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Based on policy review, contract review and staff interview, the hospital's governing body failed to ensure adequate staff to provide medical treatment during cardiopulmonary emergencies.

Findings include:

Review of the hospital's "CPR (Cardiopulmonary Resuscitation) Code" policy revised 01/01/2013 revealed "PURPOSE: to provide a consistent course of action of the staff during a life-threatening situation. POLICY: ...CPR/ACLS (Cardiopulmonary Resuscitation/ Advanced Cardiovascular Life Support) will be implemented according to ACLS/BLS guidelines by individuals who have BLS/ACLS certification.... PROCEDURE: ....C. Implement ACLS based on AHA (American Heart Association) guidelines.... E. Code team will respond to all medical emergency calls or when requested and will assume responsibility for running the code."

Review of a contract between Hospital A (named facility which is located on the sixth floor of Hospital B) and Hospital B revealed Hospital A had an agreement in place with Hospital B for Hospital B's Code Team to provide cardiopulmonary resuscitation response to Hospital A during medical emergencies when an overhead page was called. Review of the agreement revealed Hospital B (contracted facility) shall make Code Team coverage available to patients twenty-four hours per day, seven (7) days per week. Further review of the agreement revealed, Hospital B would ensure a team is available to respond to all Code Team pages who are educated in the care of the patient requiring advanced neonatal, pediatric or adult life support. Review revealed the Code Team would consist of "... 1 ACLS/PALS RN (Advanced Cardiovascular Life Support/Pediatric Advanced Life Support Registered Nurse) from Response Team... 1 ACLS/PALS RN from ICU (Intensive Care Unit) or CCU (Critical Care Unit)... 1 ACLS/PALS RN from the ED (Emergency Department) for... adult codes... Role... Manages the code cart and switches monitor from AED (Automated External Defibrillator) mode to Energy Select mode and continues as directed with defibrillation. Assists with starting IV (intravenous) lines and performs code activities as directed.... 1 EKG (Electrocardiography) tech obtains EKG... 1 RN (nurse assigned to the patient)... Historian, records code 5 sheet and completes cardiac arrest review sheet. Prints code summary... 2 respiratory therapists... Responsible for intubation, blood gasses, CPR... 1 Attending level physician and associates*...Directs code."

Review of Hospital A's Registered Nurse's job position qualifications revealed, "....BLS and ACLS (Basic Life Support and Advanced Cardiovascular Life Support) required."

Review of Hospital A's Respiratory Therapist's job position qualifications revealed, "....BLS and ACLS (Basic Life Support and Advanced Cardiovascular Life Support) required.."

Review of Archived Messages (hospital documents of archived overhead code pages) revealed on November 6, 2012 at 0144, a code five (Cardiopulmonary Resuscitation event) was called to room 6204 and on November 6, 2012 at 0220, a code red (fire emergency) was called to 6th level wing 2 (Location of room #6204).

Review revealed an incident report (Hospital A) dated November 6, 2012 at 0230 stating, "a small fire isolated to one patient room occurred within our hospital. A critically ill patient in this patient room was involved in an active code blue situation when the fire occurred. The fire appears to have been triggered by a defibrillator....The fire was quickly extinguished by staff and the sprinkler system was successfully activated...."

Interview on 01/15/2013 at 1230 revealed Hospital A has had no Code Blue events since 11/06/2012 (fire event).

Interview on 01/16/2013 at 1420 with a staff registered nurse (RN) revealed Hospital A responds to Code Blue (Cardiopulmonary Resuscitation) events during the day and Hospital B responds to Code Blue events during the night shift. The staff member stated Hospital A has a physician available during the day and staff do not overhead a Code Blue. Interview revealed Hospital B staff do not respond unless the Code Blue is paged overhead. Interview revealed there is less staff and no physician available at Hospital A during the night and a Code Blue would be paged overhead at night for Hospital B staff to assist with the Code.

Interview on 01/17/2013 at 1505 with a nursing administrative staff member revealed it is an expectation that Hospital A's charge nurse would direct the code. The staff member stated when Hospital B's code team arrives, they are assigned a role and a decision is made between the physician and Hospital A's charge nurse regarding what Hospital B staff are needed. The staff member stated "The charge nurse at (Hospital A) is the primary lead in Code Blues at all times."

