At interview with Endoscopy Technician, Staff #5
on 9/3/14 at 2:05 PM, she stated the ENT
surgeon performed a Laryngoscopy for Patient #1
that was aborted because the ENT surgeon
stated she could not see very well what she was
trying to view. She stated that Staff #1 proceeded
with the EGD and when it was completed at 9:28
AM, the ENT surgeon went in again with a
laryngoscope and was there for a minute or two.
She stated the laryngoscope was withdrawn at
9:30 AM. Staff #5 confirmed there was no
separate "Time Out" announced for the initial
Nasolaryngoscopy conducted prior to the EGD
and the second Nasolaryngoscopy after the EGD.
3. The review of the Procedure Notes and
Cardiac Resuscitation Records for Patient #1
revealed the physicians in charge of the care of
the patient failed to identify deteriorating vital
signs and provide timely intervention during the
procedure on 8/28/14. Abnormal vital signs as
well as abnormal values of peripheral capillary
(the smallest of a body's blood vessels located
away from the heart, such as, in the arms, hands,
legs and feet) oxygen saturation (a term referring
to the concentration of oxygen in the blood -
SpO2 - normal levels are considered 95 to 100
percent), and End-tidal carbon dioxide (ETCO2 -
concentration of carbon dioxide in the expired air;
normal value is 35 to 45 millimeters Mercury
(mmHg) were not addressed.
Pre procedure vital signs on 8/28/14 at 8:44.06
AM were as follows:
Blood Pressure (BP) 118/80, Pulse 62 Regular,
Respirations 16, Temperature (Temp.) 97.2
Fahrenheit, SPO2 100%.
Intra-procedure vital signs were as follows:
9:12.49 AM - BP 117/60, Pulse 71, SpO2 92%
9:16.13 AM - BP 92/54, Pulse 56, Respirations
16, SpO2 94%, ETCO2 26
9:21:42 AM - BP 89/44, Pulse 54, Respirations
17, SpO2 97%, ETCO2 19
9:26.36 AM - BP 84/40, Pulse 47, SpO2 92%
The Cardiac Arrest Record indicated that
resuscitation of the patient was initiated two
minutes later at 9:28 AM.
However, at interview with Staff #5, on 9/3/14 at
2:15 AM, she stated that following the EGD scope
withdrawal at 9:28 AM, the ENT doctor proceeded
to do another Nasolaryngoscopy. The Endoscopy
Technician reported, "ENT doctor was in there for
a minute or two before the removal of the
laryngoscope at 9:30 AM. Vital signs recorded at
9:30:04 notes a blood pressure of 85/49, no pulse
recorded, and oxygen saturation was at 92%.
In the addendum by the Anesthesiologist, Staff #2
at 2:36 PM, she notes that the patient maintained
saturation at approximately 90% during
Laryngoscopy. In another note hand written by
Staff #2, she explained that oxygen saturation
was maintained with a combination of jaw thrust
and increase in oxygen flow to 5 Liters/min
There was conflicting information in the medical
record regarding the time resuscitation was
initiated and the overall management of the
patient during the code (situations requiring
cardiopulmonary resuscitation).
There were two code records in the patient's
medical record. One of the record titled Cardiac
Arrest Record indicated the patient went into
cardiac arrested at 9:28 AM and cardiopulmonary
resuscitation was initiated at 9:30 AM. This record
notes that the first set of medications,
Epinephrine 1 milligram (mg) and Atropine 1 mg
were administered at 9:38 AM.
The second code record titled Endoscopy Code
Blue Record noted the patient had a pulse and
was in ventricular tachycardia (V-tach or VT - a
type of rapid heart beat, that starts in the bottom
chambers of the heart, called the ventricles, the
main pumping chambers of the heart) at 9:28 AM.
It was documented that assisted ventilation and
chest compression were initiated at 9:28 AM.
However, there was no indication that the
ventricular tachycardia with presence of pulse
was immediately treated in accordance with
Advanced Cardiac Life Support. Instead, the code
record notes that Epinephrine 1 mg and Atropine
1 mg were administered to the patient at 9:28
AM.
The patient was successfully resuscitated at
10:00 AM and transferred to a hospital at 10:04
AM for further management. The patient expired
at the hospital on 9/4/14 at 1:15 PM.