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Based on observation, review of clinical records, review of facility policies and procedures, and interviews, the facility failed to honor patients' rights to receive care in a safe setting by failing to document evidence of continuous cardiac monitoring in the Emergency Department (ED) for six of six patients reviewed (#4, 12, 2, 3, 4, and 5).

The hospital failed to ensure evidence of continuous cardiac monitoring in the Emergency Department (ED) for six of six patients reviewed for continuous cardiac monitoring in the ED (#4, 12, 2, 3, 4, and 5). (Refer to A0144) and appropriate fall interventions were in place for one of one patient reviewed for fall prevention (Refer to A0286). The noncompliance at the Condition of Participation of Patient Rights due to the hospital's failure to ensure that patients receive care in a safe setting resulted in Immediate Jeopardy. The Immediate Jeopardy began on 12/10/2021. The hospital was informed of the Immediate Jeopardy on 2/8/2022 at 12:20 p.m. and was ongoing as of the survey exit on 2/9/2022.

Based on observation, review of clinical records, review of facility policies and procedures, and interviews, the facility failed to provide care in a safe setting by failure to provide evidence of continuous cardiac monitoring in the Emergency Department (ED) for six of six patients reviewed with orders for continuous cardiac monitoring in the ED (#4, 12, 1, 2, 3, and 5) and failed to prevent a fall with injury (Patient #12). The patient's family found the Patient #4 unresponsive in the ED and reported it to the nursing staff. On 12/10/2021 the patient was in full cardiac arrest and pronounced dead on 12/10/2021 at 7:30 a.m. This resulted in Immediate Jeopardy that began on 12/10/2021 (Refer to A0115)

Findings include:

The Patient Rights policy with effective date of 6/2016 and revisions 5/2021 states " ...patient outcomes can be improved by respecting each patient's rights ... This policy addresses general guidelines for staff regarding respecting and supporting the patient's right to treatment or service". The 'Telemetry Policy" with effective date of 3/2016 and revisions 10/22/19 and 6/29/21 states, "In select patient care areas where patients are monitored in their respective units, such as the critical care units (ED) ... which have a central monitoring station, it is the responsibility of each patient's nurse to monitor his/her own patient's cardiac rhythm. In these units the nurse is expected to run telemetry strips minimally every 12 hours, interpret the strip as defined here within this policy (heart rate, PR, QT, QRS, and rhythm) and ensure the telemetry strips are added to the patient's medical record" "Continuous Cardiac Monitoring is available 24 hours a day, 7 days a week ... The validation of the telemetry monitor strip interpretation is the responsibility of the patient's nurse .... The responsibilities of the nurse include documentation of any changes in cardiac rhythm, regular documentation regarding patient's rhythm, verification of monitoring, and replacement of batteries as needed." "Alarms are to be set and maintained throughout the patient stay." "In select patient care areas where patients are monitored in their respective units, such as the critical care units (including ED) which have a central monitoring station, it is the responsibility of each patient's nurse to monitor his/her own patient's cardiac rhythm. In these units, the nurse is expected to run telemetry strips minimally every 12-hours, interpret the strip as defined within this policy, and ensure the telemetry strips are added to the patient's medical record."

Review of the policy titled Emergency Department Fall Risk Assessment effective 8/11/2015, and last review date 5/2021 stated "Fall precautions are initiated based on the Fall Risk Category: a. moderate/High Risk (3-4) Implement high fall risk interventions and, b. Low risk (1-2) Implement preventative interventions.
High risk interventions include Bed pressure alarm, yellow arm band on patient, yellow fall risk sign on door, yellow fall risk sign in room, placed in yellow gown, yellow slippers applied, "preventing falls" information, 30-minute rounding."

Observations made 1/3/2021 around 10:00 a.m. in the ED showed numerous patients with cardiac monitors, viewed on the central monitoring station in the ED. There was no one observed specifically watching the monitors. Patients #1, #2, and #5 were observed in the ED and Patient #3 was in the Interventional Cardiac Care Unit (ICC). Patient #4 was a closed record review, the subject of a report of an adverse event filed through the state agency, and the subject of a facility event report reviewed by the survey team.

Observations in the ED on 2/8/2022 at 3:15 p.m. revealed the presence of a dedicated monitor technician (tech) who was watching monitors in addition to providing clerical duties. The monitor tech was seen sitting in front of two computers he was facing for order entry and other clerical duties as well as answering the phone. The cardiac monitors were mounted approximately 7 feet from the floor at a right angle to where the monitor tech sat. The monitor tech was seen standing up and turning position to view the cardiac monitors.

