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Based on observation, interview, and record review, the provider failed to ensure telemetry "Monitor Technicians" followed Policies and Procedures to identify and timely notify nurses of arrhythmia changes for 1 of 5 patients (Patient #1) on telemetry, to ensure patients with telemetry orders were placed and maintained on telemetry for 1 of 6 patients (Patient #3) reviewed for telemetry, and to ensure assigned nurses used the correct equipment to receive their patients' automated telemetry alerts for 1 of 6 patients (Patient #9).

The findings included:

The provider's Policy and Procedure titled Cardiac Telemetry Monitoring in the Medical/Surgical, Telemetry and Step-Down Units, revised 08/27/20, documents, "Cardiac telemetry monitoring will be placed on all patients in the Step-Down and Telemetry units unless otherwise ordered by the physician and on Medical/Surgical patients as ordered by the physician" and "Alarm settings should be customized from the default settings to the patient's clinical situation in order to avoid "alarm fatigue"" and "The wireless telephones (Cisco phones) will be programmed to function as a secondary alert system. Each monitored patient will have their assigned nurse and nurse's phone number programmed into the Monitoring Station. If the assigned nurse is unable to respond to an alert, an escalation process will be enacted whereas a second "assigned or buddy" nurse will become the responder (Clinical Lead or other RN)."

This same Policy and Procedure also documents under Specific Roles and Responsibilities, Responsibilities of the Monitor Technician, in relevant parts, "changes alarm limits in Central Monitor per RN instructions based on patient's individual needs" and "Establishes patient's baseline rhythm and monitors for changes. Notifies RN if changes occur. If the RN assigned to the patient is unavailable, escalates the information by notifying the Clinical Lead or nurse's assigned "Buddy." Red alarms- Addresses immediately. Assures response has occurred for all Red Alarms by notifying assigned nurse. Follows escalation procedure if unable to confirm arrhythmia recognition/patient status from assigned nurse..." and "asks for assistance from RN when unable to identify rhythm."

This same Policy and Procedure also documents, under Specific Roles and Responsibilities, Responsibility of the RN, in relevant part, "Picks up wireless phone at shift start. Ensures telephone is functioning properly" and "assures telephone coverage for telemetry alarm alerts when off the unit or on break" and "Responds, promptly, to all RED Alarms as identified by the text messaging on the wireless telephone and/or as notified by the Monitor Tech. The RN must assess the patient in relation to the alarm or rhythm change. Interventions and physician notification will be performed as appropriate" and "Upon admission into the Telemetry Central Monitoring system, analyzes the patient's rhythm and individualizes alarm parameters based on the patient's condition/rhythm. Note: individualizes alarm parameters on each patient on a prn ("as needed") basis based on their condition/rhythm."

The attachment to this policy referred to as "Alarm Management Flow" documents that for "Red alarms" from the monitor, which include V-fib (ventricular fibrillation) and V-tach (ventricular tachycardia) more than 5 beats or a rate greater than 120 bpm (beats per minute), the MT (Monitor Tech) response is to notify RN immediately by calling RN on wireless phone and if no immediate response within 4 rings to notify the C3 (Clinical Lead) or, if no immediate response within 4 rings, to notify another RN on the floor. The Alarm Management Flow documents that for "Yellow alarms" from the monitor, which include V-tach greater than 10 PVC's/min (preventricular contractions per minute) and ventricular rhythm greater than 14 PVC's, as well as "leads off" for patient not monitored, to notify the RN by calling on the wireless phone and if the RN does not acknowledge/answer within 2 minutes to notify the Unit C3 (Clinical Lead) and, "If C3 does not acknowledge/answer within 2 minutes then" but provides no further direction for inability to reach the C3.

1) Review of the record reveals Patient #1 was admitted to the hospital on 11/13/21 after presenting to the Emergency Room with complaint of shortness of breath and diagnosis of "COVID+". Patient #1's "Alarm Review Report" documents he was on 2-South and an ECG (electrocardiogram) strip for 11/17/21 at 09:31:53 AM (hour: minute: second) with heart rate 118 and a ventricular rhythm as identified by distinct wave form, the letter "V" above 27 out of 38 beats and identified as "V-tach" by both the Executive Director of Nursing Administration during interview on 12/06/21 at 1:20 PM and the Director of Risk Management and Patient Safety during interview on 12/07/21 at 3:43 PM. An ECG strip dated and timed 11/17/21 at 09:45 AM documents "Code Blue called" and a rhythm identified as ventricular fibrillation by the Director of Risk Management during interview on 12/07/21 at 3:43 PM. An ECG strip dated and timed 11/17/21 at 10:03 AM was also identified as ventricular fibrillation by the Director of Risk Management during interview on 12/07/21 at 3:43 PM. Patient #1's "Code Sheet" documents the code was called at 9:48 AM on 11/17/21 but resuscitative efforts were unsuccessful with no return of spontaneous circulation.

During observation on 12/07/21 at 9:42 AM until at least 10:07 AM, Monitor Tech, Staff "A", was observed to be watching telemetry monitors for 44 patients. During this observation, multiple audible and visual alarms were observed going off simultaneously and repeatedly. Recuring alarms for various patients included "Red Alarms" for low oxygen saturation level of 84-85%, "Yellow Alarms" for "leads off," "Yellow Alarms" for "non-sustained V-tach," a flatline identified as "leadset unplugged," and alarms for one patient with low heart rate from 46 to the 50s and a second patient with low heart rate in the mid to high 50s. During the observation, Staff "A" was observed to make no more than 2 phone calls and did not ask nearby staff to check on patients.

