HospitalInspections.org

Based on a review of the Governing Body bylaws, medical records, staff interviews, policies and procedures, flow sheets, facility documentation, and the facility's incident report log, the facility failed to ensure that staff was updated on their roles and responsibilities related to troubleshooting malfunctions within the telemetry unit. The governing body also failed to ensure that outdated procedures were removed from the telemetry monitoring policy.

Findings:
A review of the facility's governing body bylaws revealed that all authority and responsibility concerning the affairs of the corporation shall be vested in a governing board, which is hereby referred to as the "Board of Directors". The board of directors shall have supervision, control, and direction of the management, affairs, and property of the corporation; shall determine the policies of the corporation and any changes thereto; shall actively prosecute the corporation's purposes and objectives; shall supervise the disbursement of its fund.

A review of Patient (P), P#1 medical record revealed that P#1 was airlifted to the facility and presented at the Emergency Department (ED) on 6/23/21 at 7:31 p.m. P#1 was brought to the ED after he had fallen out of the chair. P#1 had right-sided weakness. P#1 was alert, responsive but inappropriately answering questions. Further review of the medical record revealed that P#1 said he was not aware of where he was, could not recall his name or recognize his right hand. P#1 was admitted to the facility's ED with a diagnosis of a cerebrovascular accident (the medical term for a stroke) on 6/23/21 at 8:06 p.m. P#1 National Institutes of Health (NIH) stroke scale assessment (tool that was built to assess the cognitive effects of a stroke) score was 9 (moderate stroke symptoms = 5 to 15).

On 6/23/21 at 8:09 p.m., P#1's Computed Tomography (CT) scan of the head (medical imaging technique that produces images) revealed there were concerns for brain ischemia.

Medical Doctor (MD) EE orders on 6/23/21 at 8:21 p.m. included but not limited to:
1. Inpatient admission to the facility's neurology floor (3N).
2. Stroke (when the blood supply to part of your brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes) work-up.
3. Neurology checks every four hours (Q4).
4. Telemetry (a way to monitor a person's vital signs remotely), ECG (electrocardiography test to check heart rhythms), troponin levels (increase when the heart becomes/maybe damaged).
5. Medication (aspirin -prevent clots in blood vessels), atorvastatin (help to lower fat level in blood)


On 6/24/21 at 12:05 a.m., P#1 troponin level was 1.416 nanograms per milliliter (ng/ml) (normal value 0.00 -0.04 ng/ml). Bedside echocardiogram and ECG performed on P#1 revealed sinus tachycardia (heart beating too fast), there were no acute ischemic changes (sudden insufficient blood getting to the heart). P#1 heart chambers were not dilated (become wider).

A review of a progress note revealed the Registered Nurse (RN) AA documented on 6/24/21 at 12:35 a.m., P#1 was admitted to the unit (3N) from the ED. P#1 was drowsy, confused, and unable to answer admission questions. RN AA noted that P#1 was holding his right arm in a flexed position and weakness was noted on his right upper and lower extremity. RN AA documented she was unable to place P#1 on telemetry because the only remaining telemetry box on the unit was not functioning properly and there were no other available telemetry boxes on the unit. RN AA noted she was unable to borrow from other units. RN AA further documented that on 6/24/21 at 1:00 a.m. she attempted to return the telemetry boxes to the telemetry suite for troubleshooting. RN AA noted that the facility staff at the telemetry suite stated they do not receive telemetry boxes for troubleshooting. RN documented that the biomedical department was also contacted, and the biomedical department said they do not receive telemetry boxes for troubleshooting either. RN AA noted she notified MD EE that P#1 was not on a telemetry monitor. RN AA documented that she called the telemetry suite for a second time and explained to the telemetry staff that the facility's nursing staff were instructed to contact the telemetry suite whenever they had issues with troubleshooting a telemetry box.

On 6/24/21 at 2:06 a.m. MD II was consulted due to concerns P#1's troponin level was elevated.

On 6/24/21 at 6:20 a.m. RN AA documented the telemetry suite supervisor called her unit and instructed staff to bring the telemetry box down to the telemetry unit for troubleshooting. RN AA noted at 6:40 a.m. the staff arrived back on the unit with a telemetry box. RN AA documented she went to P#1's room to apply the telemetry box and discovered P#1 was not talking. P#1 had no pulse and was unresponsive. RN AA documented she notified the charge nurse who called the code blue (emergency code for patient unresponsive) and she started chest compressions on P#1.

A review of the facility's "Adult Code Blue Flowsheet" revealed that P#1 suffered a cardiopulmonary arrest, on 6/24/21 at 6:40 a.m. chest compression began. P#1 was intubated at 6:45 a.m. and defibrillated at 6:55 a.m. A return to circulation was achieved and the resuscitation (bring back to life) event ended at 7:02 a.m. P#1 was transferred to the Neurology Intensive Care Unit (ICU) (3W) at 7:05 a.m.
Further review of the progress note revealed the registered nurse documented that P#1 suddenly experienced a drop-in blood pressure and his heart rate was low at the Neurology ICU. P#1 suffered another cardiopulmonary arrest and chest compression began at 11:30 a.m. however P#1's family declined to continue with the resuscitation process. The RN noted that P#1 expired on 6/24/21 at 11:38 a.m.

A review of the facility's "Death certificate data sheet" revealed P#1 expired on 6/24/21 at 11:38 a.m. due to cardiac arrest (abrupt loss of heart function, breathing, and consciousness) and acute hypoxic respiratory failure (when not enough oxygen passes from the lungs to the blood).

An interview with the Registered Nurse (RN) AA took place on 7/1/21 at 8:30 a.m. in the conference room. RN AA explained that she was familiar with P#1 and recalled the incident that occurred with the patient. RN AA stated there was an order by the physician for continuous telemetry monitoring of P#1. RN AA explained that she was not able to initiate the order because the telemetry box did not work when she tried to put it on P#1. RN AA said she contacted the telemetry department and asked the telemetry tech (TT) FF if she got a reading for P#1 on the monitor, but the tech could not get a reading. RN AA stated she explained to TT FF the telemetry box was not working and that was the last remaining transmitter on the unit. RN AA further explained she asked TT FF if she could help her troubleshoot the transmitter. RN AA said TT FF stated the telemetry suite does not troubleshoot transmitters. RN AA explained that TT FF said RN AA should call the biomedical department or request a transmitters from another unit at the hospital. RN AA said the unit clerk contacted the biomedical department and the biomedical department stated they do not troubleshoot transmitters. RN AA explained they contacted several other units (4W,5W) and none of the units had an available transmitter. RN AA said she contacted the telemetry department a second time and tried to explain that unit (3N) was instructed to contact the telemetry department whenever they had an issue with troubleshooting a telemetry transmitter. RN AA explained that TT FF said the telemetry department does not troubleshoot telemetry transmitters and TT FF did not offer to replace the transmitter. RN AA stated she notified MD EE and kept him posted about her effort to get P#1 on a telemetry monitor. RN AA said around 6:20 a.m. the telemetry department called her unit (3N) and told the clerk to bring the telemetry transmitter for troubleshooting. RN AA said the clerk took the transmitter (box) to the telemetry department and brought back the same telemetry box after troubleshooting around 6:40 a.m. RN AA explained that she got the telemetry transmitter and went to put it on P#1. RN AA said when she arrived at P#1's room, P#1 was not saying anything and he was pulseless. RN AA said she immediately went to the doorway told the charge nurse that P#1 was not breathing and started CPR on the patient. RN AA said a code blue was called and the code team arrived. RN AA explained that after some rounds of CPR they found a pulse around P#1's groin and P#1 was transferred to the intensive care unit (ICU) (3W).

