HospitalInspections.org

Based on review of hospital policy, contract services agreement, job descriptions, Advanced Cardiovascular Life Support (ACLS) 2010 guidelines, medical record review, hospital document review of archived emergency code overhead pages, incident report review, staff and physician interviews and observations, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights and an organized nursing service to ensure the safety of patients.

The findings include:

1. The hospital failed to promote and protect patients' rights to the delivery of care in a safe setting as evidenced by the failure to provide safe care in an oxygen enriched environment during resuscitative efforts which included debrillation of an identified patient. A fire occurred on 11/06/2012 at 0220, during the resuscitation for 1 of 1 (Patient #1).

~ cross refer to 482.13 Patient Rights' Condition: Tag 0115.

2. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care in an oxygen enriched environment during a resuscitative event .

~ cross refer to 482.23 Nursing Services Condition: Tag 0385.

Based on review of hospital policy, contract services agreement, job descriptions, Advanced Cardiovascular Life Support (ACLS) 2010 guidelines, medical record review, hospital document review of archived emergency code overhead pages, incident report review, staff and physician interviews and observation, the hospital failed to promote and protect patients' rights by failing to ensure a safe setting for patient care.

The findings include:

The hospital failed to promote and protect patients' rights to the delivery of care in a safe setting as evidenced by the failure to provide safe care in an oxygen enriched environment during resuscitative efforts which included debrillation of an identified patient. A fire occurred on 11/06/2012 at 0220, during the resuscitation for 1 of 1 (Patient #1).

~ cross refer to 482.13(c)(2) Patient Rights' Standard: Tag 0144.

Based on review of hospital policy, contract services agreement, job descriptions, Advanced Cardiovascular Life Support (ACLS) 2010 guidelines, medical record review, hospital document review of archived emergency code overhead pages, incident report review, staff and physician interviews and observation, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care.

The findings include:

Nursing staff failed to supervise and evaluate patient care in an oxygen enriched environment during a resuscitative event for 1 of 1 fire events reviewed (Patient #1).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

Based on review of hospital policy, contract services agreement, job descriptions, Advanced Cardiovascular Life Support (ACLS) 2010 guidelines, medical record review, hospital document review of archived emergency code overhead pages, incident report review, staff and physician interviews and observation, the hospital failed to provide safe patient care in an oxygen enriched environment during defibrillation for 1 of 1 patients(Patient #1).

The findings include:

Review of CPR (Cardiopulmonary Resuscitation) Code policy revised on 03/08/2001 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....5. Code team will respond to all medical emergency calls or when requested and will assume responsibility for running the code."

A review of Hospital A's "Attachment A SERVICES" agreement revealed Hospital B (contracted facility) shall make "Code Five coverage available to patients twenty-four hours per day, seven (7) days per week." Further review of the agreement revealed, Hospital A (named facility) had an agreement with Hospital B (contract facility) to provide cardiopulmonary resuscitation response. Ongoing agreement review revealed, "Definition: Code 5: A call initiated by the operator through the paging system to activate a team to respond to a cardiopulmonary event for a pediatric or adult patient. BVM: Bag Valve Mask, the equipment used to administer ventilation to a patient who is assessed to be without spontaneous respiration. Policy: To assure patients received immediate response to a significant cardiac/respiratory event when indicated.... To provide adequately educated staff who have a working knowledge of identifying and activating a response to a cardiac/respiratory event or near respiratory/cardiac event requiring resuscitation equipment and medication. To ensure a team is available to respond to all Code 5 pages who are educated in the care of the patient requiring advanced neonatal, pediatric or adult life support. ...Respiratory therapy is responsible for maintaining all pediatric and adult intubation equipment brought to a Code 5 situation.... Code 5 Team... 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.."

A review of Advanced Cardiovascular Life Support-American Heart Association (ACLS), 2010 guidelines (used by Hospital A and Hospital B) revealed the fundamental facts for defibrillation clearance included: "Check to make sure you are clear of contact with the patient, the stretcher, or other equipment. Make a visual check to ensure that no one is touching the patient or stretcher. Be sure oxygen is not flowing across the patient's chest."

