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Immediate Jeopardy was identified on 8/23/23 at 3:05PM under Nursing Services 482.23 for failure to ensure Patient #1001, with an ESI (Emergency Severity Index) level one designation and required continuous telemetry to monitor cardiac function was assessed every two hours in accordance with policy, failed to ensure the telemonitor leads remained on the patient at all times, failed to ensure the patient's cardiac rhythm was continuously monitored, and failed to ensure the monitor technician alerted the RN when cardiac activity was not observed on the monitor. As a result, the patient's change in condition was not identified in a timely manner when the patient was found pulseless and expired.

Please refer to A-395 and A-405

Based on clinical record review, hospital policy and staff interview for 1 of 3 sampled patients reviewed for care and services (Patient #1001), the hospital failed to ensure the patient with an ESI (Emergency Severity Index) level one designation and required continuous telemetry to monitor cardiac function was assessed every two hours in accordance with policy, failed to ensure the telemonitor leads remained on the patient at all times, failed to ensure the patient's cardiac rhythm was continuously monitored, and failed to ensure the monitor technician alerted the RN when cardiac activity was not observed on the monitor. As a result, the patient's change in condition was not identified in a timely manner when the patient was found pulseless and expired. As a result of these failures, Immediate Jeopardy was identified. The findings include:


Patient #1001 arrived at the Emergency Department (ED) on 8/14/23 at 12:45PM with complaints of breathing becoming worse after blunt chest trauma and was triaged at an ESI (emergency severity index) level one, requiring every 2-hour reassessment specific to the patient's chief complaint and condition, in addition to temperature, pulse, respiratory rate, B/P, O2 saturation and pain score if appropriate.

Review of the triage note dated 8/14/23 at 12:58PM noted the patient's vital signs were documented as; pulse rate 119, respirations 16, blood pressure 107/85, and pulse oximetry 96% on room air. The note further indicated the patient was placed on continuous telemetry ay 1:10 PM.

Review of the ED provider note, (MD#1) dated 8/14/23 at 1:10PM noted the patient presented with a fall and shortness of breath. The note identified the patient reported a bureau fell on the patient's chest and was pinned for approximately 4 hours and had a head strike but did not have loss of conscious. The patient was made an ESI level one given the diminished breath sounds, was tachycardic (increased heart rate) and tachypneic (rapid/shallow breathing). The note further identified the patient will be admitted to level one telemetry, trend troponin and BMP, EKG every six hours and cardiology consult.

Physician orders dated 8/14/23 at 1:13PM directed to place the patient on cardiac telemetry for chest pain, possible ACS.

Nurse's notes dated 8/14/23 at 1:10PM noted the patient presented to ED as a level one, reports a dresser fell on him/her and was unable to get out from under it for two or three hours and woke up feeling short of breath with body pain. The note identified bruising present over abdomen and left arm. The patient was placed on 2 liters of oxygen for shortness of breath.

Nurse's notes dated 8/14/23 at 2:11PM noted critical lab, Lactic acid greater the 17.0 (normal range 0.5-2.0 mmol/L). The note lacked documentation the provider was made aware of the abnormal results.

Nurse's notes dated 8/14/23 at 2:51PM noted critical lab value Troponin 1261 (normal range 0-20ng/L). The note lacked documentation that the provider was made aware of the abnormal results.

Surgery consultation dated 8/14/23 at 3:49PM noted shortness of breath after a fall with a bureau landing on top of patient for 4 hours. X-rays and CT imaging noted no acute injury, chronic partial compression fracture of L1 vertebrae noted. The note further identified recommend medical admission for comorbidities and significantly abnormal lab findings, repeat labs, trend Ck and troponins, recommend aggressive fluid resuscitation, aggressive pulmonary hygiene due to patient having shortness of breath and if admitted trauma team to perform tertiary tomorrow morning to assess for any missed injuries.

Physician progress note dated 8/14/23 at 4:30PM noted patient has an elevated creatinine, elevated high-sensitivity troponin and elevated CK and lactic acid. The note identified concern for possibility of blunt cardiac injury given new T wave inversions in V2 through V6 with the elevated troponin. The note identified IV fluids ordered, patient continues to remain tachycardic and has an anion gap of 33 with a very high lactic acidosis and will repeat labs for patient.

Physician progress note dated 8/14/23 at 5:14PM noted patient's laboratory testing is consistent with blunt cardiac injury, ASA 325mg ordered. Repeat labs pending, will touch base with cardiology after repeat troponin.

Significant events note dated 8/14/23 at 10:57PM noted after the patient returned to bed from the commode the patient suffered a PEA (pulseless electrical activity). The note identified the patient collapsed with head on bed and body on the floor. The patient was returned to bed, found pulseless, a code was called but CPR not performed because the patient was a DNR. The patient had no pupillary response, absent of respirations and time of death was called at 10:45PM.

