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Based on a review of hospital policies and procedures, medical record reviews, review of an RCA (root cause analysis) Action Plan, internal documents and staff interviews, the hospital's governing body failed to provide effective oversight of the hospital. The facility's governing body failed to ensure an ongoing program for quality improvement and patient safety is implemented and maintained when:
1. The facility was unable to provide thorough and credible quality improvement activities for identified opportunities related to telemetry services (Patient #9, #11 and #3) and,
2. The facility did not conduct a thorough and credible review and analysis of an adverse incident (Patient #1).

Findings included:

A. Review of the facility policy titled, "Cardiac Telemetry Monitoring", # WFD.PC.023, approval date 06/2021 ... Cardiac monitor may only be placed or discontinued with a physician orders ... Personnel in the role of the Monitor tech will be responsible for monitoring cardiac telemetry, running documentation strips ...Page 9 ...The printed telemetry strips will be placed in the patient medical record ...Cardiac Telemetry Monitoring Documentation: Every 12 hours (near the beginning of the shift) and more frequently as indicated by patient condition the telemetry strip will be interpreted (rate, PR interval, QRS interval, name of rhythm) by Monitor Technician and communicated to the RN. The RN will validate the cardiac strip(s) interpretation by the Monitor Technician ... the monitor technician should immediately notify the RN of changes in patient's rhythm. Monitor strip will be run to capture changes in rate or rhythm ...The registered Nurse is responsible to ensure that the patient is being appropriately monitored at all times ...Areas where cardiac telemetry monitoring is not connected to centralized monitoring (ICU) ... Guidelines related to protocol telemetry monitoring, alarms, documentation and competency of caregivers will be followed as per this policy.

Review of the Clinical Safety Improvement Program (CSIP) 2021 Assessment showed: Telemetry technician and RN education on telemetry safety bundle, adopt standard telemetry orders and or discontinued workflow, policy was reviewed and revised, integration of telemetry reports-outs into daily safety huddle.
"The goal of achieving greater than XX% was met for 2021. We met 100% of our goals. A total of xxx,xxx was received out of a the total of xxx,xxx portion."

On 10/27/2022 11:20 AM an interview with the Director of Quality revealed they did the CSIP for telemetry, but they did not keep records of what they did. The hospital was not able to provide data of tracking and trending to achieve 100% goal met..

1. Patient #9's medical record was reviewed. Patient #9 was admitted to the cardiac telemetry unit for acute decompensation of chronic biventricular heart failure (both sides of the heart are affected, and blood does not pump as well as it should) on 08/09/2022.

a. Review of the nursing notes dated 08/16/2022 showed the respiratory therapist (RT) called "code blue" (cardiac or respiratory arrest) after finding the patient unresponsive and pulseless at 2:45AM. CPR (Cardiopulmonary resuscitation) was initiated, and Patient #9 was transferred to ICU and expired the following morning 8/17/2022 at 03:07 AM.

b. Review of the Patient #9's cardiac telemetry strips dated 08/16/2022 at 2:07 AM revealed a change in cardiac rhythm, which showed Ventricular tachycardia (VT or V-tach is a type of abnormal heart rhythm which occurs when the lower chamber of the heart beats too fast to pump well and the body doesn't receive enough oxygenated blood.)

c. There was no documentary evidence in Patient #9's medical record to indicate that the nurse was notified by the telemetry technician of the lethal cardiac rhythm change on 8/16/2022 at 2:07 AM.

d. Review of the telemetry log did not indicate Patient #9's nurse was notified of the patient's lethal cardiac rhythm change on 8/16/2022 at 2:07 AM.

e. Interview with the Director of Quality on 08/17/2022 at 8:30 AM revealed the facility Quality Program was aware of the serious event that involved Patient #9 on 08/16/2022 at 2:07 AM.

2. Patient 11's medical record was reviewed. The record indicated a physician order dated 09/02/2022 at 8:05 PM for continuous telemetry monitoring.

a. There were no cardiac telemetry monitoring strips evident in the patient's medical record. There was no documentary evidence in the patient's medical record that the physician's order on 09/02/2022 for continuous telemetry monitor was carried out.

3. Patient #3's medical record was reviewed. The record indicated Patient #3, an 82-year-old, came to the emergency room on 11/17/2020 for chest pain. Patient #3 had an extensive past cardiovascular history including coronary artery disease, CABG (coronary artery bypass graft).

a. A nursing note dated 10/17/20 3:14 AM indicated, "late entry from 8:30 PM: patient came back from CT (computed tomography) yelling that he wanted his nitro, complaining of chest pain. Vital signs taken, stable. EKG (electrocardiogram) done, indicated AMI (acute myocardial infarction). Rapid response called. Nitro given and he felt better. Around 10:15 PM while bringing his medications, the EKG tech was getting EKG on him, but he was unresponsive and code blue was called. Chest compressions started with no response. Patient pronounced at 10:51 PM."

b. The record indicated a physician's order dated 10/17/20 for cardiac telemetry monitoring.

c. The telemetry log and strips for 10/17/20 indicated:
-8:30 PM "rapid response" (due to chest pain-leads were off)
-9:26 PM "came off tele"
-9:51 PM "on for two minutes"
-9:53 PM "off tele"
-10:10 PM "leads off"

There was no documentation on the telemetry logs that the nurse was contacted or notified when telemetry monitoring was off, or that any response was received from the nurse.

d. Review of the Medical Quality Meeting Minutes, dated 2/19/21, revealed the following findings: " ...the nurse failed to follow up on the patient with vitals after a rapid response was called. Cardiac consult was ordered as routine (can be done the next day) instead of stat (right away). The nurse did not alert the telemetry monitor room when the rapid response was over and therefore the patient was not put back into telemetry monitoring in the central monitor room; telemetry monitoring technician was not able to watch the patient's cardiac rhythm. The telemetry technician sent out alerts on the nurse's facility provided phone, but the nurse did not act on the alerts ..."

e. At 12:05 PM on 10/25/22 an interview was conducted with Staff B, Director of Patient Safety. He stated that they looked at lack of communication between departments, facility, and personnel. Auditing of Rapid Response documentation occurred for three months. He stated that they educated nurses to escalate to cardiology and that Residents 1 were educated on appropriate escalation to Resident 2. He also stated that the nurse was terminated for performance.


f. On 10/27/22 at 9:15 AM a follow up interview was conducted with Staff B, Director of Patient Safety. Staff B said this was his description of the event: The nurse failed to notify the telemetry room the rapid response was completed. Resident misinterpretation of the EKG showing changes in the inferior and posterior area. The nurse, post rapid response did no additional monitoring of vital signs. The patient wasn't sent to a higher level of care. The monitor room sent two overhead broadcasts the patient was off telemetry. The nurse resigned before we even had the RCA (root cause analysis). Staff B further stated the telemetry box wasn't put back on. The nurse didn't respond to the rapid overhead page the second time which was because the telemetry box wasn't on.

g. Further review of internal facility documentation reflected a plan of correction:
Audit all rapid response EKGs to ensure a resident level 2 review and documents their review of the interpretation in the medical record.
Educate staff on Handoff Communication tools SBAR and CUS. To be utilized to communication the patient's situation, provide background history, current assessment of the patient with recommendation of the next step in their care. Also, during times when there is a concern patient care is not appropriate to speak up and escalate to the next level of authority.
Review appropriate bed placement with the Emergency Department Providers.

h. There was no indication telemetry staff were re-educated, or a change to the process implemented related to telemetry.

B. Review of the facility policy and procedure title "Occurrence Report/Notifications" last reviewed 4/2022 indicated, "The purpose of the occurrence report is to report factual information about an occurrence ...Occurrence Reports are used to improve the quality of patient care and overall safety, and/or mitigate or eliminate adverse outcomes ..." The policy and procedure further indicated " ...Risk Manager Responsibilities: 1. Regular and systematic review of all incident reports ...3. Recommends further investigation by manager, if necessary, to identify trends ..."

Review of the facility policy and procedure titled "Peer Review" last reviewed 9/2022 indicated, " ...Peer Review Criteria: ...b. Unexpected outcomes ...PROCEDURES: cases are referred to the Quality Management Department by one of the following mechanisms a. Clinical staff of Risk Management may request review of clinical practice for cases in which an occurrence has been filed ...2. Cases are either trended or referred to peer review ..."

