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Based on record reviews, interviews, review of the hospital's policies and procedures, the hospital's governance failed to ensure sufficient leadership oversight and intervention for the hospital's PCU(Progressive Care Unit) telemetry unit to ensure timely response, monitoring, and intervention necessary for the safety of patients' with identified arrhythmia, and the governance failed to ensure that the Emergency Department operated in a responsible manner to ensure the safety of those patients during patient transfer procedures.

The findings are:

Cross Reference to A 0144: The nursing staff failed to respond immediately to a potential life threatening arrhythmia for 2 of 10 patients (Patient 1 and Patient 2). There was a delay in recognition and possible treatment for the arrhythmia due to a monitor technician's failure to notify the nursing staff timely. A bed alarm was not operational for Patient 1 who was identified as a fall risk at admission and who fell during an arrhythmia episode, and nursing failed to respond to the abnormal arrhythmia.

Cross Reference to A 0392: The hospital's PCU nursing staff failed to appropriately respond and intervene for arrhythmia for 2 of 10 patients admitted to the hospital's PCU for cardiac monitoring for arrthymia identified in the emergency department. (Patient 1 and 2)

Cross Reference to A 0395: The hospital failed to ensure its Supervisor staff facilitated the transfer of patients during the admission process to ensure prompt evaluations of the patients admitted to the hospital's high risk areas for 1 of 1 Charge Nurse on the Progressive Care Unit (PCU). (Registered Nurse A9)

Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure that patients received care and services in accordance with the hospital's policies and procedures and acceptable standards of practice for 2 of 10 patient records reviewed for care and services on the hospital's Progressive Care Unit (PCU) and Emergency Department (ED).

The findings are:

Cross Reference to A 0144: The nursing staff failed to respond immediately to a potential life threatening arrhythmia for 2 of 2 patients (Patient 1 and Patient 2). There was a delay in recognition and possible treatment for the arrhythmia due to either a monitor technician's failure to notify the nursing staff timely or nursing's timely intervention when the monitor technician notified nursing staff of a potential patient's abnormal rhythm. A bed alarm was not operational for Patient 1 who was identified as a fall risk at admission, and nursing failed to respond to an abnormal arrhythmia for 2 of 2 patients requiring telemetry monitoring.

Based on record reviews, interviews, and a review of the hospital's policies, entitled, "Cardiac Central Monitoring Communication and Responsibilities" and "Fall Prevention and Injury Mitigation", the nursing staff failed to respond immediately to a potential life threatening arrhythmia for 2 of 10 patients (Patient 1 and Patient 2). There was a delay in recognition and possible treatment for the arrhythmia due to a monitor technician's failure to notify the nursing staff timely. A bed alarm was not operational for Patient 1 who was identified as a fall risk at admission and who fell during an arrhythmia episode, and nursing failed to respond to the abnormal arrhythmia on the hospital's Progressive Care Unit (PCU).

The findings included:

Cross Reference to A 0392: Nursing staff failed to respond immediately to Patient 1, who had experienced a potential life threatening arrhythmia on 2/27/19 at 7:11 AM. Patient 1 was found on the floor and was thought to have suffered a seizure. For an undetermined period of time, it was not known that the patient had instead had a cardiac event. No vital signs were documented for the patient until 8:15 AM on 2/27/2019. Monitor Technician A1 failed to identify the arrhythmia as Ventricular Tachycardia/Asystole. There was no documentation to show that the monitor technician notified a floor nurse to check on the patient related to an episode of V-tach/Asystole. (Monitor Technician A2) and (RN A3), one of one Registered Nurses interviewed related to the interpretation of the arrhythmia failed to identify Patient 1's rhythm strip as Ventricular Tachycardia.

Patient 1 - Emergency Department
On 3/26/2019 at 2:10 PM, review of Patient 1's chart revealed the patient was admitted to the Progressive Care Unit(PCU) from the Emergency Department where the patient had presented related to a possible seizure and/or syncope episode on 2/26/2019 at approximately 9:30 AM. Based on the patient's history and presenting symptoms, the patient was admitted with diagnoses including, but not limited to, Syncope and a History of Long QT Interval. Emergency department progress notes reported an initial concern that a seizure or heart rhythm irregularities may have caused the patient's syncope episode prior to admission.

Patient 1 - PCU
Review of Patient 1's admission assessment by Registered Nurse (RN) A3 on 2/27/19 at 3:31 AM revealed the patient's Morse Fall Risk Score was graded as 35 which required standard environmental safety precautions such as a bracelet that identified the patient as a fall risk. Review of a nurse note documented by RN A4 on 2/27/19 revealed, " ...entered pt (patient) room at shift change to find her/him crying, getting into bed, and the patient stated, 'I had another spell'. Upon questioning the pt said (she/he) thinks (she/he) had a seizure, pt woke up on floor very confused having difficulty getting breath, sweaty, and had urinated. Pt. currently anxious, assisted pt back to bed and calmed pt...".