Nurse's notes dated 8/14/23 at 11:12PM noted that patient was placed on bedpan around 9:50PM-10:00PM by RN # 2, and around 10:25PM RN # 2 assisted the patient off the commode and on the side of the bed. The note identified that RN # 2 assisted the patient with the patient's pants. Around 10:35PM a transporter was walking by the room and saw the patient slouched over on the bed with his/her lower half of the body on the ground. The note identified RN # 1 and RN # 2 picked the patient up off the ground and placed the patient in bed, code blue was called, the patient was a DNR/DNI, and time of death was called at 10:45PM.

Interview with MD # 1 on 8/23/23 at 8:55AM stated that he evaluated the patient on 8/14/23 at 8:30PM and observed that there was no rhythm on the telemonitor, so he checked the leads, reconnected them and then noted mild sinus tachycardia. MD # 1 stated that the patient was on oxygen and although the patient's oxygen saturation levels were in the 90's, when he took the patient off oxygen, the patient felt short of breath, so he placed the patient back on the oxygen. MD # 1 stated that after the patient expired, he went to the telemetry station and was told that there had been no read on patient #1's telemetry since around 7:00PM but that no one had reported it to the patient's nurse.

Review of the clinical record on 8/23/23 at 11AM with the Clinical Quality Performance Improvement Coordinator noted the last nursing assessment of Patient # 1001 was completed on 8/14/23 at 12:58PM. Review of the clinical record noted that although the patient's heart rate and oxygen saturation levels were documented automatically in the clinical record from 12:58PM until the patients time of death at 10:45PM, the levels were not validated by the nurse during that time. The Clinical Quality Coordinator stated that the nurse must go into the clinical record to validate the assessment. Further review of the clinical record noted a cardiac telemetry strip was run and documented on 8/14/23 at 4:30PM, (3 hours and 17 minutes after the patient was placed on the monitor).


Interview with RN # 1 on 8/23/23 at 1:10PM stated she completed the initial head to toe assessment on Patient # 1001 upon arrival to the ED at 12:45PM on 8/14/23, recalled going into see the patient during the day and reassessed his/her respiratory status and abdominal bruising but could not recall if she reassessed the patient every two hours or if she documented her findings in the clinical record. RN # 1 stated that she could not recall looking at the patient's telemetry or if she heard the alarms sounding. RN # 1 stated that approximately 25 minutes before the patient was found pulseless, she placed the patient on the commode at the patient's bedside. RN # 1 stated that the patient complained that the leads/wires from the cardiac monitor were pulling so she disconnected the patient from monitor and left the room and did not return to the patient's room until the transporter saw the patient on the floor at approximately 10:45PM. RN # 1 stated that although she is aware she should not have disconnected the patient from the cardiac monitor she wanted the patient to be comfortable while sitting on the commode. RN #1 further stated that although she wrote a nursing note on 8/14/23 at 11:12PM regarding events surrounding Patient # 1001, she did not speak to RN # 2 before writing her note and assumed that what she wrote happened.

Interview with RN # 2 on 8/24/23 at 8:50AM stated that when he started his shift around 7:00PM, Patient #1001's IV pump was alarming until he went into the patient's room around 8:20PM (one hour and 20 minutes later). RN # 2 stated that he adjusted the patient's arm, looked at the patient's oxygen and left the room. RN # 2 stated that around 9:50PM he went back into the patient's room again because of the IV alarm, silenced the alarm, and saw the patient sitting on the edge of bed hunched over asking for help with his/her pants. RN # 2 stated he removed the patient's pants and left the room. RN # 2 stated that around 10:45PM a transporter alert him that patient # 1 was on the floor. RN # 2 stated he entered the patient room and saw the patient face first into the mattress and his/her legs sprawled out on the floor. RN # 2 stated the patient was unresponsive and pulseless, called a code and was told the patient was a DNR. RN # 2 stated that when he found the patient, the patient was not connected to the leads of the cardiac monitor. RN # 2 stated that although RN # 1 documented in the clinical record that he assisted the patient off the commode, he did not assist the patient.

Interview with the ED Nurse Manager on 8/24/23 at 10:25AM stated that he spoke to RN # 2 who reported to him that he went into patient #1001's room because the IV kept occluding and the patients RN was not responding, and that the transporter alerted him that the patient was on the floor. The Nurse Manager stated that he spoke to RN # 1 who told him that she put the patient on the commode but didn't know how the patient came off the monitor. The Nurse Manager stated that RN #1 told him that when she wrote the nurse's note dated 8/14/23 at 10:51PM she assumed RN # 2 had helped the patient and that's why she wrote the note. The Nurse Manager stated that he spoke to the Monitor Tech who stated after the code her, and MD # 1 looked back on the monitor and there was nothing there. The Nurse Manager stated that the tech told him that she did not notify anyone regarding patient # 1001's monitor not transmitting during the night. The Nurse Manager further stated that he reviewed the patients clinical record after the event and identified RN # 1 did not complete her nursing assessment on the patient every two hours as required for a patient with an ESI level one. The Manager stated that the nurse is to do a full set of vital signs, including oxygen saturation and a respiratory assessment.