1. Patient # 1's medical record was reviewed. The record indicated Patient #1 was admitted to the facility on 3/15/22 and was discharged on 3/17/22. "Surgical Case Record" completed 3/15/22, 5:41 PM indicated, "PATIENT SURGERY CANCELED IN PRE-OP HOLD ...SURGERY OUTCOME CANCELED ..." The medical record further indicated:

a. "History and Physical - Adult" dated 3/15/2022, 7:01 PM indicated, "Chief Complaint: ACUTE RESPIRATORY FAILURE ...58 YEARS OLD VERY PLEASANT ...PATIENT WAS BROUGHT IN TO THE INTENSIVE CARE UNIT AFTER PATIENT BECAME HYPOXIC (absence of enough oxygen) IN PREOP AREA AND HAD TO BE INTUBATED BY ANESTHESIA ...PATIENT RECEIVED SOME IV (intravenous) REMIFENTANYL (Opioid analgesic) AND BECAME HYPOXIC REQUIRING INTUBATION. HIS PUPILS ARE PINPOINT ...TRANSFERRED TO INTENSIVE CARE UNIT ..."
The document further indicated " ...General appearance: respiratory support, intubated sedated ..."

b. "Clinical Note" dated 3/15/2022, 8:19 PM indicated, " ...when just about pt (patient) to be moved to the OR (operating room), the patient became unresponsive and apneic (temporary cessation of breathing) and his saturation (oxygen level) dropped to low 80's (normal level 95-100%) ..." The document further indicated Patient 1 required emergent intubation, Midazolam (sedative medication) to treat possible seizure because of possible local anesthetic toxicity and Naloxone (Narcan) to reverse possible remifentanyl overdose ..."

c. "CONSULTATION" note dated 3/16/2022 indicated, " ...He was brought in yesterday for elective spine surgery on his neck ...was noted to become unresponsive ..."

d. "DISCHARGE SUMMARY" dated 3/28/2022 indicated, " ...During awake intubation the patient became unresponsive. It was clearly secondary to fentanyl overdose that required emergent intubation ...wait till next day to have a complete neurological evaluation status post the emergent intubation in a patient with severe cervical stenosis (nerve compression in the neck) ..."

e. Review of the "Patient Event Record" dated 3/15/2022, 5:15 PM for Patient #1 indicated, " ...PATIENT WAS IN PRE-OP RECEIVING PRE-OPERATIVE TREATMENT ...WAS BEING PREPARED FOR AWAKE INTUBATION ...ANESTHESIA ADMINISTERED LIDOCAINE TO NUMB THE PATIENT'S THROAT AND SOON AFTER THE PATIENT BECAME UNRESPONSIVE. (SEE ANESTHESIA NOTE FOR ADDITIONAL MEDICATIONS THAT WERE ADMINISTERED.) PATIENT BECAME APNEIC AND BRADYCARDIC (low heart rate) ...BROUGHT TO THE ICU INTUBATED ..."

f. On 10/26/2022 at 11:43 AM Patient #1's medical record and event record was reviewed with the Vice President for Quality (VPQ). The VPQ stated there was no documentary evidence of an incident review or analysis conducted for the event.

g. On 10/26/2022 at 12:00 PM Patient #1's medical record and event record was reviewed with the Surgical Services Quality Coordinator (SSQC). The SSQC stated she was not aware of the event involving Patient #1 on 3/15/2022. The SSQC stated the incident was not sent to quality for peer review to ensure compliance with standards of care and conditions for participation relating to protecting a patient's right to care in a safe setting. Refer to Tag A0057.

Based on facility policy, medical record review, and interviews, it was determined the facility failed to provide a safe setting for patients in the hospital on telemetry monitoring, needing neurological checks and escalation of care for five patients (#3, #4, #7, #8, and #9) of 16 sampled patients. Patients #3, #7, and #9 were not provided telemetry monitoring, and appropriate monitoring and reassessments, resulting in their deaths. Refer to A0144.

Additionally, the facility failed to inform Patient #1's next of kin of a change of level of care and condition while in preop (time before surgery) due to an adverse reaction with anesthesia administration that resulted in incapacitation, admission to the Intensive Care Unit (ICU - critical care) and cancellation of an elective procedure. Refer to A0130.

These deficiencies are of such character as to substantially limit the hospitals capacity to furnish adequate care which adversely affect the health and safety of patients and results in the condition for participation for patient rights in noncompliance.

Based on interview and record review the facility failed to inform patients next of kin of a change of level of care and condition while in preop (time before surgery) due to an adverse reaction with anesthesia administration that resulted in incapacitation, admission to the Intensive Care Unit (ICU - critical care) and cancellation of an elective procedure in 1(#1) of 4 patients reviewed for operating room care.

This failure resulted in the violation of Patient #1's right to be informed.

Findings:

1. Patient # 1's medical record was reviewed. The record indicated Patient #1 was admitted to the facility on 3/15/22 and was discharged on 3/17/22. Patient #1's face sheet (document that gives patient information) indicated Patient# 1's spouse' name, address and two telephone numbers as the "PERSON TO NOTIFY" and "NEXT OF KIN." The "PRE-PROCEDURE COMMUNICATION" FORM indicated Patient #1 was in the facility for preop at 10:44 AM. on 3/15/2022. The record further indicated:

a. "Surgical Case Record" completed 3/15/22, 5:41 PM indicated, "PATIENT SURGERY CANCELED IN PRE-OP HOLD ...SURGERY OUTCOME CANCELED ..."

b. "History and Physical - Adult" dated 3/15/2022, 7:01 PM indicated, "Chief Complaint: ACUTE RESPIRATORY FAILURE ...58 YEARS OLD VERY PLEASANT ...PATIENT WAS BROUGHT IN TO THE INTENSIVE CARE UNIT AFTER PATIENT BECAME HYPOXIC (absence of enough oxygen) IN PREOP AREA AND HAD TO BE INTUBATED BY ANESTHESIA ...PATIENT RECEIVED SOME IV (intravenous) REMIFENTANYL (Opioid analgesic) AND BECAME HYPOXIC REQUIRING INTUBATION. HIS PUPILS ARE PINPOINT ...TRANSFERRED TO INTENSIVE CARE UNIT ..."
The document further indicated " ...General appearance: respiratory support, intubated sedated ..."

c. "Clinical Note" dated 3/15/2022, 8:19 PM indicated, " ...when just about pt (patient) to be moved to the OR (operating room), the patient became unresponsive and apneic (temporary cessation of breathing) and his saturation (oxygen level) dropped to low 80's (normal level 95-100%) ..." The document further indicated Patient 1 required emergent intubation, Midazolam (sedative medication) to treat possible seizure because of possible local anesthetic toxicity and Naloxone (Narcan) to reverse possible remifentanyl overdose ..."

d. "CONSULTATION" note dated 3/16/2022 indicated, " ...He was brought in yesterday for elective spine surgery on his neck ...was noted to become unresponsive ..."

e. "DISCHARGE SUMMARY" dated 3/28/2022 indicated, " ...During awake intubation the patient became unresponsive. It was clearly secondary to fentanyl overdose that required emergent intubation ...wait till next day to have a complete neurological evaluation status post the emergent intubation in a patient with severe cervical stenosis (nerve compression in the neck) ..."

f. There was no documentary evidence to indicate that Patient #1's spouse/next of kin was informed of the changes in Patient #1's level of care and condition, cancellation of procedure and admission to the ICU on 3/15/2022.

2. On 10/26/2022 at 12:00 PM, Patient #1's record was reviewed with the Surgical Services Quality Coordinator (SSQC). The SSQC confirmed there was no documentary evidence in Patient #1's record that his spouse/next of kin was informed of his change in condition, cancellation of procedure and admission to the ICU on 3/15/2022 while Patient #1 was incapacitated. The SSQC stated a note from the anesthesiologist written on 3/16/2022 indicated Patient #1 was extubated at 11:00 PM on 3/15/2022. The SSQC stated the note further indicated the sequence of events were discussed with the patient on 3/16/2022. The SSQC stated Patient #1's spouse should have been notified of the changes in his condition and admission to the ICU on 3/15/2022. The SSQC stated there was no facility policy and procedure to indicate when Patient #1's spouse should to have been informed of the critical change in his condition, but it was a standard of practice.


