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Based on interview, record review and policy review, the facility failed to ensure nursing staff were trained and competent to provide nursing care adequate to meet the needs of one patient (#1) when the patient went into cardiac arrest (heart stopped beating), and staff were unable to respond in a timely manner with appropriate life saving measures. (Refer to A-0395)

These failures created the potential for harm to the patient, and for harm to all patients in the facility, should they experience a life threatening emergency. The facility census was 15.

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

On 03/29/16, the survey team notified the facility of the IJ, and on 03/30/16, the hospital responded with a plan to remove the IJ by:
- Initiation of mock code blue events, along with education to the facility crash carts (mobile cart which contains emergency medical supplies and medications) and defibrillators (medical device that delivers electrical current or a "shock" to the patient's chest wall to return a patient's heart beat to normal rhythm), to be completed prior to each patient care staff member's next shift. The mock codes would continue until the facility reached 100% compliance.
- Designation of back up code team leaders who are required to be Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) certified.
- Designation of a documenter (staff member who documents times and events of the code, such as when medication is administered, and when chest compressions begin) for code blue events and initiating a process where code blue documentation would be secured.
- Review of code blue documentation completed by the Chief Clinical Officer (CCO), Director of Quality and Medical Director within 72 hours of every code blue event, to ensure compliance with standards of care, performance and documentation requirements. Variations from the expected performance would be addressed immediately with staff through remedial education by an ACLS provider. Overall completion of all education and training, as well monitoring would be reported to the Chief Executive Officer (CEO) daily until 100% of training and education was completed. 100% review of all Code Blue results would be reported to the Patient Safety and Reliability Committee, the Quality Council and the Governing Board. Further monitoring would be directed by the Quality Council.

In the facility's plan of correction, they failed to address who would cover the CCO when she was not fulfilling her role, failed to recognize the overall potential neglect of many of the nurses involved in the code blue event, and created an unsafe environment when administration failed to react and implement immediate corrective actions to prevent recurrence of a life threatening situation.

The facility's failure to provide an organized nursing service for its patients posed an Immediate Jeopardy to patients that began on 03/18/16. The Administrator was notified on 03/30/16 at 4:30 PM that the Immediate Jeopardy was ongoing.

Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff were trained and competent to provide nursing care adequate to meet the needs of one patient (#1) when the patient went into cardiac arrest (heart stopped beating), and staff were unable to respond in a timely manner with appropriate life saving measures. This had the potential to affect all patients in the facility, should they experience a life threatening emergency. The facility census was 15.

Findings included:

1. Record review of the facility policy titled, "Emergency Advanced Life support Notification System," dated 04/28/11, showed that a patient within the facility requiring resuscitative measures was provided with personnel who were capable of responding to an Emergency Advanced Life Support situation, and included the ability to use a defibrillator (medical device that delivers electrical current or a "shock" to the patient's chest wall to return a patient's heart beat to normal rhythm) and emergency medications.

2. Record review of Patient #1's History and Physical dated 02/23/16, showed that the patient was ventilator (machine that moves air into and out of the lungs) dependent, with a tracheostomy (surgically created hole made into the windpipe for passage of air), and end-stage renal disease (loss of kidney function) which required hemodialysis (dialysis, purification of blood as a substitute for normal function of the kidney).
Record review of Patient #1's Dialysis Record, showed Staff L, Dialysis Registered Nurse (RN), documented that on 03/18/16 at 4:00 PM, the patient's blood pressure dropped to 68/53 (normal parameters are between 90/60 to 130/90) and heart rate dropped to 51 beats per minute (normal parameter is 60 to 100). Documentation showed that at 4:05 PM, the patient was unresponsive, her heart rate dropped into the 30's, and 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) was called.

During an interview on 03/28/16 at 4:20 PM, Staff L stated that when she dialyzed Patient #1, Staff P, Monitor Technician (observes patients' heart rhythms on a computer for changes) came into the patient's room and said the patient had a run of ventricular tachycardia (v-tach, improper electrical activity of the heart, which makes the lower heart chambers beat rapidly, but does not always produce a pulse). Staff L stated that the patient was found to be unresponsive and had a "faint" pulse, and told Staff P to call a Code Blue.

Although requested, the facility was unable to produce the Code Blue Sheet (documentation of exact times of the events that occur during a Code Blue event) for Patient #1.

During an interview on 03/28/16 at 5:00 PM, Staff A, Licensed Practical Nurse, stated that when she arrived to the patient's room with the crash cart (mobile cart which contains emergency medical supplies and medications) and defibrillator, she witnessed the following:
- There was no Code Team Leader present to run (direct or manage) the Code Blue.
- "Everyone was frantic".
- Someone in the room said the patient had no pulse, but no cardiac compressions (rhythmic compressions on a patient's chest, to force blood flow through the heart) were started.
- Staff K, Chief Clinical Officer (CCO), who assumed responsibility as Code Team Leader, came to Patient #1's room (time unknown),
- The defibrillator advised to shock the patient, but Staff I, Agency RN, said she didn't know how to work the defibrillator.
- Patient #1 was not shocked because no one in the room knew how to use the defibrillator.
- Cardiac compressions did not begin until Staff C, Nursing Supervisor (who had been out of the hospital on lunch break), came to Patient #1's room (time unknown, but interviews show six to 15 minutes after the patient's heart rate dropped).
- The patient's heart rate was restored and the patient was transferred to the High Acuity Unit (similar to an Intensive Care Unit), but the patient did not regain consciousness.
Staff A added that there had been no additional training related to the Code Blue process since Patient #1's event.