A closed medical record review of Patient #1 revealed a 39-year-old male admitted to Hospital A on November 1, 2012 at 1440 to room 6204 with Acute Renal Failure (ARF), bacteremia (blood infection), and wound infection; had a history of recent aortic dissection post repair, end-stage renal disease (on dialysis), chronic respiratory failure (tracheostomy-surgical airway), and was a full code (cardiopulmonary resuscitation in the event of cardiac arrest). Review of 24 Hour Patient Record and Plan of Care revealed on November 1, 2012 admission, patient's Glasgow Coma Scale (GCS- neurological scale used to determine state of consciousness) at 1440 was 15 with patient responding to simple commands and able to squeeze hands; however, November 1, 2012 at 2030 to November 4, 2012 at 1945, patient's Glasgow Coma Scale (GCS) ranged from 10 to 12 with patient unable to follow verbal commands. Further review of 24 Hour Patient Record and Plan of Care revealed no nursing documentation from 11/05/2012 or 11/06/2012. Review of Respiratory Oxygen Treatment Record revealed on 11/1/2012 at 1600 to 11/05/2012 at 2245, the patient was on a trach collar with oxygen support ranging from 35% to 50% and the patient's oxygen saturation level (amount of oxygen in blood) ranged from 88% to 100%. Further record review revealed on 11/06/2012 at 0045, the patient was placed on a ventilator (machine mechanically breathing into lungs) per physician's order with 50% of oxygen support with patient's oxygen saturation level at 90%. Review of a physician's Consultation Report dictated on 11/06/2012 at 0321 revealed, "...the patient was found to be unresponsive, being ventilated and pulseless with cardiopulmonary resuscitation (CPR) in progress by (Hospital A) staff. Unfortunately, later in time, the patient deteriorated and lost pulse again. Cardiopulmonary resuscitation (CPR) was reinstituted and patient underwent ultimately three further rounds of cardiopulmonary resuscitation (CPR). Shocks were given x4....Unfortunately, at this time, the 4th shock (electrical shock to reset heart to normal rhythm) resulted in no perfusing rhythm. The patient was found to be expired at this time. The code ran for 30 minutes from 0145 to 0215. He was pronounced at 0215 from this cardiac arrest."

Review of Archived Messages (hospital documents of archived overhead code pages) revealed on November 6, 2012 at 0144, a code five 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...."

An interview with RN #4 (Registered Nurse-Monitor Technician Hospital A) conducted on 11/14/2012 at 1215 revealed, "...0129-0130, patient went asystole-flat line; told charge nurse and code called...0210, I was watching monitor, he never had a rhythm....0215, kinda heard an explosion. Everybody yelled to evacuate. I told them to turn off O2 (oxygen) supply. The strips before and during the code were left on the counter (nursing station)."

An interview with RT #1 (Respiratory Therapist Hospital A) conducted on 11/14/2012 at 1015 revealed, "...code blue called to 6204 and I disconnected patient from vent (ventilator) and started bagging (manually providing oxygen via ambu bag) the patient. Eventually, (RT #2-Hospital A) took bagging over. Patient temporarily back on vent with 100% of oxygen being delivered. Patient looses pulse, (RT #2-Hospital A) bagging patient with 100% oxygen from flometer...Right after last shock, I saw defibrillator (pads) spark (electricity) in the upper right chest area. Spark went to patient's gown. Ambu bag near pads with oxygen flow on. Charge Nurse (Hospital B-contract staff) pushing the shock button. I remember her calling clear. I think the pads ignited with ambu bag."

An interview with RN #2 (Charge Nurse Hospital A) conducted on 11/14/2012 at 1135 revealed, "....I was doing chest compressions. I saw a spark and combustion take place. The patient was not on the vent when combustion happened....patient did not have a sustainable rhythm. Fire started on right side, upper rail. Everyone trying to evacuate....flame was too high, too close to oxygen source."