Interview on 01/17/2013 at 1345 with administrative staff revealed safety concerns had been identified regarding not having adequate staff if Hospital B were not available to assist with Code Blues. The staff member stated there would not be adequate staff to respond if there were a second code simultaneously and there is not a physician available during the night. The staff member explained there is a physician (hospitalist) on the unit from 0700 through 1700 or 1800 daily and between 1800 through 0700, there is no physician on the unit. Interview revealed there were additional staff and resources available during the day to provide care for other patients during a code that would not be available during the night. The staff member stated there were concerns with the safety of other ventilator dependant patients if staff were involved with a code during the night. The staff member stated "It was reviewed and determined we would not have enough staff. We have taken more ownership by having our RNs (registered nurses) take charge (lead role) during the code." Interview revealed barriers to eliminating the agreement with Hospital B for code response included not having a physician available at night, lack of supporting staff for unit patient needs, staff self confidence and a culture change.

Based on review of the hospital's policy and procedures, medical record review, and staff interviews, the hospital failed to document in the medical record the time of pain reassessment after an intervention for 4 of 4 patients (Patient's #20, #11, #7, and #8)

The findings include:

Review of the current hospital policy and procedure (P&P) "Documentation Standards" dated 04/01/11 revealed "each separate entry must have a corresponding time of occurrence in the time column."

Review of the current hospital P&P "Pain Management" dated 12/2003 revealed "a patient is to be re-assessed after any pain medication is given. Documentation should be done on the 24-hour flow sheet, or the nurse's progress note".

Review of the 24-hour Nursing Flow Sheet revealed a table with 24 columns and 7 rows for documentation of the patient's pain assessment and reassessment. The 7 rows were labeled as 1) VAS (Visual Analog Scale) a numerical pain scale; 2) FLACC (Face, Legs, Activity, Cry and Consolability) a pain scale used for noncommunicative patients; 3) Location; 4) see narrative; 5) medicated; 6) pain score after medication; 7) initials. Across the top of the table the 24 columns were labeled with preset hourly increments i.e. 07, 08, 09, 10, 11, 12, etc.

1. Open medical record review for patient #20 revealed a 77 year old male was admitted on 01/04/2013 with the diagnoses of altered mental status, sepsis, sacral pressure wound, and right heel pressure wound.
Review of the 24-hr. Nursing Flow Sheet revealed on 01/06/2013 at 1600 patient #20 was assessed for a pain score of 8 (pain scale of 1 to 10 with 10 being the worst). Review of the Medication Administration Record (MAR) revealed on 01/06/2013 at 1610 patient #20 received Oxycodone IR (pain medication) 5 milligrams (mgs) PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed a documented pain reassessment score of 2 with no documentation of the time the pain reassessment was completed.
Review of the 24-hr. Nursing Flow Sheet revealed on 01/06/2013 at 2000 patient #20 was assessed for a pain score of 7. Review of the MAR revealed on 01/06/2013 at 2020 patient #20 received Tramadol (pain medication) 50 mgs PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/06/2013 a documented pain reassessment score of 2 with no documented time the pain reassessment was completed.