Review of an e-mail dated 2/28/2019 that RN A4 sent to Registered Nurse A2 regarding the incident with Patient 1 that occurred on the morning of 2/27/2019 revealed RN A4 wrote, "Immediately after shift report, I entered the patient's room, saw the patient getting up off the floor, and assisted the patient to bed." RN A4 documented that she/he placed the bed alarm in the "on" position after placing the patient in the bed. There was no documentation that a bed alarm activated an alarm in the nursing station or was heard by any on duty staff when the patient fell from the bed. The first documentation of the patient's fall was when RN A4 entered the patient's room after shift report and found the patient getting up from the floor.

During a telephone interview on 3/29/19 at 3:08 PM, RN A4 stated there was no call light or bed alarm going off when the patient fell. RN A4 stated that once the patient was assisted back to bed, the patient put the patient's bed alarm on and walked out to the nurse desk to let RN A3 know Patient 1 fell on the floor.

On 3/27/19, PST A2 stated she/he worked first shift on 2/27/2019 on the 7:00 AM -7:00 PM shift. PST A2 reported that she/he received information that the patient was a new admission for possible seizures. PST A2 stated, "Everybody, all patients admitted to the unit have 3 side rails (2 top and 1 bottom) raised, a bed alarm is turned on along with other interventions."

During a telephone interview on 3/29/19 at 3:08 PM, RN A4 stated, "After the patient's (Patient 1) fall, I called the monitor room to request the telemetry technicians to look back around 7:30 AM which was the time Patient 1 was found on the floor to see if there was any cardiac event. The telemetry monitor room staff faxed cardiac strips that showed a run of V-tach, what appeared to be asystole, and then a sinus brady rhythm that had occurred at 7:11 AM". RN A4 documented in the email that immediately after seeing the rhythms that she/he gave the cardiac strips along with a report to Nurse Practitioner A1. On 3/28/2019 , in a telephone interview, Nurse Practitioner 1 reported that it was about 8:15 AM before the Nurse Practitioner saw the patient. On 3/7/19, in another email from RN A4 to RN A2, RN A4 wrote that after reviewing the time stamp on the patient's Electrocardiogram (EKG) strip, the time might have been off a little.

During a telephone interview on 3/28/19, Nurse Practitioner (NP) A1 was asked about notification of the incident that occurred with Patient 1 on 2/27/19. NP A1 stated she/he arrived on the PCU floor shortly after 8:00 AM and was sure she/he had not been on the floor before 8:00 AM.


Policy
Hospital policy, entitled, "Cardiac Central Monitoring Communication and Responsibilities", reviewed 4/18/19, revealed the Monitor Technician responsibilities included "call the IP phone of the patient's nurse for any acute/lethal dysrhythmias. If no response, the charge nurse for the unit will be called. ...Lethal dysrhythmias are defined as: Asystole. Ventricular Fibrillation. Ventricular Tachycardia. 3rd Degree Heart Block...Any acute dysrhythmia will be called promptly to the nursing unit on the IP phone. The MT will save the strip and send it to the unit printer. Acute dysrhythmias are defined as: Any change in patient's rhythm or rate that is new...New ventricular rhythms...Ventricular Tachycardia runs (five beat run or greater)...First occurrence of a pause greater than 2 seconds...When nursing receives a call from Monitor room re: a change in rhythm or patient is off the monitor, the nurse must immediately go to the patient's room to assess the patient. If the nurse or charge nurse is unable to go to the patient's room, another nurse must respond. The responding nurse must verify re-establishment of the patient's rhythm with Monitor Room.

Hospital policy, entitled, "Fall Prevention and Injury Mitigation PGR", reviewed 7/1/19, revealed a Morse score of 0-44 indicated a need for standard environmental safety precautions for falls. A score of 45 is considered at risk for falls. Safe Environment interventions were for all patients, unless contraindicated, regardless of risk level and included " ...Top side rails up and no more than one bottom side rail up on the bed ...". Suggested interventions for at-risk patients based on the Fall risk assessment score of 45 or greater included " ...7.15 Use bed exit alarm, for patients meeting criteria as appropriate. Page 15 defined risk factors and what interventions to put into place for them. According to the hospital's policy, if the patient had confusion, Decreased Level of Consciousness, or had been on Seizure Precautions, the patient would have the standard interventions along with a bed or individual alarm and someone would need to stay with the patient when assisted to the toilet or bedside commode. There was no algorithm to add extra precautions for a patient with syncope.

Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure that patients received care and services in accordance with the hospital's policies and procedures and acceptable standards of practice for 2 of 10 patient charts reviewed for care and services related to telemetry monitoring on the hospital's Progressive Care Unit (PCU).
The findings are:

Cross Reference to A 0392: The hospital failed to ensure a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care for patients assessed as high risk for cardiac events in the hospital's Progressive Care Unit.

Cross Reference to A 0395: The hospital failed to ensure its Supervisory staff facilitated and followed its policies for the transfer and acceptance of patients during the admission process to ensure prompt evaluations of the patients admitted to the hospital's high risk areas for 1 of 1 Charge Nurse on the Progressive Care Unit (PCU).