During an interview with the Telemetry Technologist (TT) FF on 7/1/21 at 9:00 a.m. in the facility conference room, TT FF stated she had worked at the facility for eight months. She revealed her duties were to monitor the patient's heart rhythms and pulse oximetry readings. She added she would relay patient information to the nursing staff when she observed a problem on the monitor. TT FF stated she assisted nursing staff with the telemetry boxes when troubleshooting was required. TT FF said nursing staff could also bring the telemetry boxes to the telemetry suite for troubleshooting. She explained that if a telemetry box was not working on the floor, unit staff could contact other floors/units to ask if they had a telemetry box they could use. TT FF revealed that if a telemetry box could not be located for a patient on another floor/unit, three extra telemetry boxes were kept in the telemetry suite.
She stated that less than two months ago, a new facility change required telemetry boxes to be stored on patient floors/units instead of in the telemetry suite. As a result, nursing staff would replace batteries when the monitors showed that the telemetry box battery was low. The telemetry suite could also monitor the battery status and notify the nurse if needed

TT FF stated she remembered P#1. She revealed that RN AA called and informed her of P#1's name, room number, and telemetry box number around 2:30 a.m. RN AA had attached the telemetry monitor for P#1 and entered the medical record number. TT AA said she did not see a heart rhythm on the monitor for P#1 and, shortly after that called and followed up with RN AA. She explained she called RN AA back to ask why she was not picking P#1 up on the monitor. She stated that RN AA said she would enter the medical record number for P#1 then attach him to the monitor. She called RN AA again later to question why P#1's information was still not showing on the monitor. TT FF stated that RN AA indicated she would put him on the monitor, but she had not placed P#1 on telemetry yet. TT FF stated that around 4:00 a.m., she contacted RN BB on the floor/unit to ask why P#1 was still not on the monitor. RN BB stated that RN AA stated she was having problems with the telemetry box, and RN AA would try to resolve the issue. TT FF said she informed RN AA that they could troubleshoot the problem over the phone, and the nursing staff could get another box from a different floor/unit if needed. TT FF revealed she did not recall either RN AA or RN BB mentioning that they were not able to locate an extra telemetry box. She stated that the Telemetry Assistant Manager (AM) DD was informed of the situation when she came into work the morning of 6/24/21. AM DD called and spoke to the Unit Clerk (UC) GG and asked that the telemetry transmitter be brought to the telemetry suite for troubleshooting. The telemetry transmitter was fixed within five to ten minutes and returned to UC GG. TT FF confirmed she documented the conversations between herself, RN AA, and RN BB on the Nursing Assignment Sheet located in the telemetry suite.

During an interview with Physician (MD) EE and Chief Medical Officer (CMO) MM on 7/1/21 at 10:10 a.m. in the facility conference room, MD EE confirmed he provided care to Pt.#1 and ordered the telemetry for Pt#1. Additionally, he ordered a consult with cardiology because P#1's Troponin levels (cardiac-specific levels in the blood to help detect heart injury) were elevated. CMO MM revealed that telemetry orders were a standard protocol for a stroke patient to rule out atrial fibrillation (an irregular and often rapid heart rate) as the cause of the stroke. MD EE stated that an echocardiogram (an ultrasound of the heart muscle and valves) was ordered and performed on P#1. MD EE confirmed P#1's nurse contacted him to inform him that she could not initiate telemetry because there were no telemetry boxes available. When asked what measures had been put in place to monitor the patient since telemetry was not available, MD EE stated he consulted Cardiology. MD EE stated he was not aware if cardiology had been contacted when P#1 was not placed on telemetry. CMO MM stated that in his medical opinion, it would have been beneficial to have P#1 on telemetry to monitor his heart.

An interview with Nurse Manager (NM) JJ and Charge Nurse (CN) CC was conducted on 7/1/21 at 11:09 a.m. NM JJ explained she was briefed on the incident surrounding P#1 in the morning when she arrived to work. NM JJ said she was not present when the incident occurred. NM JJ and CN CC said they worked on the day shift and the incident occurred during the night shift. NM JJ acknowledged CN BB was on a vacation and couldn't be reached for an interview during the survey. NM JJ stated she was informed the biggest concern when the incident occurred was that P#1 needed to be monitored on telemetry and the nurse had trouble placing P#1 on telemetry. P#1 suffered cardiopulmonary arrest, was unresponsive before they could place the telemetry box on him and P#1 was transferred to the ICU. NM JJ explained the nurse attempted to borrow from other units but was not successful. NM JJ said if they had no transmitter on their unit her expectation was for staff to call other units and try to get a telemetry transmitter for the patient. NM JJ further explained that she expected the physician and telemetry suite to be notified. NM JJ explained that the telemetry suite is expected to guide the nursing staff on how to troubleshoot a transmitter. NM JJ said if the telemetry department could not troubleshoot the transmitter then it is placed in a bag, labeled, and taken to the biomedical department for replacement. NM JJ acknowledged there had been incidents in the past they did not have enough boxes for patients on the unit, but they were able to borrow from other units. NM JJ said it was her understanding that the telemetry department had backup transmitters and the telemetry suite was able to offer a replacement. NM JJ and CN CC acknowledged it was not the standard practice to have left P#1 without being continually monitored per the physician orders. NM JJ acknowledged that a nursing guideline was sent out to the staff on how to troubleshoot the transmitter about a month ago when the facility changed its procedure to start putting transmitters on the units.

An interview with Medical Doctor (MD) II and Chief Medical Officer (CMO) MM commenced on 7/1/21 at 11:33 a.m. in the conference room. MD II explained that he was in his third (3) year fellowship program in Cardiology. MD II acknowledged he was consulted by the neurology team for P#1's elevated troponin level. MD II said he remembered seeing P#1 at the unit (3N) around 1:00 a.m. MD II said when he saw P#1 he did not remember seeing telemetry on the patient. MD II explained he did not order the telemetry, he further explained the other physician (MD EE) ordered the telemetry. MD II explained he was only consulted to the unit on an as-needed basis. MD II said he ordered a bedside echocardiogram for P#1 when he was consulted. MD II explained that if P#1 had been his patient and he was notified by the nurse that she could not get a transmitter for the patient, he would have called the telemetry suite to investigate further. MD II explained he was on the unit when the nurse activated the code. MD II said he was the first physician to arrive and chest compression had already started, he said it appeared there was a telemetry transmitter sitting next to the patient around 6:40 a.m. MD II stated he did not know if it was the standard practice for the facility to have waited for a long time before getting a transmitter for P#1. CMO MM explained the facility eventually brought a transmitter for P#1. CMO MM explained that when the physician had given his order it was the responsibility of the nursing staff to follow through.