3. 10/21/2022 at 10:54 AM a telephone interview was conducted with Patient #1. Patient #1 stated he was scheduled for neck fusion (procedure to help stabilize spine and reduce pain) on 3/15/2022. Patient #1 stated during anesthesia administration in preop he became unresponsive which resulted in the cancellation of his procedure and admission to the ICU. Patient # 1 stated his spouse who was listed as his next of kin was not informed of the situation and his admission to the ICU while he was incapacitated on 3/15/2022.

Based on facility policy, medical record, staffing sheets, staffing grids and interviews the facility failed to provide care in a safe setting in 3 (#3, #4, #11) of 16 sampled patients.

Findings included:
1.
Review of Patient # 11's medical record reveals that patient is a 56-year-old female with past medical history of poorly controlled hypertension, who presented the Emergency Room on 09/02/22 with altered mental status with right sided gaze and right sided weakness.

Further Review of Patient #11 medical record reveals physician orders for continuous Telemetry monitoring on 09/02/2022 8:05 PM, and Telemetry monitoring continuous 09/13/2022 5:17 PM. No telemetry strips were found in the medical record.

Review of Patient # 11 medical record reveals Physician orders for neuro checks (Neurologic assessment/ Glasgow Coma Scale) every four hours on 09/13/2022 at 4:13PM in the MICU (Medical Intensive Care Unit). Upon review of the nursing assessment shows from 09/13/2022 through 09/19/2022 identified missed opportunity 30 times for neurological assessments.

Review of the facility internal document reveals that a STAT CT (computerized tomography) is to be done within 4 hours.

Review of Patient #11 medical record reveals that on 09/16/2022 at 6:45 AM Patient #11 was found on the floor. On 09/16/2022 at 6:58 AM a STAT CT head was ordered. Further review of the medical record shows that the RN (Registered Nurse) called Imaging at 10:50 AM for the STAT CT and the CT tech informed the RN that they have been calling MICU, but no one answered the phone. The CT was completed on 09/16/2022 at 11:44 AM, approximately 4.76 hours later.

On 10/25/2022 at 12:05 PM an interview was conducted with RN M who confirmed that Patient #11 fell out of bed and no staff was available. The Physician ordered a STAT CT and there was a delay in it being done because they did not have a unit secretary, and no one was available to answer the phone.

10/27/2022 at 1:30 PM an interview with the Quality Coordinator, Staff SS confirmed that the neuro- checks were not done for Patient #11.



2.
Review of the HPI (History of Present Illness) in the medical record, dated 11/17/20, reflected that Patient #3, an 82-year-old, came to the emergency room for a chief complaint of chest pain. Patient #3 had an extensive past cardiovascular history including coronary artery disease, CABG (coronary artery bypass graft: open heart surgery) in 2006 with multiple stents placed prior to the CABG and multiple stents placed after the CABG, and atrial fibrillation (A-fib) since 2020. He had labs significant for troponin 1.23 (an abnormal finding of protein in the blood indicating heart muscle damage or heart attack. Normal range is 0-0.04 ng/mL).

A review of physician's orders in the medical record reflected an order dated 11/17/20 for cardiac telemetry monitoring.
Review of the telemetry log for 11/17/20 revealed the following findings:
8:30 PM rapid, code blue 10:18 PM, the rate and rhythm was noted to be 104 and A-fib. 10:10 PM leads off and overhead broadcast was announced.
There was no further documentation on the logs that the nurse was contacted or notified, or that any response was received from the nurse.

Upon review of a nursing note in the medical record, entered by RN EE (registered nurse) on 2 Central, a medical-telemetry nursing unit where Patient #3 was admitted, the following documentation was discovered:
11/18/20 3:14 AM (late entry for 11/17/20 8:30 PM): Patient came back from CT (computed tomography) yelling that he wanted his nitro, complaining of chest pain. (Nitroglycerin which is used to prevent angina (chest pain) and to relieve an angina attack that is already occurring.) Vital signs taken, stable. EKG (electrocardiogram) done, indicated AMI (acute myocardial infarction). Rapid response called. Nitro given and he felt better.

Review of the Discharge Summary dated 11/18/20 05:55 AM for Patient #3 revealed troponins were trended and increased from 1.23 to 1.95 to 3.0 (an abnormal finding of protein in the blood indicating heart muscle damage or heart attack. Normal range is 0-0.04 ng/mL). Later that evening rapid response was called for chest pain. Patient was administered sublingual (SL) nitro (nitroglycerin) with resolution of chest pain and improvement in his blood pressure. Approximately 30 to 60 minutes after the rapid response, code blue was called for asystole (no detectible heart rhythm). After approximately 30 minutes the family made the decision to discontinue all lifesaving measures and the patient expired.
The discharge diagnosis reflected on the discharge summary was chest pain and cardiopulmonary arrest.

At 12:05 PM on 10/25/22 an interview was conducted with Staff B, Director of Patient Safety. Staff B stated that after the event, they looked at lack of communication between departments, facility, and personnel, conducted auditing of Rapid Response documentation occurred for three months, and educated nurses to escalate to cardiology. First year Resident Doctors were educated on appropriate escalation to second year Resident Doctors. The nurse was terminated for performance.

On 10/26/22 at 11:57 AM an interview was conducted with Staff C, Director of Quality, which revealed that she believed Patient #3 had a possible MI (myocardial Infarction or heart attack) upon review of troponins. "The EKG showed changes. Normally you would look at the EKG and if you saw an issue, notify the doctor. They should have called a rapid response sooner. They should have contacted the STEMI (S-T elevated MI) MD (medical doctor). He interprets whether it is or isn't. He is reachable by phone. The nurse should have called the doctor".

On 10/27/22 at 9:15 AM a follow up interview was conducted with Staff B, Director of Patient Safety. Staff B said this was the description of the event: The nurse failed to notify the telemetry room the rapid response was completed. The Resident Doctor misinterpreted the EKG as not showing changes in the inferior and posterior area. The nurse, post rapid response did no additional monitoring or vital signs. The patient wasn't sent to a higher level of care. The monitor room sent two overhead broadcasts the patient was off telemetry. The nurse resigned before we even had the RCA (root cause analysis). The patient had a nitro patch on and refused it. The Resident said to give him sublingual nitro instead. At the time of the rapid response the telemetry box was removed from the patient. The crash cart was brought in, and they were going to cardiovert (a medical procedure that uses quick, low-energy shocks to restore a regular heart rhythm). The telemetry room knew there was a rapid response in the room. The nurse didn't call to let the telemetry room know the rapid response was over. The telemetry box wasn't put back on. The nurse didn't respond to the rapid overhead page the second time which was because the telemetry box wasn't on.

Review of internal facility documentation revealed that around 10:15 PM on 11/17/20 while the nurse, RN EE was bringing Patient #3's medications, the EKG tech was in the room to give Patient #3 an EKG, but he was unresponsive. A code blue was called. Chest compressions started with no response. Patient #3 was pronounced at 10:51 PM.


Review of Policy PI 024.946 title Risk Management/Patient Safety Plan reveals:
A proactive ongoing systematic approach for the detection and resolution of events that may or do impact patient safety will be supported through: Recognition and acknowledgement of the potential for medical/health errors and/or injuries and risks to patient safety; ...Process and system focused corrections to reduce related failures including thorough and credible Serious Event Analysis and routine Failure Mode and Effects Analysis, Minimization of individual blame or retribution for involvement in a medical/health care error; Organizational learning about medical/health care error; and, The support of sharing of lessons learned to effect behavioral changes organizational wide and across other health care organizations.

