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CONTINUUM REHABILITATION HOSPITAL OF NORTH TEXAS L
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on review of documents and interview with staff, the facility failed to ensure that patients receive care in a safe setting, as policy and procedure for emergency treatment was not followed for 2 of 2 patients whose records were reviewed. Code blue cardiac resuscitation records were not complete for Patients #1 and #2; there was no record of the monitoring of the heart rhythm for either patient during code blue events as required by policy.
Findings were:
According to facility policy and procedure, entitled Provision of Care Code Blue Policies, PCN-NU-17-028, page 7 of 11 states that " When the code is called, go immediately to the crash cart and attach the monitor electrodes to the patient. Record the pattern continuously during the code. " The section entitled Code Team Responsibilities outlines on page 9 of 11 the duties of the Code Recorder. The recorder utilizes a paper code record which is located on the crash cart. The recorder documents all aspects of the code, including the heart monitor patterns. The policy states that the heart monitor strips are to be placed on the back of the code record and placed in the patient ' s chart.
Review of the medical record of Patient #1 revealed that the attending physician noted in the Discharge Summary that nursing staff placed a defibrillator monitor on the patient but there was " no shockable rhythm seen. " Review of code blue records of Patient #1 revealed no evidence that the staff performing CPR recorded the heart rhythm patterns of the patient during the code blue event.
Review of the code blue record of Patient #2 revealed no evidence that the staff performing CPR recorded the heart rhythm patterns of the patient during the code blue event, as documentation of such was not included.
An in-person interview was conducted the afternoon of 9/18/12 with the facility Chief Nursing Officer (CNO) who acknowledged that there was no documentation that nursing staff monitored the heart rhythm of Patient #1 or Patient #2 during code blue events.