During an interview with the Assistant Nurse Manager for Inpatient Cardiology Telemetry, (AM) DD on 7/1/21 at 2:45 p.m. in the facility conference room, she confirmed she remembered P#1. She recalled that she arrived to work at 6:30 a.m. on 6/24/21. The telemetry tech (TT) FF informed her there had been multiple issues that concerned communication throughout the night with RN AA. TT FF told her that P#1 should have been on telemetry; however, there was no reading on the monitor. AM DD asked TT FF if the telemetry box had been through troubleshooting, and TT FF replied that it had not. AM DD stated she contacted the RN AA to bring the telemetry box to the telemetry suite for service. She confirmed that UC GG brought the telemetry box to the telemetry suite, and UC GG returned it for P#1. AM DD stated that P#1 became unresponsive before telemetry was established for P#1. AM DD indicated that she would give them a working box from the telemetry suite if a telemetry box were not working. AM DD stated that telemetry boxes with problems should be troubleshot by the Telemetry Suite soon as possible. AM DD explained that if a telemetry box was not functioning correctly, the telemetry suite staff should troubleshoot the box over the phone with the floor/unit staff. If that was not successful, the floor/unit staff could bring the transmitter to the telemetry suite, or the telemetry suite staff could go to the floor/unit to troubleshoot the box. Additionally, staff could also call other floors/units to locate an extra box. If a telemetry box continued to malfunction or another box could not be located, the telemetry suite could give another box to a patient. The technician would then contact AM DD via text or phone call. AM DD acknowledged it was the responsibility of the telemetry suite to troubleshoot the telemetry boxes when called or informed of a problem by the floor/unit staff. The telemetry suite staff are trained to respond to the patient's floor to troubleshoot a telemetry issue if needed. AM DD confirmed there were three extra telemetry boxes in the telemetry suite as backups, three telemetry boxes in the Supervisor Suite, and additional telemetry boxes kept by the House Supervisor. Per AM DD, the telemetry suite staff did not have to contact her first to assign one of the extra telemetry boxes. Staff had permission to assign a telemetry box to a patient and inform her afterward. AM DD further revealed she had never been aware of any other medical incident when a telemetry box was unavailable for a patient. However, she confirmed that there had been instances when there were not enough telemetry boxes for patients. If the staff could not locate another telemetry box, they would have to call other units to find one. In addition, the staff had to acquire a doctor's order to remove the telemetry from a patient with a lesser need for telemetry monitoring to give it to a patient with a greater need for monitoring. AM DD explained that they had placed orders in the past to order additional boxes from their supplier. AM DD confirmed the facility put in a new hospital-wide process for telemetry boxes. As of 6/1/21 the telemetry boxes were housed on patient floors and were no longer being stored in the telemetry suite. The purpose behind the new process was to improve the efficiency of providing a telemetry box to a patient. The change keeps floor staff from going to the telemetry suite to sign a telemetry box out. In addition, the telemetry suite was responsible for troubleshooting the telemetry boxes before the hospital initiated the new process.

A telephone interview with Clerk (C) GG took place on 7/1/21 at 3:36 p.m. in the conference room. C GG explained she had worked at the facility for twenty-eight (28) years. C GG she was not on the unit when the incident started but when she arrived the nursing staff told her they needed a telemetry transmitter for P#1. C GG explained that she called two units at the hospital but was not able to get a transmitter for P#1. C GG said she contacted the telemetry department for troubleshooting, and was told they do not troubleshoot transmitters and the department did not offer a replacement. C GG explained there had been a time they had no transmitter on the unit, but they were able to borrow from other places. C GG said she was finally able to take the transmitter to the telemetry department for troubleshooting, she said when she returned to the unit she handed the transmitter to the nurse however, at that time the charge nurse had activated a code blue for P#1.

An interview was conducted with the Director of Biomedical department (DB) HH on 7/1/21 at 4:08 p.m. DB HH explained their job responsibility included inspection and maintenance of all patient equipment except radiological equipment. DB HH explained they often go to the hospital units to inspect telemetry transmitters but there are no annual maintenance done on them. DB HH explained when a transmitter needed repair, they would send it to the manufacturer for replacement. DB HH explained the department is open during the day, but they have biomedical techs on call that will come in at night if the need arises. DB HH explained that minor troubleshooting issues are done by the telemetry department but if the telemetry department cannot fix the transmitter it will be sent to the biomedical department. DB HH explained the biomedical department would rather replace and not repair a telemetry box.

An interview took place with Director Clinical Excellence (DC) KK on 7/1/21 at 4:30 p.m. in the conference room. DC KK explained she was aware of the incident with P#1. DC KK stated the facility scheduled a root cause analysis (RCA) on the event, but it had not been completed. DC KK stated the facility tries to complete an RCA as close as an event occurs and not more than two to three months from the incident. DC KK explained the RCA process obtained information from the staff involved in the incident, interview staff, compile information, identify the root cause event, and find opportunities for improvement and make action plans. DC KK said they reported their findings from an RCA to the facility's quality board as well as governing body and it will be discussed in their minute meetings. DC KK explained the regulatory department had been able to get some statements from the staff involved in P#1's incident. DC KK said from her understanding the facility knew there was human error involved and they had started coaching staff working at the telemetry department. DC KK explained the facility recently made a process change to get the telemetry transmitter to the patient as soon as possible and the facility was in the process of revising the policies. DC KK explained previously the unit staff had to go to the telemetry department to pick up a transmitter whenever they needed it however, with the new process they had put the transmitters on each unit to get the transmitter close to the patient as fast as possible. DC KK explained that quality checks and failure effect mood analysis are carried out on the telemetry transmitters related to troubleshooting around the leads and batteries.

During a follow-up interview with Assistant Nurse Manager for Inpatient Cardiology Telemetry (AM) DD, on 7/2/21 at 11:00 a.m. in the facility conference room, AM DD stated there was not a current procedure or book/log that the telemetry suite tech would use to document a conversation between a nurse and a telemetry technician regarding establishing a patient on telemetry. Documentation only began when a patient showed a baseline rhythm or pulse oximetry reading on the telemetry monitor. AM DD stated the Nursing Assignment sheet, used by the telemetry suite, confirmed which patients a telemetry technician would monitor during the shift they worked. She further confirmed that P#1 did not have continuous telemetry monitoring after leaving the emergency department until he was found unresponsive on 6/24/21.

A review of the facility's document titled "Medical Equipment Management Plan" revealed that there was no preventive maintenance to be performed on a telemetry transmitter.

A review of the facility's policy number 233 titled "Telemetry Monitoring Policy" last reviewed on 7/28/2020 revealed the purpose of the policy is to provide a uniform, consistent method of monitoring the patient's heart rhythm and/or oxygen saturation, to detect life-threatening and/or lethal dysrhythmias/desaturations on monitored patients.
Telemetry Monitoring: A patient telemetry monitoring unit records the electrical activity (ECG) of the heart and pulse oximetry. The purpose of telemetry monitoring is to detect significant and life-threatening variations in a patient's cardiac rhythm to facilitate early therapeutic intervention(s). The patient telemetry monitoring transmitter sends the data to a local monitoring station at the nurse's station (referred to as the Client) and a centralized monitoring station located in the telemetry suite.
Telemetry Transmitter: Device used to transmit data from the patient to centralized monitors at the nurse station and telemetry suite.
I. Adult Hospital Guidelines
A. Obtain a physician order for continuous telemetry monitoring. If a patient's condition warrants, the Registered Nurse (RN) may initiate telemetry monitoring until a physician (MD) order is obtained within 24 hours.
1. A physician must evaluate the continued need for telemetry monitoring every 24 hours.

B. Call Extension number to notify the Telemetry Monitor Technician in the telemetry suite the patient has orders for telemetry monitoring.
1. The Telemetry technician will set up the telemetry transmitter with new batteries and monitoring cables for ECG and/or pulse oximetry (ox) (if ordered).
2. The Telemetry technician will log the telemetry transmitter number and pulse oximetry cable number.
3. The RN or designee picking up the telemetry transmitter brings a label with the patient information.
a. Using the patient label, the following information is entered on each patient by the Monitor technician at the centralized telemetry monitors:
1. First and last name
2. Date of birth
3. Medical Record Number (MRN)
4. Room number
b. The telemetry transmitter is then "synched" to the PicIx by the telemetry technician before leaving the telemetry suite.

