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Based on staff interviews, medical record review, and review of nursing resource material, the nursing service did not assure nursing personnel were properly trained and competent to administer a continuous intravenous (IV) dopamine infusion (a drug diluted in a bag of IV solution that is commonly used during a cardiac arrest emergency to increase the patients blood pressure) to a 17-year old patient who presented to the emergency department (ED) on 7/2/14 for treatment of attempted suicide by a drug overdose. The patient's blood pressure dropped significantly after her arrival to the ED and the physician directed staff to start an IV dopamine drip (infusion). Nursing staff were unfamiliar with dopamine and unsure of how to administer the medication. At least 33 minutes elapsed before staff initiated the dopamine drip. Staff did not closely monitor and record the patients low blood pressure in accordance with accepted standards of nursing practice after it was initially found to be very low and required treatment with IV dopamine. No doppler probe (a hand held, non-invasive device used to detect the blood pressure) was available for emergency department staff use when the automated digital blood pressure monitor was unable to detect the patient's blood pressure. Nursing personnel were unable to demonstrate proficiency in recording the care and treatment provided to the patient while in the ED. Nursing staff completing the cardiac arrest record (a pre-printed form used to record all interventions that occur during a resuscitation) failed to include the dosages of the numerous medications administered during the resuscitation of the patient.

Due to the severity of the situation and the potential for harm to all patients, the hospital was not in compliance with the Condition of Participation for Nursing Services. This revisit and complaint allegation survey also determined that the IJ cited during 4/25/14/complaint survey and 5/15/14 revisit survey had not been removed.

Refer to deficiency at A 397.

Based on observation, record review, and interview, the facility failed to meet the emergency needs of 2 of 2 patients receiving medical care in the Emergency Department (Patient 51, Patient 52).

Findings include:

1) The facility failed to provide services, equipment, personnel and resources within timeframes that protect the health and safety of patients receiving medical care in the Emergency Department (see A-1103).

2) The facility failed to maintain current policies and procedures for emergency medical services provided to all patients who receive medical care in the Emergency Department (see A-1104).

Based on observation, record review, and interview, the facility failed to ensure that emergency services requirements were met for 2 of 2 patients who received medical care in the Emergency Department (Patient 51, Patient 52).

Findings include:

The facility is not compliant with 42 CFR §482.55 (see A-1100).

Based on staff interviews, medical record review and review of nursing resource material, the nursing service did not assure nursing personnel were properly trained and competent to provide nursing care in accordance with the individual needs of each patient for 1 of 2 (Patient 51) medical records reviewed. On 7/15/14 the hospital identified a census of 2 patients.

Findings included:

1. On 7/15/14 review of Patient 51's closed medical record showed the 280-pound, 17-year old patient presented to the emergency department on 7/2/14 at 9:03 AM for treatment of an attempted suicide by intentionally overdosing on multiple medications. She was awake, cooperative and told staff she had ingested an unknown amount of several medications belonging to a family member at 1:30 AM that morning. A relative accompanying the patient showed staff the multiple empty, 90-count medication bottles and said the patient took an unknown amount of each of them. The bottles included: Aspirin 81 milligrams (mg.) - an anti-inflammatory and blood thinner; Irbesartan 150 mg.-for treatment of high blood presure; Minocycline 50 mg.- antibiotic; Metoprolol 50 mg.-for treatment of high blood pressure; Furosemide 40 mg.-diuretic (water pill) for treatment of fluid retention; HTCZ 25 mg.- used to treat high blood pressure and fluid retention; Diltiazem 240 mg.- used to treat high blood pressure and chest pain; Ibuprofen 800 mg.-used to treat pain, inflammation and fever.

