HospitalInspections.org

Based on document review and interview, the facility failed to ensure that all entries in the medical record are complete for 3 of 5 (Pt # 1, Pt # 4, Pt # 5) closed medical records reviewed.

Findings:

1. Review of facility policy titled: Emergency Advanced Life Support Notification System, release date 5/2015, indicated, on page 2, under Documentation 1. "ALS events (including the arrival time of emergency personnel) are documented in the patient's medical record.", and b. "Code team record sheet."

2. Review of medical record (MR) for Pt # 1, indicated incompleteness in area for "Code Blue Flowsheet": Airway/Ventilation, Intubation, Family Notified, CPR Stopped.

3. Review of MR for Pt # 4, indicated incompleteness in area for "Code Blue Flowsheet": Summary of Events Preceding Code/Precipitating Factors, ECG Rhythm, BP, Pulse, Family Notified, IV Therapy.

4. Review of MR for Pt # 5, indicated incompleteness in area for "Code Blue Flowsheet": Time, ECG Rhythm, BP, Pulse, Resp, CPR, Bolus Therapy, IV Therapy, Family Notified.

5. In interview on 3/29/2017 at approximately 9:30 am with administrative staff members A # 1, A # 2 and A # 3, the following was confirmed:
A. That the code blue flowsheets were incomplete.
B. That it is the responsibility of the nursing staff-nurse designated as writer to complete documentation of code events.
C. No other documentation was provided prior to exit.