C. The patient is placed on a telemetry transmitter by the nurse caring for the patient or designated
the staff member on the unit utilizing two (2) patient identifiers with the order.
1. The patient/family is given a brief explanation of the telemetry transmitter and its purpose.
2. Skin Preparation is be done to promote better adhesion of electrodes:
D. Once the patient is placed on the telemetry transmitter, verification of the patient's waveforms must be completed by the RN at the unit's centralized monitoring system utilizing the instructions below:
1. To place a patient on the client monitor with the mouse go to an empty sector.
a. Click on "Manage Patient"
b. Then Click on "Overview"
c. Click on "Telemetry" then "Room Number" where the patient is located.
d. The equipment number will automatically pop up- Click "OK".
2. Once completing all steps, the patient's rhythm and/or pulse oximetry can be viewed in the assigned sector on the Client monitor.
E. If equipment malfunction occurs, the Telemetry transmitter is replaced. The Telemetry Monitor Technician Contacts Biomedical Engineering for repair.

A review of the facility's policy number 984 titled "Telemetry Suite Scope of Service" last reviewed on 9/10/2020 revealed that the purpose of the telemetry suite is to meet the mission of the facility in providing excellence in the care of the whole person (body, mind, and soul) and to provide services to acutely/chronically ill patients regardless of their social, economic, and religious backgrounds.
SERVICES PROVIDED
1. Telemetry monitoring.
2. Pulse oximetry monitoring
Treatments, Interventions, and Activities Provided
1. Ensures telemetry monitor and/or pulse oximetry cable are prepared for pick-up by unit staff.
2. Notify Nurses when a patient has a change in their telemetry
3. Notify the floor when the battery needs replacing
4. Initiate a code blue or the rapid response team if the patient's condition warrants.
A review of the facility's policy number 384 titled "Patient Rights and Responsibilities Policy" last reviewed on 8/2/2018 revealed that the hospital is committed to providing safe, quality medical care to every patient. It is our policy to respect the individuality and dignity of every patient. The hospital supports the patient's right to know about their medical condition and the right to participate in the decisions that affect their well-being.
As a patient, or when appropriate, the patient's representative as allowed by law, you have the following rights:
1. Safe Care
A. To expect reasonable continuity of care when appropriate and to be informed of available and realistic patient care options when care at our facility is no longer appropriate.
C. To receive care in a safe environment while maintaining your privacy.
D. To appropriate assessment and management of your symptoms, including pain.

2. Information
A. To be informed of the nature of your illness and treatment options, including potential risks, benefits, alternatives, and outcomes in terms you can understand.

A review of the facility's policy number 3299 titled "Nursing Documentation Policy" last reviewed 11/14/2019 revealed the nursing care documentation guidelines will be adhered to ensure care is provided to and documented for each patient based on a nursing assessment. The documentation of assessment, plan, intervention and patient response shall occur as close to the real-time of occurrence as possible. The goal of the assessment is to determine the care, treatment, and services that will meet the patient's initial and continuing needs.

Reassessment
A. Each patient is reassessed as necessary based on the plan of care or changes in condition.
B. Reassessment may also be based on the patient's diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; discharge planning needs; and/or setting requirements.
C. Reassessment of the patient shall be performed at regular intervals in the course of care
by nursing staff.
D. Reassessments are performed to determine a patient's response to care/treatment.
E. Reassessment shall take place when there is a significant change in a patient's condition or a change in diagnosis.
F. Patients will be reassessed by a registered nurse at least every shift to document changes in the patient's condition, and/or diagnosis, and to determine the patient's response to intervention.
G. Nursing reassessment of a patient will reflect at a minimum:
I. A review of the patient's specific data
ii. Pertinent changes
iii. Responses to intervention
iv. Appropriate frequency for the patient population and/or individual patient need
v. Assessments and reassessments are documented in the electronic health record and appropriate paper records are utilized for documentation during downtime. Other facility documentation.

A review of the facility's document titled "Telemetry Report Sheet" dated 6/24/21 revealed the facility failed to log P#1's telemetry transmitter number, patient label, or nurse name in the telemetry report sheet.

A review of the facility's document titled "Nursing Notification Sheet" dated 6/24/21 and completed by TT FF failed to reveal any information about P#1's name, P#1's room number, or any communication between the nursing staff and telemetry department.

A review of the facility's incident report log related to equipment malfunctions from 4/5/21

Based on review of the medical record, telemetry report sheets, death certificate data sheet, policies and procedures, and staff interviews, it was determined the facility failed to provide adequate evaluation, supervision, training to the facility staff to meet one of five sampled patients' (P#1) nursing care needs while receiving care at the facility. Specifically, the facility failed to start and continuously monitor Patient #1 (P#1) on telemetry as the physician ordered before P#1 suffered a cardiopulmonary arrest. P#1 expired at the facility on 6/24/21 at 11:38 a.m.

Findings:

A review of Patient (P) #1 medical record revealed that P#1 was airlifted to the facility and presented at the Emergency Department (ED) on 6/23/21 at 7:31 p.m. P#1 was brought to the ED after he had fallen out of the chair. P#1 had a right-sided weakness. P#1 was alert, responsive but inappropriately answering questions. Further review of the medical record revealed that P#1 said he was not aware of where he was, could not recall his name or recognize his right hand. P#1 was admitted to the facility's ED with a diagnosis of a cerebrovascular accident (is the medical term for a stroke) on 6/23/21 at 8:06 p.m. P#1 National Institutes of Health (NIH) stroke scale assessment (widely used tool that was built to assess the cognitive effects of a stroke) score was 9 (moderate stroke symptoms = 5 to 15).

On 6/23/21 at 8:09 p.m. P#1's Computed Tomography (CT) head scan result revealed that there were concerns for brain ischemia.

Medical Doctor (MD) EE orders on 6/23/21 at 8:21 p.m. included but not limited to:
1. Inpatient admission to the facility's neurology floor (3 North-3N).
2. Stroke (when the blood supply to part of your brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes) work-up.
3. Neurology checks every four hours (Q4).
4. Telemetry (a way to monitor a person's vital signs remotely), ECG (check heart rhythms), troponin levels (increase when the heart becomes/maybe damaged).
5. Medication (aspirin (prevent clots in blood vessels), atorvastatin (help to lower fat level in blood)

A review of P#1 progress note revealed the Registered Nurse (RN) AA documented that on 6/24/21 at 12:35 a.m. P#1 was admitted to the unit (3N) from the ED. P#1 was drowsy, confused, and unable to answer admission questions. RN AA noted that P#1 was holding his right arm in a flexed position and weakness was noted on his right upper and lower extremity. RN AA documented she was unable to place P#1 on telemetry because the only remaining telemetry box on the unit was not functioning properly and there were no other available telemetry boxes on the unit. RN AA noted she was unable to borrow from other units. RN AA further documented that on 6/24/21 at 1:00 a.m. she attempted to return the telemetry boxes to the telemetry suite for troubleshooting. RN AA noted that the facility staff at the telemetry suite stated they do not receive telemetry boxes for troubleshooting. RN documented that the biomedical department was also contacted, and the biomedical department said they do not receive telemetry boxes for troubleshooting either. RN AA noted she notified MD EE that P#1 was not on a telemetry monitor. RN AA documented that she called the telemetry suite for a second time and explained to the telemetry staff that the facility's nursing staff were instructed to contact the telemetry suite whenever they had issues with troubleshooting a telemetry box.
On 6/24/21 at 2:06 a.m. MD II was consulted due to concerns P#1's troponin level was elevated.

