HospitalInspections.org

Based on review of medical records (MR), review of facility documents and interview with staff, it was determined that the facility failed to ensure patients in the progressive care unit (PCU) that are placed on telemetry monitoring [a method used to continously monitor the electrical activity of a patients heart] is monitored to detect abnormal heart rhythms and that a process is in place to notify nursing staff, when patients are monitored remotely (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.


The IJ was identified on 5/13/2025 at 12:40 PM. The IJ template was provided to the facility on 5/13/25 at 4:56 PM and an acceptable IJ removal plan was recieved on 5/14/25 at 11:35 AM. The facility implemented the following: the house supervisor will on a shift by shift basis, inform the monitor technicians of their assignment to include all units of responsibility, both house supervisors and monitor technicians were educated on this process, monitor technicians were educated on the notification process and the steps to be taken in the event an arrythmia is detected, monitoring of telemetry PCU patients will be done by the 5 East 24/7, the bedside monitoring system was re-installed and put into working order on 5/13/24 allowing for bedside monitoring of all PCU patients (including the ability to monitor remotely). On 5/14/25 at 12:25 PM the surveyors verified full implementation and the IJ was removed. Verification of implementation was completed through a facility tour of the PCU and 5 East unit, review of staff education and signed attestations of education, and staff interviews.

Based on observation, medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure patients in the progressive care unit (PCU) that are placed on telemetry monitoring [a method used to continuously monitor the electrical activity of a patient's heart] is monitored to detect abnormal heart rhythms and that a process is in place to notify nursing staff, when patients are monitored remotely.

Findings include:

On 05/12/25 at 10:26 AM, during a tour of the PCU, Staff (S)6 (Registered Nurse [RN]) stated that in the PCU patient cardiac rhythms are monitored [telemetry monitoring] and are displayed on a monitor which can only be seen behind the nurse's station on the PCU, or on the 5th Floor telemetry unit. S6 stated that on the PCU, they frequently do not have a monitor technician assigned to watch the telemetry monitor, or a staff member at the nurse's station to answer phones if a monitor technician from the 5th floor called to report an arrythmia [irregularities in the heartbeat]. S6 stated that they do not have the ability to view the telemetry monitors from the patient's bedside, and do not carry telephones to receive calls directly from monitor technicians. S6 further stated that until November 2024, the PCU had a dedicated monitor technician on day shift, 7:00 AM-3:00 PM, until the monitor tech [technician] went out on medical leave." Once [he/she] left, we were completely reliant on the monitor tech upstairs [5th floor telemetry unit]."

During an interview, S6 revealed that on 05/07/25, after dayshift began, a patient in the PCU was found unresponsive while nursing staff were performing patient care in other rooms. S6 stated that the nurse had not been notified that the patient had a change on the cardiac monitor. A code blue (a hospital code used to refer to a life-threatening medical emergency) was called on the patient (patient (P)1), who was transferred to the Intensive Care Unit (ICU), and expired that day.

At 10:58 AM, during a tour of the PCU, the cardiac monitor was observed behind the nurse's station, facing inside so that it could only be visualized from behind the nurse's station. S6 confirmed that there are alarms for each patient, but they could only be heard near the monitor.

At 11:19 AM, during a tour of the 5th floor telemetry unit, the telemetry monitors, including a monitor for the PCU, were observed. S3 (monitor technician) stated that he/she was responsible for watching the monitor for the PCU "just in case the nurses are busy." S3 provided a telemetry communication log, which he/she stated the monitor technicians use to document when they notify other units of arrythmias. There was no documentation of any notification from the 5th floor monitor tech to the PCU, on 05/07/2025 between 5:47 AM and 7:18 PM.

At 1:56 PM, during a review of staffing, S10 was identified as the monitor technician working on the 5th floor telemetry unit on 05/07/25 during the dayshift.