The medical record for Patient #4 was reviewed. The section of the medical record titled "Emergency Documentation" revealed the patient arrived to the facility on 12/9/2021 at 10:31 a.m. Review of Patient #4's History of Present Illness (HPI) documented by the physician revealed the patient's Chief Complaint was abnormal blood work, Hemoglobin of 6 g/dl (normal range for men is 13.5-17.5 grams per deciliter).
Patient #4 was a 53 year-old male with a past medical history significant for ESRD (End Stage Renal Disease) hemodialysis dependent, atrial fibrillation, long term anticoagulation, and left arm AV shunt came to the Emergency room for evaluation of low hemoglobin. Patient had a revision of the left AV shunt ...sent to the ED for transfusion ...patient also reported weakness and mild shortness of breath." The patient's vital signs were stable. Further review of the section of the HPI "Assessment/Plan revealed in part, "Chest x-ray was suggestive of pleural effusion versus pneumonia."


Patient #4 was admitted to an inpatient unit, ICC but was holding in the ED for bed availability. Continuous cardiac monitoring was ordered on 12/9/2021 at 6:46 p.m. The ER physician ordered an initial Troponin level obtained and resulted 0.83 ng/L (normal 0-0.04 ng/L) at 1600pm 12/9/21. The admitting ARNP ordered an additional Troponin level to be drawn at 0:00 a.m. on 12/10/2021 by the Lab. This Troponin level was not obtained nor escalated by nurse. After discussion with the Lab Director, it was noted that when the label printed for the 0:00 a.m. labs, the phlebotomist misread the label as being for 6:00 a.m. and placed the label with the other morning draw labels. This resulted in the Troponin level not being drawn by the lab or nursing. Nursing signed an order off at 5:07a.m. with no follow-up on why the ordered troponin level had not been performed.

Nursing Notes dated 12/10/21 at 5:55 a.m. stated, "wife calling for update. assurances that [Patient #4] has been sleeping post medication administration at 11:00 p.m. she reports that she will be coming in to see patient this am. monitoring continues. awaits bed assignment". On 12/10/2021 at approximately 7:00 a.m. the patient was found unresponsive by his family. Patient #4 was evaluated by nursing and found to be in ventricular fibrillation (a life threatening heart rhythm that results in a rapid, inadequate heartbeat), was coded and expired after family elected to discontinue life support. Nursing Notes dated 12/10/21 at 9:13 a.m. revealed in part, "During morning shift report the patient's family alerted nursing staff that patient was not responding to her, I placed patient on 3 lead monitor and pads and [patient] was Asystole, we called a code blue and worked the code for 5-10 minutes and the family member called her daughter and the family collectively agreed to terminate efforts, Time of Death 7:05 a.m. on 12/10/2021." There was no documentation by the nursing staff of cardiac monitoring in the clinical record until the patient was found unresponsive by family members on 12/10/2021 at approximately 7:00 a.m. when there was a rhythm strip showing ventricular fibrillation. There was inadequate supervision of Patient #4 to prevent patient from pulling cardiac leads, as evidenced by leads being off for an extended period that was not recognized timely by the facility staff.

Patient #12 was an 82-year-old male who arrived in the ED 1/19/2022 at 4:28 p.m. He was referred by his primary care physician (PCP) after being found hypoxic (below-normal level of oxygen in the blood) with an (oxygen saturation rate) SPO2 of 73% (normal 95-100%) in the outpatient setting. The patient reported falling three times since the day prior to admission. The patient reported shortness of breath, headaches, and cough for the past one and a half months. On arrival to the ED his oxygen saturation rate was 77% on room air. The chest x-ray in the ED suggested developing CHF (congestive heart failure). He was positive for COVID-19 (Coronavirus Disease 2019) on both antigen and PCR (polymerase chain reaction test) (for Coronavirus 2019) testing. Diagnoses included acute respiratory failure with hypoxemia, Pneumonia due to COVID-19, non-St elevated myocardial infarction (also called NSTEMI, is a type of heart attack. While it is less damaging to your heart then a STEMI, it is still a serious condition that needs immediate diagnosis and treatment). with initial Troponin 0.23 ng/dl, repeat troponin 0.21 (normal 0-0.04 ng/L), Acute kidney injury superimposed on chronic kidney disease stage II, chronic anemia (hemoglobin 10.2 and hematocrit 31.7 on admission) essential hypertension, BPH (benign prostatic hypertrophy, mixed anxiety and depressive disorder, and dyslipidemia. Patient #12 was ordered to continue atenolol (high blood pressure medication) and Plavix (medication that reduces the risk of heart disease and stroke in people at high risk) and started Lovenox (medication that prevents blood clots) subcutaneously. Pneumonia due to COVID-19, CHF, acute kidney injury superimposed on chronic kidney disease stage 2, chronic anemia (hemoglobin 10.2 and hematocrit 31.7 on admission), essential hypertension, benign prostatic hyperplasia, mixed anxiety and depressive disorder, and dyslipidemia. A fall risk assessment using the University of Colorado health fall risk assessment was completed 1/19/2022 at 2:58 p.m. with a fall risk score of 4. A high fall risk is defined as a fall risk score of 3 or more points. Patient #12's fall risk score was 4 indicating high fall risk.