During an interview on 03/29/16 at 9:15 AM, Staff M, Registered Respiratory Therapist (RT), stated that when she arrived to Patient #1's room, the patient was unresponsive, had a thready (weak or faint) pulse and her tracheostomy tube was protruding from her neck (indicated it was not in a position that was secure). Staff M stated that she changed the patient's tracheostomy tube, which took approximately five minutes, and then found the patient pulseless (without a heartbeat). Staff M stated that she did not know who ran the Code Blue until after Staff C arrived to the patient's room. Staff M added that several days after Patient #1's Code Blue event, Staff F, RT Director, informed her that the facility would conduct mock Code Blues (simulated Code Blue), but they had not occurred.

During an interview on 03/29/16 at 11:22 AM, Staff F stated that she had the following concerns about Patient #1's Code Blue event:
- The staff member (unknown) who applied the defibrillator pads (pads that adhere to the skin of the patient, used to administer electrical shock to a patient's chest wall) fumbled with the pads and may not have applied them correctly.
- No one was in charge of directing staff during the Code Blue and no one administered (lifesaving) medications until Staff C came into the patient's room, which was approximately 10 to 15 minutes after the patient's heart rate dropped.
- At one point during the Code Blue, she saw everyone move away from the patient as if the patient would be shocked, but the shock never occurred.
- Because of the concerns, she desired mock Code Blue events to be held for staff so that everyone would be more familiar with what to do, but they had not occurred since Patient #1's Code Blue event.
Staff F added that they did not receive annual competency training on the defibrillator.

During an interview on 03/29/16 at 2:41 PM, Staff O, Agency RN, confirmed the following about Patient #1's Code Blue event:
- She was the primary care nurse for the patient.
- During the Code Blue, Staff A repeatedly asked Staff K what to do for the patient, but Staff K responded only by asking where Staff C was.
- Staff could not figure out how to use the defibrillator.
- No chest compressions were initiated on the pulseless patient until Staff C entered the room, which was approximately six to 10 minutes later.
Staff O stated that the day Patient #1 coded was her second day working in patient care at the facility, and that she received no orientation to facility policies, protocols, crash cart or defibrillator. Staff O added that she was not Advance Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) certified and never had been.

3. Observation at the main nurses' station, and concurrent interview on 03/29/16 at 9:50 AM, showed the following:
- Staff B, Agency RN, stated that she had worked at this facility two to three times weekly for the prior six months.
- Staff B stated that she could attach the defibrillator pads to a patient and follow defibrillator prompts; however, she did not know where the shock button was located on this particular defibrillator.
- Staff B failed to be able to demonstrate accurate use of the defibrillator.

During an interview on 03/29/16 at 10:15 AM, Staff D, RN Educator, stated that she had never provided any on-site defibrillator education to agency staff.

During an interview on 03/29/16 at 2:20 PM, Staff C stated that she retrospectively reviewed (reviewed at a later date/time) Patient #1's cardiac monitor rhythm strips (recording of the patient's electrical heart activity) and believed the patient's Code Blue began at 4:03 PM. Staff C stated that when she arrived to Patient #1's room at approximately 4:12 PM, no one was doing anything. Staff C stated that she asked if the patient had a pulse, and when nursing staff attempted to feel the patient's pulse, they did not check the patient's carotid pulse (area in the neck where pulse can easily be felt if present during a Code Blue). Staff C stated that she checked for the patient's carotid pulse, found the patient pulseless, had a backboard (stiff board that allows chest compressions to be effective enough to pump blood through the heart) placed under the patient and instructed staff to begin chest compressions and administer lifesaving medications. The patient's heart rate returned to 130 beats per minute (bpm). Staff C added that she spoke with Staff K, CCO, and informed her on the third day (first business day) following Patient #1's code that the facility needed to hold mock Code Blues based on the outcome of Patient #1's Code Blue event, but they had not occurred.

During an interview on 03/29/16 at 4:33 PM, Staff K, CCO, stated:
- None of the staff in Patient #1's room knew if the patient was a full code (to be resuscitated, which included chest compressions or life saving medications).
- No one in the patient's room knew the patient's blood pressure.
- She was responsible for assuming the Code Blue team leader position.
- She was not ACLS certified and never had been.
- She did not check the patient for a pulse nor did she look at the patient's rhythm (computer screen on the defibrillator which showed whether or not the patient has a life sustaining or lethal heart rhythm) during the code.
- She was in Patient #1's room for "maybe seven minutes".
- When Staff C entered the room, she stated that the patient did not have a pulse, chest compressions were started and lifesaving medications were administered.
- She recognized there were issues with the Code Blue process and was concerned about staff and their inability to use the defibrillator.
- She had not completed education or mock Code Blues since Patient #1's Code Blue event with patient care staff.

During an interview on 03/29/16 at 3:19 PM, Staff J, Chief Executive Officer, stated the following:
- She was concerned about the Code Blue process for Patient #1, because the patient went a significant amount of time without chest compressions.
- The facility did not initiate education related to the events of the code because they did not know if the failures were a "code issue" or an "individual (staff member) issue".
- She assumed Staff K debriefed staff (reviewed the events of the Code Blue with nursing staff, what went wrong and what went right) after Patient #1's Code Blue event.
- She did not know if the facility held mock Code Blues.

4. Record review of the facility's mock code documentation for the prior six months, showed staff had failed to perform mock codes since 10/13/15.

5. Record review of the facility policy titled, "Assessment/Reassessment - Interdisciplinary Patient," dated 08/2013, showed that patients were re-evaluated by a licensed nurse at a minimum every 12 hour shift, and included the patient's response to care, treatment and services, and recorded in the patient medical record.

6. Record review of Patient #1's Nurses Notes, showed there were no nursing assessments documented after 03/18/16 at 1:28 AM (Respiratory progress note showed that the patient was transferred to Hospital B at 8:20 PM, almost 19 hours after the last nursing assessment).

It was later confirmed that the patient expired in Hospital B.








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