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 document review and interview, the registered nurse (RN) failed to ensure the implementation of the facility policy related to Code Blue situations for 1 of 1 patient involved in such an event, patient #1.

Findings Include:
1. Review of the policy Code Blue Response, policy number PC 8.30, last reviewed 1/15/15, indicated under procedure, it reads: 1...Stays with the patient. Instructs a staff member to announce Code Blue, and to telephone 911 for emergency medical services and obtain the emergency care...Follow AED (automated external defibrillator) guidelines. Applies AED Pads and allows AED to check cardiac rhythm. Follows AED prompt for shock and continues CPR (cardio pulmonary resuscitation)...5. All Staff Respondents process code response and document on code response form.

2. Review of the medical record for patient #1 indicated:
A. The "Observation Sheet" for 15 minute checks done by CNAs (certified nursing assistants) indicated that at 3:30 AM on 6/20/15, the patient was "sleeping" in their room (documented by CNA P5); at 3:45 AM, it noted that the patient was "quiet" and "non responsive", by RN P2; and at 4 AM, it was noted: "EMS" (emergency medical system/staff) "CPR", by LPN (licensed practical nurse) #52, the clinical manager.
B. Per the nursing note by RN P2 at 5:00 AM on 6/20/15, the patient received HS (bedtime) meds as ordered and requested and received their PRN (as needed) inhaler at 10:30 PM. The patient was on continuous oxygen at 3 Liters/nasal canula via concentrator. Staff checked on the patient every 15 minutes and no signs of distress were noted. The CNA checked on the patient at 3:30 AM and noted the patient was still breathing, but at 3:45 AM the CNA "notified nurse that pt was no longer breathing. Vital signs assessed, 911 notified, physicians notified, supervisors notified, and family notified".

3. At 10:10 AM on 11/13/15, interview with staff member # 52, the LPN and clinical manager, indicated there was no documentation of staff having utilized the AED, and that no code response form was completed after the code on 6/20/15 for patient #1, as required per facility policy. No further documentation was provided prior to exit.