On 6/24/21 at 6:20 a.m. RN AA documented the telemetry suite supervisor called her unit and instructed staff to bring the telemetry box down to the telemetry unit for troubleshooting. RN AA noted at 6:40 a.m. the staff arrived back on the unit with a telemetry box. RN AA documented she went to P#1's room to apply the telemetry box and discovered P#1 was not talking. P#1 had no pulse and was unresponsive. RN AA documented she notified the charge nurse who called the code blue (emergency code for patient unresponsive) and she started chest compressions on P#1.

A review of the facility's "Adult Code Blue Flowsheet" revealed that P#1 suffered a cardiopulmonary arrest, on 6/24/21 at 6:40 a.m. chest compression began. P#1 was intubated at 6:45 a.m. and defibrillated at 6:55 a.m. A return to circulation was achieved and the resuscitation (bring back to life) event ended at 7:02 a.m. P#1 was transferred to the Neurology Intensive Care Unit (ICU) (3W) at 7:05 a.m.
Further review of the progress note revealed the registered nurse documented that P#1 suddenly experienced a drop-in blood pressure and his heart rate was low at the Neurology ICU. P#1 suffered another cardiopulmonary arrest and chest compression began at 11:30 a.m. however P#1's family declined to continue with the resuscitation process. The RN noted that P#1 expired on 6/24/21 at 11:38 a.m.

A review of the facility's "Death certificate data sheet" revealed P#1 expired on 6/24/21 at 11:38 a.m. due to cardiac arrest (abrupt loss of heart function, breathing, and consciousness) and acute hypoxic respiratory failure (when not enough oxygen passes from the lungs to the blood).


An interview with the Registered Nurse (RN) AA took place on 7/1/21 at 8:30 a.m. in the conference room. RN AA explained that she was familiar with P#1 and recalled the incident that occurred with the patient. RN AA stated there was an order by the physician for continuous telemetry monitoring of P#1. RN AA explained that she was not able to initiate the order because the telemetry box did not work when she tried to put it on P#1. RN AA said she contacted the telemetry department and asked the telemetry tech (TT) FF if she got a reading for P#1 on the monitor, but the tech could not get a reading. RN AA stated she explained to TT FF the telemetry box was not working and that was the last remaining transmitter on the unit. RN AA further explained she asked TT FF if she could help her troubleshoot the transmitter. RN AA said TT FF stated the telemetry suite does not troubleshoot transmitters. RN AA explained that TT FF said RN AA should call the biomedical department or request a transmitters from another unit at the hospital. RN AA said the unit clerk contacted the biomedical department and the biomedical department stated they do not troubleshoot transmitters. RN AA explained they contacted several other units (4W,5W) and none of the units had an available transmitter. RN AA said she contacted the telemetry department a second time and tried to explain that unit (3N) was instructed to contact the telemetry department whenever they had an issue with troubleshooting a telemetry transmitter. RN AA explained that TT FF said the telemetry department does not troubleshoot telemetry transmitters and TT FF did not offer to replace the transmitter. RN AA stated she notified MD EE and kept him posted about her effort to get P#1 on a telemetry monitor. RN AA said around 6:20 a.m. the telemetry department called her unit (3N) and told the clerk to bring the telemetry transmitter for troubleshooting. RN AA said the clerk took the transmitter (box) to the telemetry department and brought back the same telemetry box after troubleshooting around 6:40 a.m. RN AA explained that she got the telemetry transmitter and went to put it on P#1. RN AA said when she arrived at P#1's room, P#1 was not saying anything and he was pulseless. RN AA said she immediately went to the doorway told the charge nurse that P#1 was not breathing and started CPR on the patient. RN AA said a code blue was called and the code team arrived. RN AA explained that after some rounds of CPR they found a pulse around P#1's groin and P#1 was transferred to the intensive care unit (ICU) (3W).

During an interview with the Telemetry Technologist (TT) FF on 7/1/21 at 9:00 a.m. in the facility conference room, TT FF stated she had worked at the facility for eight months. She revealed her duties were to monitor the patient's heart rhythms and pulse oximetry readings. She added she would relay patient information to the nursing staff when she observed a problem on the monitor. TT FF stated she assisted nursing staff with the telemetry boxes when troubleshooting was required. TT FF said nursing staff could also bring the telemetry boxes to the telemetry suite for troubleshooting. She explained that if a telemetry box was not working on the floor, unit staff could contact other floors/units to ask if they had a telemetry box they could use. TT FF revealed that if a telemetry box could not be located for a patient on another floor/unit, three extra telemetry boxes were kept in the telemetry suite.
She stated that less than two months ago, a new facility change required telemetry boxes to be stored on patient floors/units instead of in the telemetry suite. As a result, nursing staff would replace batteries when the monitors showed that the telemetry box battery was low. The telemetry suite could also monitor the battery status and notify the nurse if needed

TT FF stated she remembered P#1. She revealed that RN AA called and informed her of P#1's name, room number, and telemetry box number around 2:30 a.m. RN AA had attached the telemetry monitor for P#1 and entered the medical record number. TT AA said she did not see a heart rhythm on the monitor for P#1 and, shortly after that called and followed up with RN AA. She explained she called RN AA back to ask why she was not picking P#1 up on the monitor. She stated that RN AA said she would enter the medical record number for P#1 then attach him to the monitor. She called RN AA again later to question why P#1's information was still not showing on the monitor. TT FF stated that RN AA indicated she would put him on the monitor, but she had not placed P#1 on telemetry yet. TT FF stated that around 4:00 a.m., she contacted RN BB on the floor/unit to ask why P#1 was still not on the monitor. RN BB stated that RN AA stated she was having problems with the telemetry box, and RN AA would try to resolve the issue. TT FF said she informed RN AA that they could troubleshoot the problem over the phone, and the nursing staff could get another box from a different floor/unit if needed. TT FF revealed she did not recall either RN AA or RN BB mentioning that they were not able to locate an extra telemetry box. She stated that the Telemetry Assistant Manager (AM) DD was informed of the situation when she came into work the morning of 6/24/21. AM DD called and spoke to the Unit Clerk (UC) GG and asked that the telemetry transmitter be brought to the telemetry suite for troubleshooting. The telemetry transmitter was fixed within five to ten minutes and returned to UC GG. TT FF confirmed she documented the conversations between herself, RN AA, and RN BB on the Nursing Assignment Sheet located in the telemetry suite.

During an interview with Physician (MD) EE and Chief Medical Officer (CMO) MM on 7/1/21 at 10:10 a.m. in the facility conference room, MD EE confirmed he provided care to Pt.#1 and ordered the telemetry for Pt#1. Additionally, he ordered a consult with cardiology because P#1's Troponin levels (cardiac-specific levels in the blood to help detect heart injury) were elevated. CMO MM revealed that telemetry orders were a standard protocol for a stroke patient to rule out atrial fibrillation (an irregular and often rapid heart rate) as the cause of the stroke. MD EE stated that an echocardiogram (an ultrasound of the heart muscle and valves) was ordered and performed on P#1. MD EE confirmed P#1's nurse contacted him to inform him that she could not initiate telemetry because there were no telemetry boxes available. When asked what measures had been put in place to monitor the patient since telemetry was not available, MD EE stated he consulted Cardiology. MD EE stated he was not aware if cardiology had been contacted when P#1 was not placed on telemetry. CMO MM stated that in his medical opinion, it would have been beneficial to have P#1 on telemetry to monitor his heart.