Based on record reviews, interviews, and review of the hospital's policy, entitled, "Cardiac Central Monitoring Communication and Responsibilities", the hospital's PCU(Progressive Care Unit) nursing staff failed to appropriately respond and intervene for arrhythmia for 2 of 10 patients admitted to the hospital's PCU for cardiac monitoring for arrthymia identified in the emergency department. (Patient 1 and 2)

The findings included:

Patient 1
Nursing staff failed to respond immediately to Patient 1 who had experienced a potential life threatening arrhythmia on 2/27/19 at 7:11 AM on the PCU. Patient 1 was found on the floor and was thought to have suffered a seizure. For an undetermined period of time, it was not known that the patient had a cardiac event. No vital signs were documented for the patient until 8:15 AM. on 2/27/2019. Monitor Technician A1 failed to identify the arrhythmia as Ventricular Tachycardia/Asystole (VTach/Asystole). There was no documentation to show that the Monitor Technician A2 notified a floor nurse to check on the patient related to an episode of V-tach/Asystole. Registered Nurse A3) who interviewed related to the interpretation of the patient's arrhythmia failed to identify Patient 1's rhythm strip as Ventricular Tachycardia. Patient 1 was transferred on 2/27/2019 to another heart hospital for surgery.

Record Review
Patient 1 was admitted from the emergency department on 2/26/19 with diagnoses including, but not limited to, Syncope and a History of Long QT Interval. Review of Patient 1's chart on 3/27/19 revealed a nurse's note documented by RN A4 dated 2/27/19 at 7:30 AM that stated, " ...entered pt (patient) room at shift change to find the patient crying, getting into bed, and the patient stated, "I had another spell". Upon questioning, the patient said "I think I had a seizure". The patient was very confused, had difficulty getting breath, sweaty, and had urinated. Patient currently anxious, assisted pt back to bed and calmed pt. Called monitor room and had them send rhythm results, found that at 7:11, pt had vtach(ventricular tachycardia) then a 12 second pause and then bradycardia, spoke to cardiologist and hospitalist about incident". Further review of the cardiovascular charting by RN A4 revealed the patient had an irregular rhythm with Sinus Bradycardia, Sinus Arrest, and V-tach (Ventricular Tachycardia) at 7:11 AM on 2/27/2019. No vital signs for the patient were documented until 8:15 AM on 2/27/19. There was no documentation that nursing staff assessed the patient or notified the patient's physician that the patient had an episode of V-tach/V-fib followed by a 14 second pause at 7:11 AM that resulted in the patient's fall onto the floor in a confused state.
The patient was transferred to another hospital for heart surgery on 2/27/2019.

Interviews
PST A2
During an interview on 3/28/19 at 9:52 AM, PST A2 identified the cardiac strip dated 2/27/19 at 7:11 AM for Patient 1 as V-fib and not V-tach. PST A2 stated this was a deadly rhythm and that the nurse would be notified immediately and it would be documented on the communication log.

Monitor Technician A1
During an interview on 3/27/19 at 3:00 PM, Monitor Technician A1 stated that she/he started printing rhythm strips a little after 7:00 AM on 2/27/19. Monitor Technician A1 stated she/he reviewed the rhythm strips recorded for the past hour to see if any abnormal rhythms had been missed. Monitor Technician 1 stated that when she/he reviewed Patient 1's rhythm strip, and saw the pauses, and the strip was funny looking, she/he notified RN A3(night nurse) to check the patient since she/he was not sure what was going on with the patient. Monitor Technician A1 repeated that she/he spoke with RN A3 (night shift nurse) who stated the day shift nurse had not gotten the phone yet. Monitor Technician A1 reported that she/he notified RN A3 that it looked like the patient was coming off the monitor and coming back on the monitor, but the Monitor Technician was not sure what was happening. Monitoring Technician A1 reported that RN A3 said she/he would let RN A4(day shift nurse) know and have RN A4 call the Monitor Technician back. Monitor Technician A1 stated no one called back so she/he called the nurse's telephone again and spoke with RN A4 this time. Monitor Technician A1 reported that she/he had saved the cardiac strip, and when RN A4 saw the patient's rhythm strip, RN A4 stated this event must have been the time when the patient had a seizure. Monitor Technician A1 stated RN A4 did not mention if RN A3 passed on the message about the monitor technician's concern that the patient may have been coming off the monitor and back on. Monitor Technician A1 stated she /he asked the nurse(RN A4) to look at the cardiac strip and printed it off to the printer on the PCU floor. Monitor Technician A1 stated that she/he spoke with RN A3 about the pauses and told RN A3 that she/he wasn't sure what was going on or happening with the patient. When asked about why there was no documentation in the communication log of calling the nurse to check on the patient, Monitor Technician A1 stated her/his process was to write the information on a scrap piece of paper with the time, and then transfer the information to the communication log, but for some reason, this communication was not added to the log. When asked if she/he was informed of the process that happened after printing the strips to the floor, Monitor Technician A1 stated no one had ever told her/him that the patient's rhythm had been V-tach or asystole.