On 1/20/2022 around 1:00 p.m. patient was found on the floor with a laceration to the left side of the scalp with bleeding, agonal breathing (gasping for air), cyanosis (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood), in asystole (the cessation of electrical and mechanical activity of the heart). A code blue was called, and resuscitation attempts were unsuccessful. Last documented vital signs 1/20/2022 at 10:06 a.m. Heart rate - 76 [beats per minute], Respiratory rate 26 [breaths per minute], - Blood pressure 132/61 [mm Hg], mean arterial pressure (MAP) 85 mm Hg. SPO2 was 94% on oxygen at 14 liters per minute.

A nurses note written by RN B on 1/20/2022 at 11:00 a.m. reported "patient remains awake/alert, vital signs stable. Remains on high flow O2 (oxygen) at 14 liters per nasal cannula, remains tachypneic (rapid respiratory rate) respiratory rate 26-30, patient however, denied dyspnea (shortness of breath). Speech clear, denies pain or discomfort, awaiting room assignment at this time".

During an interview with the ED Director on2/10/2022 around 2:30 p.m., she stated that the record reporting a fall risk score of 4 was correct and is considered high risk for falls and that the tab alarm and 30-minute rounding was not done according to the policy.
Policy review for "Emergency Department Fall Risk Assessment" confirmed this.

Nurse B, the nurse on duty 1/20/2022 for the 9 a.m. to 9 p.m. shift was assigned to Patient #12 reported a summary of the event during an interview 2/8/2022 at 4:30 p.m. He stated he assumed care of Patient #12 sometime between 9:30 to 10:00 a.m. on 1/20/2022 during bedside shift report (approximately 9:30 a.m.). He said they were doing walking rounds and noted that the patient had his oxygen nasal cannula half in and half out, that he did not keep the O2 (oxygen) on. He said he can't remember if the patient took his leads off at that time. He stated after he finished walking rounds he went back to the area and found the patient was still in bed, confused but redirectable. He said that the emergent alarms sound different then when the patient is off the monitor. He said he saw the patient at 10:45 a.m. and at that time Patient #12 was on high flow oxygen with continuous pulse oximetry, and the patient had no complaints. He said he was seeing his other patients at the time of the incident. He reported having 5 patients of whom 4 were being held in the ED waiting to be transferred. He said he can't remember what level of care they were. He stated that he checks his patients every two hours and this patient's door was closed because of the COVID so he did not hear the cardiac monitor alarm.

The Unit Secretary/Monitor Tech on 2/8/2022 at 3:15 p.m. stated that his role is to consult with physicians and watch the monitors. He said that he places strips in the charts every 4 hours.

During an interview with the facility team including the Chief Nursing Officer (CNO), Chief Quality Officer (CQO), Executive Director of Nursing, and Risk Manager, on 2/8/2022 at 4:00 p.m. the CNO provided an overview of what actions were taken to mitigate the Immediate Jeopardy. The CNO stated there were three sets of education provided to the ED staff in mid-December [2021], Clinical Documentation, Clinical Alarms in the Emergency Department, and changes were made to the telemetry policy 1/27/2022, the change states "Patients that are admitted but are being held in ED for a bed are to be monitored as an admitted patient". The CNO reported that after the initial event a dedicated Unit Secretary/Monitor Tech (US/MT) began. He stated that they soon realized this was too much for the US/MT to manage alone so the facility then assigned beds in the ED for holding admitted patient to the central telemetry station located in the Progressive Care Unit (PCU). He reported audits were conducted daily since 1/22/2022 that recorded the number of holds, number of holds with telemetry orders, fall risk assessment, fall interventions, telemetry compliance, and falls. He said that bed alarms are being implemented in all ED rooms. According to the CNO, the telemetry monitor techs in PCU observe up to 48 monitors each and the telemetry station has two dedicated monitor techs until the volume exceeds 48 monitors each when they add a third monitor tech.


During an interview on 1/3/2022 at 10:15 a.m., the Director of the Emergency Department stated there is no designated monitor tech and each primary nurse is responsible for watching the patients' telemetry monitor, and that the alarms are a joint effort. When asked how the ED manages lead failure, she did not specify, but said that there is a sleep mode that disables the alarm at the patient bedside, but the desk alarm still sounds at the nurses' station.

