HospitalInspections.org

Based on staff interview, policy review, and record review, it was determined the hospital failed to establish a clear policy for staff to verify code status prior to initiating a "Code Blue" or begining CPR. This lack of policy guidance had the potential to result in inconsistent responses from staff. It could cause staff to delay calling a "Code Blue" or starting CPR when staff did not know a patient's code status and elected to find the code status in the medical record prior to initiating CPR. A delay in code response could make the difference between a patient living or dying. Also, lack of policy guidance could result in staff immediately initiating CPR in patients who turned out to have physician orders for DNR. This would violate patient rights to have advance directives honored and result in a failure to follow physician DNR orders. Findings include:

A hospital policy, "Code Blue," revised 2/10, stated all patients would be considered a "Full Code" unless written physician orders specified otherwise. The policy did not address if or how hospital staff were expected to verify code status, such as whether a physician's order was present for DNR/DNI.

On 5/11/10 at 2:15 PM, the Director of Quality Management, Director of Nursing, and a hospitalist MD were interviewed together. They explained patient code status was listed in medical records on the first page of nurses' notes and on a physicians' order form for resuscitation status. Code status was also reviewed during staff report regarding patients at each change of shift. The Director of Quality Management and Director of Nursing explained the hospital had considered using bracelets on patients to identify code status and had elected not to do so because they considered bracelets as "not safe."

During an interview on 5/12/10 at 2:30 PM, the Director of Quality Management explained the reason bracelets were considered "unsafe." She stated different hospitals used different colors to represent code status. Many of their staff had worked at other hospitals. Using colors, she explained, could confuse staff, especially agency staff who worked at different hospitals, potentially resulting in an inappropriate response to a code. When asked the expected procedure to verify code status, she stated she was not sure. She stated the hospital had not had to initiate many Code Blues.

During an interview on 5/12/10 between 10:00 - 10:30 AM, RN 1 described an incident in February 2010. She stated an agency CNA called her into the room of a patient whose blood sugar had declined and who was not responsive. RN 1 had not been assigned the patient and was unfamiliar with the patient's code status. The patient's medical record could not be found at the nurses' station. Later, RN 1 discovered the medical record had been in the medication room with another nurse. She described having pressed the Code Blue button in the patient's room to get some help. Help arrived and the patient recovered. She stated she knew the code status of her own patients but did not know the code status of the patients assigned to other nurses. This became an issue, she explained, when she had to cover for other nurses at lunch time or when she was called into a room belonging to a patient not already assigned to her care. She stated she thought it would be helpful to have some indication of patient code status closer to patients or their rooms.

During an interview on 5/13/10 at 1:30 PM, RN 2 described an incident when she had been called to the room of a patient with whom she was not familiar. She did not know the patient's code status and sent a CNA to look it up in the patient's medical record. She stated it could have been a problem if the record had not been found quickly. She stated she thought it would be a lot easier if patients wore a bracelet to identify code status.

During an interview on 5/13/10 at 7:20 AM, RN 3 stated she would initiate a code immediately if a patient stopped breathing. She would not take the time to find the chart to verify code status. She stated she would later stop the code if she found out the patient had a DNR order. Similarly, during an interview on 5/12/10 at 7:45 AM, RN 4 stated if a patient stopped breathing, she would initiate a code and continue until someone told her the patient had DNR orders.

During an interview on 5/12/10 at 2:00 PM, RN 5 stated she did not know if Patient #4, who was assigned to her that day, had DNR orders or not. She went to the nursing station and looked at his medical record before giving the surveyor a definitive answer.

The hospital failed to give clear direction on how to verify code status and respond quickly and accurately to patient conditions requiring a code response.

Based on staff interview and review of medical records and quality improvement documents, it was determined the hospital failed to ensure preventative actions were taken to protect patients from burns. This directly impacted 1 of 1 patient (#11) who suffered burns from a chemical heating pad. This had the potential to place other patients at risk of burns. Findings include:

Patient #11's medical record documented a 23 year old male who was admitted to the hospital on 4/07/10 and was discharged on 5/11/10. His diagnoses included inflammation of the spinal cord with quadriplegia. A "NURSES NOTE" by the RN, dated 4/30/10 at 7:35 PM, stated "Pt had heating pads on his hands today because they were cold but refused to have towels between his hands and the heating pads. Pt has two blisters on his right hand."

An "INCIDENT REPORT," completed by the same RN at 11:30 PM on 4/30/10, stated a nurse's aide had placed the hot packs on Patient #11's hands and he had suffered 2 blisters. The incident report stated Patient #11 refused to have a sheet or towel placed between the hot pack and his hands. The incident report stated "Pad removed. Wound team following [with] treatment as needed." Under the heading "Actions Implemented," the report stated "Physical Therapy to work [with] nursing to provide education to nursing about [quadriplegia] care re: sensations."

The Director of Quality Management was interviewed on 5/13/10 at 10:15 AM. She stated she did not know what type of hot pack was used or where the aide had obtained the hot pack. The Director of Physical Therapy, who was also the manager of the wound care team, joined the interview with the Director of Quality Management. The Director of Physical Therapy also stated she did not know what type of hot pack had been used. She stated the physical therapy department had decided not to use hot packs because of the possibility of burns. Then she went to the clean central supply on the medical floor to investigate. She returned at 11:00 AM with several "Accu-Therm Hot Packs." She stated she had just removed them from the supply cart. The packs consisted of a plastic bag with crystals and fluid in a separate bag. The surveyor broke the fluid bag and mixed it with the crystals. The bag immediately became hot. The temperature of the bag was measured at 115.6 degrees Farenheit. Until then the hot packs had been available for use by staff. The Director of Quality stated staff had not been trained in the use of the hot packs. The hot packs were removed from the supply cart at that time.

The hospital failed to remove the hot packs after Patient #11 was burned and failed to educate staff in their safe use.