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Based on record review and interview, the facility failed to ensure Monitor Techs followed Policies and Procedures to initiate a Code Blue response for 1 of 1 patients (Patient #1) with a lethal heart rhythm.

The findings included:

The facility's Policy titled "Telemetry Monitoring," origination 02/2024 and last revised 07/2024 documents, "In the event that a suspected life-threatening rhythm is detected the Monitor/Telemetry Technician will initiate the following procedure:
a. Life Threatening arrhythmias include:
i. Sustained ventricular tachycardia: 30 second strip of V-tach or >30 beat run of V-Tach
ii. Ventricular fibrillation
iii. 3rd degree heart block (new onset)
iv. Asystole
b. Activate a "Code Blue" response to the patient's bedside
c. Subsequently notify the Primary RN or Charge RN and document communication within the EHR [electronic health record], or Facility approved pathway.
d. Capture a copy of rhythm disclosure with interpretation and send to unit."

Patient #1's History and Physical documents he was over 80 years old and was brought to the Emergency Department by Fire Rescue after he was found wandering outside and had a low blood pressure. Patient #1's History and Physical documents his medical history included congestive heart failure (condition in which the heart can't pump enough blood resulting in fluid buildup), atrial fibrillation (type of irregular heartbeat), a CT scan showed pulmonary edema (fluid in the lungs) and large volume ascites (fluid collection within the abdomen). Patient #1's laboratory tests revealed acute kidney injury and elevated troponin (heart enzyme) levels suspicious for a type 2 MI (type of Myocardial Infarction or heart attack) and consults were ordered for cardiology (heart specialist) and nephrology (kidney specialist). Patient #1 was admitted to the hospital, had a physician order on 12/05/24 at 4:40 PM for telemetry monitoring (remote heart monitoring), and was transferred to an inpatient unit on 12/05/24 at 9:50 PM.
Review of Patient #1's telemetry print outs reveal on 12/05/24 between 9:49 PM and 10:15 PM his heart rhythm was primarily atrial fibrillation. Patient #1's telemetry print out at 10:15 PM shows his heart rate increased from 60 to 116 and the rhythm identified by the telemetry software was "V tach" (Ventricular tachycardia, a fast irregular heartbeat that starts in the heart's lower chambers and can become life threatening if it lasts for more than a few seconds at a time), and later that minute his heart rhythm was identified as V fib/V tach (V fib, or ventricular fibrillation, is a life threatening arrhythmia caused when the lower chambers of the heart quiver rather than beat normally which prevents the heart from pumping blood and leads to cardiac arrest. This is an emergency that requires immediate attention.) Patient #1's telemetry print out identifies from 10:16 PM to 10:19 PM he alternated between asystole (cardiac arrest, when the heart stops beating) and V fib/V tach, then was in atrial fib at 10:19 PM for approximately 40 seconds before converting to and staying in asystole for 9 minutes until the time a Code Blue was called at 10:25 PM. Patient #1's Resuscitation Record reveals CPR (cardiopulmonary resuscitation) started 12/05/24 at 10:25 PM and ACLS (Advanced Care Life Support) was attempted but unsuccessful in regaining spontaneous circulation, and the patient died when CPR was stopped in accordance with his representative's direction on 12/05/24 at 10:36 PM.

The Monitor Room Escalation and Resolution Log dated 12/05/24 got Monitor Tech, Staff A documents one entry for Patient #1 with a "1st escalation" of "[name of Unit Secretary] V fib 22.16" and "2nd escalation" of "[name of nurse] V fib 22:18 [10:18 PM]."

During telephonic interview on 01/09/25 at 4:51 PM Monitor Tech, Staff A confirmed she monitored telemetry for Patient #1 the evening of 12/05/24 and stated when Patient #1 had a "burst" of V fib, which she clarified as a couple seconds, she called the Unit Secretary who told her the patient had just arrived and was in a room near her and Staff A told the Unit Secretary about the burst of V fib and asked her to tell the nurse to check Patient #1; that when Patient #1 had another burst of V fib less than a minute later she called the Charge Nurse; then she heard pages for a "Rapid Response" and then a "Code Blue"; that Staff A did not call a Code Blue but did what she was supposed to in having the nurse check the patient; and when asked what she should have done Staff A says to have the nurse check the patient which is what she did and that since it was a burst of V fib and return to A fib "we don't call a Code Blue for that." Staff A did not acknowledge Patient #1 was in a lethal rhythm for 10 minutes before a Code Blue was called, during which Staff A should have called a Code Blue per the facility's Telemetry Policy and Procedures or that Staff A would call a Code Blue for lethal rhythms in the future.

Review of Monitor Tech schedules from 12/22/24 to 01/04/25 revealed Staff A monitored telemetry since Patient #1's death, on the night shifts of 12/31/24 and 01/01/25.

During interview on 01/10/25 at 3:50 PM with the Chief Nursing Officer (CNO), she reported Staff A had a meeting with her manager about this incident and to go over the Telemetry Policy and Procedures but Staff A walked out of the meeting without receiving or agreeing to follow the policy because Staff A did not think she had done anything wrong. The CNO could provide no evidence that Staff A reviewed the Telemetry Policy and Procedures and/or agreed to follow them to protect patients in lethal rhythms before she worked again as a Monitor Tech.

Based on record review and interview, the facility failed to ensure Monitor Techs followed Policies and Procedures to initiate a Code Blue response for 1 of 1 patients (Patient #1) with a lethal heart rhythm and after this was identified that it was addressed to prevent other patients from harm.