During an interview on 1/3/2022 at 10:25 a.m. with the Clinical Coordinator of the ED, she stated that the staffing for the ED is based on the numbers of ED patients seen. She said that there is no additional staff provided for patients holding for inpatient admission. She said seven patients were holding in the ED at the time, and that two of the med/surg [medical surgical] patients had just been given bed assignments.

During an interview on 1/3/2022 at 10:55 a.m., the Director of Risk Management and Patient Safety stated there is no assigned monitor tech in the ED, that the Charge Nurse watches the monitors.

During an interview 1/3/2022 at approximately 12:00 p.m. with the ED Director and the Executive Director of Nursing Services, the ED Director stated that telemetry strips are not placed in the chart for ED patients or for holding patients in the ED. The Executive Director of Nursing Services stated she agreed the same standard of care should be applied for patients holding in the ED for beds as for the patients in the various inpatient units.

The facility failed to follow their telemetry policy.

Patient #1, a 70 year-old female presented to the ED 1/3/2022 at 6:50 a.m. after waking in a pool of sweat, jaw pain, and discomfort to the epigastric area. The patient consents were present and signed. Electrocardiogram (EKG) completed - normal sinus rhythm rate 61 no ectopy, anterior t-wave inversions. Troponin negative (<0.03 ng/L). Was on hold in the ED awaiting a bed in ICC. Continuous cardiac monitoring was on the chest pain protocol, and cardiac monitoring was observed, but no rhythm strips or rhythm interpretation was documented in the clinical record. Was discharged home on 1/3/2022 at 1:03 p.m.

Patient #2, was admitted to the facility via ambulance on 1/3/2022 at 05:18 a.m. Documentation by the Emergency Department revealed the patient's chief complaint was chest pain, intermittently, worse with deep inspiration or coughing. on 1/3/2022 at 5:26 a.m., the ED physician reviewed the EKG which revealed the patient's Heart rate was 62 [beats per minute], and no ectopy [abnormal heart beats], "ED interpretation ...IRBBB (incomplete Irregular Right Bundle Branch Block-occurs in conductions in which the right ventricle of the heart is enlarged). Further documentation revealed during the physical examination, "Cardiovascular: Regular, rate and rhythm." Continued review revealed the section titled Impression Plan/Diagnosis, Abnormal EKG and the patient was being admitted by Emergency Medicine Services, to the Observation Telemetry Unit. At 5:32 A.M., the ED physician ordered Cardiac Monitoring "Constant Order." Patient was admitted and was held for an ICC bed until 1/4/2022. The first rhythm strip in the chart was recorded 1/4/2022 at 8:12 a.m. after patient arrived in the ICC unit. Continuous cardiac monitoring was observed, but there was no documentation of it in the ED record.

A 69-year-old male presented to the ED 1/3/2022 5:18 a.m. with complaints of (c/o) chest pain. The patient was observed to be on a cardiac monitor, but no record of it was in the clinical record. Clinical record documentation reported oxygen saturation rate on arrival was 100% on room air. There was no documentation of the order or the nonrebreather in the clinical record. The next recorded oxygen saturation rate was 1/3/2022 at 2:53 p.m. was 97%. There was no record of vital signs including oxygen saturation rate from 7:53 a.m. until 1/3/2022 at 2:53 p.m. The remaining documented oxygen saturation rate results were over 90% on room air. Troponin negative (<0.03 ng/L). Patient was admitted and holding for an ICC bed until approximately 7:30 a.m. on 1/4/2022. The first rhythm strip in the chart was recorded 1/4/2022 at 8:12 a.m. after patient arrived in the ICC unit. Continuous cardiac monitoring was ordered 1/3/2022 at 5:35 a.m., was observed to be on cardiac monitoring, but there was no documentation of it in the ED record.

Patient #3, a 58-year-old female admitted to the ED on 12/28/2021 at 0:24 a.m. with c/o chest pain and SOB for approximately 2 weeks. The admitting diagnosis was chest pain, jaw pain, and abnormal EKG. She was recently out of town. Upon return she experienced worsening Shortness of Breath (SOB), fatigue, and inability to lie flat. Cardiac Troponin test results in ED were negative for three times. Patient was seen in the ED for this visit. There were no cardiac rhythm strips in the record from the ED.
Patient #3 was in the ICC unit in a room on 1/3/2022 at 10:40 a.m. The telemetry was not functioning due to damage from a storm, therefore, the nurses are connecting her to a portable cardiac monitor for getting out of bed.