The patients initial blood pressure at 9:04 AM was 76/48 (normal is 120/80) and heart rate was 62 (normal is 60-100). The patients next documented blood pressure was 16 minutes later, at 9:20 AM, and was 85/42 with a heart rate of 69. Her next blood pressures at 9:30 and 9:40 AM were recorded at 90/40 and her heart rate had dropped to a rate 50. At 9:42 AM the patients blood pressure dropped significantly to 65/36 and her heart rate to a rate of 43. The patient was symptomatic and sweating profusely. At that time the ED physician (MD-X) directed nursing staff to start a continuous intravenous (IV) dopamine infusion (A drug diluted in a bag of IV solution that is commonly used during a cardiac arrest emergency to increase the patients blood pressure. The rate of infusion is gradually adjusted to the desired increase in blood pressure). The medical record showed the dopamine infusion was not initiated until 10:15 AM or 33 minutes after prescribed by MD-X. After the 9:42 AM blood pressure reading nursing staff did not monitor and record the patient's blood pressure again until 10:29 AM (47 minutes later and result of 84/58) , even though the patient's cardiac and respiratory functions were deteriorating. The patient's blood pressure was not monitored or recorded again until 11:23 AM (54 minutes later). During this time the patient's heart rate and respirations were rapidly deteriorating, requiring cardio-pulmonary resuscitation and an external pacemaker (a device placed on the outside of the body that delivers electric current impulses to stimulate the heartbeat of patients with an abnormally slow heart rhythm). The patient's medical record did not contain a cardiac arrest record (a form used to record the patients condition and all interventions that occur during the resuscitation) the resuscitation. According to American Heart Association guidance for conducting resuscitation efforts during a cardio-pulmonary arrest, the cardiac arrest record form should be completed during the event to ensure accurate data is collected.

At 11:40 AM the patient again required cardio-pulmonary resuscitation. Review of a cardiac arrest record showed staff administered numerous emergency medications during the resuscitation efforts but did not document the dosages given. Also, staff did not document the type or size of the endotracheal tube used to intubate the patient. The patient was transferred by air ambulance to a nearby hospital where she died shortly after her arrival.

During an interview on 7/16/15 at 8:30 AM, MD-X said he was the ED physician on duty on 7/2/14 when Patient 51 presented to the ED. He said the patient received the dopamine infusion late because it took a long time for nurses to calculate the infusion rate of the dopamine. He said, "the nurses were busy and running around", and he couldn't do the dopamine infusion himself. He said he didn't want one of the ED registered nurses (RN LL), who usually worked on the upstairs inpatient floor, working in the ED again because, "she didn't know what the heck was going on", and that she should be kept "upstairs". MD-X said the automated blood pressure machine was not detecting the patient's blood pressure and they needed a doppler (a hand-held, non-invasive device used to detect blood pressure and pulses) but one could not be found. He also said arterial blood gases (blood test from an artery that measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood) could not be obtained from the critically ill patient because the hospital laboratory was not equipped to perform this test. The physician also said it took 17 minutes to get the patient into the helicopter for transfer because she was too big and the helicopter too small.

During an interview on 7/16/15 at 9:20 AM, the ED registered nurse supervisor (RN MM) said she was on duty on 7/2/14 with RN LL when Patient 51 presented to the ED. She said RN LL could not initiate the dopamine infusion because she wasn't comfortable giving an IV medication she had never given before. RN MM said she was comfortable administering the dopamine infusion but it took awhile to get the dopamine infusion started because she needed the hospital pharmacist to assist her with calculating the dosage and infusion rate. When interviewed concerning the lack of blood pressure results in the patient's medical record, RN MM said the automated blood pressure machine they were using wouldn't display the blood pressure reading.

During an interview on 7/17/14 at 8:00 AM, RN LL said she didn't feel comfortable preparing and administering the dopamine IV infusion for Patient 51 so she "handed it off to the supervisor to do". She said she has never in her nursing career started a dopamine infusion and she calls the "regulars" in the ED or the nursing supervisor for assistance. She said she is scheduled on the inpatient unit and only works in the ED as needed. She said she has received no training in administering dopamine since Patient 51 was treated in the ED.