During interview on 12/07/21 at 1:02 PM with the Monitor Tech, Staff "A", who had been on duty for 2-South on 11/17/21 between 7 AM and 7 PM (before and during Patient #1's Code Blue), Staff "A" reported she had called the PCT (Patient Care Technician) right away after the monitor alarm to notify them that Patient #1 was off the monitor but they did not answer their phone; that Staff "A" later learned the PCT had changed phones without letting her know; Staff "A" said she then called the nurse who checked on Patient #1 right away and called a Code Blue. Staff "A" denied any delay in letting the nurse know of the alarm and reported she had thought the problem was the patient's leads were off because the "computer can't tell the difference." Staff "A" reported on the day of interview, 12/07/21, she was monitoring 44 patients on telemetry (on 2-South). Although Staff "A" reported the monitors were very busy with alarms constantly going off that day, she denied feeling overwhelmed because she said it had been worse when all their patients had "COVID." Staff "A" denied nurses individualizing alarm settings for their patients to decrease the number of alarms going off but said they keep "default alarm parameters" for everybody. Although she reported awareness of the term "alarm fatigue," she said it would be "too much" to try to change alarm parameters for individual patients.

During interview with the Registered Nurse, Staff "B", who was assigned to Patient #1 on 2-South on 11/17/21 since 7 AM, she reported when the Monitor Tech called her on 11/17/21 to report Patient #1's leads were off, she was in an adjacent room and promptly checked on him, found him unresponsive, called a Code Blue, and "CPR" (cardiopulmonary resuscitation) was started but staff could not revive him.

Review of Staff "A"'s personnel file revealed she was hired in 2014 and completed annual trainings for telemetry including basic arrhythmias in May of 2021, but no evidence of refresher training for arrhythmias since she had failed to recognize ventricular tachycardia on 11/17/21.

During interview on 12/06/21 at 1:20 PM, the Executive Director of Nursing Administration reported the action plan in response to this event includes consulting appropriate departments about moving telemetry monitors to quieter areas on the nursing units and to set up a class in February 2022 for remediation for all Monitor Technicians.

During interview on 12/07/21 at 4:22 PM, the Director of Risk Management explained plans to retrain all 35 Monitor Technicians in February 2022 and the reason this had not been done was to wait for a quality, trusted contractor to perform the training. Upon request for evidence of retraining to Staff "A" regarding arrhythmias, facility documentation received on 12/08/21 documents a discussion in which Staff "A" reported she believed the V. tach to be "artifact" and the future "expectation" of "refresher class for arrhythmias". The provider could produce no evidence of retraining for Staff "A" regarding lethal arrythmias since Patient #1's misidentified "V-tach" and delay in response on 11/13/21.

The website https://www.emedicinehealth.com/heart_rhythm_disorders/article_em.htm documents, "The arrhythmias that can often lead to death in minutes are ventricular fibrillation and ventricular tachycardia. Although others may also cause death, these two arrhythmias can quickly and severely alter the heart's ability to effectively pump blood. Immediate electrocardioversion to put the heart back into a more effective rhythm that allows the heart to pump blood effectively can be life-saving."

2) During observation of telemetry monitoring on the 4-South unit on 12/06/21 beginning at 11:18 AM, room 410-1 was observed to have no telemetry monitoring and to be indicated on the monitor as "standby." Patient #3 was observed in bed in 410-1 on 12/06/21 at 11:29 AM.

Record review revealed Patient #3's admitting diagnoses were "infected decubitus ulcer, tachycardia" and orders on 12/01/21 documented to admit Patient #3 to inpatient with "level of care" as "med surg (medical surgical) telemetry." Further review of Patient #3's record revealed no documentation of telemetry monitoring for Patient #3 since their admission on 12/01/21.

During further observation on 12/06/21 at 2:07 PM, Patient #3 was observed in bed in room 410-1 with no visible telemetry box or wires, the telemetry box labeled for that room and bed was observed at the nursing station, and the telemetry monitor status for Patient #3's bed showed as "standby."

During interview on 12/06/21 at 2:10 PM, the RN (Registered Nurse) assigned to Patient #3, Staff "B" reported Patient #3 was on telemetry monitoring; however, after shown the telemetry box at the nursing station, denied any orders for telemetry monitoring of Patient #3 and denied that Patient #3 had a cardiac diagnosis. During further interview on 12/06/21 at 12:15 PM the Lead Transitional Care Coordinator, Staff "C" confirmed Patient #3 had telemetry orders since admission on 12/01/21, that these orders were not followed, and that there was no physician order to discontinue telemetry.

During interview on 12/06/21 at 2:36 PM, the Assistant Nurse Manager of 4-South explained under the current process an admission order must be "opened" to check if telemetry is ordered in the "level of care" because the word "telemetry" is not readily visible in the order listing.

3) During interview with a Registered Nurse on 2-South, Staff "D" on 12/07/21 beginning at 1:22 PM, Staff "D" reported she was not aware that the policy permitted alarm parameters to be individualized for patients according to their condition so as to decrease redundant alarms that contribute to "alarm fatigue" and also reported that about 50% of the automated telemetry alerts that came to her phone each day were not for her patients and she did not know why she received those alerts. Staff "D" reported that one of such patients she received repeated alerts for that day was Patient #9 for oxygen levels in the mid-80s, below the default setting of 92%.

During interview on 12/07/21 at 4:15 PM, the Executive Director of Nursing Administration explained the nurse assigned to Patient #9 on 2-South was carrying a 5th floor phone which could not be programmed to receive automated telemetry alerts on the 2nd floor; that staff had been told not to use the other floors' phones since they were not compatible; and it was for this reason that another nurse with a 2nd floor phone (Staff "D") was receiving Patient #9's alerts whereas Patient #9's nurse could only receive phone calls about this patient. The Executive Director of Nursing Administration reported Patient #9's oxygen levels had dropped further and Patient #9 was transferred to the Intensive Care Unit for a higher level of care.