Further review of internal facility documentation reflected a plan of correction dated 2/19/21 indicated: Audit all rapid response EKGs to ensure a resident level 2 review and documents their review of the interpretation in the medical record. Educate staff on Handoff Communication tools SBAR and CUS (To be utilized to communication the patient's situation, provide background history, current assessment of the patient with recommendation of the next step in their care.) Also, during times when there is a concern patient care is not appropriate to speak up and escalate to the next level of authority. Review appropriate bed placement with the Emergency Department Providers.
There was no indication telemetry staff were educated, or a change to the process implemented related to telemetry.

3.
Review of the medical record for Patient #4 revealed the patient presented to the facility ED on 1/16/2022 at 9:12PM for a complaint of Left Flank pain. Review of the record revealed the patient was triaged by an RN (registered nurse) at 9:15PM. The patient's vital signs were blood pressure 159/85, pulse 65 bpm, respiration rate 18, oxygen saturation 96 % on room air, temperature 98.3. Review of the triage assessment revealed the RN assigned the patient an acuity level of ESI - 2.

Review of doctors' notes reveal at 10:45PM on 01/16/2022, Patient #4 received a CT (computerized tomography) of the abdomen and pelvis with contrast and subsequently developed chest pain, burning sensation and throat swelling concerning for suspected anaphylaxis due to the CT dye. The patient was prescribed and given IV (intravenous) Solumedrol and IV Benadryl. At 11:00PM a verbal order from the physician to the nurse was given for IM (intramuscular) epinephrine 0.5mvg. The nurse administered the epinephrine IV (instead of IM), and the patient immediately went into ventricular tachycardia (VTach). Stat EKG was ordered and showed ST elevation in AVR, with ST depressions (indicating a blockage of the involved coronary artery and that the heart muscle is currently dying). This persisted on repeat EKG' s. At 01:15 AM, Patient was taken straight from the ER to the Catheterization Lab for emergency heart catheterization, then admitted to ICU following the procedure for further monitoring.

Interview on 10/24/2022 at 2:20 PM regarding Patient #4 with Staff B, Director of Patient Safety, he summarized the even as: Patient #4 had a CT with contrast which resulted in SOB and difficulty breathing. A verbal order was given for Epinephrine. An adverse reaction to receiving this medication occurred. The result was the incorrect route of mediation (epinephrine), which was given IV instead of IM. Patient developed multiple episodes of non-sustained V Tach on the monitor. The nurse that gave the medication was on orientation, but the preceptor was in the room at the time. The physician was in the room and noted the error. The patient was already on telemetry monitoring, an EKG was done immediately, ST elevation was noted (indicating a blockage of the involved coronary artery and that the heart muscle is currently dying). Patient taken to catheterization lab. Patient was admitted to ICU (Intensive Care Unit) for further monitoring and went home 4 days later. Staff B further stated he was not aware of any other issues when reviewing this chart. When asked if he noticed that no assessment or reassessment was completed on this patient in the ER other than on initial triage for approximately 4 hours, he stated he was aware, but does not know why he did not include it in your serious event analysis. He also stated that all involved in the event analysis were aware that the reassessment of vitals was not completed on this patient, therefore no further actions, or change in processes were completed to address the reassessment issue in the ER department.

Based on staff interview and facility document review, the facility failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program related to telemedicine and nursing services, and medication administration to improve the quality of healthcare provide to the public . Refer to A0273, A0283, A0309.

These deficiencies are of such character as to substantially limit the hospitals capacity to furnish adequate care which adversely affect the health and safety of patients and results in the condition for participation for QAPI in noncompliance.

Based on staff interview and facility document review it was determined the facility failed to implement timely actions to improve performance. The facility failed to address identified problem areas related to the telemedicine in 1 of 1 QAPI plan.
Finding includes:
On 10/25/2022 at 09:30AM, interview with staff HH, RN Director of Telemetry, HH stated he had "identified problem areas related to his telemetry department and was capturing data since August 2022 related to the following: patient care data, critical values, escalation of critical values, durations patients on and off telemetry, staff breaks and telemetry rounding by management." "I was capturing this data as we have had sentinel incident and events in which patients have been harmed and expired related to telemetry."
On 10/25/2022 at 9:40AM this data was reviewed and confirmed to be correct.
On 10/25/2022 at 10:00AM, interview with staff B, Director of Patient Safety, confirmed he was aware of the data being collected by Telemetry and confirmed no processes to measure, analyze, and track quality indicators was being implemented.
On 10/25/2022 at 10:00AM, interview with staff C, Director of Quality confirmed she was aware of the data being collected by Telemetry and confirmed no processes to measure, analyze, and track quality indicators was being implemented by the Quality Department.
On 10/27/2022 at 10:30AM review of the Hospital wide QAPI program failed to find any quality improvement processes or plan related to Telemetry.

Based on policy and procedure review, medical record reviews, internal facility documentation, interviews, review of staffing grids and staffing sheets, it was determined that the hospital failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, including a complete analysis of adverse events, development of an effective plans of correction, and measures in place to track performance and success related to:
1. Cardiac telemetry monitoring for 3 patients (#1, #3, and #9) of 17 sampled patients,

2. Medication administration adverse incident involving Patient #1.

Findings included

1.
Review of the facility policy titled, "Cardiac Telemetry Monitoring", # WFD.PC.023, approval date 06/2021 ... Cardiac monitor may only be placed or discontinued with a physician orders ... Personnel in the role of the Monitor tech will be responsible for monitoring cardiac telemetry, running documentation strips ...Page 9 ...The printed telemetry strips will be placed in the patient medical record ...Cardiac Telemetry Monitoring Documentation: Every 12 hours (near the beginning of the shift) and more frequently as indicated by patient condition the telemetry strip will be interpreted (rate, PR interval, QRS interval, name of rhythm) by Monitor Technician and communicated to the RN. The RN will validate the cardiac strip(s) interpretation by the Monitor Technician ... the monitor technician should immediately notify the RN of changes in patient's rhythm. Monitor strip will be run to capture changes in rate or rhythm ...The registered Nurse is responsible to ensure that the patient is being appropriately monitored at all times ...Areas where cardiac telemetry monitoring is not connected to centralized monitoring (ICU) ... Guidelines related to protocol telemetry monitoring, alarms, documentation and competency of caregivers will be followed as per this policy.

Review of the Clinical Safety Improvement Program (CSIP) 2021 Assessment showed: Telemetry technician and RN education on telemetry safety bundle, adopt standard telemetry orders and or discontinued workflow, policy was reviewed and revised, integration of telemetry reports-outs into daily safety huddle.
"The goal of achieving greater than XX% was met for 2021. We met 100% of our goals. A total of xxx,xxx was received out of a the total of xxx,xxx portion."

On 10/27/2022 11:20 AM an interview with the Director of Quality revealed they did the CSIP for telemetry, but they did not keep records of what they did. Also was not able to disclose what they tracked and trended to come up with the 100% goals met.

A review of Patient #9's medical record reveals that the patient was admitted on 08/09/2022 on the cardiac telemetry unit for acute decompensation of chronic biventricular heart failure (both sides of the heart are affected, and blood does not pump as well as it should). Review of the nursing notes dated 08/16/2022 showed the respiratory therapist (RT) called "code blue" (cardiac or respiratory arrest) after finding the patient unresponsive and pulseless at 2:45AM. CPR (Cardiopulmonary resuscitation) was initiated, and Patient #9 was transferred to ICU and ultimately was expired at 03:07 AM.
Review of the Patient #9's cardiac telemetry strips dated 08/16/2022 at 2:07 AM revealed a change in cardiac rhythm, which showed Ventricular tachycardia (VT or V-tach is a type of abnormal heart rhythm which occurs when the lower chamber of the heart beats too fast to pump well and the body doesn't receive enough oxygenated blood.)
Upon further review of Patient #9's medical record, there was no evidence that the telemetry technician notified the nurse of the lethal cardiac rhythm change.
Upon review of the telemetry log, no evidence was found of notification of Patient #9's nurse of a lethal cardiac rhythm change.
Interview with the Director of Quality on 08/17/2022 at 8:30 AM revealed the facility is aware of the event with Patient #9 that occurred on 08/16/2022 at 2:07 AM.

Review of Patient #11 medical record reveals a Physician order for telemetry monitoring continuous dated 09/02/2022 at 8:05 PM. Further review of the medical record reveals no cardiac telemetry monitoring strips evident.
Interview with the Director Patient Safety on 10/26/2022 at 9:00 AM disclosed that the complete medical record was provided.