An interview with Nurse Manager (NM) JJ and Charge Nurse (CN) CC was conducted on 7/1/21 at 11:09 a.m. NM JJ explained she was briefed on the incident surrounding P#1 in the morning when she arrived to work. NM JJ said she was not present when the incident occurred. NM JJ and CN CC said they worked on the day shift and the incident occurred during the night shift. NM JJ acknowledged CN BB was on a vacation and couldn't be reached for an interview during the survey. NM JJ stated she was informed the biggest concern when the incident occurred was that P#1 needed to be monitored on telemetry and the nurse had trouble placing P#1 on telemetry. P#1 suffered cardiopulmonary arrest, was unresponsive before they could place the telemetry box on him and P#1 was transferred to the ICU. NM JJ explained the nurse attempted to borrow from other units but was not successful. NM JJ said if they had no transmitter on their unit her expectation was for staff to call other units and try to get a telemetry transmitter for the patient. NM JJ further explained that she expected the physician and telemetry suite to be notified. NM JJ explained that the telemetry suite is expected to guide the nursing staff on how to troubleshoot a transmitter. NM JJ said if the telemetry department could not troubleshoot the transmitter then it is placed in a bag, labeled, and taken to the biomedical department for replacement. NM JJ acknowledged there had been incidents in the past they did not have enough boxes for patients on the unit, but they were able to borrow from other units. NM JJ said it was her understanding that the telemetry department had backup transmitters and the telemetry suite was able to offer a replacement. NM JJ and CN CC acknowledged it was not the standard practice to have left P#1 without being continually monitored per the physician orders. NM JJ acknowledged that a nursing guideline was sent out to the staff on how to troubleshoot the transmitter about a month ago when the facility changed its procedure to start putting transmitters on the units.

An interview with Medical Doctor (MD) II and Chief Medical Officer (CMO) MM commenced on 7/1/21 at 11:33 a.m. in the conference room. MD II explained that he was in his third (3) year fellowship program in Cardiology. MD II acknowledged he was consulted by the neurology team for P#1's elevated troponin level. MD II said he remembered seeing P#1 at the unit (3N) around 1:00 a.m. MD II said when he saw P#1 he did not remember seeing telemetry on the patient. MD II explained he did not order the telemetry, he further explained the other physician (MD EE) ordered the telemetry. MD II explained he was only consulted to the unit on an as-needed basis. MD II said he ordered a bedside echocardiogram for P#1 when he was consulted. MD II explained that if P#1 had been his patient and he was notified by the nurse that she could not get a transmitter for the patient, he would have called the telemetry suite to investigate further. MD II explained he was on the unit when the nurse activated the code. MD II said he was the first physician to arrive and chest compression had already started, he said it appeared there was a telemetry transmitter sitting next to the patient around 6:40 a.m. MD II stated he did not know if it was the standard practice for the facility to have waited for a long time before getting a transmitter for P#1. CMO MM explained the facility eventually brought a transmitter for P#1. CMO MM explained that when the physician had given his order it was the responsibility of the nursing staff to follow through.

During an interview with the Assistant Nurse Manager for Inpatient Cardiology Telemetry, (AM) DD on 7/1/21 at 2:45 p.m. in the facility conference room, she confirmed she remembered P#1. She recalled that she arrived to work at 6:30 a.m. on 6/24/21. The telemetry tech (TT) FF informed her there had been multiple issues that concerned communication throughout the night with RN AA. TT FF told her that P#1 should have been on telemetry; however, there was no reading on the monitor. AM DD asked TT FF if the telemetry box had been through troubleshooting, and TT FF replied that it had not. AM DD stated she contacted the RN AA to bring the telemetry box to the telemetry suite for service. She confirmed that UC GG brought the telemetry box to the telemetry suite, and UC GG returned it for P#1. AM DD stated that P#1 became unresponsive before telemetry was established for P#1. AM DD indicated that she would give them a working box from the telemetry suite if a telemetry box were not working. AM DD stated that telemetry boxes with problems should be troubleshot by the Telemetry Suite soon as possible. AM DD explained that if a telemetry box was not functioning correctly, the telemetry suite staff should troubleshoot the box over the phone with the floor/unit staff. If that was not successful, the floor/unit staff could bring the transmitter to the telemetry suite, or the telemetry suite staff could go to the floor/unit to troubleshoot the box. Additionally, staff could also call other floors/units to locate an extra box. If a telemetry box continued to malfunction or another box could not be located, the telemetry suite could give another box to a patient. The technician would then contact AM DD via text or phone call. AM DD acknowledged it was the responsibility of the telemetry suite to troubleshoot the telemetry boxes when called or informed of a problem by the floor/unit staff. The telemetry suite staff are trained to respond to the patient's floor to troubleshoot a telemetry issue if needed. AM DD confirmed there were three extra telemetry boxes in the telemetry suite as backups, three telemetry boxes in the Supervisor Suite, and additional telemetry boxes kept by the House Supervisor. Per AM DD, the telemetry suite staff did not have to contact her first to assign one of the extra telemetry boxes. Staff had permission to assign a telemetry box to a patient and inform her afterward. AM DD further revealed she had never been aware of any other medical incident when a telemetry box was unavailable for a patient. However, she confirmed that there had been instances when there were not enough telemetry boxes for patients. If the staff could not locate another telemetry box, they would have to call other units to find one. In addition, the staff had to acquire a doctor's order to remove the telemetry from a patient with a lesser need for telemetry monitoring to give it to a patient with a greater need for monitoring. AM DD explained that they had placed orders in the past to order additional boxes from their supplier. AM DD confirmed the facility put in a new hospital-wide process for telemetry boxes. As of 6/1/21 the telemetry boxes were housed on patient floors and were no longer being stored in the telemetry suite. The purpose behind the new process was to improve the efficiency of providing a telemetry box to a patient. The change keeps floor staff from going to the telemetry suite to sign a telemetry box out. In addition, the telemetry suite was responsible for troubleshooting the telemetry boxes before the hospital initiated the new process.

An interview took place with Director Clinical Excellence (DC) KK on 7/1/21 at 4:30 p.m. in the conference room. DC KK explained she was aware of the incident with P#1. DC KK stated the facility scheduled a root cause analysis (RCA) on the event, but it had not been completed. DC KK stated the facility tries to complete an RCA as close as an event occurs and not more than two to three months from the incident. DC KK explained the RCA process obtained information from the staff involved in the incident, interview staff, compile information, identify the root cause event, and find opportunities for improvement and make action plans. DC KK said they reported their findings from an RCA to the facility's quality board as well as governing body and it will be discussed in their minute meetings. DC KK explained the regulatory department had been able to get some statements from the staff involved in P#1's incident. DC KK said from her understanding the facility knew there was human error involved and they had started coaching staff working at the telemetry department. DC KK explained the facility recently made a process change to get the telemetry transmitter to the patient as soon as possible and the facility was in the process of revising the policies. DC KK explained previously the unit staff had to go to the telemetry department to pick up a transmitter whenever they needed it however, with the new process they had put the transmitters on each unit to get the transmitter close to the patient as fast as possible. DC KK explained that quality checks and failure effect mood analysis are carried out on the telemetry transmitters related to troubleshooting around the leads and batteries.

