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 observation, interview, record review, and policy review the facility failed to:
- Provide emergency services medically appropriate for treatment and stabilization in the Emergency Department (ED) of one expired patient (#11) of one expired patient in the ED reviewed. (C-284)
- Provide appropriate staffing on nights, weekends, and holidays, to administer immediate life safety measures without the assistance of non-employed Emergency Medical Service (EMS) within the ED. (C-284)
- Ensure the selected urgent and/or critical laboratory test selected by the emergency room (ED) provider was adequately supplied and immediately available to meet the emergency needs of any patients. (C-282)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Provision of Services. The facility census was one.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 01/03/19, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 01/04/19, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Effective immediately, the facility was to no longer use EMS support at any time for a code blue or rapid response situation, including after hours and on holidays.
- The facility will ensure adequate and appropriate staffing and plan in place at all times to cover a code blue or rapid response situation.
- Adopt policy and procedures to ensure adequate and appropriate staffing and plan in place at all times to cover a code blue or rapid response situation.
- The facility will complete a MOCK code blue to ensure understanding of revised code blue policy and protocols starting 01/03/19. Mock code blues will be conducted every shift for two weeks, then alternating shifts daily until revisit.
- A debriefing session will be held immediately following MOCK drill and re-education as appropriate.
- ACLS refresher training course will be held for all employees that were required to have ACLS certification, prior to their next scheduled shift.
- All code blue and rapid response charts will be audited daily until revisit.
- Effective immediately, a physician will be on call within a 30 minute response.
- A PDSA review will be conducted to evaluate and develop improved procedures related code blue and rapid response indefinitely.
- In the event that critical labs were unavailable that would delay emergent patient care, I-70 hospital will go on ambulance diversion.
- For walk in patients who need laboratory test not immediately available, and unaware of the diversion, the facility will assess and transfer out.
Based on interview and record review the facility failed to ensure the urgent and/or critical laboratory test selected by the Emergency Department (ED) provider was adequately supplied and immediately available to meet the emergency needs of any patients. This failure affects all patients within the facility. The facility census was one.

Findings included:

Review of the diversion log showed that the facility was on diversion, on the dates of August 16, 2018 and October 23, 2018, because of the lack of cardiac laboratory test kits to identify acute heart attack.

Review of the facility's undated document titled, "I 70 Lab Critical Needs!" showed the availability of laboratory test:
- Most Critical needs;
- B-type natriuretic peptide (BNP, used to determine if patient has heart failure,) one remaining;
- Troponin (protein to detect heart muscle injury,) three remaining;
- Amylase (protein to detect disorder of the pancreas and other medical conditions,) 0 remaining;
- Lipase (protein to detect disorder of the pancreas and other medical conditions,) 0 remaining;
- Creatine Kinase (CK, enzyme used to identify muscle damage of the heart,) 0 remaining;
- Glucose (use to measure the amount of sugar in the blood,) 0.5 week of slides remaining;
- Urine HCG test (used to diagnosis pregnancy,) approximately 10 test remaining; and
- Sysmex/hematology QC (machine to test the Complete blood count,) expires in 12 days.

Review of the facility's Nurse Practitioner (NP) position description showed that NP has the authority to deliver health care services and treatments including the following:
- Chest pain;
- Congestive heart failure;
- Diabetes mellitus;
- Respiratory distress;
- Abdominal Pain;
- Upper/lower gastrointestinal disorders; and
- pregnancy.
All the above health care services could require laboratory tests that the facility did not have immediately available or was in short supply.

During a telephone interview on 01/04/19 at 9:20 AM, Staff M, Advanced Practice Registered Nurse (APRN), stated that she had concerns the facility did not have appropriate laboratory tests and supplies to adequately treat patients. She stated that at that time, the facility had limited Troponin test, only one BNP, and only two intraosseous needles (needles used to puncture the bone to deliver fluids and medication in the event that staff cannot enter a blood vein). The staff did not have the capability to place a central line (catheter placed into large vein to deliver fluids and medications) and made patient safety a concern.

During an interview on 01/04/19 at 11:30 AM, Staff T, Physician Assistant (PA), stated that the ED had limited laboratory test. For example, he had an inpatient that required a BNP and he did not want to use the last test. Staff T had his staff obtain the BNP and physically transport the sample to a nearby hospital for analysis.

Review of the facility's undated policy titled, "Supply Shortage Procedure," showed that if the laboratory runs out of supplies, depending upon the supply, the laboratory will send the patient samples to our Reference Lab. In extreme situations or CRITICAL situations, the laboratory personnel or available nursing personnel who were on backup will transport blood specimens to one of our surrounding hospitals. The safety of the patient was our primary concern, the ED provider will make the call on what was urgent/critical and what was not. The ER provider and the CEO will make the executive decision on whether or not the ED was to go on diversion until the appropriate supplies were received.

Further review showed that the facility policies did not address procedures of transportation, receipt, and reporting of specimen results.

Even though requested, the facility failed to show that the nearby hospitals were CLIA certified for the appropriate test.