RN A3 (Night Shift Registered Nurse)
On 3/28/19 at 7:40 AM, an interview was conducted with RN A3 (Night Shift Registered Nurse) who
stated that all the staff (off-going and on-coming) huddle at about 7:00 AM between 5-10 minutes. After that, the night shift nurses go with the day shift nurses to each patient room to give an individualized patient report. RN A3 stated that she/he had gone to Patient 1's doorway with RN A4 and had given report. RN A3 stated that at that time she/he had physically laid eyes on the patient who was in bed sleeping. RN A3 stated that after giving report to RN A4, she/he left to give report to another nurse.
RN A3 stated that RN A4 came to her and stated Patient 1 had a seizure. RN A3 stated she/he went to the patient's room where the patient was back in bed. The patient was speaking with RN A4 and was tearful telling RN A4 what had happened. RN A3 stated she/he called for an EKG(Electrocardiogram) stat. RN A3 stated she/he reported to RN A4 that the patient had been in sinus rhythm the whole night. According to RN A3, she/he was not notified of any pauses or problems with the patient's rhythm that night. RN A3 stated the EKG that was done was not ordered as a result of any pauses the patient had, but because of the seizure or event. When asked if she/he had any knowledge of Patient 1's run of Ventricular Tachycardia followed by a long pause, RN A3 stated she/he had been unaware of this when she/he left for the day. When asked what the protocol was for V-tach, RN A3 stated ACLS (Advanced Cardiac Life Support).
When asked if a Monitor Technician had called the morning of 2/27/19 and spoken with her/him about an abnormal rhythm or something funny with the rhythm, or maybe the patient was going off the floor and being taken off the monitor, RN A3 stated that no one had called and no one had asked her/him to check on the patient. When asked what she/he would do if someone called and reported something was going on but they were not sure what it was, RN A3 stated she/he would go and check the patient. RN A3 stated nurses should get up and check patient's any time the monitor technicians call or if there is a pause in the rhythm of any amount to see if the patient is symptomatic. When shown Patient 1's cardiac strip showing V Tach dated 2/27/19 at 7:11 AM, RN A3 stated several times it was V-fib(Ventricular Fibrillation). When the surveyor asked if she/he was sure, RN A3 then stated it was V-tach (Ventricular tachycardia). RN A3 reported the treatment upon assessment of a patient that has a pulse and is breathing, but not responding, would be to get a set of vital signs and call for a Rapid Response. Review of the RN A3's time card revealed she/he had clocked off the floor at 7:49 AM.

RN A4 Day Shift Registered Nurse
During a telephone interview on 3/29/19 at 3:08 PM, RN A4 stated the nursing staff did a morning huddle around 7:00 AM. that took about 5 minutes, and then the night shift and day shift nurses do morning rounding where the night shift nurse gives report. RN A4 reported the door to Patient 1's room was closed when she/he received report from night shift nurse. After report, RN A4 stated she/he opened the door to Patient 1's room, walked in, and found the patient in the process of getting up off the floor, very anxious and upset. RN A4 reported there was no call light or bed alarm going off. Once the patient was in bed, RN A4 stated she/he put the patient's bed alarm on and walked out to the nurse desk to let RN A3 know about Patient 1. RN A4 reported RN A3 walked into the patient's room and almost simultaneously, within seconds, the EKG technician arrived. RN A4 stated that RN A3 did not order the EKG in the timeframe when she/he had gone to the nurse desk and when RN A3 had arrived in the patient's room. It must have been ordered before or the EKG technician may have already been on the floor. RN A4 reported RN A3 reported to her/him that RN A3 reported during morning rounds that the Monitor Technician had reported a "pause" (possibly between 3-4 AM). RN A4 reported that she/he asked RN A3 if an EKG was ordered related to the
patient's pause, and RN A3 responded that she/he hadn't ordered an EKG but would. RN A4 reported that if she/he was notified of a pause, she/he would assess the patient, and if any findings or a long pause, she/he would contact the physician/cardiologist and request an order for an EKG. RN A4 stated that no monitor technician notified her/him of a cardiac event or to check on the patient prior to finding the patient on the floor. RN A4 stated that when the patient was hooked up to the EKG, a monitor technician called her/him or she/he called the monitor technician, not sure about who called who about what. At some point after getting the patient back in bed, RN A4 stated she/he requested the monitor technician to print the telemetry strips that showed the patient's V-tach and Asystole.

Nurse Practitioner A1
During a telephone interview on 3/28/19, Nurse Practitioner (NP) A1 was asked about the incident with Patient 1 on 2/27/19. NP A1 stated that she/he was looking at the note in the patient's record. NP A1 stated that she/he arrived on the floor shortly after 8:00 AM. on the morning of 2/27/2019, and
was certain that she/he had not been on the floor before 8:00 AM. NP A1 stated that he/she was
sitting at the nurse station when a nurse came and showed some cardiac telemetry strips.
NP A1 reported that she/he did not see or review an EKG report. NP A1 stated since she/he had no prior knowledge of the patient, she/he had to review the patient's (electronic) record, and it took time to pull the patient's record up and review. NP A1 stated the nurse reported Patient 1 passed out and was found on the floor that morning, and the nursing staff were concerned about seizures. The nurse that showed the cardiac strips was concerned that the patient had a significant event. I looked at the strips. Some looked like movement. V-tach and Asystole was obvious. NP A1 stated she/he saw the patient between 8:15 AM and 8:30 AM.