On 05/13/25 at 10:22 AM, on the 5th floor telemetry unit, during an interview, S10 (monitor technician) stated that the PCU usually has a monitor tech watching their telemetry monitors, but as of last Wednesday [05/07/25], he/she was told they had to watch the monitors for PCU. S10 stated that on 05/07/25, he/she was made aware that a patient on PCU had a cardiac arrythmia when "the nurse manager called up here and asked if I noticed. I said no, I didn't notice, because I was paying attention to the other monitors. That morning, nobody told me that they didn't have a tech." S10 stated that he/she can tell when the PCU has a monitor tech, when seeing activity on the monitor screen from the PCU. On the screen, a modified view of a PCU patient's cardiac rhythm was observed, and S10 stated, "see, they have someone today. They are looking at the monitor down there [PCU] right now. That's how I know they have someone watching."

At 10:37 AM, an interview occurred with S11 (RN, PCU and ICU [intensive care unit]). S11 stated that on 05/07/25, there was no monitor technician or unit secretary working at the PCU nurse's station. At approximately 8:23 AM, PCU staff called a code blue after one of his/her patients (P1) was found unresponsive by a resident and cardiologist. S11 stated that after the patient was transferred to the ICU, he/she checked the telemetry strips, and learned that at 8:10 AM, the patient's heartrate was 38, and at 8:17 AM was showing PEA (pulseless electrical activity). S11 stated he/she never received a call from the monitor technician. On Friday, 05/09/25, S11 stated that a conversation with S4 (Emergency Department [ED] Director) revealed that "there was a miscommunication between the two floors [PCU and the 5th floor tele unit 5 East] and that nobody was watching the telemetry monitors. The floor [PCU] needs to inform the 5th floor when there is no monitor tech. After that incident, they started calling us. In two years, I've never gotten a call from them, and we haven't had a full-time monitor tech since November."

At 11:20 AM, behind the PCU nursing station, a staff member was observed modifying the view of the cardiac monitors. S6 confirmed that PCU nurses can modify the view of each PCU patient's cardiac rhythm while looking at the cardiac monitor; however, this does not confirm that a monitor technician is staffed at the PCU nurse's station for the day.

Facility policy titled, "Admission, Transfer, and Discharge Critical Care Unit," revised on 01/09/2024, stated, "... 1. The Admission, Transfer and Discharge policy will be effective for Critical Care Units: Intensive Care Unit (ICU), Progressive Care Unit (PCU), and Open- Heart Recovery (OHR). ... Admission Criteria ... 1. Monitoring (at least every 1-2 hours for ICU and Every 4 hours for PCU) 1.1 Vital Signs: Temperature, Pulse, Respirations, Blood Pressure, and Pulse Oximetry 1.2 Cardiac Monitoring ..."

At 12:23 PM, an interview occurred with S1 (Chief Nursing Officer), S4, and S12 (Manger of 5th Floor Telemetry Unit). S1, S4, and S12 all confirmed that there is no formal or written process for who is watching the PCU telemetry monitors when there is not a monitor technician in the PCU. S1 stated that the process "will be formalized." S1, S4, and S12 all confirmed that they need to discuss how this process is going to be handled as a nursing group, and that no education has been documented providing the facility staff on who is primarily responsible for watching the PCU monitors and, if the 5 East monitor technicians are watching, what is the process if they are unable to reach someone via phone in the PCU to notify nurses of a patient cardiac event.

P1's medical record was reviewed, and the following was revealed:

P1 arrived in the ED via ambulance with paramedics on 04/19/2025, for altered mental status. It is documented in the past medical history that P1 had a history of, including but not limited to, anemia (a blood disorder in which the blood has a reduced ability to carry oxygen), anxiety (a state of uneasiness and apprehension), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a disorder of carbohydrate metabolism characterized by impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar in the blood), end stage renal disease (ESRD, the last stage of chronic kidney disease) on dialysis (a treatment that filters waste and excess fluid from the blood) gastroesophageal reflux disease (a chronic condition where stomach acid frequently flows back into the esophagus), hypertension (high blood pressure), pneumonia (inflammation of the lungs) and seizures (a sudden burst of abnormal electrical activity in the brain that affects awareness and muscle control).