During an interview on 01/04/19 at approximately 9:45 AM, Staff I, Chief Executive Officer (CEO), stated that she was aware of the short supplies. In addition to the list of short supplies, the facility only had two computed tomography syringes (CT, syringes used to deliver contrast during CT used to view inside the body without surgical cut). Staff I stated that if the facility could make payroll on 01/04/19, they would have been able to order the supplies needed. The laboratory supplier had placed the facility on "pay up front," to obtain any laboratory tests because the facility was not current on the debt owed.

During an interview on 01/04/19 at 12:30 PM, Staff B, Chief Nursing Officer (CNO), stated that because they did not have the laboratory test immediately available and had to send the laboratory specimens to a nearby hospital for analysis, it delayed patient care and was not safe.

Based on observation, interview, record review and policy review, the facility failed to provide emergency services medically appropriate for treatment and stabilization in the Emergency Department (ED) to one patient (#11) of one expired patient in the ED reviewed, with their own facility staff by calling Emergency Medical Services (EMS) to act as additional assistance during a code blue (emergency situation where a patient's heart or breathing stopped and staff quickly respond with a process specific to restoring the heartbeat or breathing). This failure had the potential to affect every patient that came to the ED. The facility census was one.

Findings included:

Review of the facility's policy titled, "Code Blue," dated 02/13/10, showed the directives for the following staff to respond to code blue announcements:
- The ED physician;
- One ED registered nurse (RN);
- The Director of Nursing, if available; and
- The Team Leader from the nursing department in which the Code Blue has been called.

Review of Patient #11's medical record showed:
The patient was an [AGE] year old male that was brought to the ED by EMS on 01/01/19 at 9:05 AM with shortness of breath and fatigue that had become much worse that morning. Upon his arrival to the ED, he had tachycardia (abnormally rapid heartbeat), oxygen level in the 80's (normal oxygen level, 90 - 100), finger stick glucose result at home reported by patient's wife read "HIGH", indicating a blood sugar greater than 400 (normal glucose less than 180, one to two hours after a meal). There was no documentation that the facility obtained another finger stick glucose in the ED. Patient was on oxygen four liters per nasal cannula (a device used to deliver supplemental oxygen) when he arrived and after the patient was sat up his oxygen level raised into the low 90's for a short period of time. The patient was not placed on a non-rebreather mask (oxygen delivery that allows for a higher concentration of oxygen). The patient was given a nebulizer (a device that turns liquid medication into a mist for inhalation into the lungs) treatment to help make breathing easier. The patient's heart rate dropped into the 30's (normal heart rate, 60 - 100 per minute), no atropine (medication used to increase the heart rate) was given at that time and the patient was immediately moved from ED room two to ED room one in preparation for intubation. As Staff G, NP gathered supplies, the patient became unresponsive. Patient was intubated and became pulseless at that time. Advanced Cardiac Life Support (ACLS) protocol was initiated.

Review of ED Nurse's note dated 01/01/19 showed that:
- At 9:40 AM a nebulizer treatment was started.
- At 9:50 AM, the treatment was completed, heart rate dropped into the mid 30's and his breathing was more labored. The patient was moved from ED room two to ED room one prior to treating Patient #11's bradycardia (abnormally slow heart rate if left untreated can lead to cardiac arrest [heart stops beating]). After the patient was moved, there was no palpable pulse found and pulseless electrical activity (PEA, the monitor shows a heart rhythm that should produce a pulse, but does not) on the monitor. Cardiopulmonary Resuscitation (CPR) was started.
- At 10:01 AM, Epinephrine (medication used in emergency medical treatment to stimulate the heart) was given and CPR was continued.
- At 10:05 AM, CPR continued, no palpable pulse and PEA on the monitor. Epinephrine given.
- At 10:12 AM, Epinephrine given and CPR continued (seven minutes between doses).
- At 10:20 AM, Epinephrine given and CPR continued (eight minutes between doses).
- At 10:26 AM, Epinephrine given and CPR continued (six minutes between doses).
- At 10:29 AM, there was a possible faint palpable pulse present, CPR was stopped.

ACLS guidelines recommend Epinephrine to be administered every three to five minutes.

Review of the ED Progress note dated 01/03/19 at 00:22 AM, late entry,(after the surveyors began the investigation) showed that Patient #11 presented to the ED via EMS for shortness of breath that became "much worse this am", as reported by the patient's wife. Home glucose reading: HIGH. On arrival the patient was tachycardic and tachypneic (abnormally rapid breathing). Patient's daughter in-law reports that she had discovered that the patient had not taken medications as prescribed. While doing a re-examination and more in-depth history with patient and family, the patient was noted to have decreased oxygen saturation and decreased heart rate. Although patient was bradycardic in normal sinus rhythm, the patient was moved to ER room one in preparation for impending intubation. Patient was still spontaneously breathing, but with decreased effort. The patient became unresponsive while gathering supplies in preparation for intubation. Patient lost a pulse during intubation and CPR was initiated immediately. ACLS protocol was initiated with Epinephrine and Sodium Bicarbonate (medication used in the treatment of metabolic acidosis which may occur in uncontrolled diabetes), as the patient was presumed to be acidotic due to critically high glucose level.