2.
Review of the HPI (History of Present Illness) in the medical record, dated 11/17/20, reflected that Patient #3, an 82-year-old, came to the emergency room for a chief complaint of chest pain. Patient #3 had an extensive past cardiovascular history including coronary artery disease, CABG (coronary artery bypass graft: open heart surgery) in 2006 with multiple stents placed prior to the CABG and multiple stents placed after the CABG, and atrial fibrillation (A-fib) since 2020. Patient #3 had labs significant for troponin 1.23 (an abnormal finding of protein in the blood indicating heart muscle damage or heart attack. Normal range is 0-0.04 ng/mL).

Upon review of a nursing note in the medical record, entered by RN EE (registered nurse) on 2 Central, a medical-telemetry nursing unit where Patient #3 was admitted, the following documentation was discovered:
11/17/20 3:14 AM (late entry from 11/16/20 8:30 PM): patient came back from CT (computed tomography) yelling that he wanted his nitro, complaining of chest pain. Vital signs taken, stable. EKG (electrocardiogram) done, indicated AMI (acute myocardial infarction). Rapid response called. Nitro given and he felt better. Around 10:15 PM while bringing his medications, the EKG tech was in his room to perform an EKG on him, but he was unresponsive and code blue was called. Chest compressions started with no response. Patient pronounced at 10:51 PM.

A review of physician's orders in the medical record reflected an order dated 11/17/20 for cardiac telemetry monitoring.

Review of the telemetry log for 11/17/20 revealed the following findings:
8:30 PM rapid, code blue 10:18 PM. The rate was 104 and rhythm was noted to be A-fib. 10:10 PM leads off and broadcast was announced.
There was no further documentation on the logs that the nurse was contacted or notified, or that any response was received from the nurse.

Review of the Discharge Summary dated 11/18/20 05:55AM for Patient #3 revealed troponins were trended and increased from 1.23 to 1.95 to 3.0 (an abnormal finding of protein in the blood indicating heart muscle damage or heart attack. Normal range is 0-0.04 ng/mL). Later that evening rapid response was called for chest pain. Patient was administered sublingual (SL) nitro (nitroglycerin) with resolution of chest pain and improvement in his blood pressure. Approximately 30 to 60 minutes after the rapid response, code blue was called for asystole (no detectible heart rhythm). After approximately 30 minutes the family made the decision to discontinue all lifesaving measures and the patient expired.
The discharge diagnosis reflected on the discharge summary was chest pain and cardiopulmonary arrest.

At 12:05 PM on 10/25/22 an interview was conducted with Staff B, Director of Patient Safety. Staff B stated that after the event, they looked at lack of communication between departments, facility, and personnel, conducted auditing of Rapid Response documentation occurred for three months, and educated nurses to escalate to cardiology. First year Resident Doctors were educated on appropriate escalation to second year Resident Doctors. The nurse was terminated for performance.

At 11:57 AM on 10/26/22 an interview was conducted with Staff C, Director of Quality, which revealed that she believed Patient #3 had a possible MI upon review of troponins. She stated "The EKG showed changes. Normally you would look at the EKG and if you saw an issue, notify the doctor. They should have called a rapid response sooner. They should have contacted the STEMI (S-T elevated MI) MD (medical doctor). He interprets whether it is or isn't. He is reachable by phone. The nurse should have called the doctor".

On 10/27/22 at 9:15 AM a follow up interview was conducted with Staff B, Director of Patient Safety. Staff B said this was his description of the event: The nurse failed to notify the telemetry room the rapid response was completed. Resident misinterpretation of the EKG showing changes in the inferior and posterior area. The nurse, post rapid response did no additional monitoring or vital signs. The patient wasn't sent to a higher level of care. The monitor room sent two overhead broadcasts the patient was off telemetry. The nurse resigned before we even had the RCA (root cause analysis). The patient had a nitro patch on and refused it. The Resident said to give him sublingual nitro instead. At the time of the rapid response the telemetry box was removed from the patient. The crash cart was brought in and they were going to cardiovert. The telemetry room knew there was a rapid response in the room. The nurse didn't call to let the telemetry room know the rapid response was over. Clearly the telemetry box wasn't put back on. The nurse didn't respond to the rapid overhead page the second time which was because the telemetry box wasn't on.

Further review of internal facility documentation reflected a plan of correction dated 2/19/21 indicated:
Audit all rapid response EKGs to ensure a resident level 2 review and documents their review of the interpretation in the medical record.
Educate staff on Handoff Communication tools SBAR and CUS. To be utilized to communication the patient's situation, provide background history, current assessment of the patient with recommendation of the next step in their care. Also, during times when there is a concern patient care is not appropriate to speak up and escalate to the next level of authority.
Review appropriate bed placement with the Emergency Department Providers.
There was no indication telemetry staff were educated, or a change to the process implemented related to telemetry.

1. Patient # 1's medical record was reviewed. The record indicated Patient #1 was admitted to the facility on 3/15/22 and was discharged on 3/17/22. "Surgical Case Record" completed 3/15/22, 5:41 PM indicated, "PATIENT SURGERY CANCELED IN PRE-OP HOLD ...SURGERY OUTCOME CANCELED ..." The medical record further indicated:

a. "History and Physical - Adult" dated 3/15/2022, 7:01 PM indicated, "Chief Complaint: ACUTE RESPIRATORY FAILURE ...58 YEARS OLD VERY PLEASANT ...PATIENT WAS BROUGHT IN TO THE INTENSIVE CARE UNIT AFTER PATIENT BECAME HYPOXIC (absence of enough oxygen) IN PREOP AREA AND HAD TO BE INTUBATED BY ANESTHESIA ...PATIENT RECEIVED SOME IV (intravenous) REMIFENTANYL (Opioid analgesic) AND BECAME HYPOXIC REQUIRING INTUBATION. HIS PUPILS ARE PINPOINT ...TRANSFERRED TO INTENSIVE CARE UNIT ..."
The document further indicated " ...General appearance: respiratory support, intubated sedated ..."

b. "Clinical Note" dated 3/15/2022, 8:19 PM indicated, " ...when just about pt (patient) to be moved to the OR (operating room), the patient became unresponsive and apneic (temporary cessation of breathing) and his saturation (oxygen level) dropped to low 80's (normal level 95-100%) ..." The document further indicated Patient 1 required emergent intubation, Midazolam (sedative medication) to treat possible seizure because of possible local anesthetic toxicity and Naloxone (Narcan) to reverse possible remifentanyl overdose ..."

c. "CONSULTATION" note dated 3/16/2022 indicated, " ...He was brought in yesterday for elective spine surgery on his neck ...was noted to become unresponsive ..."

d. "DISCHARGE SUMMARY" dated 3/28/2022 indicated, " ...During awake intubation the patient became unresponsive. It was clearly secondary to fentanyl overdose that required emergent intubation ...wait till next day to have a complete neurological evaluation status post the emergent intubation in a patient with severe cervical stenosis (nerve compression in the neck) ..."

2. Review of the "Patient Event Record" dated 3/15/2022, 5:15 PM for Patient #1 indicated, " ...PATIENT WAS IN PRE-OP RECEIVING PRE-OPERATIVE TREATMENT ...WAS BEING PREPARED FOR AWAKE INTUBATION ...ANESTHESIA ADMINISTERED LIDOCAINE TO NUMB THE PATIENT'S THROAT AND SOON AFTER THE PATIENT BECAME UNRESPONSIVE. (SEE ANESTHESIA NOTE FOR ADDITIONAL MEDICATIONS THAT WERE ADMINISTERED.) PATIENT BECAME APNEIC AND BRADYCARDIC (low heart rate) ...BROUGHT TO THE ICU INTUBATED ..."

3. On 10/26/2022 at 11:43 AM Patient #1's medical record and event record was reviewed with the Vice President for Quality (VPQ). The VPQ stated there was no documentary evidence of an incident review or analysis conducted for the event.