The findings included:

The facility's Policy titled "Telemetry Monitoring," origination 02/2024 and last revised 07/2024 documents, "In the event that a suspected life-threatening rhythm is detected the Monitor/Telemetry Technician will initiate the following procedure:
a. Life Threatening arrhythmias include:
i. Sustained ventricular tachycardia: 30 second strip of V-tach or >30 beat run of V-Tach
ii. Ventricular fibrillation
iii. 3rd degree heart block (new onset)
iv. Asystole
b. Activate a "Code Blue" response to the patient's bedside
c. Subsequently notify the Primary RN or Charge RN and document communication within the EHR [electronic health record], or Facility approved pathway.
d. Capture a copy of rhythm disclosure with interpretation and send to unit."

Patient #1's History and Physical documents he was over 80 years old and was brought to the Emergency Department by Fire Rescue after he was found wandering outside and had a low blood pressure. Patient #1's History and Physical documents his medical history included congestive heart failure (condition in which the heart can't pump enough blood resulting in fluid buildup), atrial fibrillation (type of irregular heartbeat), a CT scan showed pulmonary edema (fluid in the lungs) and large volume ascites (fluid collection within the abdomen). Patient #1's laboratory tests revealed acute kidney injury and elevated troponin (heart enzyme) levels suspicious for a type 2 MI (type of Myocardial Infarction or heart attack) and consults were ordered for cardiology (heart specialist) and nephrology (kidney specialist). Patient #1 was admitted to the hospital, had a physician order on 12/05/24 at 4:40 PM for telemetry monitoring (remote heart monitoring), and was transferred to an inpatient unit on 12/05/24 at 9:50 PM.
Review of Patient #1's telemetry print outs reveal on 12/05/24 between 9:49 PM and 10:15 PM his heart rhythm was primarily atrial fibrillation. Patient #1's telemetry print out at 10:15 PM shows his heart rate increased from 60 to 116 and the rhythm identified by the telemetry software was "V tach" (Ventricular tachycardia, a fast irregular heartbeat that starts in the heart's lower chambers and can become life threatening if it lasts for more than a few seconds at a time), and later that minute his heart rhythm was identified as V fib/V tach (V fib, or ventricular fibrillation, is a life threatening arrhythmia caused when the lower chambers of the heart quiver rather than beat normally which prevents the heart from pumping blood and leads to cardiac arrest. This is an emergency that requires immediate attention.) Patient #1's telemetry print out identifies from 10:16 PM to 10:19 PM he alternated between asystole (cardiac arrest, when the heart stops beating) and V fib/V tach, then was in atrial fib at 10:19 PM for approximately 40 seconds before converting to and staying in asystole for 9 minutes until the time a Code Blue was called at 10:25 PM. Patient #1's Resuscitation Record reveals CPR (cardiopulmonary resuscitation) started 12/05/24 at 10:25 PM and ACLS (Advanced Care Life Support) was attempted but unsuccessful in regaining spontaneous circulation, and the patient died when CPR was stopped in accordance with his representative's direction on 12/05/24 at 10:36 PM.

The Monitor Room Escalation and Resolution Log dated 12/05/24 got Monitor Tech, Staff A documents one entry for Patient #1 with a "1st escalation" of "[name of Unit Secretary] V fib 22.16" and "2nd escalation" of "[name of nurse] V fib 22:18 [10:18 PM]."

During telephonic interview on 01/09/25 at 4:51 PM Monitor Tech, Staff A confirmed she monitored telemetry for Patient #1 the evening of 12/05/24 and stated when Patient #1 had a "burst" of V fib, which she clarified as a couple seconds, she called the Unit Secretary who told her the patient had just arrived and was in a room near her and Staff A told the Unit Secretary about the burst of V fib and asked her to tell the nurse to check Patient #1; that when Patient #1 had another burst of V fib less than a minute later she called the Charge Nurse; then she heard pages for a "Rapid Response" and then a "Code Blue"; that Staff A did not call a Code Blue but did what she was supposed to in having the nurse check the patient; and when asked what she should have done Staff A says to have the nurse check the patient which is what she did and that since it was a burst of V fib and return to A fib "we don't call a Code Blue for that." Staff A did not acknowledge Patient #1 was in a lethal rhythm for 10 minutes before a Code Blue was called, during which Staff A should have called a Code Blue per the facility's Telemetry Policy and Procedures or that Staff A would call a Code Blue for lethal rhythms in the future.

Review of Monitor Tech schedules from 12/22/24 to 01/04/25 revealed Staff A monitored telemetry since Patient #1's death, on the night shifts of 12/31/24 and 01/01/25.

During interview on 01/10/25 at 3:50 PM with the Chief Nursing Officer (CNO), she reported Staff A had a meeting with her manager about this incident and to go over the Telemetry Policy and Procedures but Staff A walked out of the meeting without receiving or agreeing to follow the policy because Staff A did not think she had done anything wrong. The CNO could provide no evidence that Staff A reviewed the Telemetry Policy and Procedures and/or agreed to follow them to protect patients in lethal rhythms before she worked again as a Monitor Tech.

During interview on 01/10/25 at 2:06 PM the Patient Safety Director provided 27 "Education Acknowledgement/Attestation Sheets" for the policy on Telemetry Monitoring and information on responding to life-threatening arrythmias and stated all but 2 Monitor Techs who only worked "as needed" had completed this education. Further review of this documentation and comparison to the Monitor Tech schedules for 12/22/24 to 01/04/25 revealed 8 Monitor Techs who worked during this time had not completed the re-education, including Staff A, and these Monitor Techs worked a total of 17 12-hour shifts. Most notably, 3 of 6 night shift Monitor Techs (MTs) on duty 12/27/24, 3 of 5 night shift MTs on 12/28/24, and 4 of 6 night shift MTs on 01/03/25 did not have evidence of this re-education.