Review of the CPR Flow Sheet dated 01/01/19 at 9:50 AM showed that the following EMS staff were present; Staff D, Paramedic; Staff E, Emergency Medical Technician (EMT); and Staff F, EMT. Epinephrine was documented at 10:01 AM, 10:07 AM (six minutes between doses), 10:12 AM, 10:20 AM (eight minutes between doses), 10:26 AM (six minutes between doses), 10:32 AM (six minutes between doses); 10:38 AM (six minutes between doses); 10:58 AM (10 minutes between doses), 11:04 AM (six minutes between doses), and 11:08 AM (ACLS recommends every three to five minutes). Atropine was documented at 10:34 AM and 10:42 AM.
The EMS staff were not employed at the hospital and had not gone through the orientation process and/or approved by the govering body.

Observation of a mock code conducted on 01/03/19 at 5:15 PM showed that:
- Staff R, Certified Nurse Assistant (CNA) did not know how to use the phone system to page overhead to announce a code blue;
- Staff C, RN and Staff Y, RN could not find the synchronization button (used to deliver an on demand shock to stimulate the heart) on the defibrillator during the mock code;
- Staff G, NP called out an order for amiodarone (medication used to treat arrhythmias [irregular heartbeat]) 150 mg to be given as a first dose for pulseless [DIAGNOSES REDACTED] (ACLS recommends 300mg as first dose).

During an interview on 01/03/19 at 9:20 AM, Staff G, Nurse Practitioner (NP), stated that:
- EMS left and then were called back for "more hands" during the code blue;
- At night, weekends and holidays they call EMS for more hands because they do not have enough staff to run a really efficient code;
- EMS do what they were directed to do by the facility and have definitely participated in codes when called to help;
- Per ACLS practice, epinephrine was to be given every three to five minutes. The code documentation does not show everything that happened;
- Patient #11 was in ED room two, his heart rate dropped into the 30's and was experiencing symptomatic bradycardia; and
- She did not treat the bradycardia because she thought she needed to intubate and left to get supplies.

During an interview on 01/03/19 at 1:30 PM, Staff J, RN, stated that:
- With Patient #11, EMS came back in to help them with the code because the only other staff in the building was a "cook";
- EMS was called back to help with CPR because it was a holiday and the facility had minimal staff;
- If a patient were to code, they moved the patient to the trauma room (ED room one) because otherwise they would have to move the crash cart to the other rooms; it was easier and only took 30 seconds to move the patient; and
- If necessary, EMS comes back to the hospital to help out when they need extra hands.

During an interview on 01/02/19 at 4:15 PM, Staff B, Chief Nursing Officer (CNO), stated that:
- Epinephrine was not given every three to five minutes;
- ACLS protocol was not followed properly;
- Patient was moved to ED room one out of convenience;
- There was no treatment for a heart rate in the 30's;
- There was a delay in treatment when the patient was moved from ED room two to ED room one;
- EMS was called back after they left the hospital because the ED staff needed help;
- EMS personnel were not employees of the hospital;
- EMT's helped with CPR, if a paramedic came they could give medications, and could intubate patients; and
- There was no contract between the hospital and EMS for EMS to provide help.

During a telephone interview on 01/03/19 at 1:55 PM, Staff D, Paramedic, stated that:
- The EMS crew was called back to the facility and thought it was to transport a patient but when they arrived, the patient was intubated and they were needed to assist with CPR rotation;
- He performed CPR on Patient #11;
- None of the EMS staff were employed at the hospital;
- When he and other EMS staff help with compressions during a code at the hospital, they can also intubate if needed;
- The facility staff will call EMS directly for faster response when needed for an emergency instead of a call placed to dispatch;
- He has gone to the facility after he has received a call to lend a hand with emergencies because they were a small hospital and were not always adequately staffed; and
- While they were treating Patient #11, it took them out of service of the community for an hour and a half; that caused two other communities EMS crew to cover their service.

During an interview on 01/03/19 at 3:45 PM, Staff O, Radiology Technician (RT), stated that:
- She was on call on 01/01/19 and was called in to do a chest x-ray;
- EMS was called in to help with the code;
- Three EMS workers arrived to the facility, two provided assistance with CPR rotation because the patient (#11) was very large and the facility staff was exhausted after they had performed compressions repeatedly, while the third provided support to the family;
- She helped in recording the code events by writing times on a paper towel;
- There was confusion on some of the times during the code between the clock and the paper; and
- There was no formal review of events after a Code Blue.

During a telephone interview on 01/04/19 at 9:20 AM, Staff M, Advanced Practice Registered Nurse (APRN), stated that she was aware that night shift nurses have called EMS to help because they have less staff.

During an interview on 01/03/19 at 11:45 AM, Staff H, Chief of Staff, stated that:
- It was okay to use EMS for emergency situations because they were adequately trained;
- All staff should follow ACLS guidelines; and
- She was not on call for the ED.

During an interview on 01/03/19 at 1:00 PM, Staff I, Chief Executive Officer (CEO), stated that:
- It was not appropriate for EMS to be called to help in the ED during an emergency;
- EMS should not have provided services in the hospital after called back by staff;
- She expected staff to follow ACLS protocol.