4. On 10/26/2022 at 12:00PM Patient #1's medical record and event record was reviewed with the Surgical Services Quality Coordinator (SSQC). The SSQC stated she was not aware of the event involving Patient #1 on 3/15/2022. The SSQC stated the incident was not sent to quality for peer review.

5. Review of the facility policy and procedure title "Occurrence Report/Notifications" last reviewed 4/2022 indicated, "The purpose of the occurrence report is to report factual information about an occurrence ...Occurrence Reports are used to improve the quality of patient care and overall safety, and/or mitigate or eliminate adverse outcomes ..." The policy and procedure further indicated " ...Risk Manager Responsibilities: 1. Regular and systematic review of all incident reports ...3. Recommends further investigation by manager, if necessary, to identify trends ..."

6. Review of the facility policy and procedure titled "Peer Review" last reviewed 9/2022 indicated, " ...Peer Review Criteria: ...b. Unexpected outcomes ...PROCEDURES: cases are referred to the Quality Management Department by one of the following mechanisms a. Clinical staff of Risk Management may request review of clinical practice for cases in which an occurrence has been filed ...2. Cases are either trended or referred to peer review ..."

Based on interviews and record reviews the facility's governing body failed to ensure an ongoing program for quality improvement and patient safety is implemented and maintained in 4 adverse events of 16 reviewed.
1. The facility was unable to provide thorough and credible quality improvement activities for identified opportunities related to telemetry services (Patient #9, #11 and #3) and,
2. The facility did not conduct a thorough and credible review and analysis of an adverse incident (Patient #1).

Findings included:

A. Review of the facility policy titled, "Cardiac Telemetry Monitoring", # WFD.PC.023, approval date 06/2021 ... Cardiac monitor may only be placed or discontinued with a physician orders ... Personnel in the role of the Monitor tech will be responsible for monitoring cardiac telemetry, running documentation strips ...Page 9 ...The printed telemetry strips will be placed in the patient medical record ...Cardiac Telemetry Monitoring Documentation: Every 12 hours (near the beginning of the shift) and more frequently as indicated by patient condition the telemetry strip will be interpreted (rate, PR interval, QRS interval, name of rhythm) by Monitor Technician and communicated to the RN. The RN will validate the cardiac strip(s) interpretation by the Monitor Technician ... the monitor technician should immediately notify the RN of changes in patient's rhythm. Monitor strip will be run to capture changes in rate or rhythm ...The registered Nurse is responsible to ensure that the patient is being appropriately monitored at all times ...Areas where cardiac telemetry monitoring is not connected to centralized monitoring (ICU) ... Guidelines related to protocol telemetry monitoring, alarms, documentation and competency of caregivers will be followed as per this policy.

Review of the Clinical Safety Improvement Program (CSIP) 2021 Assessment showed: Telemetry technician and RN education on telemetry safety bundle, adopt standard telemetry orders and or discontinued workflow, policy was reviewed and revised, integration of telemetry reports-outs into daily safety huddle.
"The goal of achieving greater than XX% was met for 2021. We met 100% of our goals. A total of xxx,xxx was received out of a the total of xxx,xxx portion."

On 10/27/2022 11:20 AM an interview with the Director of Quality revealed they did the CSIP for telemetry, but they did not keep records of what they did. Also was not able to disclose what they tracked and trended to come up with the 100% goals met.

1. Patient #9's medical record was reviewed. Patient #9 was admitted to the cardiac telemetry unit for acute decompensation of chronic biventricular heart failure (both sides of the heart are affected, and blood does not pump as well as it should) on 08/09/2022.

a. Review of the nursing notes dated 08/16/2022 showed the respiratory therapist (RT) called "code blue" (cardiac or respiratory arrest) after finding the patient unresponsive and pulseless at 2:45 AM. CPR (Cardiopulmonary resuscitation) was initiated, and Patient #9 was transferred to ICU (Intensive care unit) and expired the following morning 8/17/2022 at 03:07 AM.

b. Review of the Patient #9's cardiac telemetry strips dated 08/16/2022 at 2:07 AM revealed a change in cardiac rhythm, which showed Ventricular tachycardia (VT or V-tach is a type of abnormal heart rhythm which occurs when the lower chamber of the heart beats too fast to pump well and the body doesn't receive enough oxygenated blood.)

c. There was no documentary evidence in Patient #9's medical record to indicate that the nurse was notified by the telemetry technician of the lethal cardiac rhythm change on 8/16/2022 at 2:07 AM.

d. Review of the telemetry log did not indicate Patient #9's nurse was notified of the patient's lethal cardiac rhythm change on 8/16/2022 at 2:07 AM.

e. Interview with the Director of Quality on 08/17/2022 at 8:30 AM revealed the facility Quality Program was aware of the serious event that involved Patient #9 on 08/16/2022 at 2:07 AM.

2. Patient 11's medical record was reviewed. The record indicated a physician order dated 09/02/2022 at 8:05 PM for continuous telemetry monitoring.

a. There were no cardiac telemetry monitoring strips evident in the patient's medical record. There was no documentary evidence in the patient's medical record that the physician's order on 09/02/2022 for continuous telemetry monitor was carried out.

3. Patient #3's medical record was reviewed. The record indicated Patient #3, an 82-year-old, came to the emergency room for chest pain. Patient #3 had an extensive past cardiovascular history including coronary artery disease, CABG (coronary artery bypass graft).

a. A nursing note dated 11/17/20 3:14 AM indicated, late entry from 11/16/20 8:30 PM: patient came back from CT (computed tomography) yelling that he wanted his nitro, complaining of chest pain. Vital signs taken, stable. EKG (electrocardiogram) done, indicated AMI (acute myocardial infarction). Rapid response called. Nitro given and he felt better. Around 10:15 PM while bringing his medications, the EKG tech was in the room to complete an EKG on him, but Patient #3 was unresponsive and code blue was called. Chest compressions started with no response. Patient was pronounced at 10:51 PM.

b. The record indicated a physician's order dated 11/17/20 for cardiac telemetry monitoring.

c. The telemetry log and strips for 11/17/20 indicated: 8:30 PM "rapid response" (due to chest pain-leads were off), 9:26 PM "came off tele", 9:51 PM "on for two minutes", 9:53 PM "off tele", 10:10 PM "leads off".

There was no documentation on the telemetry logs that the nurse was contacted or notified when telemetry monitoring was off, or that any response was received from the nurse.

d. Review of the Medical Quality Meeting Minutes, dated 2/19/21, revealed the following findings: " ...the nurse failed to follow up on the patient with vitals after a rapid response was called. Cardiac consult was ordered as routine (can be done the next day) instead of stat (right away). The nurse did not alert the telemetry monitor room when the rapid response was over and therefore the patient was not put back into telemetry monitoring in the central monitor room; telemetry monitoring technician was not able to watch the patient's cardiac rhythm. The telemetry technician sent out alerts on the nurse's facility provided phone, but the nurse did not act on the alerts ..."

e. At 12:05 PM on 10/25/22 an interview was conducted with Staff B, Director of Patient Safety. Staff B stated that after the event, they looked at lack of communication between departments, facility, and personnel, conducted auditing of Rapid Response documentation occurred for three months, and educated nurses to escalate to cardiology. First year Resident Doctors were educated on appropriate escalation to second year Resident Doctors. The nurse was terminated for performance.


f. On 10/27/22 at 9:15 AM a follow up interview was conducted with Staff B, Director of Patient Safety. Staff B said this was his description of the event: The nurse failed to notify the telemetry room the rapid response was completed. Resident misinterpretation of the EKG showing changes in the inferior and posterior area. The nurse, post rapid response did no additional monitoring or vital signs. The patient wasn't sent to a higher level of care. The monitor room sent two overhead broadcasts the patient was off telemetry. The nurse resigned before we even had the RCA (root cause analysis). Staff B further stated the telemetry box wasn't put back on. The nurse didn't respond to the rapid overhead page the second time which was because the telemetry box wasn't on.

g. Further review of internal facility documentation dated 2/19/21 reflected a plan of correction: Audit all rapid response EKGs to ensure a resident level 2 review and documents their review of the interpretation in the medical record.
Educate staff on Handoff Communication tools SBAR (a communication tool for giving information to another provider that stands for Situation, Background, Assessment and Recommendation) and CUS ( A communication tool with terms to assist in escalation of care that stands for Concern, Uncomfortable, Safety) . To be utilized to communication the patient's situation, provide background history, current assessment of the patient with recommendation of the next step in their care. Also, during times when there is a concern patient care is not appropriate to speak up and escalate to the next level of authority. Review appropriate bed placement with the Emergency Department Providers.

h. There was no indication telemetry staff were re-educated, or a change to the process implemented related to telemetry.

