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Based on record review and staff interviews, it was determined the facility failed to completely analyze an adverse event for Patient #1 and failed to implement 2 of 3 corrective actions for Patient #1.

The findings include:

Record review of the electronic medical record for Patient #1 revealed the patient presented to the Emergency Department (ED) on 03/12/20 at 2:36 PM with shortness of breath, fever, fatigue, and coughing. His chest X-ray showed Pneumonia (PNA) and pleural effusion. Patient #1 was in the ED for 11 hours and was stable. He was admitted on 03/13/20 at 1:15 AM to One North, a newly created Unit that was located on the same floor adjacent to the ED.

One North could hold up to four patients. The rooms were all negative pressure rooms to hold symptomatic COVID-19 patients. Patient #1's cardiac monitoring device was not able to send a signal to the telemonitoring unit and the cardiac rhythm was unable to be monitored as ordered by the physician. An initial assessment was completed by Employee F, Critical Care Registered Nurse, on 03/13/20 at 1:30 AM which revealed Patient #1 was confused and agitated. Pulse oxygenation saturation was 98% on room air. The cardiac rhythm was documented as normal sinus rhythm. There was no care plan initiated on admission regarding Patient #1's medical problems. Patient #1 was placed on a portable cardiac rhythm machine. The portable machine was unable to send a signal out to the telemetry monitoring unit for telemetry staff to monitor the patient's cardiovascular status.

Two Critical Care nurses were assigned to take care of the four patients located on One North. Employee F, Critical Care Registered Nurse, had to take another patient to Radiology for a procedure. Employee G, Critical Care Registered Nurse, received report from Employee F, Critical Care Registered Nurse for Patient #1 to monitor the patient while their nurse was off the Unit. Employee G, Critical Care Registered Nurse, was taking care of his two assigned patients as well as Patient #1. Employee G, Critical Care Registered Nurse attempted to replace the cardiac monitoring wires back onto Patient #1 on 03/13/20 at 2:06 AM. He was unable to get Patient #1 to keep the wires on. Patient #1 was agitated. There was no documentation found that the Supervisor was notified for assistance with Patient #1.

Sixteen minutes later, Employee F, Critical Care Registered Nurse, returned from Radiology. She checked on Patient #1 and found him with pale, bluish lips and skin, and no palpable pulse. CPR was initiated and code blue was called. Efforts to resuscitate the patient were unsuccessful. The patient expired on 03/13/20 at 2:55 AM.

A confidential document was submitted to the Agency for Health Care Administration on 04/14/20 for review. The cardiac monitoring equipment was corrected and sends the signals appropriately to the telemonitoring unit. The rooms on One North were upgraded to include a camera in every room and a staff member monitors the cameras every shift. Corrective actions included review of policy regarding sequestering equipment that may have been involved in an adverse incident and education to staff regarding 24/7 availability of Biomedical staff.

The complaint survey was conducted on 10/28/20. Six months after the event occurred, the facility did not complete their action plan which included re-education to all staff.

On 10/29/20 at 2:00 PM, an interview was conducted with Employee D, Vice President of Quality and Education. She confirmed that the facility had not initiated any projects due to the adverse event with Patient #1.

On 10/29/20 at 2:40 PM, an interview was conducted with Employee E, Quality Regulatory Specialist. She was not aware of any data that was gathered or being analyzed as a result of Patient #1's adverse event. She did not have any additional information regarding any process changes or education as a result.

On 10/29/20 at 3:30 PM, a group interview with Employee A, Risk Manager, Employee B, Critical Care Administrator, and Employee C, Emergency Department Administrator, confirmed that the facility had not initiated a project related to Patient #1's adverse event.

Based on electronic record review, review of policy and procedure, and facility staff interviews, the facility failed to initiate a care plan for 1 ( #1) of 3 monitored patients who presented with respiratory problems and a change in condition.


The findings include:

1) Record review of the electronic medical record for Patient #1 revealed the patient presented to the Emergency Department (ED) on 03/12/20 at 2:36 PM with shortness of breath, fever, fatigue, and coughing. His chest x-ray showed Pneumonia (PNA) and pleural effusion.

Patient #1 was in the ED for 11 hours and was stable. He was admitted on 03/13/20 at 1:15 AM to One North that was located on the same floor adjacent to the ED. One North could hold up to four patients. The rooms were all negative pressure rooms to hold symptomatic COVID-19 patients. Patient #1's cardiac monitoring device was not able to send a signal to the telemonitoring unit and the cardiac rhythm was unable to be monitored as ordered by the physician. An initial assessment was completed by Employee F, Critical Care Registered Nurse, on 03/13/20 at 1:30 AM which revealed Patient #1 was confused and agitated. Pulse oxygenation saturation was 98% on room air. The cardiac rhythm was charted as normal sinus rhythm. There was no care plan initiated on admission regarding Patient #1's medical problems.

Patient #1 was placed on a portable cardiac rhythm machine. The portable machine was unable to send a signal out to the telemetry monitoring unit. Two Critical Care nurses were assigned to take care of the four patients located on One North. Employee F, Critical Care Registered Nurse, had to take another patient to radiology for a Stat (immediate) procedure. Employee G, Critical Care Registered Nurse, received report from Employee F, Critical Care Registered Nurse for Patient #1. Employee G, Critical Care Registered Nurse, was taking care of his two assigned patients as well as Patient #1. Employee G, Critical Care Registered Nurse attempted to replace the cardiac monitoring wires back onto Patient #1 on 03/13/20 at 2:06 AM. He was unable to get Patient #1 to keep the telemetry monitor wires on due to agitation.

There was no record of documentation that the Nursing Supervisor was notified for additional assistance in the Unit. Sixteen minutes later, Employee F, Critical Care Registered Nurse, returned from radiology. She checked on Patient #1 and found him with pale, bluish lips and skin, and no palpable pulse. CPR was initiated and code blue was called. Efforts to resuscitate the patient were unsuccessful. The patient expired on 03/13/20 at 2:55 AM.

A confidential document was submitted to the Agency for Health Care Administration on 04/14/20 for review. The cardiac monitoring equipment was corrected and sends the signals appropriately to the telemonitoring unit. The room on One North was upgraded to include a camera in every room and a staff member monitors the cameras every shift. The complaint survey was conducted on 10/28/20. Six months after the event occurred, the facility did not complete their action plan which included re-education to all staff.

Two nurses that were assigned to care for the patient on admission were not available for interview. Interview with Employee A, Risk Manager, on 10/29/20 at 9:25 AM revealed the two nurses assigned to One Nurse on 03/13/20, resigned abruptly. Two attempts were made to contact these two nurses but there were no return phone calls. On 10/29/20 at 3:30 PM, an interview was conducted with Employee B, Critical Care Administrator. He confirmed that the Problem List should be initiated upon admission. There was no documentation from the facility to re-educate staff on the importance of elevating concerns to the physician or calling the Supervisor for assistance.

Review of the Administrative Hospital-wide Policy and Procedure titled "Problem List Documentation" with an issue date of 09/09/14 and a last review date of 09/13/16. Page two states all patients will have a Problem List initiated on Admission generated from the admission order and shall be added to as problems are identified during the visit."