Review of the Nursing Flow Sheet revealed on 01/06/2013 at 2300 patient #20 was assessed for a pain score of 7. Review of the MAR revealed on 01/06/2013 at 2315 patient #20 received Oxycodone IR (pain medication) 5 mgs PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/06/2013 a documented pain reassessment score of 0 with no documented time the pain reassessment was completed.
Review of the Nursing Flow Sheet revealed on 01/07/2013 at 0200 patient #20 was assessed for a pain score of 9. Review of the MAR revealed on 01/07/2013 at 0215 patient #20 received Acetaminophen (pain medication) 650 mgs PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/07/2013 a documented pain reassessment score of 0 with no documented time the pain reassessment was completed.
Review of the Nursing Flow Sheet revealed on 01/07/2013 at 1500 patient #20 was assessed for a pain score of 10. Review of the MAR revealed on 01/07/2013 at 1500 patient #20 received Acetaminophen (pain medication) 650 mgs PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/07/2013 a documented pain reassessment score of 2 with no documented time the pain reassessment was completed.
Review of the Nursing Flow Sheet revealed on 01/08/2013 at 1300 patient #20 was assessed for a pain score of 9. Review of the MAR revealed on 01/08/2013 at 1330 patient #20 received Oxycodone IR (pain medication) 5 mgs PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/08/2013 a documented pain reassessment score of 0 with no documented time the pain reassessment was completed.
Review of the Nursing Flow Sheet revealed on 01/08/2013 at 2200 patient #20 was assessed for a pain score of 7. Review of the MAR revealed on 01/08/2013 at 2250 patient #20 received Oxycodone IR (pain medication) 5 mgs PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/08/2013 a documented pain reassessment score of 2 with no documented time the pain reassessment was completed.
Review of the Nursing Flow Sheet revealed on 01/08/2013 at 0900 patient #20 was assessed for a pain score of 9. Review of the MAR revealed on 01/09/2013 at 0940 patient #20 received Oxycodone IR (pain medication) 5 mgs PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/09/2013 a documented pain reassessment score of 2 with no documented time the pain reassessment was completed.
Review of the Nursing Flow Sheet revealed on 01/09/2013 at 1700 patient # 20 was assessed for a pain score of 6. Review of the MAR revealed on 01/09/2013 at 1700 patient #20 received Oxycodone IR (pain medication) PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/09/2013 a documented pain reassessment score of 4 with no documented time the pain reassessment was completed.
Review of the Nursing Flow Sheet revealed on 01/09/2013 at 2200 patient #20 was assessed for a pain score of 5. Review of the MAR revealed on 01/09/2013 at 2230 patient #20 received Tramadol (pain medication) 50 mgs PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/09/2013 a documented pain reassessment score of 0 with no documented time the pain reassessment was completed.
Review of the Nursing Flow Sheet revealed on 01/10/2013 at 0500 patient #20 was assessed for a pain score of 6. Review of the MAR revealed on 01/10/2013 at 0530 patient #20 received Oxycodone IR (pain medication) 5 mgs PO (orally). Further review of the 24-hr. Nursing Flow Sheet revealed on 01/10/2013 a documented pain reassessment score of 2 with no documented time the pain reassessment was completed.
An interview on 1/17/2013 at 1500 with the Director of Quality revealed the "pain score after medication" column is used for the nurses to document their reassessment of the patient's pain after an intervention. After further review of the Nursing Flow Sheet the Director of Quality identified that the pain reassessment is documented in the same time slot as the initial pain assessment but the reassessment is not timed. Following continued review of the 24-hr. Nursing Flow Sheet the Director of Quality was unable to identify the "time" of the pain reassessment. The interview revealed the hospital policy regarding "documentation standards" requiring each separate entry to have a corresponding time documented in the time column was not being followed.



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2. Open medical record review for patient #11 revealed a 55 year old female admitted on 01/03/2013 with a diagnosis of shortness of breath and respiratory failure.

Review of the 24-hr Nursing Flow Sheet revealed on 01/13/2013 at 0100 the patient was assessed for a pain score of 2. Review of the MAR (medication administration record) revealed on 01/13/2013 at 0055 the patient received Acetaminophen (pain medication) 650 mg (milligrams) orally (by mouth). Further review of the 24-hr Nursing Flow Sheet revealed on 01/13/2013 a documented pain reassessment score of "sleeping" with no documented time the reassessment was completed.

Review of the 24-hour (hr) Nursing Flow Sheet revealed on 01/13/2013 at 2100 the patient was assessed for a pain score of 6 (pain scale of 1 - 10 with 10 the worst pain). Review of the MAR revealed on 01/13/2013 at 2125 the patient received Oxycodone IR (pain medication) 5mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/13/2013 a documented pain reassessment score of 2 with no documented time the reassessment was completed.

Review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 at 0340 the patient was assessed for a pain score of 8. Review of the MAR revealed on 01/15/2013 at 0340 the patient received Oxycodone IR 5 mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 a documented pain reassessment score of 0 with no documented time the reassessment was completed.

Review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 at 1100 the patient was assessed for a pain score of 6. Review of the MAR revealed on 01/15/2013 at 1100 the patient received Oxycodone IR 5 mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 a documented pain reassessment score of 0 with no documented time the reassessment was completed.

Review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 at 2025 the patient was assessed for a pain score of 4. Review of the MAR revealed on 01/15/2013 at 2025 the patient received Acetaminophen 650mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 a documented pain reassessment score of 0 with no documented time the reassessment was completed.

On 01/16/2013 at 1015 an interview with RN #1 revealed the pain reassessment is documented in the same time slot on the flow sheet that the initial pain assessment score and medication are documented. She said "pain reassessment after oral (po) medication is 1 hour and after IV (intravenous) medication you reassess the patient's pain in 30 minutes." Further interview revealed "can not identify the specific time the reassessment was done but we know it was done after the medication was given."