Interview on 7/17/14 at 8:35 AM with RN AA, on duty on the inpatient unit, revealed she has never administered dopamine. She said if she was directed to infuse dopamine she could read the instructions from information contained in a notebook on the crash cart. When asked to see the instructions, RN AA removed a 3-ring binder from the top of the crash cart and slowly leafed through multiple pages before coming to the directions for administering dopamine. She said she wouldn't calculate the dosage and infusion rate herself but would get help from another nurse. If another nurse wasn't available she said she would try to administer the dopamine herself and then ask someone to check it. The interview revealed the dopamine medication is pre-mixed in a bag of IV solution and is no longer kept on the crash cart. The dopamine is instead kept in a automated medication dispensing cabinet (called a Pyxis MedStation) in the medication room that requires a password to unlock and entry of other information in order to retrive the medication.

During interview on 07/17/14 at 9:05 a.m., RN DD stated that she had never administered Dopamine. She stated that she would " call the pharmacy to confirm how to do it properly . . .look it up in books. . .confirm with the doctor. . .confirm with another nurse. " She stated that she has been rotating to work in the Emergency Department for the past two weeks and works there when they need help or when they are short-staffed. Nurse DD stated that Dopamine is kept on the medication cart and would not be found anywhere else. She stated that a pharmacist is on call 24 hours and could come in if needed.

During an interview on 7/16/14 at 1:05 PM, the Acting Clinical Director, (MD Y) said he expects nursing staff in the emergency department to be able to administer a Dopamine drip. He said ignorance and imcompetence of the nurses was the reason the initiation of the dopamine intravenous infusion for Patient 51 was delayed.

Failure of the nursing service to assure nursing staff were properly trained and competent to administer dopamine created an Immediate Jeopardy situation for any patient presenting to the ED or hospital inpatient who required this medication.

Based on interviews with medical staff, the hospital did not have the capability of performing arterial blood gas testing ( a laboratory test using blood from an artery that measures the acidity and the levels of oxygen and carbon dioxide in the blood. Arterial blood gas analysis is a common investigation in emergency departments for monitoring patients with acute and chronic illnesses -such as acute respiratory failure or chronic obstructive pulomary disease). This has the potential to affect the emergency laboratory needs of all hospital inpatients and those patients presenting to the hospital with an emergency condition.

Findings include:

During an interview on 07/16/14 at 8:30 AM, MD X said, "we can't even do blood gases here" and " that's pretty bad. " MD X stated that he told MD Y about the lack of blood gas equipment that he needed but did not know the results of his report. According to MD X, "You can be the best mechanic but forget about fixing the car if you don't have the right tools."

During an interview on 07/16/14 at 12:40 PM, MD Y, the Acting Clinical Director, said the hospital is unable to fully assess the respiratory status of it's patients and that laboratory services are needed 24 hours per day, 7 days a week, which is currently not the case. He said the hospital has purchased a machine that will test venous blood gases (an alternative method of estimating carbon dioxide level and pH that does not require arterial blood sampling) but it is not ready for use and laboratory staff have not been trained to operate it.

