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Based on interview and record review, the facility failed to ensure:

1. Registered Nurse (RN) 1 followed the facility's policy and procedures (P/P) by failing to follow the physician's orders for implementing STAT (immediately) continuous cardiac monitoring (CCM, continuous monitoring of the patient's heart rhythm so change in cardiac rhythm [electrical activity of the heart that must work properly for the heart to beat adequately and pump blood around the body] or cardiac arrest [when the heart stops beating suddenly] can be recognized immediately). (refer to A-398)

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure Registered Nurse (RN) 1 followed the facility's policy and procedures (P/P) by failing to follow the physician's orders for implementing STAT (immediately) continuous cardiac monitoring (CCM, continuous monitoring of the patient's heart rhythm with a small portable electronic device so change in cardiac rhythm [electrical activity of the heart that must work properly for the heart to beat adequately and pump blood around the body] or cardiac arrest [when the heart stops beating suddenly] can be recognized immediately), for one sampled patient (Patient 1).

This deficient practice delayed the identification of Patient 1's cardiac arrest, resulting in Patient 1's death.

On 2/24/2022, at 3:22 pm, the facility was notified that an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation was identified regarding the facility's failure to follow the facility's policy and procedures for following physician's orders when the nurse assigned (RN 1) to Patient 1 did not implement CCM on Patient 1 on 2/8/2022, which resulted in Patient 3's death. The Assistant Medical Center Administrator - Quality Operations (A-QO), Chief Nurse Executive (CNE), Sr. Vice President, Area Manager (Sr.VP-AM), Chief Operating Officer (COO), and Area Medical Director, Chief of Staff (AMD-CS) were present during the notification of the IJ situation.

On 2/25/2022, at 1:03 pm, the IJ situation was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyors verified and confirmed the implementations of the IJ Removal Plan while onsite by observation, interview, and limited record review. The IJ was removed in the presence of A-QO, CNE, Sr.VP-AM, COO, AMD-CS, the Regional Director Accreditation and Licensing (RD-AL), and the Assistant Medical Group Administrator of Surgical Services (AMGA-SS).

The acceptable IJ Removal Plan were as follows:

1. The facility developed and implemented standardized operating procedure (SOP, step-by-step instructions) for CCM on 2/11/2022. SOP includes expectations on communication from nursing to monitor technicians and adherence to policy SC.PCS.010 (cardiac monitoring for adults).

2. The charge nurses (a nurse in charge of a hospital ward) or designee (a person selected to carry out a role) in all units with CCM will review every patient admitted on CCM for compliance of SOP and policy SC.PCS.010 once a shift. This review will be completed with the monitor technician (provides care and monitor patients for their cardiac rhythms) on duty. Validation of the review is documented on CCM Audit Log which was implemented on 2/11/2022.

3. Education of the SOP and policy SC.PCS.010 with all RNs assigned units capable of telemonitoring (monitoring of the patient at a distance) began on 2/11/2022. Only RNs who have received training and attested to education will be assigned to patients with orders for CCM. All RNs on initial hire and contracted RNs will receive training during the onboarding process and ongoing as needed (i.e., if monitoring equipment is upgraded or replaced).

Findings:

During a review of Patient 1's History and Physical (H&P), dated 2/8/2022, the H&P indicated Patient 1 was recently admitted to the facility from 2/2/2022 to 2/6/2022 for exacerbation of congestive heart failure (serious condition in which the heart does not pump blood as efficiently as it should) requiring diuresis (removing extra fluid from the body). Patient 1 diagnoses included the presence of an automatic implantable cardioverter defibrillator (A battery-powered device placed under the skin that keeps track of heart rate. If an abnormal heart rhythm is detected the device will deliver an electric shock to restore a normal heartbeat if your heart is beating chaotically and too fast), and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The H&P indicated Patient 1 reported shortness of breath (difficulty breathing) on the most recent admission on 2/8/2022.

During a review of the Order Review (physician's orders), dated 2/8/2022, the physician's order, time at 8:19 am, indicated Patient 1 was to have STAT (immediate) CCM.