EKG Technician A1
An interview on 3/27/19 at 3:48 PM with EKG Technician A1 revealed the EKG Technician was at a desk in his/her office when the printer went off, and she/he saw an order for a stat EKG for Patient 1. RN A3 called at approximately 7:12 AM, and EKG Technician A1 told the nurse that she/he was on the way. When she/he entered the patient's room, Patient 1 was in bed, upset, and wet.

Data Review
Review of an e-mail sent on 2/28/19 from RN A4 to RN A2 about the incident that occurred on 2/27/2019 with Patient 1 revealed the shift change report from the night nurse included the patient had been a new admit for possible seizures and possible cardiac issues. The night nurse reported that the telemetry monitoring room called a 2.7 second pause to the night RN, and that the night RN would order an EKG before she/he left for the day. The night nurse (RN A3) did order the EKG, but the EKG was ordered after the patient's cardiac incident. I(RN A4) went to the patient's room and the night shift nurse(RN A3) went to the nurse station. When the day shift nurse(RN A4) entered the patient's room, the day shift nurse saw the patient getting off the floor. The nurse assisted the patient to bed and placed the bed alarm "on". Upon questioning the patient, the patient stated she/he woke up on the floor and was having a hard time breathing and confused. The patient reported that she/he had no idea how she/he got on the floor and assumed she/he fell during a seizure. After notifying the charge nurse and paging the physician on call, the day shift RN A4 reported that she/he called the monitor room for a look back around 7:30 AM, which was the time that the day shift nurse noted the patient on the floor, to see if there was any cardiac event. The monitor room faxed the patient's cardiac strips which showed a run of V-tach, what appeared to be asystole, then a sinus Brady rhythm which was documented as 7:11 AM. Immediately after seeing the rhythms, RN A4 gave the the rhythm strips and a report to Nurse Practitioner A1. Another e-mail sent 3/7/19 from RN A4 to RN A2 clarified the time of the incident on 2/27/19 to state that after reviewing the EKG, the time stamp was 7:19 AM, and she/he had stated in the prior e-mail the incident happened at 7:30 AM; so the time was off a few minutes since she/he had already entered the room and found the patient prior to the EKG being done.

On 3/36/2019, review of the hospital's report, revealed, "...The patient had an episode of V-tach/V-fib followed by a 14 second pause. The PCU was notified and (Nurse Practitioner) NP A1- was on the unit to follow up on patient. EKG was ordered and the patient was transferred to the Heart Hospital approximately 2.5 hours later under the care of Dr. --- with Electrophysiology for AICD (Automatic Implantable Cardiac Defibrillator) placement.

RN A6 (Educator)
During an interview on 3/29/19 at 4:32 PM, RN A6, the nurse educator for basic cardiac was asked about the treatment for V-tach versus V-fib. According to the nurse, V-fib would require defibrillation, while V-tach would require the nurse to check for a pulse. Without a pulse, the Advanced Cardiac Life Support(ACLS) algorithm would be used. With a pulse, treatment orders would be obtained from the physician. When asked what the rhythm strip showed for Patient 1 on 2/27/19 at 7:11 AM, RN A6 stated the top part of the strip was V-tach. When asked if she/he would expect an experienced PCU nurse to identify this rhythm immediately, RN A6 asked if the PCU nurses were ACLS trained. When the nurse educator was told they are, RN A6 stated, "yes", she/he would expect the nurse to identify it immediately.

Policy
Review of the hospital's policy, entitled, "Cardiac Central Monitoring Communication and Responsibilities", reviewed 4/18/19, revealed the Monitor Technician(MT) responsibilities included that the MT (Monitor Tech) must initial and save strips of any reported rhythm. The MT will call the IP phone of the patient's nurse for any acute/lethal dysrhythmias. If no response, the charge nurse for the unit will be called. "...Lethal dysrhythmias are defined as: Asystole. Ventricular Fibrillation. Ventricular Tachycardia. 3rd Degree Heart Block...Any acute dysrhythmia will be called promptly to the nursing unit on the IP phone. The MT will save the strip and send it to the unit printer. Acute dysrhythmias are defined as: Any change in patient's rhythm or rate that is new...New ventricular rhythms...Ventricular Tachycardia runs (five beat run or greater)...First occurrence of a pause greater than 2 seconds...When nursing receives a call from Monitor room re: a change in rhythm or patient is off the monitor, the nurse must immediately go to the patient's room to assess the patient. If the nurse or charge nurse is unable to go to the patient's room, another nurse must respond. The responding nurse must verify re-establishment of the patient's rhythm with Monitor Room.



Patient 2
Nursing staff failed to appropriately monitor Patient 2's cardiac rhythm status during a transfer from the Emergency Department(ED) to the Progressive Care Unit(PCU). An undetermined period of time elapsed from the time ED nurse, RN A7 left Patient 2 in a room on the Progressive Care Unit(PCU) without the patient's cardiac rhythm being monitored until the time RN A8 had come in to place a PCU monitor on the patient. The ED nurse, RN A7, stated she/he called for assistance from the patient's room on the call system and then went to the nurse station twice to get assistance leaving Patient 2 unmonitored. When RN A7 could not get a nurse from the PCU staff to accept the patient, RN A7 left the patient without securing PCU nursing personnel for an appropriate interdepartmental transfer for a patient with a critical rhythm. When PCU staff entered the patient's room and connected the patient to the monitor, Patient 2 was transferred to the Intensive Care Unit related to third degree heart block. It was an undetermined time after the ED staff left the patient until the PCU staff applied the monitor to the patient and discover a critical rhythm that necessitated a transfer to the intensive care unit.