B. Review of the facility policy and procedure title "Occurrence Report/Notifications" last reviewed 4/2022 indicated, "The purpose of the occurrence report is to report factual information about an occurrence ...Occurrence Reports are used to improve the quality of patient care and overall safety, and/or mitigate or eliminate adverse outcomes ..." The policy and procedure further indicated " ...Risk Manager Responsibilities: 1. Regular and systematic review of all incident reports ...3. Recommends further investigation by manager, if necessary, to identify trends ..."

Review of the facility policy and procedure titled "Peer Review" last reviewed 9/2022 indicated, " ...Peer Review Criteria: ...b. Unexpected outcomes ...PROCEDURES: cases are referred to the Quality Management Department by one of the following mechanisms a. Clinical staff of Risk Management may request review of clinical practice for cases in which an occurrence has been filed ...2. Cases are either trended or referred to peer review ..."

1. Patient # 1's medical record was reviewed. The record indicated Patient #1 was admitted to the facility on 3/15/22 and was discharged on 3/17/22. "Surgical Case Record" completed 3/15/22, 5:41 PM indicated, "PATIENT SURGERY CANCELED IN PRE-OP HOLD ...SURGERY OUTCOME CANCELED ..." The medical record further indicated:

a. "History and Physical - Adult" dated 3/15/2022, 1901 (7:01 p.m.) indicated, "Chief Complaint: ACUTE RESPIRATORY FAILURE ...58 YEARS OLD VERY PLEASANT ...PATIENT WAS BROUGHT IN TO THE INTENSIVE CARE UNIT AFTER PATIENT BECAME HYPOXIC (absence of enough oxygen) IN PREOP AREA AND HAD TO BE INTUBATED BY ANESTHESIA ...PATIENT RECEIVED SOME IV (intravenous) REMIFENTANYL (Opioid analgesic) AND BECAME HYPOXIC REQUIRING INTUBATION. HIS PUPILS ARE PINPOINT ...TRANSFERRED TO INTENSIVE CARE UNIT ..."
The document further indicated " ...General appearance: respiratory support, intubated sedated ..."

b. "Clinical Note" dated 3/15/2022, 8:19 PM indicated, " ...when just about pt (patient) to be moved to the OR (operating room), the patient became unresponsive and apneic (temporary cessation of breathing) and his saturation (oxygen level) dropped to low 80's (normal level 95-100%) ..." The document further indicated Patient 1 required emergent intubation, Midazolam (sedative medication) to treat possible seizure because of possible local anesthetic toxicity and Naloxone (Narcan) to reverse possible remifentanyl overdose ..."

c. "CONSULTATION" note dated 3/16/2022 indicated, " ...He was brought in yesterday for elective spine surgery on his neck ...was noted to become unresponsive ..."

d. "DISCHARGE SUMMARY" dated 3/28/2022 indicated, " ...During awake intubation the patient became unresponsive. It was clearly secondary to fentanyl overdose that required emergent intubation ...wait till next day to have a complete neurological evaluation status post the emergent intubation in a patient with severe cervical stenosis (nerve compression in the neck) ..."

e. Review of the "Patient Event Record" dated 3/15/2022, 5:15 PM for Patient #1 indicated, " ...PATIENT WAS IN PRE-OP RECEIVING PRE-OPERATIVE TREATMENT ...WAS BEING PREPARED FOR AWAKE INTUBATION ...ANESTHESIA ADMINISTERED LIDOCAINE TO NUMB THE PATIENT'S THROAT AND SOON AFTER THE PATIENT BECAME UNRESPONSIVE. (SEE ANESTHESIA NOTE FOR ADDITIONAL MEDICATIONS THAT WERE ADMINISTERED.) PATIENT BECAME APNEIC AND BRADYCARDIC (low heart rate) ...BROUGHT TO THE ICU INTUBATED ..."

f. On 10/26/2022 at 11:43 AM Patient #1's medical record and event record was reviewed with the Vice President for Quality (VPQ). The VPQ stated there was no documentary evidence of an incident review or analysis conducted for the event.

g. On 10/26/2022 at 12:00 PM Patient #1's medical record and event record was reviewed with the Surgical Services Quality Coordinator (SSQC). The SSQC stated she was not aware of the event involving Patient #1 on 3/15/2022. The SSQC stated the incident was not sent to quality for peer review.

Based on observation, medical record reviews, facility policy review, and interviews it was determined the facility failed to provide:

A. Telemetry monitoring, and appropriate monitoring of vital signs and reassessments, in 4 (Patients #3, #7, #8, #9) of 16 patients, resulting in deaths. Refer to A0392.

B. Adequate staffing and adhere to the policy and procedure of adequate staffing in 4 (MICU, CSU, SICU and 3 East) nursing areas reviewed out of 4, resulting in the injury of a patient. Refer to A0398.

C. Safe verbally ordered medication administration to 1 patients (#4) of 17 patients sampled in the Emergency Department. Refer to A0407.

Based on record reviews, policy review, review of internal facility documentation, interviews, staffing sheets and staffing grids, the hospital failed to ensure the nursing care and services provided to patients met professional standards of practice for five patients (#3, #4, #7, #8, and #9) of 17 sampled patients.
1. Patients #3, #7, and #8, #9 were not provided telemetry monitoring, and appropriate monitoring of their vital signs and reassessments, resulting in their deaths.
2. Patient #7 stat (right away) laboratory orders were not completed, in which patient expired.

Findings included:
1.
Review of the HPI (History of Present Illness) in the medical record, dated 11/17/20, reflected that Patient #3, an 82-year-old, came to the emergency room for a chief complaint of chest pain. Patient #3 had an extensive past cardiovascular history including coronary artery disease, CABG (coronary artery bypass graft: open heart surgery) in 2006 with multiple stents placed prior to the CABG and multiple stents placed after the CABG, and atrial fibrillation (A-fib) since 2020. He had labs significant for troponin 1.23 (an abnormal finding of protein in the blood indicating heart muscle damage or heart attack. Normal range is 0-0.04 ng/mL).

A review of physician's orders in the medical record reflected an order dated 11/17/22 for cardiac telemetry monitoring.
Review of the telemetry log for 11/17/20 revealed the following findings:
Events:
8:30 PM rapid, code blue 10:18 PM. The rate was 104 and rhythm was noted to be Atrial fibrillation (A-fib). 10:10 PM leads off and broadcast was announced.
There was no further documentation on the logs that the nurse was contacted or notified, or that any response was received from the nurse.

Upon review of a nursing note in the medical record, entered by RN EE (registered nurse) on 2 Central, a medical-telemetry nursing unit where Patient #3 was admitted, the following documentation was discovered:
11/18/20 3:14 AM (late entry for 11/17/20 8:30 PM): Patient came back from CT (computed tomography) yelling that he wanted his nitro, complaining of chest pain. (Nitroglycerin which is used to prevent angina (chest pain) and to relieve an angina attack that is already occurring.) Vital signs taken, stable. EKG (electrocardiogram) done, indicated AMI (acute myocardial infarction). Rapid response called. Nitro given and he felt better. Around 10:15 PM while bringing his medications, the EKG tech was getting EKG on him, but he was unresponsive and code blue was called. Chest compressions started with no response. Patient pronounced at 10:51 PM.


Review of the Discharge Summary for Patient #3 revealed troponins were trended and increased from 1.23 to 1.95 to 3.0. Later that evening rapid response was called for chest pain. Patient was administered sublingual (SL) nitro (nitroglycerin) with resolution of chest pain and improvement in his blood pressure. Approximately 30 to 60 minutes after the rapid response, code blue was called for asystole (no detectible heart rhythm). After approximately 30 minutes the family made the decision to discontinue all lifesaving measures and the patient expired.
The discharge diagnosis indicated on the discharge summary was chest pain and cardiopulmonary arrest.