Interview with RN #3 (ICU nurse Hospital B) conducted on 11/14/2012 at 1145 revealed, "...compressions already in process. I placed leads on the patient, pads were already on...(Physician A-Hospital B) mostly calling the code....three rounds of drugs, three rounds of shocks, total of four shocks. 200 joules for first shock and 360 joules for last shock. I called clear, looked all around to make sure everyone was clear and lastly looked at my feet and I pressed shock. Fire came out of ambu opening. My job was to defib and make sure that everybody was safe. The ambu bag was in the bed with opening facing downward, parallel to patient's body. Immediately after flame-continuous, we heard a hissing sound. We all left...I could not breathe or see. I ended up in the emergency department..."

An interview with RN #5 (primary nurse Hospital A) conducted on 11/14/2012 at 1235 revealed she was the recorder during the code. The nurse stated, "...someone asked how long had it been and I remember 26 minutes...we were getting ready to call it (stop the code) and somebody said, "let's try one more shock."...everybody nodded heads in consensus with shock. I looked up and saw sparks...sparks from right shoulder area then lots of smoke..."

A telephone interview with RT #2 (Respiratory Therapist Hospital A) conducted on 11/14/2012 at 1420 revealed, "...at some point, I started to bag patient when first shock was delivered. I think four-six shocks were delivered. The first three shocks, the ambu bag was off of the patient and with the fourth shock, the ambu bag was in the bed, right side of the bed, right shoulder/arm. Spark came from the defib (pads). The ambu bag was on patient's chest, cannot recall side. I remember spark, flame, and running down the hall closing doors. I did not turn off oxygen (in patient's room) because there was flame all around. I turned off O2 valve outside the room (patient's room)."

An interview with Physician #A (Hospitalist Hospital B) conducted on 11/14/2012 at 1047 revealed, "about 0145, overhead code was called and I was in the ER (emergency department).... I was leading the code...three cycles of ACLS (Advanced Cardiovascular Life Support). Patient never had any return of a pulse. I called out time of 0215, thirty minutes into code. We made a consensus with the third shock and with the fourth shock, I wanted to complete three cycles. I evacuated at the time of fire." Interview revealed Physician #A was watching the cardiac monitor when the fire occurred and she was unable to see where the fire originated.

An interview with Physician B (ICU Intensivist Hospital B) conducted on 11/14/2012 at 1255 revealed, "....I arrived after one minute of page. The patient was connected to ventilator (mechanical machine breathing into lungs) and brady (heart rate below 60 beats per minute)...this was a 30 minute code. Hospitalist primarily calling (running) the code. The patient did not have much spontaneous rhythm. I felt femoral pulse. The patient received three to four shocks. Clear was called and the nurse ((ICU nurse-Hospital B) looked around before delivering shocks. The patient was being bagged by respiratory therapy (RT #2 Hospital A). The respiratory therapist was not bagging when shocks were delivered. A spark occurred when defib (defibrillator-a dose of electricity to help set heart to natural rhythm) fired, a distinct spark in the right pectoralis (right chest) where you could place a pad. Then thin, significant smoke that rose up and a hissing sound. I told everybody to get out of room. Then black smoke rolled out of room. Registered Nurse (RN #2 Hospital A Charge Nurse) came back with a fire extinguisher and I unloaded the fire extinguisher. About twenty minutes or so after the fire, I went back into the room and turned off O2 (oxygen) source to ambu bag."

An interview with RN #6 (Registered Nurse Hospital B-Assistant Director, Staff Educator/Development) conducted on 11/14/2012 at 1610 revealed, "I am the primary instructor and coordinator for BLS/ACLS (Basic Life Support/Advance Cardiovascular Life Support). I teach the 2010 ACLS guidelines. The clear chant means, I'm clear, you're clear, and oxygen's clear. Oxygen clear means oxygen is off of the bed, away from the patient."

An interview with Administrative Staff (Chief Nursing Officer Hospital A) conducted on 11/15/2012 at 0955 revealed, "I arrived onsite twenty minutes after receiving a telephone call. Between the times of 0315-0330, ten patients were moved to rooms in (Hospital B) and two vent (ventilated) patients were moved to the ED (Emergency Department) and ICU (Intensive Care Unit) in (Hospital B). Crime scene tape was placed by the police." Interview revealed firemen were present and staff were providing care to the patients in the hallway when the staff member arrived. Interview revealed equipment was sequestered by the police and placed in a locked area. Further interview revealed the hospital had undergone repair from water damage related to the fire and 11 patients were transferred back to the hospital on 11/14/2012.