Patient #5, a 70-year-old female admitted to the ED 12/14/2021 at 6:27 a.m. for Myocardial Infarction, unstable angina, angina, anxiety, pulmonary embolism, atypical chest pain, aortic dissection (medical emergency where the inner layer of the large blood vessel from the heart tears), pneumonia, gastroesophageal reflux disease (GERD) (acid reflux), costochondritis (inflammation of the cartilage that connects a rib to the breastbone) , pleurisy (inflammation of the tissues that line the lungs and chest cavity), chest wall pain, chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), biliary disease (diseases affecting the bile ducts, gallbladder, and other structures involved in the production and transportation of bile). An order for cardiac monitoring was present 12/14/2021 at 6:27 a.m. No cardiac rhythm strips were in the ED clinical record despite an order for continuous cardiac monitoring 12/14/2021 at 6:27. After the patient left the ED for the cardiac catheterization lab 12/14/2021 at 1:11 p.m., the rhythm strips were posted in chart. Troponin levels were completed as ordered.

Based on record review, interviews, review of facility documents, and review of policy and procedure, the hospital failed to ensure that clear expectations for patient safety were implemented by the Quality Assurance and Performance Improvement (QAPI) Program. The QAPI system failed to react to adverse incidents and failed to develop and implement measures to prevent further occurrences after two incidents of cardiac lead failure for an extended time with patients found unresponsive.

The condition is not met due to the systemic failure to maintain a functioning QAPI system to investigate, track and trend, implement measures to prevent unobserved cardiac rhythm change due to lead failure. The Chief Quality Officer failed to ensure that serious adverse/sentinel event interventions and auditing of interventions to prevent the opportunity for further unobserved cardiac rhythm change that caused Immediate Jeopardy to the safety of patients in the hospital Emergency Department (Refer to A0286, A0144, A0386).

Based on observation, review of clinical records, review of facility policies and procedures, facility reports, QAPI agenda, and interviews, the facility failed to identify performance improvement indicators to prevent the recurrence of a continuous cardiac monitoring event that may have led to one patient's (Patient #12) being found on the floor in cardiac arrest. Patient #12 was pronounced dead 1/20/2022 at 12:46 p.m.

The findings include:

Review of the policy titled Emergency Department Fall Risk Assessment effective 8/11/2015, and last review date 5/2021 stated "Fall precautions are initiated based on the Fall Risk Category: a. moderate/High Risk (3-4) Implement high fall risk interventions and, b. Low risk (1-2) Implement preventative interventions.
High risk interventions include Bed pressure alarm, yellow arm band on patient, yellow fall risk sign on door, yellow fall risk sign in room, placed in yellow gown, yellow slippers applied, "preventing falls" information, 30-minute rounding."

Observations in the Emergency Department (ED) on 2/8/2022 at 3:15 p.m. revealed the presence of a dedicated monitor technician (tech) who was watching monitors in addition to providing clerical duties. The monitor tech was seen sitting in front of two computers he was facing for order entry and other clerical duties as well as answering the phone. The cardiac monitors were mounted approximately seven feet from the floor at a right angle to where the monitor tech sat. The monitor tech was seen standing up and turning position to view the cardiac monitors.

The medical record for Patient #12 was reviewed. Patient #12 was an 82-year-old male who arrived in the ED on 1/19/2022 at 4:28 p.m. He was referred by his primary care physician (PCP) after being found hypoxic [below normal level of oxygen in the blood] with an (oxygen saturation rate) SPO2 of 73% (normal 95-100%) in the outpatient setting. The patient reported falling three times since the day prior to admission. The patient reported shortness of breath, headaches, and cough for the past one and a half months. On arrival to the ED his oxygen saturation was 77% on room air. The chest x-ray in the ED suggested developing CHF (congestive heart failure). He was positive for COVID-19 (Coronavirus Disease 2019) on both antigen and PCR (polymerase chain reaction test) (for Coronavirus Disease 2019) testing. Diagnoses included acute respiratory failure with hypoxemia, Pneumonia due to COVID-19, non-St elevated myocardial infarction (also called NSTEMI, is a type of heart attack. While it is less damaging to your heart then a STEMI, it is still a serious condition that needs immediate diagnosis and treatment) with initial Troponin 0.23 ng/L, repeat Troponin 0.21 ng/L (normal 0-0.04 ng/L), Acute kidney injury superimposed on chronic kidney disease stage II, chronic anemia (hemoglobin 10.2 g/dl and hematocrit 31.7% on admission) essential hypertension, BPH (benign prostatic hypertrophy, mixed anxiety and depressive disorder, and dyslipidemia. Patient #12 was ordered to continue atenolol (high blood pressure medication) and Plavix (medication that reduces the risk of heart disease and stroke in people at high risk) and started Lovenox (medication that prevents blood clots) subcutaneously. A fall risk assessment using the University of Colorado health fall risk assessment was completed 1/19/2022 at 2:58 p.m. with a fall risk score of 4. A high fall risk is defined as a fall risk score of 3 or more points. Patient #12's fall risk score was 4 indicating high fall risk.