Interview with the Monitor Technician on 8/24/23 at 11:40AM stated that patient # 1001 was off the monitor from around 7:15PM but hadn't noticed it until after the patient expired and MD # 1 came to the telemetry room. The Monitor Technician stated that she did not alert the patient's nurse that the patient was off telemetry because she did not know she was supposed to, and the machine wasn't alarming. The monitor technician stated that, that night she was monitoring approximately 45 telemetry monitors and no nurse came to her to check in.

Review of the hospital policy for ED Nursing assessment, plan of care and documentation guidelines noted the RN will perform the initial assessment based upon chief complaint, patient history and presenting signs and symptoms, including a head-to-toe physical assessment and document findings on the patients triaged as a level 1, 2 or 3 in a timely manner. The policy further identified reassess the patients initially triaged as a 1, 2 or 3 approximately every 2 hours and more frequently as needed. This includes assessment specific to the patient's chief complaints and condition, in addition to temperature, pulse, respiratory rate, B/P, O2 saturation if appropriate pain score.

Review of the hospital policy for cardiac monitoring noted the RN is to confirm and document the patient rhythm upon initiation of monitoring and the monitoring technician is to within the first 2 hours of every 8-hour shift, run and analyze a rhythm strip for each patient, documenting measurements, rhythm interpretation and alarm parameters.

Immediate Jeopardy was identified on 8/23/23 at 3:05PM. The hospital implemented an immediate action plan which included:

RN's and Monitor Technicians were educated on the cardiac monitoring policy, including telemetry is to remain on patient until order is discontinued, or patient is discharged from the hospital;

Monitor Technician's will notify the RN of rhythm changes, rate changes or pulse oximetry alarms in a timely manner;

All ED RNs were educated on nursing assessment, plan of care, and documentation guidelines including patient assessment consistent with patients assigned ESI; and

Reassessing patients initially triaged as an ESI level 1, 2 or 3 approximately every 2 hours and more frequently as needed

Based on observations, clinical record review, interviews, and reciew of hospital policies, for 1 of 3 sampled patients (Patient #1009) who was reviewed for medication administration, the Hospital failed to adhere to infection control practices during IV medication administration, and failed to initiate medication consistent with the physician's order. The findings include:


a. Patient # 1009 was admitted to the hospital with a diagnosis that included asthma and malignant neoplasm of the cervix. Observations made during a tour of the hospital on 8/24/23 at 11:45 AM identified that Patient # 1009 had an intravenous (IV) fluid Lactaid Ringers infusing continuously without a medication label indicating the start date/time and correct patient identifying information. Additionally, the IV tubing for the medication magnesium sulfate infusing into patient # 1009 had an expiration label indicating that the tubing was good for 96 hours.

Review of hospital documentation identified that a new bag of Lactaid Ringers was initiated on 8/24/23 at 1200.

Review of facility policy on intravenous therapy identified that all IV bags, and tubing should be labeled with the appropriate printed IV medication/solution or IV tubing label. Additionally, intermittent administration sets should be changed at 24 hours.

Interview with RN #15 on 8/24/23 at 11:51 AM identified that the medication Lactaid Ringers should be labeled with the expiration date and correct patient identifying information. Additionally, RN #15 stated the expectation is to verify infusing IV fluids during shift report but this wasn't done when she arrived at 7 AM. RN #15 further identified that the Lactaid Ringers IV would be discarded and correctly administered secondary to surveyor inquiry.

b. Review of the physician's order dated 8/24/23 at 10:45 AM directed the medication magnesium sulfate 2 grams (g)/ 50 millimeters (ml) to be administered at a rate of 50 ml/ hour (hr).

Observations made during a tour of the hospital on 8/24/23 at 11:45 am identified that RN #15 placed the medication magnesium sulfate in the intravenous (IV) pump and initiated the drug at a rate of 100 ml/hr. Upon surveyor inquiry RN #15 changed the IV pump rate to 50 ml/hr.

Interview with RN #15 on 8/24/23 at 11:51 AM identified that the medication magnesium sulfate is pre-set to infuse at a rate of 100 ml/ hr in the IV pump settings but the physician's order directed to infuse the medication at a rate of 50 ml/hr. Additionally, RN #15 stated to administer the medication correctly nurses have to manually change the settings.

The hospital failed to ensure that IV magnesium sulfate was initiated according to the physician order.

Review of facility policy on intravenous therapy/ intravenous infusion pump use procedure identified that nurses should not use the basic mode of infusion pump unless the medication is not it the pumps library. Additionally, the Pharmacy should be notified for the need to add medications to the library.