Observation on 11/15/2012 at 1205 revealed an uncovered bed that was sequestered after the fire on 11/06/2012. Observation of the bed revealed the right upper siderail covered with a black substance and an internal control panel attached to the right upper siderail that was completely burned. Continued observation revealed a mattress with the right upper quadrant burned with visible mattress foam padding exposed.

Consequently, contracted staff responded to a code five on 11/06/2012 at 0144 to assist with ACLS/CPR (Advanced Cardiovascular Life Support/Cardiopulmonary resuscitation). Staff failed to protect patients' rights to the delivery of care in a safe setting as evidenced by the failure to follow ACLS (Advance Cardiovascular Life Support) guidelines and render safe care in an oxygen enriched environment during resuscitative efforts which included debrillation of an identified patient. A fire occurred on 11/06/2012 at 0220, during the resuscitation for 1 of 1 (Patient #1).

Based on review of hospital policy, contract services agreement, job descriptions, Advanced Cardiovascular Life Support (ACLS) 2010 guidelines, medical record review, hospital document review of archived emergency code overhead pages, incident report review, staff and physician interviews and observation, the nursing staff failed to supervise and evaluate patient care in an oxygen enriched environment during a resuscitative event for 1 of 1 fire events reviewed (Patient #1).

The findings include:

Review of CPR (Cardiopulmonary Resuscitation) Code policy revised on 03/08/2001 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....5. Code team will respond to all medical emergency calls or when requested and will assume responsibility for running the code."

A review of Hospital A's "Attachment A SERVICES" agreement revealed Hospital B (contracted facility) shall make "Code Five coverage available to patients twenty-four hours per day, seven (7) days per week." Further review of the agreement revealed, Hospital A (named facility) had an agreement with Hospital B (contract facility) to provide cardiopulmonary resuscitation response. Ongoing agreement review revealed, "Definition: Code 5: A call initiated by the operator through the paging system to activate a team to respond to a cardiopulmonary event for a pediatric or adult patient. BVM: Bag Valve Mask, the equipment used to administer ventilation to a patient who is assessed to be without spontaneous respiration. Policy: To assure patients received immediate response to a significant cardiac/respiratory event when indicated.... To provide adequately educated staff who have a working knowledge of identifying and activating a response to a cardiac/respiratory event or near respiratory/cardiac event requiring resuscitation equipment and medication. To ensure a team is available to respond to all Code 5 pages who are educated in the care of the patient requiring advanced neonatal, pediatric or adult life support. ...Respiratory therapy is responsible for maintaining all pediatric and adult intubation equipment brought to a Code 5 situation.... Code 5 Team... 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.."

A review of Advanced Cardiovascular Life Support-American Heart Association (ACLS), 2010 guidelines (used by Hospital A and Hospital B) revealed the fundamental facts for defibrillation clearance included: "Check to make sure you are clear of contact with the patient, the stretcher, or other equipment. Make a visual check to ensure that no one is touching the patient or stretcher. Be sure oxygen is not flowing across the patient's chest."