On 1/20/2022 around 1:00 p.m. patient was found on the floor with a laceration to the left side of the scalp with bleeding, agonal breathing (gasping for air), cyanosis (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood), in asystole (the cessation of electrical and mechanical activity of the heart). A code blue was called, and resuscitation attempts were unsuccessful. Patient #12 was pronounced dead 1/20/2022 at 12:46 p.m. Last documented vital signs 1/20/2022 at 10:06 a.m. Heart rate - 76 [beats per minute], Respiratory rate 26 [breaths per minute], Blood pressure 132/61 [mm Hg], mean arterial pressure (MAP) 85 mm Hg. SPO2 was 94% on oxygen at 14 liters per minute.

A nurses note written by RN B on 1/20/2022 at 11:00 a.m. reported "patient remains awake/alert, vital signs stable. Remains on high flow O2 (oxygen) at 14 liters per nasal cannula, remains tachypneic (rapid respiratory rate) respiratory rate 26-30, patient however, denied dyspnea (shortness of breath). Speech clear, denies pain or discomfort, awaiting room assignment at this time".

During an interview with the ED Director on 2/10/2022 around 2:30 p.m., she stated that the record reporting a fall risk score of 4 was correct and is considered high risk for falls and that the tab alarm and 30-minute rounding was not done according to the policy.
Policy review for "Emergency Department Fall Risk Assessment" confirmed this.

RN B, the nurse on duty 1/20/2022 for the 9 a.m. to 9 p.m. shift was assigned to Patient #12 reported a summary of the event during an interview 2/8/2022 at 4:30 p.m. He stated he assumed care of Patient #12 sometime between 9:30 to 10:00 a.m. on 1/20/2022 during bedside shift report (approximately 9:30 a.m.). He said they were doing walking rounds and noted that the patient had his oxygen nasal cannula half in and half out, that he did not keep the oxygen on. He said he can't remember if the patient took his leads off at that time. He stated after he finished walking rounds he went back to the area and found the patient was still in bed, confused but redirectable. He said that the emergent alarms sound different then when the patient is off the monitor. He said he saw the patient at 10:45 a.m. and at that time Patient #12 was on high flow oxygen with continuous pulse oximetry, and the patient had no complaints. He said he was seeing his other patients at the time of the incident. He reported having 5 patients of whom 4 being held in the ED waiting to be transferred. He said he can't remember what level of care they were. He stated that he checks his patients every two hours and this patient's door was closed because of the COVID so he did not hear the cardiac monitor alarm.

The Unit Secretary/Monitor Tech on 2/8/2022 at 3:15 p.m. stated that his role is to consult with physicians and watch the monitors. He said that he places strips in the charts every 4 hours.

During an interview with the facility team including the Chief Nursing Officer (CNO), Chief Quality Officer (CQO), Executive Director of Nursing, and Risk Manager, on 2/8/2022 at 4:00 p.m. the CNO provided an overview of what actions were taken to mitigate the Immediate Jeopardy for the Conditions of Participation for Patient Rights and Nursing Services. The CNO stated there were three sets of education provided to the ED staff in mid-December [2021], Clinical Documentation, Clinical Alarms in the Emergency Department, and changes were made to the telemetry policy 1/27/2022, the change states "Patients that are admitted but mare being held in ED for a bed are to be monitored as an admitted patient". The CNO reported that after the initial event a dedicated US/MT began. He stated that they soon realized this was too much for the US to manage alone so the facility then assigned beds in the ED for holding admitted patient to the central telemetry station located in PCU. He reported audits were conducted daily since 1/22/2022 that recorded the number of holds, number of holds with telemetry orders, fall risk assessment, fall interventions, telemetry compliance, and falls. He said that bed alarms are being implemented in all ED rooms. According to the CNO, the telemetry monitor techs in PCU observe up to 48 monitors each and the telemetry station has two dedicated monitor techs until the volume exceeds 48 monitors each when they add a third monitor tech.

The hospital's investigation documented the Analysis of incident revealed Patient #12 was slightly confused and secondary to COVID-19 precautions, required door closure which prevented visual observation, Patient was taking blood thinners and was weak and fatigued from COVID disease process. Patient had not been transferred to an inpatient hospital bed and remained on ED stretcher. Patient had a frequent fall history and fall precautions had not been put in place. Patient hourly rounding completed at 10:45 a.m. and the next round completed at 12:34 p.m. Cardiac monitor lead found off patient at 12:34 p.m. The monitor was removed and tested by Biomed and found to be working correctly.
Corrective Actions reported to the [Florida] state survey agency stated on January 21, 2022, the ED monitors were routed up to the central monitoring hub to ensure additional 24/7 monitoring with daily auditing being performed by nursing leadership. Adjustments were made to the monitoring equipment to increase the sound of alarms in both the patient rooms and the nursing station in the ED. Education of the ED staff and central monitoring staff for the process of monitoring ED patients in the central hub. Daily auditing in the ED is performed to verify that Fall Assessments and appropriate interventions are being placed per policy. Addition of position change alarms to the ED rooms to bolster the fall interventions, Addition of 2-way radios for ED nursing staff so that even when not in the main station, they can be reached.