3. Open medical record review for patient #7 revealed a 67 year old male admitted on 12/07/2012 with diagnosis of Respiratory Failure status post tracheostomy (incision and tube placement in the neck to assist a person in breathing)

Review of the 24-hour Nursing Flow Sheet revealed on 01/11/2013 at 2200 the patient was assessed for a pain score of 4. Review of the MAR revealed on 01/11/2013 at 2200 the patient received Oxycodone IR 5mg orally. Further review of the 24-hour Nursing Flow Sheet revealed on 01/11/2013 a documented pain reassessment score of "sleeping" with no documented time the reassessment was completed.

Review of the 24-hr Nursing Flow Sheet revealed on 01/12/2013 at 0200 the patient was assessed for a pain score of 4. Review of the MAR revealed on 01/12/2013 at 0210 the patient received Oxycodone IR 5mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/12/2013 a documented pain reassessment score of "sleeping" with no documented time the reassessment was completed.

Review of the 24-hr Nursing Flow Sheet revealed on 01/13/2013 at 0500 the patient was assessed for a pain score of 3. Review of the MAR revealed on 01/13/2013 at 0520 the patient received Acetaminophen 650 mg, (pain medication) orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/13/2013 there is no documented pain reassessment.

Review of the 24-hr Nursing Flow Sheet revealed on 01/14/2013 at 0050 the patient was assessed for a pain score of 4. Review of the MAR revealed on 01/14/2013 at 0050 the patient received Acetaminophen 650 mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/14/2013 a documented pain reassessment score of 0 with no documented time the reassessment was completed.

On 01/17/2013 at 1500 an interview with Director of Quality revealed the "pain score after medication" column is used for the nurses to document their reassessment of the patient's pain after an intervention. After reviewing the nursing flow sheet he identified that the pain reassessment is documented in the same time slot as the initial pain assessment but the reassessment is not timed. After reviewing the 24-hr Nursing Flow Sheet he was not able to identify the "time" of the pain reassessment.

4. Open medical record review for patient #8 revealed a 72 year old male admitted on 12/03/2012 with a diagnosis of respiratory failure with tracheostomy and chronic obstructive pulmonary disease.

Review of the 24-hr Nursing Flow Sheet revealed on 01/11/2013 at 2200 the patient was assessed for a pain score of 9. Review of the MAR revealed on 01/11/2013 at 2240 the patient received Morphine Sulfate (pain medication) 10mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/11/2013 a documented pain reassessment score of 5 with no documented time the reassessment was completed.

Review of the 24-hr Nursing Flow Sheet revealed on 01/14/2013 at 2300 the patient was assessed for a pain score of 9. Review of the MAR revealed on 01/14/2013 at 2318 the patient received Morphine Sulfate 10mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/14/2013 there was no documented time of pain reassessment.

Review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 at 1615 the patient was assessed for a pain score of 9. Review of the MAR revealed on 01/15/2013 at 1615 the patient received Morphine Sulfate 10mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 a pain reassessment score of 2 with no documented time the reassessment was completed.

Review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 at 2300 the patient was assessed for a pain score of 6. Review of the MAR revealed on 01/15/2013 at 2330 the patient received Morphine Sulfate 10mg orally. Further review of the 24-hr Nursing Flow Sheet revealed on 01/15/2013 a pain reassessment score of "sleeping" with no documented time the reassessment was completed.

On 01/17/2013 at 1500 an interview with the Administrative Staff, the Director of Quality and the Director of Nursing, revealed that row #7, "pain score after medication", on the 24-hr Nursing Flow Sheet is used for the nurses to document their reassessment of the patient's pain after an intervention. After reviewing the nursing flow sheet they identified that the pain reassessments are documented in the same time "slot" "column" as the initial pain assessment and the pain reassessment is not timed. After reviewing the 24-hr Nursing Flow Sheet they were not able to identify the "time" the pain reassessment was completed or documented.

Based on hospital policy review, medical record review and staff interview, the hospital failed to obtain a physician order for mechanical ventilation settings before initating ventilatory managment for 4 of 4 patients (#1, #8, #15 and #9).

The findings include:

Review of the hospital's policy, " PROTOCOLS, PHYSICIAN ORDERS FOR RESPIRATORY CARE", revised 3/06, revealed, "...POLICY: A. Physician Orders: 1. All orders must be provided by Medical Staff or Allied Health who have been granted privilege to do so by Hospital Governing Board 2. Orders must be complete. Lack of a complete order necessitates a call to the physician for clarification..."

Review of the hospital's policy, "VENTILATOR MANAGEMENT", revised 3/13/06, revealed, "...POLICY: The Respiratory Therapist will provide mechanical ventilation to those patients in need upon receipt of a physician order..."