A closed medical record review of Patient #1 revealed a 39-year-old male admitted to Hospital A on November 1, 2012 at 1440 to room 6204 with Acute Renal Failure (ARF), bacteremia (blood infection), and wound infection; had a history of recent aortic dissection post repair, end-stage renal disease (on dialysis), chronic respiratory failure (tracheostomy-surgical airway), and was a full code (cardiopulmonary resuscitation in the event of cardiac arrest). Review of 24 Hour Patient Record and Plan of Care revealed on November 1, 2012 admission, patient's Glasgow Coma Scale (GCS- neurological scale used to determine state of consciousness) at 1440 was 15 with patient responding to simple commands and able to squeeze hands; however, November 1, 2012 at 2030 to November 4, 2012 at 1945, patient's Glasgow Coma Scale (GCS) ranged from 10 to 12 with patient unable to follow verbal commands. Further review of 24 Hour Patient Record and Plan of Care revealed no nursing documentation from 11/05/2012 or 11/06/2012. Review of Respiratory Oxygen Treatment Record revealed on 11/1/2012 at 1600 to 11/05/2012 at 2245, the patient was on a trach collar with oxygen support ranging from 35% to 50% and the patient's oxygen saturation level (amount of oxygen in blood) ranged from 88% to 100%. Further record review revealed on 11/06/2012 at 0045, the patient was placed on a ventilator (machine mechanically breathing into lungs) per physician's order with 50% of oxygen support with patient's oxygen saturation level at 90%. Review of a physician's Consultation Report dictated on 11/06/2012 at 0321 revealed, "...the patient was found to be unresponsive, being ventilated and pulseless with cardiopulmonary resuscitation (CPR) in progress by (Hospital A) staff. Unfortunately, later in time, the patient deteriorated and lost pulse again. Cardiopulmonary resuscitation (CPR) was reinstituted and patient underwent ultimately three further rounds of cardiopulmonary resuscitation (CPR). Shocks were given x4....Unfortunately, at this time, the 4th shock (electrical shock to reset heart to normal rhythm) resulted in no perfusing rhythm. The patient was found to be expired at this time. The code ran for 30 minutes from 0145 to 0215. He was pronounced at 0215 from this cardiac arrest."

Review of Archived Messages (hospital documents of archived overhead code pages) revealed on November 6, 2012 at 0144, a code five 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...."

An interview with RN #4 (Registered Nurse-Monitor Technician Hospital A) conducted on 11/14/2012 at 1215 revealed, "...0129-0130, patient went asystole-flat line; told charge nurse and code called...0210, I was watching monitor, he never had a rhythm....0215, kinda heard an explosion. Everybody yelled to evacuate. I told them to turn off O2 (oxygen) supply. The strips before and during the code were left on the counter (nursing station)."

An interview with RT #1 (Respiratory Therapist Hospital A) conducted on 11/14/2012 at 1015 revealed, "...code blue called to 6204 and I disconnected patient from vent (ventilator) and started bagging (manually providing oxygen via ambu bag) the patient. Eventually, (RT #2-Hospital A) took bagging over. Patient temporarily back on vent with 100% of oxygen being delivered. Patient looses pulse, (RT #2-Hospital A) bagging patient with 100% oxygen from flometer...Right after last shock, I saw defibrillator (pads) spark (electricity) in the upper right chest area. Spark went to patient's gown. Ambu bag near pads with oxygen flow on. Charge Nurse (Hospital B-contract staff) pushing the shock button. I remember her calling clear. I think the pads ignited with ambu bag."

An interview with RN #2 (Charge Nurse Hospital A) conducted on 11/14/2012 at 1135 revealed, "....I was doing chest compressions. I saw a spark and combustion take place. The patient was not on the vent when combustion happened....patient did not have a sustainable rhythm. Fire started on right side, upper rail. Everyone trying to evacuate....flame was too high, too close to oxygen source."

Interview with RN #3 (ICU nurse Hospital B) conducted on 11/14/2012 at 1145 revealed, "...compressions already in process. I placed leads on the patient, pads were already on...(Physician A-Hospital B) mostly calling the code....three rounds of drugs, three rounds of shocks, total of four shocks. 200 joules for first shock and 360 joules for last shock. I called clear, looked all around to make sure everyone was clear and lastly looked at my feet and I pressed shock. Fire came out of ambu opening. My job was to defib and make sure that everybody was safe. The ambu bag was in the bed with opening facing downward, parallel to patient's body. Immediately after flame-continuous, we heard a hissing sound. We all left...I could not breathe or see. I ended up in the emergency department..."

An interview with RN #5 (primary nurse Hospital A) conducted on 11/14/2012 at 1235 revealed she was the recorder during the code. The nurse stated, "...someone asked how long had it been and I remember 26 minutes...we were getting ready to call it (stop the code) and somebody said, "let's try one more shock."...everybody nodded heads in consensus with shock. I looked up and saw sparks...sparks from right shoulder area then lots of smoke..."

