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SELECT SPECIALTY HOSPITAL - ERIE
RESPIRATORY CARE SERVICES POLICIES
Tag No.: A1160
Based on review of facility documents and review of medical records (MR), and staff interview (EMP), it was determined that the facility failed to follow written policies for cardiopulmonary resuscitation for one of three cardiopulmonary resuscitative medical records reviewed (MR12).
Findings include:
Review of facility policy and procedure "Resuscitation Orders" (Directive For Care) dated April 1, 2018, revealed, "... Purpose: To provide a clear, consistent, and concise method for documenting the options to be taken in the event of a cardiopulmonary arrest. ... 1. Upon admission, all patients must have resuscitation orders documented in the medical record. Previous orders from the transferring facility cannot be used. 2. The order must be signed by a competent patient, or designee, and physician. Once signed by the patient, or designee the order will be followed. ... Physicians assess the decision-making capacity of their patients at every clinical encounter. ..."
1. Review of MR12 on October 2, 2018, at 11:00 AM, revealed that the patient was admitted on August 4, 2018, with a "Resuscitation Orders/Consent" form dated August 8, 2018, at 13:25. A check mark was noted in front of "Do not Resuscitate (DNR)" on the order form. The form was signed by the patient, an RN witness, and the physician.
2. Continued review of MR12 revealed that the patient was transferred for vent-dependent respiratory failure. The record also indicated that a a Rapid Response was initiated on August 15, 2018, which indicated "0935 to 0947 Code Documentation Pt. Bradycardic on monitor low 40's once this RN arrived at room ... was dusky grey with no pulse. ... was being weaned from vent on trach collar. Code initiated CPR [Cardiac Pulmonary Resuscitation] started compressions per RT (Respiratory Therapist) placed immediately on full vent support One round of compressions yielded a pulse with a HR now tachy low 100's. ... MD notified ..."
3. Interview with EMP14 on October 2, 2017, at approximately 12:15 PM confirmed that the patient was ordered DNR (Do not Resuscitate), and that CPR was initiated.