Observations
Observations in an unoccupied PCU patient room on 3/28/19 revealed a wooden box attached to the wall. The wooden box had a lock verified with RN A1. RN A1 asked the staff member sitting at the desk about a key. The staff member provided a key from a drawer at the desk. According to the staff member, the wooden boxes housing the telemetry monitors are locked once cleaned and after the patient is discharged.

Record Review
The facility admitted Patient 2 on 2/16/19 from the hospital's emergency department with diagnoses including, but not limited to, Acute Congestive Heart Failure Exacerbation. On 3/28/2019 at 11:05, review of Patient 2's chart revealed the patient presented to the hospital's Emergency Department(ED) on 2/16/19 at 19:11 PM with a chief complaint of 2-3 day history of shortness of breath(SOB). Review of the patient's emergency department assessment revealed "mild dysnea on exertion that has worsened over the last 2-3 days to where the patient is short of breath with exertion and conversation, denies congestive heart failure, Chronic Obstructive Pulmonary Disease (COPD), or Emphysema, no history of Asthma, and was evaluated by a cardiologist recently. The patient denies chest pain or palpations." Vital signs were recorded as: "Oral temperature - 97.7; pulse - 85; respirations - 22; pulse oximeter - 95%(percent) on room air. Blood pressure (BP) - 143/86. Patient has clear but slightly diminished breath sounds bilaterally. Chest x-ray, 12 Lead Electrocardiogram (EKG); lab work ordered." Review of the Chest X-ray report dated 2/16/19 at 22:11 PM, revealed, "Impression: findings of pulmonary edema with pleural effusions suggesting congestive heart failure. Enlarged bilateral Hilar either related to pulmonary arterial enlargement or hilar adenopathy. EKG shows controlled Atrial Fibrillation, Telemetry shows sinus arrhythmia. Admit to inpatient. Diagnosis: Congestive Heart Failure (HF)". Review of the patient's history and physical dated 2/17/19 at 00:47 AM revealed Patient 2 had been evaluated in the ED and Chest X-ray showed pulmonary edema with pleural effusions suggestive of congestive heart failure. The EKG showed sinus bradycardia with no Ischemic changes. The heart rate ranged from 51- 60, which the patient stated was his/her normal baseline. The Internal Medicine hospitalist was consulted for admission to the PCU.

On 3/27/19 at 12:30 PM, review of Patient 2's chart revealed an ED nurse's note dated 2/17/19 at 5:10 AM that revealed documentation of physician notification that the patient's heart rate dropped to 39 with the patient being asymptomatic. There had been no other vital signs documented for this event. The physician ordered the patient would continue to be monitored as there was already a cardiology consult placed. Further documentation by the ED nurse revealed the patient's monitored heart rate dropped to 36 on 2/17/19 at 5:36 AM, with the rhythm documented as complete heart block. There was no documentation that any other vital signs were taken along with a physical check of the patient's heart rate at that time to see if there was cause for concern. During an interview on 3/29/19 at 4:50 PM, the basic dysrhythmia course instructor (RN A6) was asked what should be done in this type of situation where the patient run a (monitored) heart rate in the 40s to 60s and drops to the 30s. RN A6 stated the nurse should go in, reassess the patient, and repeat vital signs. Review of Patient 2's Electrocardiogram (EKG) strip dated 2/17/19 at 5:38 a.m., revealed, "2nd(second) Degree AVB Block Type 2, Heart Rate 39 Beats Per Minute." Documentation showed Emergency Department RN A7 obtained the patient's vital signs at 8:28 AM, and called the report to the Registered Nurse (RN) on the PCU. At 8:28 AM, the patient's vital signs were recorded as; "Temperature- 98.3; Pulse-66; Respiratory-18; Oxygen Saturation-93%(percent) on 2 Liters via nasal cannula; BP(Blood Pressure) 136/79." Documentation in the patient's emergency department chart revealed RN A7 transported the patient to the PCU at approximately 8:52 AM on 2/17/2019 and after calling for assistance on the call light, and going to the nurse station twice to get a nurse to accept the patient, RN A7 left the patient on the PCU unmonitored.

Review of the Patient 2's record revealed an EKG completed on 2/17/19 at 9:33 AM on the PCU unit. RN A8 documented the patient's son was present with the patient at 9:40 AM. Review of physician orders revealed a "Change Bed Request" order put in by RN A10 on 2/27/19 at 9:42 AM, "Need ICU(Intensive Care Unit) Bed". Under Cardiovascular systems review, dated 2/17/19 for 9:45 AM, documentation by RN A8 revealed, "Telemetry dc'd"(discontinued) for the entry as to whether a cardiac monitor was in place. Vital signs were documented at 9:55 AM by the PCU staff with a monitored heart rate of 53. It was noted that the patient was in complete heart block at this time. On 2/17/19 at 10:05 AM, RN A8 called to give report to the ICU. An SBAR (Situation, Background, Assessment, Recommendation) note documented by RN A8 for 2/17/19 at 10:06 AM (used to guide the hand off process in transfers) revealed the patient arrived from the ED with 3rd degree heart block, EKG done, and physician aware to transfer pt to ICU.