A telephone interview with RT #2 (Respiratory Therapist Hospital A) conducted on 11/14/2012 at 1420 revealed, "...at some point, I started to bag patient when first shock was delivered. I think four-six shocks were delivered. The first three shocks, the ambu bag was off of the patient and with the fourth shock, the ambu bag was in the bed, right side of the bed, right shoulder/arm. Spark came from the defib (pads). The ambu bag was on patient's chest, cannot recall side. I remember spark, flame, and running down the hall closing doors. I did not turn off oxygen (in patient's room) because there was flame all around. I turned off O2 valve outside the room (patient's room)."

An interview with Physician #A (Hospitalist Hospital B) conducted on 11/14/2012 at 1047 revealed, "about 0145, overhead code was called and I was in the ER (emergency department).... I was leading the code...three cycles of ACLS (Advanced Cardiovascular Life Support). Patient never had any return of a pulse. I called out time of 0215, thirty minutes into code. We made a consensus with the third shock and with the fourth shock, I wanted to complete three cycles. I evacuated at the time of fire." Interview revealed Physician #A was watching the cardiac monitor when the fire occurred and she was unable to see where the fire originated.

An interview with Physician B (ICU Intensivist Hospital B) conducted on 11/14/2012 at 1255 revealed, "....I arrived after one minute of page. The patient was connected to ventilator (mechanical machine breathing into lungs) and brady (heart rate below 60 beats per minute)...this was a 30 minute code. Hospitalist primarily calling (running) the code. The patient did not have much spontaneous rhythm. I felt femoral pulse. The patient received three to four shocks. Clear was called and the nurse ((ICU nurse-Hospital B) looked around before delivering shocks. The patient was being bagged by respiratory therapy (RT #2 Hospital A). The respiratory therapist was not bagging when shocks were delivered. A spark occurred when defib (defibrillator-a dose of electricity to help set heart to natural rhythm) fired, a distinct spark in the right pectoralis (right chest) where you could place a pad. Then thin, significant smoke that rose up and a hissing sound. I told everybody to get out of room. Then black smoke rolled out of room. Registered Nurse (RN #2 Hospital A Charge Nurse) came back with a fire extinguisher and I unloaded the fire extinguisher. About twenty minutes or so after the fire, I went back into the room and turned off O2 (oxygen) source to ambu bag."

An interview with RN #6 (Registered Nurse Hospital B-Assistant Director, Staff Educator/Development) conducted on 11/14/2012 at 1610 revealed, "I am the primary instructor and coordinator for BLS/ACLS (Basic Life Support/Advance Cardiovascular Life Support). I teach the 2010 ACLS guidelines. The clear chant means, I'm clear, you're clear, and oxygen's clear. Oxygen clear means oxygen is off of the bed, away from the patient."

An interview with Administrative Staff (Chief Nursing Officer Hospital A) conducted on 11/15/2012 at 0955 revealed, "I arrived onsite twenty minutes after receiving a telephone call. Between the times of 0315-0330, ten patients were moved to rooms in (Hospital B) and two vent (ventilated) patients were moved to the ED (Emergency Department) and ICU (Intensive Care Unit) in (Hospital B). Crime scene tape was placed by the police." Interview revealed firemen were present and staff were providing care to the patients in the hallway when the staff member arrived. Interview revealed equipment was sequestered by the police and placed in a locked area. Further interview revealed the hospital had undergone repair from water damage related to the fire and 11 patients were transferred back to the hospital on 11/14/2012.

Observation on 11/15/2012 at 1205 revealed an uncovered bed that was sequestered after the fire on 11/06/2012. Observation of the bed revealed the right upper siderail covered with a black substance and an internal control panel attached to the right upper siderail that was completely burned. Continued observation revealed a mattress with the right upper quadrant burned with visible mattress foam padding exposed.

Consequently, contracted staff responded to a code five on 11/06/2012 at 0144 to assist with ACLS/CPR (Advanced Cardiovascular Life Support/Cardiopulmonary resuscitation). Staff failed to protect patients' rights to the delivery of care in a safe setting as evidenced by the failure to follow ACLS (Advance Cardiovascular Life Support) guidelines and render safe care in an oxygen enriched environment during resuscitative efforts which included debrillation of an identified patient. A fire occurred on 11/06/2012 at 0220, during the resuscitation for 1 of 1 (Patient #1).