1. Open medical record review conducted on 01/16/2013 for patient #1 revealed a 64-year-old admitted on 01/11/2013 for Hypoxic respiratory failure with a tracheostomy (breathing tube) placed on 12/28/2012. Continued record review revealed on 01/11/2013, admission order for respiratory to evaluate and treat. Ongoing record review revealed a respiratory care mechanical ventilator flow sheet with documentation on 01/11/2013 at 1140, patient was on PSV (Pressure Support Ventilation). Further record review revealed no physician order for the ventilator setting.

Interview conducted on 01/16/2013 at 1130 with RT (Respiratory Therapist) #1 revealed, "...our protocol allows us (RT) to start vent settings without a doctor order."

Interview conducted on 01/16/2013 at 1532 with RT #2 revealed, "...evaluate and treat means to clinically evaluate the patient...there are three parts to the clinical evaluation: work of breathing, evaluate graphic values, and ABG (Arterial Blood Gas)...the nurse receiving a patient from another hospital, will give vent orders at the bedside...we have automony in our clinical practice..."

2. Open medical record review conducted on 01/16/2013 for patient #8 revealed a 72-year-old admitted on 12/03/2012 for Respiratory failure with a tracheostomy placed on 11/26/2012. Continued record review revealed on 12/03/2013 at 1600, admission order for respiratory to evaulate and treat. Ongoing record review revealed a respiratory care mechanical ventilator flow sheet with documentation on 12/03/2012 at 2020, patient was on PSV. Further record review revealed no physician order for the ventilator setting.

Interview conducted on 01/16/2013 at 1130 with RT (Respiratory Therapist) #1 revealed, "...our protocol allows us (RT) to start vent settings without a doctor order."

Interview conducted on 01/16/2013 at 1532 with RT #2 revealed, "...evaluate and treat means to clinically evaluate the patient...there are three parts to the clinical evaluation: work of breathing, evaluate graphic values, and ABG (Arterial Blood Gas)...the nurse receiving a patient from another hospital, will give vent orders at the bedside...we have automony in our clinical practice..."

3. Open medical record review conducted on 01/16/2013 for patient #15 revealed a 82-year-old admitted on 12/21/2012 for Respiratory failure with a tracheostomy placed on 12/10/2012. Continued record review revealed on 12/21/2012, admission order for respiratory to evaluate and treat. Ongoing record review revealed a respiratory care mechanical ventilator flow sheet with documentation on 12/21/2012 at 0730, patient was on PSV. Further record review revealed no physician order for the ventilator setting.

Interview conducted on 01/16/2013 at 1130 with RT (Respiratory Therapist) #1 revealed, "...our protocol allows us (RT) to start vent settings without a doctor order."

Interview conducted on 01/16/2013 at 1532 with RT #2 revealed, "...evaluate and treat means to clinically evaluate the patient...there are three parts to the clinical evaluation: work of breathing, evaluate graphic values, and ABG (Arterial Blood Gas)...the nurse receiving a patient from another hospital, will give vent orders at the bedside...we have automony in our clinical practice..."



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4. Open medical record review for patient #9 revealed a 77 year-old male admitted on 12/24/2012 with the diagnoses of chronic respiratory failure secondary to Pott's disease (tuberculous arthritis of the intervertebral joints affecting the spine), severe restrictive lung physiology, severe kyphosis, and chronic tracheostomy (surgical opening in the trachea), and Pulmonary Hypertension (increased blood pressure in the arteries and veins of the lungs causing shortness of breath with exhertion). Further review of Patient # 9's History and Physical revealed Patient # 9 had a history of a recent past hospital admission due to "oxygen saturations decreasing to the 70's , with minimal activity, during the day when off the ventilator." Review of the History and Physical revealed Patient # 9 was admitted for continued support on the ventilator and to receive ongoing assessments for weaning to a tracheostomy collar during the day.
Review of admission orders dated 12/24/2012 at 1609 revealed Patient #9's physician orders included a Respiratory order to "evaluate and treat." Further review of Patient #9's admission orders revealed there was no physician order for ventilator settings for Patient #9 who was admitted on 12/24/2012 with a past medical history of failure to wean off ventilator support.
In an interview on 01/17/2013 at 1500 with the Quality Director he stated, "the respiratory orders to evaluate and treat are currently rewritten to include ventilator settings." The Quality Director said, "We have gone through all the charts and audited to be sure the charts were complete and inclusive of ventilator settings because we recognize the respiratory orders should include ventilator settings." Interview confirmed the "Ventilator Management" policy and the "Physician Order" policy was not being followed.