Interviews
RN A7 (Emergency department RN)
On 3/28/18 at 11:00 AM, Emergency Department(ED) RN A7, RN A7 stated that she/he was a Travel Nurse and had worked in the ED for about 9 weeks. RN A7 stated she/he called the PCU and gave report to RN A8. Information included the patient was currently in Atrial Fibrillation, but there had been concerns about the patient being in possible heart block. RN A7 reviewed the ED Discharge Summary and stated the time of the phone report would have been 8:52 AM on 2/17/19, and she/he would document the information after giving report. Upon review of the ED Discharge tracker, the nurse stated that by 9:21 AM on 2/17/19, ED RN A7 returned to the ED from transferring the patient to the PCU.

Face to face interview on 3/29/19 at 4:12 p.m., RN A7 stated the PCU nurse was not waiting in the patient's room when she/he arrived to the room in the PCU. RN A7 stated, "I put on the call light and no one came. I went to the nurse station was told they would send someone to the room. I waited and then went back to the nurse station. The unit secretary called the RN and said the RN was in the cafeteria. I ran into the charge nurse on the way back to the patient's room and told the Charge Nurse I had to leave. The Charge Nurse asked if the patient was on the monitor, and I told the Charge Nurse no. The Charge Nurse didn't follow me to the room. I didn't see a nurse in the room before I left. On the way back to the ED, I didn't encounter a nurse." When asked about the patient's heart block prior to transferring to the floor, RN A7 stated, "What I read was Atrial fibrillation. Heart block was not obvious, and there was no mention of that in the physician's notes. If I thought there was a change, I would assess the patient and document."

RN A7 stated that she/he was not sure what time she/he got to the PCU, but stated it takes about 5-10 minutes depending on elevator traffic. Once in the patient's room, she/he hit the call light and transferred the patient to the bed. RN A7 stated a staff answered the call light by speaker and told the ED nurse someone was on the way. After a few minutes without anyone showing up, RN A7 stated she/he left the patient with the son in the room, and went to the nurse station to get help leaving the patient with no licensed nurse watching the transport monitor. RN A7 stated that she/he spoke with a male staff member at the nurse desk and returned to the room. RN A7 reported that she/he believes that the transport monitor was removed from the patient, and placed on a stretcher outside the patient's room in the hall. RN A7 stated that she/he gave them (PCU staff) 5 minutes to respond. After no one came to accept the patient, RN A7 reported that she/he left the patient with the son unmonitored, went to the nurse desk, and again spoke with the male staff member. The male staff member called a nurse on the phone and stated the nurse was in the cafeteria and it would be another 5 minutes. RN A7 reported that he/she asked to speak to the charge nurse who was around the corner of the nurse station. RN A7 stated that she/he informed the charge nurse, RN A10, that the patient was in room 300. RN A7 stated the charge nurse asked if the patient was on a monitor, and RN A7 told her/him that the patient was not on the monitor. RN A7 stated the Charge Nurse said, "Don't you think a monitored patient should be on a monitor?" RN A7 told the charge nurse that she/he would speak to the ED charge nurse when she/he got back to the ED. RN A7 stated she/he told the charge nurse that she/he had not been aware it was policy for the ED staff to put the telemetry monitor on the patient and that she/he did not know where the PCU staff kept the telemetry monitors. According to RN A7, the charge nurse stated she/he would go see the patient, but the Charge Nurse did not follow the ED RN back to the patient's room. RN A7 stated she/he got the stretcher and returned to the ED. RN A7 stated there was no staff member in the patient's room when she/he left the PCU. When asked about whether this was a one time event or if it seems to be a problem on the unit with the staff response to ED transfers, RN A7 stated that certain PCU staff come right away to assist with a transfer. There are other staff that do not come right away.