The CQO reported during an interview on 2/10/2022 at 9:30 a.m. the process of completing QAPI reviews. She showed a computerized report with numerous tabs of data collection by department. For each metric there is a target and for those metrics not meeting target an action plan is reported. She shared that action plans use the Plan, Do, Study, Act (PDSA) method for implementing change.
The CQO reported during an interview 2/10/2022 at 12:30 p.m. that the QAPI process was changed, and the facility uses something called Project Excellence. She said that with this process the meetings are more meaningful and use dashboards to present information that is addressed using evidence-based practice. A review of the quality plan and reports revealed the update of the quality process and printed versions of the series of dashboards used on the virtual reports. In addition to the dashboards, there were formatted action plans.
The facility had recently implemented "Smart Goals" and was used for the ED fall occurring in January 2022. A QAPI accountability plan started December 2021 and is a document reviewed for serious events at Quality Improvement Committee (QIC), Medical Executive Committee (MEC), and the board as a standing agenda item. There was no QAPI meeting in December 2021. Prior to December 2021 the facility reviewed serious safety events only.

Based on observation, clinical record review, review of facility policies and procedures, and interviews, the facility failed to provide appropriate nursing oversight regarding nursing response to a cardiac rhythm and to adequately supervise two of six patients reviewed (Patient #4 and Patient #12) Facility staff did not observe the change in the Patient #4 and Patient #12's lethal cardiac rhythm on the cardiac monitor. The patient's family found the Patient #4 unresponsive in the ED and reported it to the nursing staff. On 12/10/2021 the patient was in full cardiac arrest and pronounced dead on 12/10/2021 at 7:30 am. On 1/20/2022 around 1:00 p.m. Patient #12 was found on the floor with a laceration to the left side of the scalp with bleeding, agonal breathing, cyanosis, in asystole.

There was inadequate supervision of (Patient #4 and Patient #12) to prevent patients from pulling cardiac leads, resulting in leads being off for an extended period that was not recognized timely by the facility staff. (Refer to A0386)

There was inadequate nursing oversight for nursing response to changes in cardiac rhythm changes for (Patient #4 and Patient #12), resulting in an unseen change in cardiac rhythm. (Refer to A0386) and a fall (Patient #12) without appropriate fall risk interventions in place. (Refer to A0286, A0386, and A0144)

The hospital's noncompliance with the Conditions of Participation of Nursing Services due to the hospital's failure to provide appropriate nursing oversight resulted in Immediate Jeopardy. The Immediate Jeopardy began on 12/10/2021. The hospital was informed of the Immediate Jeopardy on 2/8/2022 at 12:20 p.m. and was ongoing as of the survey exit on 2/9/2022.

Based on observation, staff interview, state agency reports, and facility and patient record review, and facility incident report, the facility failed to provide appropriate nursing oversight regarding nursing response to a cardiac rhythm change and delayed response to a patient with an unrecognized change in cardiac rhythm for 2 of 7 (Patient #4, and Patient #12) patients sampled. There was inadequate nursing oversight and supervision for nursing response to changes in cardiac rhythm changes for (Patient #4, and Patient #12), resulting in an unseen change in cardiac rhythm. The patients family found the Patient #4 unresponsive in the ED and reported it to the nursing staff. On 12/10/2021 the patient was in full cardiac arrest and pronounced dead on 12/10/2021 at 7:30 a.m. This resulted in Immediate Jeopardy that began on 12/10/2021. On 1/20/2022 around 1:p.m. Patient #12 was found on the floor with a laceration to the left side of the scalp with bleeding, agonal breathing, cyanosis, in asystole. (Refer to A0385).

Findings include:

Observations made 1/3/2021 around 10:00 a.m. in the Emergency Department (ED) showed numerous patients with cardiac monitors, viewed on the central monitoring station in the ED. There was no one observed specifically watching the monitors.

Observations in the ED on 2/8/2022 at 3:15 p.m. revealed the presence of a dedicated monitor tech who was watching monitors in addition to providing clerical duties. The monitor technician (tech) was seen sitting in front of two computers he was facing for order entry and other clerical duties as well as answering the phone. The cardiac monitors were mounted approximately 7 feet from the floor at a right angle to where the monitor tech sat. The monitor tech was seen standing up and turning position to view the cardiac monitors.