A review of the facility's policy number 3299 titled "Nursing Documentation Policy" last reviewed 11/14/2019 revealed the nursing care documentation guidelines will be adhered to that ensured care is provided to and documented for each patient based on a nursing assessment. The documentation of assessment, plan, intervention, and patient response shall occur as close to the real-time of occurrence as possible. The goal of the assessment is to determine the care, treatment, and services that will meet the patient's initial and continuing needs.
Reassessment
A. Each patient is reassessed as necessary based on the plan of care or changes in condition.
B. Reassessment may also be based on the patient's diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; discharge planning needs; and/or setting requirements.
C. Reassessment of the patient shall be performed at regular intervals in the course of care
by nursing staff.
D. Reassessments are performed to determine a patient's response to care/treatment.
E. Reassessment shall take place when there is a significant change in a patient's condition or a change in diagnosis.
F. Patients will be reassessed by a registered nurse at least every shift to document changes in the patient's condition, and/or diagnosis, and to determine the patient's response to intervention.
G. Nursing reassessment of a patient will reflect at a minimum:
I. A review of the patient's specific data
ii. Pertinent changes
iii. Responses to intervention
iv. Appropriate frequency for the patient population and/or individual patient need
v. Assessments and reassessments are documented in the electronic health record and appropriate paper records are utilized for documentation during downtime.

A review of the facility's document titled "Telemetry Report Sheet" dated 6/24/21 revealed the facility failed to log P#1's telemetry transmitter number, patient label, or nurse name in the telemetry report sheet.
A review of the facility's document titled "Nursing Notification Sheet" dated 6/24/21 and completed by TT FF failed to reveal any information about P#1's name, P#1's room number, or any communication between the nursing staff and telemetry department.

Based on review of staff interviews, policies and procedures, telemetry report sheet, and nursing notification sheet, the facility staff failed to adhere to the facility's policies and procedures related to telemetry monitoring of one of five sampled patients (P#1) at the facility.

Findings:

An interview with the Registered Nurse (RN) AA took place on 7/1/21 at 8:30 a.m. in the conference room. RN AA explained she was familiar with P#1 and recalled the incident that occurred with the patient. RN AA said the physician ordered continuous telemetry monitoring of P#1. RN AA explained she was not able to initiate the order because the telemetry box did not work when she tried to put it on P#1. RN AA said she contacted the telemetry department and asked the telemetry tech (TT) FF if she got a reading for P#1 on the monitor, but the tech did not get a reading, RN AA stated she explained to TT FF the telemetry box was not working and that was the last remaining transmitter on the unit. RN AA further explained that she asked TT FF if she could help her troubleshoot the transmitter. RN AA said TT FF stated the telemetry suite does not troubleshoot transmitters. RN AA explained that TT FF said RN AA should call the biomedical department or request a transmitters from another unit at the hospital. RN AA said the unit clerk contacted the biomedical department and the biomedical department also stated they do not troubleshoot transmitters. RN AA explained they contacted several other units (4W,5W) and none of the units had a available transmitter. RN AA said she contacted the telemetry department a second time and tried to explain that the unit (3North-3N) was instructed to contact the telemetry department whenever they had an issue with troubleshooting a telemetry transmitter. RN AA explained that TT FF said the telemetry department does not troubleshoot telemetry transmitters and TT FF did not offer to replace the transmitter. RN AA said she notified MD EE and kept him posted about her efforts to get P#1 on a telemetry monitor. RN AA said around 6:20 a.m. the telemetry department called her unit (3N) and told the clerk to bring the telemetry transmitter for troubleshooting. RN AA said the clerk took the transmitter (box) to the telemetry department and brought back the same telemetry box after troubleshooting around 6:40 a.m. RN AA explained she got the telemetry transmitter and went to put it on P#1. RN AA said that when she arrived at P#1's room, P#1 was not saying anything and he was pulseless. RN AA said she immediately went to the doorway told the charge nurse that P#1 was not breathing and started CPR on the patient. RN AA said a code blue was called and the code team arrived. RN AA explained that after some rounds of CPR they found a pulse around P#1's groin and P#1 was transferred to the intensive care unit (ICU) (3W).

During an interview with the Telemetry Technologist (TT) FF on 7/1/21 at 9:00 a.m. in the facility conference room, TT FF stated that she had worked at the facility for the past eight months. She revealed that her duties were to monitor the patient's heart rhythms and pulse oximetry readings. She added that she would relay patient information to the nursing staff when she observed a problem on the monitor. TT FF stated she assisted nursing staff with the telemetry boxes when troubleshooting was required. TT FF said that nursing staff could also bring the telemetry boxes to the telemetry suite for troubleshooting. She explained that if a telemetry box was not working on the floor, unit staff could contact other floors/units to ask if they had a telemetry box they could use. TT FF revealed that if a telemetry box could not be located for a patient on another floor/unit, three extra telemetry boxes were kept in the telemetry suite.
She stated that less than two months ago, a new facility change required telemetry boxes to be stored on patient floors/units instead of in the telemetry suite. As a result, nursing staff would replace batteries when the monitors showed that the telemetry box battery was low. The telemetry suite could also monitor the battery status and notify the nurse if needed. TT FF stated that she remembered P#1. She revealed that RN AA called and informed her of P#1's name, room number, and telemetry box number around 2:30 a.m. RN AA had attached the telemetry monitor for P#1 and entered the medical record number. TT AA said that she did not see a heart rhythm on the monitor for P#1 and, shortly after that, called and followed up with RN AA. She explained that she called RN AA back to ask why she was not picking P#1 up on the monitor. She stated that RN AA said she would enter the medical record number for P#1 then attach him to the monitor. She called RN AA again later to question why P#1's information was still not showing on the monitor. TT FF stated that RN AA indicated she would put him on the monitor, but she had placed P#1 on telemetry yet. TT FF stated that around 4:00 a.m., she contacted RN BB on the floor/unit to ask why P#1 was still not on the monitor. RN BB stated that RN AA stated she was having problems with the telemetry box, and RN AA would try to resolve the issue. TT FF said that she informed RN AA that they could troubleshoot the problem over the phone, and the nursing staff could get another box from a different floor/unit if needed. TT FF revealed that she did not recall either RN AA or RN BB mentioning that they were unable to locate an extra telemetry box. She stated that the Telemetry Assistant Manager (AM) DD was informed of the situation when she came into work the morning of 6/24/21. AM DD called and spoke to the Unit Clerk (UC) GG and asked that the telemetry transmitter be brought to the telemetry suite for troubleshooting. The telemetry transmitter was fixed within five to ten minutes and returned to UC GG. TT FF confirmed she documented the conversations between herself, RN AA, and RN BB on the Nursing Assignment Sheet located in the telemetry suite.

