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Based on staff interview and medical record and policy review, it was determined that the hospital failed to evaluate nursing care related to the circumstances surrounding the death of one patient (#4). It was determined that the hospital failed to respond to a cardiac monitor alarm and the suction equipment malfunctioned for Patient #4 during a cardiac arrest resulting in a determination of immediate jeopardy (A395). The cumulative effect of this systemic practice failed to ensure the patient's nursing needs were safely met.

Based on staff interview and medical record and policy review, it was determined that the hospital failed to evaluate nursing services in regard to failure to respond to a cardiac monitor alarm and the malfunction of equipment which delayed treatment for one patient (Patient #4). This deficient practice had the potential to affect all patients receiving care in the hospital.

Findings include:

Review of the medical record of Patient #4 revealed the patient presented to the Emergency Department on 06/30/15 at 04:24 PM after the patient's family complained that the patient had become increasingly weak and despite eating several large meals per day, looked as if he was losing weight. It was reported by family the patient had a tendency to gorge food and needed to be watched at all times. The patient had a history of a stroke and myocardial infarction. The Admission Assessment indicated the patient was 5'10" tall but weighed only 80 pounds. Staff in the Emergency Department described the patient as "severely emaciated." The patient was admitted to the Oncology/Medical-Surgical Unit on 06/30/15 at 11:07 PM with the diagnosis of failure to thrive.

Review of the physician orders revealed the patient was to be placed on a cardiac monitor and to watch the patient eat all meals. According to the Nursing Flowsheet, the patient was requesting to eat at 11:07 PM. It was further noted that the nurse notified the physician of the patient's request. The physician gave permission for the patient to eat and to monitor the patient.

A Nursing Note, filed as an addendum, at 05:15 AM, documented that at 02:00 AM on 07/01/15, Patient #4 was provided with a sandwich, soup, gram crackers, and peanut butter. It was further noted that the patient was monitored while he ate and the food was tolerated well by the patient. Another Nursing Note, filed as an addendum at 05:04 AM, documented that at 02:20 AM, Patient #4's cardiac monitor was alarming announcing the patient was in ventricular tachycardia, a lethal arrhythmia. When the nurse entered the room, the patient was unresponsive.

Review of the Code Sheet revealed that the event was recognized at 02:22 AM, two minutes after the alarm sounded. The patient's heart rhythm was noted to be asystole at this time. The Cardiopulmonary Resuscitation Form documented at 02:36AM " possible sinus brady, unable to get doppler soon enough". A detailed printout of the Vocera alarm details was reviewed. According to the printout, the alarm, with an urgent priority, revealing the patient was in V Tach was delivered to the nurse's Vocera at 02:20:40 AM. Staff B, present during the review of the Vocera printout, stated the nurse reported not hearing the alarm.

Review of the Physician's Discharge Summary documented that a large volume of food was found in Patient #4's throat during intubation. Further review of The Physician's Discharge Summary revealed that despite intubation, administration of emergency medications, chest compressions, and defribillation the patient was pronounced dead at 02:46 AM.

Review of the RN's summary of Patient #4's event documented that "...there was no suction available in the room and there was a delay in setting it up d/t (due to) broken equipment.

Review of the Coroner report dated 07/28/15, revealed at section V "Aspiration of food in the trachea and bronchi (perimortem/agonal)." The cause of death was listed; however, as "natural".

On 08/28/15 at 11:05 AM, Staff B stated during an interview that the nurse said he/she did not hear the alarm. When asked if there was an investigation to determine why there was a delay Staff B stated "No". When asked if there was an investigation into why the equipment did not function and if the vocera/cardiac monitor was sent to Clinical Engineering per hospital policy, Staff B stated "No". When asked if there was an investigation as to why and/or how Patient #4 had a large amount of food in his throat, Staff B stated "No".

Staff B was interviewed on 08/28/15 at 03:45 PM. It was confirmed with Staff B that the Vocera being used by the nurse who reported not hearing the lethal alarm of Patient #4 was not sent to Clinical Engineering to be checked as required by facility policy. It was further confirmed there was no investigation to ascertain what broken equipment delayed the set up of the suction.

The facility policy titled Medical Equipment Management Plan was reviewed on 08/28/15 at 02:30 PM. According to the policy, critical equipment failures are defined as device failures resulting in the potential or actual patient injury or death. Critical equipment failures should be immediately reported to Clinical Engineering.

There was no evidence that the hospital took immediate action to ensure emergency equipment was functioning appropriately or that malfunctioned equipment was reported to Clinical Engineering per policy.