HospitalInspections.org

Based on interview and record review, the facility's designated officer (Personnel #4) for quality assessment and performance improvement did not complete an incident report and/or root cause analysis after identifying multiple problems during a "code blue" event of 1 of 1 patient (Patient #1) on 9/13/15. Personnel #4 did not adhere to facility policies and procedures.

Findings included:

On 9/13/15 at 3:15 AM Patient #1 was found to have agonal breathing and a "code blue" was activated twice. A code blue record was not documented. There was no assigned staff to record the code blue activity. The emergency equipment and drugs were not readily available. The physician on call did not promptly respond to the code blue. Patient #1 was eventually transferred to an acute care hospital. An incident and/or root cause analysis was not completed.

In an interview on 10/28/15 at 8:35 AM, Personnel #4 confirmed the above findings.

Policy # R03A (1) "Risk Management (Incident) Reporting..." revised 1/1/15 required "Purpose: To provide a mechanism whereby incidents are identified, rated by severity, and addressed in an efficient and effective manner."

Policy # S01-A/ 400-QM "Sentinel Event Policy" revised 1/1/14 required "Policy: In order to ensure patient and employee safety, any incident meeting the definition of sentinel event...will be investigated to discover the systems and processes underlying the apparent cause of the event..."

Based on interview and record review, the facility's nursing staff on the night shift (7:00 PM to 7:00 AM) of 9/12/15 did not ensure equipment and drugs were available to assist patients who have cardiac and pulmonary emergencies, citing 1 of 1 patient who was found to have agonal breathing on 9/13/15 at 3:15 AM.

Findings included:

Personnel #5 received a report that Patient #1 had breathing difficulties on 9/13/15 at 3:15 AM. According to a "RRT (respiratory response therapy) Record" dated 9/13/15 at 3:15 AM the patient was found without his nasal cannula and had agonal breathing." Per interview with Personnel #5 on 10/28/15 at 10:19 PM via phone, she observed Patient #1 was pale and had difficulty breathing. Personnel #5 stated she activated the "code blue" and brought the emergency cart to the patient's room. Physician #6 responded to the code blue and wanted to intubate the patient. The emergency cart did not have equipment and supplies. The respiratory box located on the side of the emergency cart did not have emergency equipment and medications either. Personnel #5 stated Personnel #1 was called to ask where the equipment and medications for intubation was. Personnel #1 directed the staff to the location.

In an interview on 10/28/15 at 8:35 AM, Personnel #4 confirmed the above findings.

Policy # E02-N "Emergency Equipment (Code Cart and Defibrillator) Checking Procedure revised 7/1/14 required "Purpose: To establish a process to ensure that the crash cart, intubation box, and defibrillator are checked every shift..."

Policy # E01-P "Emergency Drug Supplies" revised 7/2015 required "Purpose: Certain drugs must be readily available for emergency use..."