During an interview with the Assistant Nurse Manager for Inpatient Cardiology Telemetry, (AM) DD on 7/1/21 at 2:45 p.m. in the facility conference room, she confirmed she remembered P#1. She recalled that she arrived to work at 6:30 a.m. on 6/24/21. The telemetry tech (TT) FF informed her that there had been multiple issues that concerned communication throughout the night with RN AA. TT FF told her that P#1 should have been on telemetry; however, there was no reading on the monitor. AM DD asked TT FF if the telemetry box had been through troubleshooting, and TT FF replied that it had not. AM DD stated she contacted the RN AA to bring the telemetry box to the telemetry suite for service. She confirmed that UC GG brought the telemetry box to the telemetry suite, and UC GG returned it for P#1. AM DD stated P#1 became unresponsive before telemetry was established for P#1. AM DD indicated she would give them a working box from the telemetry suite if a telemetry box did not work. AM DD stated that telemetry boxes with problems should be troubleshot by the telemetry suite soon as possible. AM DD explained that if a telemetry box did not function correctly, the telemetry suite staff should troubleshoot the box over the phone with the floor/unit staff. If that were not successful, the floor/unit staff could bring the transmitter to the telemetry suite, or the telemetry suite staff could go to the floor/unit to troubleshoot the box. Additionally, staff could also call other floors/units to locate an extra box. If a telemetry box continued to malfunction or another box could not be located, the telemetry suite could give another box to a patient. The technician would then contact AM DD via text or phone call. AM DD acknowledged that it was the responsibility of the telemetry suite to troubleshoot the telemetry boxes when called or informed of a problem by the floor/unit staff. The telemetry suite staff are trained to respond to the patient's floor to troubleshoot a telemetry issue if needed. AM DD confirmed there were three extra telemetry boxes in the telemetry suite as backups, three telemetry boxes in the Supervisor suite, and additional telemetry boxes kept by the House Supervisor. Per AM DD, the telemetry suite staff did not have to contact her first to assign one of the extra telemetry boxes. Staff had permission to assign a telemetry box to a patient and inform her afterward. AM DD further revealed she had never been aware of any other medical incident when a telemetry box was not available for a patient. She confirmed there had been instances when there was not enough telemetry boxes for patients. If the staff could not locate another telemetry box, they would have to call other units to find one. In addition, the staff had to acquire a doctor's order to remove the telemetry from a patient with a lesser need for telemetry monitoring to give it to a patient with a greater need for monitoring. AM DD explained they had placed orders in the past to for additional boxes from their supplier. AM DD confirmed the facility put in a new hospital-wide process for telemetry boxes. As of 6/1/21 the telemetry boxes were housed on patient floors and were no longer being stored in the telemetry suite. The purpose behind the new process was to improve the efficiency of providing a telemetry box to a patient. The change keeps floor staff from going to the telemetry suite to sign a telemetry box out. In addition, the telemetry suite was responsible for troubleshooting the telemetry boxes before the hospital initiated the new process.


A telephone interview with Clerk (C) GG took place on 7/1/21 at 3:36 p.m. in the conference room. C GG stated she had worked at the facility for twenty eight (28) years. C GG stated she was not on the unit when the incident started but when she arrived the nursing staff told her they needed a telemetry transmitter for P#1. C GG stated she called two units at the hospital but was not able to get a transmitter for P#1. C GG stated she contacted the telemetry department for troubleshooting, and was told they did not troubleshoot transmitters the department did not offer a replacement. C GG explained there had been a time they had no transmitter on the unit, but they were able to borrow from other places. C GG said she was finally able to take the transmitter to the telemetry department for troubleshooting, she said when she returned to the unit she handed the transmitter to the nurse however, at that time the charge nurse had activated a code blue for P#1.

During a follow-up interview with Assistant Nurse Manager for Inpatient Cardiology Telemetry (AM) DD, on 7/2/21 at 11:00 a.m. in the facility conference room, AM DD stated there was not a current procedure or book/log that the telemetry suite tech would use to document a conversation between a nurse and a telemetry technician regarding establishing a patient on telemetry. Documentation only began when a patient showed a baseline rhythm or pulse oximetry reading on the telemetry monitor. Additionally, AM DD stated the Nursing Assignment sheet, used by the telemetry suite, confirmed which patients a telemetry technician would monitor during the shift they worked. She further confirmed that P#1 did not have continuous telemetry monitoring after leaving the emergency department until he was found unresponsive on 6/24/21.

A review of the facility's policy number 233 titled "Telemetry Monitoring Policy" last reviewed on 7/28/2020 revealed the purpose of the policy is to provide a uniform, consistent method of monitoring the patient's heart rhythm and/or oxygen saturation, to detect life-threatening and/or lethal dysrhythmias/desaturations on monitored patients.
Telemetry Monitoring: A patient telemetry monitoring unit records the electrical activity (ECG) of the heart and pulse oximetry. The purpose of telemetry monitoring is to detect significant and life-threatening variations in a patient's cardiac rhythm to facilitate early therapeutic intervention(s). The patient telemetry monitoring transmitter sends the data to a local monitoring station at the nurse's station (referred to as the Client) and a centralized monitoring station located in the telemetry suite.
Telemetry Transmitter: Device used to transmit data from the patient to centralized monitors at the nurse station and telemetry suite.
I. Adult Hospital Guidelines
A. Obtain a physician order for continuous telemetry monitoring. If a patient's condition warrants, the Registered Nurse (RN) may initiate telemetry monitoring until a physician (MD) order is obtained within 24 hours.
1. A physician must evaluate the continued need for telemetry monitoring every 24 hours.

B. Call Extension number to notify the Telemetry Monitor Technician in the telemetry suite the patient has orders for telemetry monitoring.
1. The Telemetry technician will set up the telemetry transmitter with new batteries and monitoring cables for ECG and/or pulse oximetry (ox) (if ordered).
2. The Telemetry technician will log the telemetry transmitter number and pulse oximetry cable number.
3. The RN or designee picking up the telemetry transmitter brings a label with the patient information.
a. Using the patient label, the following information is entered on each patient by the Monitor technician at the centralized telemetry monitors:
1. First and last name
2. Date of birth
3. Medical Record Number (MRN)
4. Room number
b. The telemetry transmitter is then "synched" to the PicIx by the telemetry technician before leaving the telemetry suite.

C. The patient is placed on a telemetry transmitter by the nurse caring for the patient or designated
the staff member on the unit utilizing two (2) patient identifiers with the order.
1. The patient/family is given a brief explanation of the telemetry transmitter and its purpose.
2. Skin Preparation is be done to promote better adhesion of electrodes:
D. Once the patient is placed on the telemetry transmitter, verification of the patient's waveforms must be completed by the RN at the unit's centralized monitoring system utilizing the instructions below:
1. To place a patient on the client monitor with the mouse go to an empty sector.
a. Click on "Manage Patient"
b. Then Click on "Overview"
c. Click on "Telemetry" then "Room Number" where the patient is located.
d. The equipment number will automatically pop up- Click "OK".
2. Once completing all steps, the patient's rhythm and/or pulse oximetry can be viewed in the assigned sector on the Client monitor.
E. If equipment malfunction occurs, the Telemetry transmitter is replaced. The Telemetry Monitor Technician Contacts Biomedical Engineering for repair.
F. Removal of telemetry transmitter for transport to diagnostic tests/procedures will be at the physician's discretion and requires a physician order (current clinical status should determine appropriateness).
G. If the patient is transferring to another unit or room location, an extension number is called, and the telemetry monitor technician is informed of the change. The patient's information is updated in the central monitors in the telemetry suite.

A review of the facility's document titled "Telemetry Report Sheet" dated 6/24/21 revealed that the facility failed to log P#1's telemetry transmitter number, patient label, or nurse name in the telemetry report sheet.

A review of the facility's document titled "Nursing Notification Sheet" dated 6/24/21 and completed by TT FF failed to reveal any information about P#1's name, P#1's room number, or any communication between the nursing staff and telemetry department.