Patient #4 was a 53-year-old male admitted on 12/9/2021 at 10:31 a.m. to the ED for a blood transfusion. Patient #4 had diagnoses of end-stage renal disease (ESRD) (hemodialysis dependent), anemia, and Type II myocardial infarction. The patient was holding in the ED for availability of an inpatient bed. Continuous cardiac monitoring was ordered on 12/9/2021 at 6:46 p.m. There was no documentation of cardiac monitoring in the clinical record until the patient was found unresponsive by his family on 12/10/2021 at approximately 7:00 a.m. when the nurse hooked up the monitor and ran a rhythm strip showing ventricular fibrillation.

The facility's investigation information related to the incident stated:
The night of 12/9/2021 staffing in the Emergency Department included a Charge RN, two staff nurses and a tech/secretary. Nursing leadership was able to meet the ED staffing matrix by obtaining one travel nurse on overtime who was able to come and work at 11:00 p.m. to 5:00 a.m., 12/10/2021 and an additional nurse was able to cover the hours from 5:00 a.m. to 7:00 a.m. There was one environmental service worker that was cleaning discharge beds on other units leaving the ED nursing staff responsible to clean rooms after discharges. At the time of the event there were 18 patients in the ED. Thirteen of the 18 patients were holding for inpatient beds with three to four waiting for Intensive Care Unit (ICU) beds. The ED nurses had to care for the 13 holding patients, that included three or four patients with critical care needs, in addition to patients presenting to the ED. The ED nurses had to care for the 13 holding patients, that included three or four patients with critical care needs, in addition to patients presenting to the ED. The nurse assigned to Patient #4 transferred one of the holding patients to the floor around 5:50 a.m. The nurse then transported another patient to the floor. Upon return to the ED, the nurse then cleaned the treatment room and brought another critical patient into the treatment room from the lobby. These activities diverted much time from the nurse's monitoring of Patient #4.

According to facility operations during 12-9-2021 the facility was on Status Red (A state process where EMS will not send the facility patients until the Code Red is resolved) and a Code Purple (A facility process that is enacted during Code Red scenarios when the facility implements "all hands on deck" until Code Red is resolved) was called. This necessitated an increased focus on staffing levels during that time.

Review of the policy, "Organization-wide Flow of Patients, Code Purple effective 2/11/2015, revised 3/3/2020 defined Code Purple as "a hospital wide alert implemented when capacity is restricted due to hospital throughput issues. The policy states the same level of care will be provided regardless of hold status or location in the organization."

During an interview on 1/3/2022 at 10:25 a.m. with the Clinical Coordinator of the ED, she stated that the staffing for the ED is based on the numbers of ED patients seen. She said that there is no additional staff provided for patients holding for inpatient admission. She said seven patients were holding in the ED at the time, and that two of the med/surg (medical/surgical) patients had just been given bed assignments.

During an interview on 1/3/2022 at 10:55 a.m., the Director of Risk Management and Patient Safety stated there is no assigned monitor tech in the ED, that the Charge Nurse watches the monitors.

During an interview 1/3/2022 at approximately 12:00 p.m. with ED Director and the Executive Director of Nursing Services, the ED Director stated that telemetry strips are not placed in the ED chart or for holding patients in the ED. The Executive Director of Nursing Services stated that she agrees the same standard of care should be held for patients holding in the ED for beds as for the patients in the various units on the floor.

There was inadequate supervision of Patient #4 to prevent patient from pulling cardiac leads, resulting in leads being off for an extended period that was not recognized timely by the facility staff. After the family telling the staff that Patient #4 was not responsive, the nursing staff evaluated the patient and found the cardiac leads laying in the bed beside the patient. The nursing staff replaced the cardiac leads and found the patient to be in ventricular fibrillation. A code blue was called and resuscitation was attempted. The patient expired after family elected to discontinue life support.

There was inadequate supervision of Patient #12 to prevent patient from falling and pulling off cardiac leads. During an interview with the ED Director 2/10/2022 around 2:30 p.m., she stated that the record reporting a fall risk score of 4 was correct and is considered high risk for falls and that the tab alarm and 30-minute rounding was not done according to the policy.
Policy review for "Emergency Department Fall Risk Assessment" confirmed this.
On 1/20/2022 around 1:00 p.m. patient was found on the floor with a laceration to the left side of the scalp with bleeding, agonal breathing (gasping for air), cyanosis (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood), in asystole (the cessation of electrical and mechanical activity of the heart). A code blue was called, and resuscitation attempts were unsuccessful. Last documented vital signs 1/20/2022 at 10:06 a.m. Heart rate - 76 [beats per minute], Respiratory rate 26 [breaths per minute], - Blood pressure 132/61 [mm Hg], mean arterial pressure (MAP) 85 mm Hg. SPO2 was 94% on oxygen administered at 14 liters per minute.