RN A8 (PCU Nurse)
During an interview on 3/26/19 at approximately 3:45 PM, RN A8 stated she/he remembered an incident report had been filed due to concerns that when Patient 2 was placed on a monitor, she/he was in heart block. RN A8 stated that he/she believed the cardiologist, Dr. --- may have been on the floor at the time. They (Nurses) called for a stat EKG. According to RN A8, the cardiologist agreed the patient was in 3rd(third) degree heart block and ordered a transfer to the ICU (Intensive Care Unit). RN A8 stated that she/he may not have met the nurse (from the ED), but she/he was there when the ED nurse left. According to RN A8, the patient was on the PCU telemetry monitor and a transport monitor (Zoll) was placed on the patient in anticipation of the patient's transfer to the ICU. RN A8 reported that she/he could not recall who put the transfer monitor on the patient, but the patient had been put on the PCU monitor box and vital signs were taken. According to the nurse, when the monitor box showed complete heart block, she/he placed an order for an EKG. When asked why there wasn't a telemetry rhythm strip documented in the patient's record for the time period the patient was on the PCU, RN A8 stated that once a patient has a monitor placed on them, the monitor tech will see someone is on, and call the floor staff. Either that or the floor nurse would call and let the monitor tech know that a new patient is on. The nurse will ask the monitor tech to run a strip. RN A8 stated that she/he wasn't sure what had happened in this case. When asked about the timeline of assessment for this patient, RN A8 stated they had been looking at the patient's rhythm strip and getting the patient on a monitor and getting vital signs. Usually 2 nurses would do a skin check on the patient and then based on the patient's diagnosis, an overall assessment of systems (cardiology, neurology, etc) would be completed. When asked about why there was not a documented assessment of the patient in the record (for the PCU) other than vital signs, the nurse stated she/he usually completed an assessment as soon as possible, but hadn't in this case since the patient had only been on the PCU for a short period of time, and the priority was to get the patient moved to ICU. According to the nurse, the patient was on the PCU floor for approximately 20-30 minutes, maybe shorter, maybe longer. RN A8 was not able to state the exact time she/he had gone into the patient's room, but stated an EKG had been ordered at 9:25 AM. A review of non-medication orders revealed no documentation that an EKG had been ordered.

Monitoring Technician A3 Report
Review of the PCU's (3rd floor) Monitoring Technician Rhythm Report revealed that no patient had been documented as occupying Room 300, (Patient 2's assigned PCU room) from 2:00 AM through 12:00 Noon on 2/17/19. Review of the Monitor Technician's documentation on the Communication Log revealed an entry dated 2/17/19 at 9:51 AM for Patient 2 that showed the Monitor Tech called a PCU nurse, stating, "Can Not see poss(ible) HR (heart rate) block". During a telephone interview on 3/28/19 at 10:44 AM, Monitor Tech A3 stated she/he could not recall the documentation since she/he was at home and did not have a copy of the communication/rhythm log. According to Monitor Tech A3, if /she had seen a heart block, she/he would have saved it in the system and printed it. When asked if the patient should have had a documented telemetry strip in the record if the patient had only been there on the floor for 30 minutes to an hour, the Monitor Tech stated there should be a rhythm strip in the record.

RN A10 Charge Nurse
During an interview on 3/27/19 at 2:10 PM, RN A10 stated that when a patient is brought to the PCU, the ED nurses put the telemetry monitor on the patient. RN A10 stated she/he did not believe a nurse was not in the room because she/he remembers that RN A8 put the patient on the telemetry monitor. When asked about a telemetry strip not being found in Patient 2's record for the PCU, RN A10 stated that it isn't documented when they place a patient on the monitor, since they can see it is running on a monitor on the floor. Sometimes she/he may call the monitor tech to let them know a patient is going to a room and placed on a monitor.

RN A9 ED Nurse Manager
During an interview on 3/27/19 at 10:07 AM, RN A9 (ED Nurse Manager) verified she/he received the "All Hands On" report because a patient had been dropped off without a monitor put on. According to the Nurse Manager, the ED nurse called report and also called a second time to let the nurse know she/he was on the way with the patient. The patient had been transferred with a Lifepack monitor from the ED. When the ED nurse hit the call bell, the floor was supposed to send in a PCU RN to accept the patient. RN A9 reported that she/he told RN A7, who had transported the patient from the ED to the PCU, if she/he remembered where the staff kept the telemetry boxes. According to the Nurse Manager, RN A7 stated she/he didn't know they(telemetry) was kept (in a wooden box in the patient's room). According to RN A9, RN A7 lef

Based on record reviews and interviews, the hospital failed to ensure its Supervisor staff facilitated the transfer of patients during the admission process to ensure prompt evaluations of the patients admitted to the hospital's high risk areas for 1 of 1 Charge Nurse on the Progressive Care Unit (PCU). (Registered Nurse - Charge Nurse A9)

The findings are:

Cross Reference to A 0392: Nursing staff failed to appropriately monitor Patient 2's cardiac rhythm status during a transfer from the Emergency Department to the Progressive Care Unit. An undetermined period of time elapsed from the time an ED RN A7, left Patient 2 in a room on the Progressive Care Unit(PCU) without the patient's cardiac rhythm being monitored until the time RN A8 had come in to place a PCU monitor on.

Face to face interview on 3/29/19 at 4:12 p.m., ED RN A7 stated that the PCU nurse was not waiting in the patient's room when she/he arrived. ED RN A7 stated, "I put on the call light and no one came. I went to the nurse station was told they would send someone to the room. I waited and then went back to the nurse station. The unit secretary called the RN and then said the nurse was in the cafeteria. I ran into the charge nurse on the way back to the room and told him/her I had to leave. The charge nurse asked if the patient was on the monitor, I told him/her no. She didn't follow me to the room. I didn't see a nurse in the room before I left." The patient was left by the ED RN A7 staff and there an undetermined time before the PCU staff evaluated the patient. When the PCU staff did evaluate the patient, the patient was discovered to be in complete heart block and was transferred to the intensive care unit.