HospitalInspections.org

Based on record review and interview, the hospital failed to measure, analyze, and track quality for 2 of 2 code incidents (Patient #4 and #9), in that, the quality management information did not include evidence of analysis as of 03/16/15 regarding A) Patient #4's 08/01/2014 code incident and B) Patient #9's 06/24/2014 code incident.

Findings Included

A) Patient #4's record on 08/04/2014 reflected, "Do Not Resuscitate...(signed on 07/07/2014 by two nurses, the patient and a physician on 07/08/2014) Physician Progress Notes...ACLS started...intubated...External pacing was initially attempted but there were mechanical issues...wrong pads on cart..."

The QA/Risk Management information did not include evidence of an analysis regarding the 08/04/2014 incident for Patient #4 as of 03/16/2015.

During an interview in the conference room on 03/16/2015 at 4:00 PM, Personnel #1 was asked about the physician progress note for Patient #1 of wrong pads on cart (crash cart) during the patient's code. Personnel #1 copied some of the record including the 08/04/2014 progress note and sent it on 12/15/14 to the Vice Chief of Staff to review the case. Personnel #1 was asked if she had seen that the physician had documented wrong pads on cart. Personnel #1 stated, "I must have." Personnel #1 was asked if there was an incident report. Personnel #1 stated, "I don't have one." Personnel #1 was asked if the incident had been evaluated. Personnel #1 stated, "No. I haven't gotten a review back (from the physician)." Personnel #1 was asked if the incident had been reviewed in the Quality meetings. Personnel #1 stated, "No."

B) Patient #9's record reflected, "...Physician Progress Notes...resuscitation in progress ...reviewed DNR status...verified DNR...code called...Do Not Resuscitate...(signature of spouse) 06-12-14...(signature of 2 nurses) 06/12/14...(signature of MD) 11-30-14...Medical Power of Attorney...If I have execute a Directive...then that Directive shall stand as the final expression of my right to refuse medical treatment...do not want to be on life support...procedures to be withheld or discontinued include cardiac resuscitation, mechanical respiration, tube feeding and antibiotics...17th day of April, 2007."
The QA/Risk Management information did not include evidence of an analysis regarding the 06/24/2014 incident for Patient #9 as of 03/16/2015.

During a telephone interview on 03/20/2015 ending at 9:12 AM, Physician #9 was asked about the 6/24/14 Patient #9 code. including the DNR status issue. Physician #9 stated, "The primary nurse was in there and did not know the code status." Physician #9 was asked if she was called and given the opportunity to participate in a hospital QA/analysis process for the code issues. Physician #9 stated, "No. I talked to the nurse manager and others about my frustration (unknown code status) with the situation."

The September 2012, revised "Incident Report" policy required, "The incident report provides an effective method of reporting variances to the Hospital Quality and Risk Management...staff that witness or discover an adverse event will complete the incident report...notify the attending physician...notify the patient family...notify the administrator...The Quality/Risk Manager will initiate intensive analysis..."