A review of the ADT (Admission, Discharge, Transfer) log indicated that P1 was brought to the ED on 04/19/2025 and was admitted to the ICU. P1 was transferred to the 6E Medical Surgical Unit on 04/30/2025 and then transferred to the PCU on 05/06/2025.

A progress note entered by S13 (Medical Resident) on 05/07/2025 at 6:44 AM, stated, "... Subjective ... 4/21 Code blue during HD [hemodialysis, a procedure for removing metabolic waste products or toxic substances from the bloodstream by dialysis] (cardiac and resp [respiratory] arrest) ROSC [Return of Spontaneous Circulation] achieved after 2 minutes." The "plan" section of the progress note stated, "... CV [cardiovascular] ... Plan Cardiac monitoring, pulse ox [pulse oximetry], vital signs ..."

Facility provided Electrocardiograms (ECG, a test to record the electrical signals in the heart) were reviewed. An ECG dated 05/07/2025 at 8:10 AM stated, "... HR (ECG): [37] BPM [Beats Per Minute] ... Event: Asystole ..." A second ECG dated 05/07/2025 at 8:17 AM stated, "HR (ECG) 68 BPM ... Event: Asystole ... "

The "Significant Event Addendum" note entered by S11 on 05/07/2025 at 10:45 AM, stated, "Patient Vitals taken and assessed at 7:30 am. Patient was talking in Spanish and sleeping/resting. Alert but confused. Not oriented. [His/her] HR [heart rate] was 62 NSR [normal sinus rhythm], BP [blood pressure] 100/41, SPO2 [oxygen saturation] 97%. ... As per night shift, Patient was coughing phlegm and every time he wanted to drink, he was coughing more. I did not give the patient [his/her] breakfast to prevent any aspiration. 08:23 [8:23 AM] patient found unresponsive, no pulse Code blue was initiated, with ACLS [Advanced Cardiac Life Support] protocol. Intubated by anesthesia, no complications noted. Patient got total of 2 doses of epi [Epinephrine, ], 1 D50 [Dextrose] and pulse + at 08:32 ROSC achieved at 08:32 am Code blue documentation done on [name of electronic medical record system]. Patient was safely transported to ICU with monitor on."

The "Code Documentation" entered by a Pulmonology Resident, dated 05/07/2025 at 9:12 AM, stated, "... Pt [patient] with multiple comorbidities including Insulin-dependent T2DM [type two diabetes], ESRD, on HD, HTN [hypertension], Seizures, Anxiety and MDD [Major Depressive Disorder], Septic Shock [a condition of physiologic shock caused by an overwhelming infection) secondary to infected dialysis catheter on 04/19, Cardiac arrest during HD on 04/21, Subacute parenchymal pontine hemorrhage [bleeding in the brain] on 04/27, persistent thrombocytopenia [low blood platelet count] with multiple cryoprecipitate [a blood product] transfusions that coded 2 times during this hospital course. This morning pt coded with ROSC at 8 minutes. Pt was intubated during the event by anesthesia. Family was extensively explained about event, prognosis and was inquired about code status. After discussion with patient's mother, and daughter, wife [name], decided to change code status to DNR/DNI [ Do not resuscitate/Do not Intubate]. Decision was made to keep patient intubated and to continue current management, if pt decompensates again, family does not want to pursue with chest compressions or re-intubation if needed. ... "

A nursing note entered on 05/07/2025 at 9:45 AM, by an RN, stated, "Patient's heart rate dropped to the 40's on monitor with agonal rhythm. ICU team made aware and at bedside immediately to assess. No Pulses palpable. Patient was pronounced at 9:45 AM by [Physician's name]. Family at bedside."

A "Death Note" entered on 05/07/2025 at 11:50 AM, by a Critical Care Resident, stated, "Called by RN for no palpable pulses Pt's code status is DNR/DNI. On exam, the patient was unresponsive, pupils dilated, fixed & non reactive to light. No response to verbal and tactile stimuli. Heart sounds absent. BP was un recordable. EKG showed no electrical activity. ... Pronounced dead at [sic] 05/07/25, at 9:45am by [Physician's name]."