient event was completed on 08/28/14 and the following concerns were identified:
1. A non-employee Agency Registered Nurse assigned to the patient care did not know how to call code blue during the event.
2. Enhance monitoring for patient at risk.
3. Security of the sharps box in patient rooms.
4. Code cart on 2nd floor missing Versed medication.
5. Short supply of Sisco/ Spectra link phone on the 2nd floor medical units.
6 A need to educate nurses on hospital emergency procedure and enhanced patient monitoring.

The surveyor requesteed evidence to substantiate preventive action was implemented for the above identified concerns. The Quality Manager stated corrective action has not been developed or implemented as of 09/08/14.

Based on observation, staff interview and policy review the Director or Nursing Services failed to ensure non-employee Registered Nurses have been oriented to the hospital emergency procedures. On 08/09/14, 2 of 2 Registered Nurses ( RN -A and RN -B ) providing patient care did not know the hospital emergency phone number to dial for medical and non medical emergencies.
A root cause analysis identified on 08/28/14, a non-employee agency Nurse (RN-C) working in the hospital on [DATE] did not know how to call a Code Blue during a medical emergency involving a patient (#1). This failure presents a potential risk to patient safety.

The findings include:

Observation conducted on 09/08/14 beginning at 1:45 PM on a second floor Medical unit revealed two non- employee Registered nurses are working during the 7 AM - 7:30 PM shift. In an interview with RN-A on 09/08/14 at 2:00 PM, the nurse stated she had been working with the hospital affiliated agency since 2008. The surveyor asked the nurse to explain the hospital procedure to call an emergency code. The nurse stated she would leave the patient room and call 4444 from the nurses' station. Her other option would be to press the call bell and wait for another staff to come and assist.
Immediately after the interview the RN informed the nurse manager she did not know the phone number to dial in an emergency. The nurse manager directed RN-A to the nurses' station and showed her the emergency number posted on a telephone at the nurses' station.

In an interview with the Nurse Manager on 09/08/14 at 2:40 PM, the nurse Manager stated we dial * for rapid response and all hospital emergency codes. The nurse manager states each nurse is supposed to be assigned and carry a Sisco Link phone each shift. For the past 6 months only one Sisco Link phone is available on the unit and it is assigned to the charge nurse. The nurse manager states she has reported it to the hospital IT (information Technology).

During an interview with RN-B on 09/08/14 at 2:15 PM, the nurse stated this was her first day back at this hospital. She stated she is employed by an agency that is an affiliate of the hospital. The nurse stated she received an initial orientation at the agency and a brief hospital orientation to the unit. When asked to explain the hospital emergency procedure and phone number to dial for an emergency code, the nurse stated she would dial "0" from the patient telephone in the room and tell the operator the location of the emergency. She stated "I am not sure what the number is here, we do team nursing on this floor and I could ask the other RN I am working with."

An interview was conducted with the hospital Risk/ Quality Manager on 09/08/14 beginning at 10:45 AM, to review an adverse patient event which occurred on 08/09/14 concerning Patient #1. The manager stated a root cause analysis (RCA) of the patient event was completed on 08/28/14. The clinical record of Patient #1 and the root cause analysis related to the event that occurred on 8/9/14 were reviewed. The RCA identified among other findings that the non-employee Agency Registered Nurse assigned to Patient #1's care on 8/9/14 did not know how to call a code blue during the event.

The hospital policy /procedure # 5.11 titled "Rapid Response, Code Blue policy" dated 09/09/13 specified "to bring a team of skilled clinicians together to a patient bedside to assess a patient's condition and determine if a higher level of care, Rapid Response or Code Blue is warranted. If a primary nurse, charge nurse or any other clinician identifies clinical help is necessary, they may call a rapid response. The Rapid response, Code Blue policy procedure #5.11 dated 9/09/13, did not include or specify the number to dial for Rapid Response and Code Blue.