During an interview on 2/22/2022, at 3:08 pm, with Telemetry Manager (TM), TM stated Patient 1 was not monitored for CCM when Patient 1 was admitted to the Medical-Surgical Telemetry Unit (MTU, units where patients are under constant electronic monitoring) on 2/8/2022 (at approximately 8:00 am). TM stated Patient 1 was not monitored for CCM as ordered by the physician (on 2/8/22, at 8:19 am) because Patient 1's assigned nurse (RN 1) did not contact the Central Monitoring Station (CMS, the station outside of the MTU that monitors all patients for their cardiac rhythms) when Patient 1 was admitted to the MTU on 2/8/2022. TM stated the MTU's process for admitting patients who were on CCM was for the assigned RN to contact the CMS to start CCM. TM stated the RN must also confirm with the CMS that the patient's cardiac rhythm was seen and monitored at the CMS. TM stated the CMS's staff are assigned to monitor all patients who are on cardiac monitoring for their cardiac rhythms. TM stated the CMS would communicate any cardiac alarms (abnormal changes to the patient's cardiac rhythm) to the nurses on the MTU. TM stated RN 1 did not print an initial cardiac rhythm strip for Patient 1 when he was admitted to the MTU but should have. TM stated the initial cardiac rhythm strip (a printout of the patients cardiac rhythm) confirms what cardiac rhythm the patient is experiencing.

During a phone interview on 2/24/2022, at 10:20 am, with RN 2, RN 2 stated RN 1 had asked him to cover for Patient 1 so that RN 1 could attend to Patient 31 on 2/8/2022 at around 1:10 pm. RN 2 stated he did not recall if Patient 1 was on any type of cardiac monitoring, including CCM. RN2 stated RN3 was then asked to cover for Patient 1 during RN2's lunch break on 2/8/2022 at around 2:20 pm.

During an interview on 2/23/2022, at 12:40 pm, with RN 3, RN 3 stated she received handoff report (to convey essential patient care information) for Patient 1 from RN 2 on 2/8/2022 at around 2:30 pm. RN 3 stated Patient 1 was found unresponsive during her nurse assessment at around 2:30 pm on 2/8/2022. RN 3 stated she called the CMS monitor technician to review Patient 1's cardiac rhythm strip but was told that there was none recorded for Patient 1. RN 3 stated that if there are no cardiac rhythm strips recorded, Patient 1 could not have been on CCM. RN 3 stated the alarms (cardiac alarms for when the patient's cardiac rhythm changes) should have been alarming prior her finding Patient 1 unresponsive since the patient was likely in cardiac arrest. RN 3 stated Patient 1's cardiac alarms were not alarming when she found Patient 1 unresponsive.

During an interview on 2/24/2022, at 8:33 am, with the Director of Nurse Operations (DNO), DNO stated Patient 1 was "not connected" to the CMS. The DNO stated Patient 1 was not continuously monitored for cardiac rhythm as ordered by the physician. The DNO could not verbalize if RN 1's failure to follow the physician's order for CCM resulted in the delay of the identification Patient 1's cardiac arrest.

During an interview on 2/24/2022, at 10:37 am, with TM, TM stated there was no copy of Patient 1's cardiac rhythm available for review to determine Patient 1's actual time of cardiac arrest (which occurred on 2/8/2022) because Patient 1 was not being continuously monitored for cardiac rhythm.

During a phone interview on 2/24/2022, at 2:28 pm, with Monitor Tech 1, Monitor Tech 1 stated she was the technician assigned at the CMS to monitor all the patients (who were on CCM) for their cardiac rhythms. Monitor Tech 1 stated she was assigned to the CMS on 2/8/2022. Monitor Tech 1 stated she called the MTU after she was notified of Patient 1's code blue (hospital emergency code used to describe the critical status of a patient) (on 2/8/2022 at 2:30 pm). Monitor Tech 1 stated Patient 1 was not monitored for cardiac rhythm by the CMS. Monitor Tech 1 stated the process for ensuring that a patient is monitored from the CMS was for nursing staff to contact the CMS for new admissions with physician's orders for CCM. Monitor Tech 1 stated she was not notified that Patient 1 was admitted to the MTU on 2/8/2022 with physician's orders for CCM.

During a review of the Multi-Disciplinary Progress Note, dated 2/8/2022, the progress note indicated, on 2/8/2022, at 2:30 pm, Patient 1 was found unresponsive and pulseless. The progress note indicated code blue and cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure aiming to keep blood and oxygen flowing through the body when a person's heart or breathing stops) was initiated.

During a review of CPR Record, dated 2/8/2022, the CPR record indicated Patient 1 expired, and the code blue ended on 2/8/2022 at 2:41 pm.

During a review of the policy Cardiac Monitoring (Adult), revised 12/17/2018, the policy indicated the definition of cardiac telemetry monitoring (monitoring of heart electrical activity) is an intervention to continuously monitor the cardiac rhythm and any associated changes in rate and/or characteristics. Cardiac Telemetry monitoring is utilized throughout multiple patient care units with 24-hour visualization by competent healthcare personnel. A physician order is required for telemetry monitoring/cardiac monitoring and discontinuation. Monitor strips will be printed when: a patient is placed on monitor (initial strip).