Based on observation, record review, and interview, the facility failed to provide services, equipment, personnel, and resources within timeframes that protect the health and safety of patients for 1 of 2 patients who received medical care in the Emergency Department (Patient 52).
Findings include:
1) According to the medical record, Patient 52 was having a seizure and in respiratory distress upon arrival of the Code Blue Team. Review of the Code Blue Critique revealed " Recommendation: Hospital M ' s helicopter flatbed would not advance forward far enough to secure (Patient 52) in the helicopter. There was a delay of 12 minutes trying to load (Patient 52). We left the ER for the helicopter at 13:58 and turned to the ER at 14:15. " The patient expired at 14:20. According to the Cardiac Arrest Record, at 1315, Patient 52 had a pulse of 140 and BS (blood sugar) of 152. The Comments stated, " Mercy flight crew arrived. Pt. placed on flight crew ' s monitor . . .1327 Pt. lifted with assist of 8 people to ER gurney. 1328 Pt. lost pulse and in PEA (pulseless electrical activity). . . Flight team and code team transferring pt. to ER c (with) chest compressions + ventilations continuing. Arrival to ER @ 1331. Pulse done. No pulse. Remains in PEA. . . 1338 Crew extubated Combi-tube (device used to provide an airway to facilitate the mechanical ventilation of a patient in respiratory distress) - placement of ET (endotracheal) tube (a catheter inserted through the mouth or nose) . . .1339 Successful intubation by flight crew. ET tube secured by flight crew. . .1342 Chest compressions stopped . . .Flight team states pupils were fixed. Flight crew prepared pt. to move to helicopter. . .1358 Flight team and code team moved pt. to helicopter . . .1415 Flight team and code team arrived to ER continuing chest compressions and ventilations. Agonal rhythm (a variant of asystole treated with cardiopulmonary resuscitation and administration of intravenous epinephrine) on monitor. No pulse. . . 1420 Code called and pt. pronounced dead. "
Review of the Progress Notes for Patient 52, written by Nurse B, dated 06/25/2014 at 13:58, stated, " Pt. was loaded onto aircrew stretcher and taken to helo pad for loading and transfer to [Hospital M]. On transfer pt. remained on cardiac monitor and was being ventilated with bag valve mask. On arrival at helicopter the helicopter gurney was slid out and ER gurney was raised to height of Helo gurney. Pt. was then slid over onto helo gurney, the gurney was slid sideways into the helo but gurney would not slide forward and lock into the helo. Aircrew staff was trouble shooting situation and stated that he thought do (sic) to her wt. being mostly upper body and quite heavy that it was jamming the sliding mechanism. I tried lifting on head of gurney to relieve some of the wt. at the head of gurney but it still would not slide into helo. While trouble shooting was going on, 1 aircrew staff continued using Bag valve mask to give rescue breathing. Pt. heart rate began slowly dropping, when pt. heart rate was in 60 ' s I took over rescue breathing and aircrew staff gave her 1 mg of epinephrine IV. Pt. heart rate dropped into 40 ' s quickly, aircrew took over rescue breathing and I started chest compressions. We then unloaded pt. from helicopter to return to Er for treatment on the way to ER bag valve mask rescue breathing was being provided and [MD Y] was above pt. on gurney doing chest compressions. Pt. arrived in ER again at 14:15. "
During interview with RN MM on 07/16/14 at 9:20 AM, she stated that they had " trouble getting (Patient 52) on the helicopter. " She stated that the patient ' s weight, age, height, and " what was going on " with the patient were known by the helicopter company prior to arrival. Although she stated that a nurse or EMT (emergency medical technician) goes with the patient onto the helipad with a security escort, the RN MM verified that there was no written policy regarding roles and responsibilities for helicopter transport.
During interview with MD Y on 07/16/14 at 12:40 PM., he stated that the difficulty getting the patient into the helicopter was a " factor of measurement vs. weight. " MD Y could not identify measures that had been implemented to mitigate this risk for future helicopter transports.
2) During a tour of the Emergency Department on 07/16/14 at 9:20 AM, there was no call system that was readily accessible to patients. This finding was verified with Nurse MM, who found a bell and put it on the counter during this tour. When asked how the patient would reach the bell from their bed, she stated that the staff would put the bell on a table that could be moved next to the patient ' s bed. There was neither a bell in exam room 2 nor in the negative pressure room. According to Nurse MM, " I haven ' t put a bell . . . we check on them. " She verified that there was no other way for patients to call the nurses.
3) During a tour of the Emergency Department on 07/16/14 at 9:20 AM, observations revealed that manual blood pressure cuffs were attached to the walls of patient rooms. Nurse MM verified that there were no other manual blood pressure cuffs available for use in areas other than in these patient rooms.

Based on interview and record review, the facility failed to maintain current policies and procedures on poison control protocol, which affected 1 of 2 patients (Patient 51) who received medical care in the emergency department.

Findings include:

1) Patient 51 was a 17-year old who presented to the Emergency Department on 07/02/14 at 9:03 AM for treatment of an attempted suicide through ingestion of multiple medications.

2) During interview with MD X on 07/16/14 at 8:30 AM, he stated that Poison Control connected hospital staff to a "1-800 number in Louisiana" who recommended supportive care. MD X stated that he "would call a local number instead."

3) During interview with MD Y on 07/16/14 at 12:40 PM, he stated that the "1-800 number" was the correct resource.

4) There was no evidence of a policy or procedure regarding how poison control services should be accessed, which could delay care to patients who need poison control services.