Review of the facility policy titled, "Cardiac Telemetry Monitoring", # WFD.PC.023, approval date 06/2021 ... Cardiac monitor may only be placed or discontinued with a physician orders ... Personnel in the role of the Monitor tech will be responsible for monitoring cardiac telemetry, running documentation strips ...Page 9 ...The printed telemetry strips will be placed in the patient medical record ...Cardiac Telemetry Monitoring Documentation: Every 12 hours (near the beginning of the shift) and more frequently as indicated by patient condition the telemetry strip will be interpreted (rate, PR interval, QRS interval, name of rhythm) by Monitor Technician and communicated to the RN. The RN will validate the cardiac strip(s) interpretation by the Monitor Technician ... the monitor technician should immediately notify the RN of changes in patient's rhythm. Monitor strip will be run to capture changes in rate or rhythm ...The registered Nurse is responsible to ensure that the patient is being appropriately monitored at all times ...Areas where cardiac telemetry monitoring is not connected to centralized monitoring (ICU) ... Guidelines related to protocol telemetry monitoring, alarms, documentation and competency of caregivers will be followed as per this policy.

At 12:05 PM on 10/25/22 an interview was conducted with Staff B, Director of Patient Safety. He stated that they looked at lack of communication between departments, facility, and personnel. Auditing of Rapid Response documentation occurred for three months. They educated nurses to escalate to cardiology. Residents 1 educated on appropriate escalation to Resident 2. The nurse was terminated for performance.

At 11:57 AM on 10/26/22 an interview was conducted with Staff C, Director of Quality, which revealed that she believed Patient #3 had a possible MI(myocardial infarction or heart attack) upon review of troponins. "The EKG showed changes. Normally you would look at the EKG and if you saw an issue, notify the doctor. They should have called a rapid response sooner. They should have contacted the STEMI (S-T elevated MI) MD (medical doctor). He interprets whether it is or isn't. He is reachable by phone. The nurse should have called the doctor".

On 10/27/22 at 9:15 AM a follow up interview was conducted with Staff B, Director of Patient Safety. Staff B said this was the description of the event: The nurse failed to notify the telemetry room the rapid response was completed. The Resident Doctor misinterpreted the EKG as not showing changes in the inferior and posterior area. The nurse, post rapid response did no additional monitoring or vital signs. The patient wasn't sent to a higher level of care. The monitor room sent two overhead broadcasts the patient was off telemetry. The nurse resigned before we even had the RCA (root cause analysis). The patient had a nitro patch on and refused it. The Resident said to give him sublingual nitro instead. At the time of the rapid response the telemetry box was removed from the patient. The crash cart was brought in, and they were going to cardiovert (a medical procedure that uses quick, low-energy shocks to restore a regular heart rhythm). The telemetry room knew there was a rapid response in the room. The nurse didn't call to let the telemetry room know the rapid response was over. The telemetry box wasn't put back on. The nurse didn't respond to the rapid overhead page the second time which was because the telemetry box wasn't on.

Review of internal facility documentation revealed that around 10:15 PM on 11/17/20 while the nurse, RN EE was bringing Patient #3's medications, the EKG tech was in the room to give Patient #3 an EKG, but he was unresponsive. A code blue was called. Chest compressions started with no response. Patient #3 was pronounced at 10:51 PM.
Review of Policy PI 024.946 title Risk Management/Patient Safety Plan reveals:
A proactive ongoing systematic approach for the detection and resolution of events that may or do impact patient safety will be supported through: Recognition and acknowledgement of the potential for medical/health errors and/or injuries and risks to patient safety; ...Process and system focused corrections to reduce related failures including thorough and credible Serious Event Analysis and routine Failure Mode and Effects Analysis, Minimization of individual blame or retribution for involvement in a medical/health care error; Organizational learning about medical/health care error; and, The support of sharing of lessons learned to effect behavioral changes organizational wide and across other health care organizations.

Further review of internal facility documentation reflected a plan of correction dated 2/19/21 indicated: Audit all rapid response EKGs to ensure a resident level 2 review and documents their review of the interpretation in the medical record. Educate staff on Handoff Communication tools SBAR and CUS (To be utilized to communication the patient's situation, provide background history, current assessment of the patient with recommendation of the next step in their care.) Also, during times when there is a concern patient care is not appropriate to speak up and escalate to the next level of authority. Review appropriate bed placement with the Emergency Department Providers.
There was no indication telemetry staff were educated, or a change to the process implemented related to telemetry.

Review of the facility policy titled "Stat orders." Reviewed 3/22 states, "stat orders should only be used in cases of extreme emergency or for life threatening situations." 2. Laboratory orders: the lab will respond within 15-30 minutes for stat orders.


Review of the medical record for Patient #8 revealed the patient a 79 year old female past medical history significant for atrial fibrillation on Eliquis was brought in to the ER (Emergency Room) as a stoke alert by EMS (Emergency Medical Services) on 10/13/2022 at 5:41 PM, for evaluation of altered mental status with aphasia and confusion and right sided weakness just prior to a ground level fall.
At 5:44 PM Stat (right away) order for cardiac continuous monitoring was placed.
At 9:05 PM, Patient was placed on a ventilator. (3.5 hrs. after arriving).
At 10:30 PM the patient was transferred to ICU (Intensive Care unit).
Further review of the patients record revealed the stat orders for Telemetry had NOT been completed whilst the patient was in the ER.

2.
Review of the medical record for patient #7 revealed the patient an 82 year old woman with a past medical history of CHF (Congestive Heart Failure) and hypertension was brought in by EMS as a trauma on 10/8/2022 at 04:33AM for a complaint of a fall at home.

At 06:38 AM a Stat order for Troponin was placed (Troponin is a type of protein found in the muscles of your heart that is normally found in the blood when heart muscles become damaged, as heart damage increases, greater amounts of troponin are released in the blood.)
At 07:00 AM, a Stat order for telemetry, continuous cardiac monitoring was placed.
At 10:52 AM patient was found Asystole, code blue called, patient expired at 11:12 AM.
Further review of the patients record revealed the stat orders for Troponin or Telemetry had NOT been completed.

Based on the facility staffing grids, staffing sheets, job description, and interviews the facility failed to adhere to the policy and procedure of adequate staffing. In 4 (MICU, CSU, SICU and 3 East) nursing areas reviewed out of 4.
Findings included:
1. Review of the facility staffing grid reveals that the Medical Intensive Care Unit (MICU) staffing grid is two patients for one Registered Nurse and a Clinical Nurse Coordinator /Charge Nurse with no patients for day shift and night shift.
Actual staffing sheets provided was for 46 shifts during the time period of October 01, 2022, through October 24, 2022, days and nights shifts for MICU (Medical Intensive Care) shows that the Registered Nurse cared for greater than 2 Patients 86 times.

2. Review of the staffing grid reveals that for the Cardio/ Surgical intensive care unit (CSU) staffing grid is two patients for one Registered Nurse and a Clinical Nurse Coordinator /Charge Nurse with no patients for day shift and night shift.

Actual staffing sheets provided was 46 shifts, during the time period of October 01, 2022, through October 24, 2022, days and nights shifts shows that in the CSU (Cardio/ Surgical intensive care unit) that the Registered Nurse cared for greater than 2 Patients 102 times.

3. Review of the staffing grid reveals that for the Surgical Intensive Care Unit / Trauma unit (SICU) staffing grid is two patients for one Registered Nurse and a Clinical Nurse Coordinator /Charge Nurse with no patients for day shift and night shift.

Actual staffing schedule provided was 42 shifts, during the time period of October 01, 2022, through October 24, 2022, (days and nights shifts) shows that in the SICU (surgical Intensive care unit/Trauma unit) that the Registered Nurse cared for greater than 2 patients 39 times.

4. Review of the staffing grid reveals that for the 3 East staffing grid is five patients for one Register Nurse and a Clinical Nurse Coordinator with no patients for day shift and night shift.

Actual staffing sheets provided 36 shifts, during the time period of October 01, 2022, through October 24, 2022, days and nights shifts for 3 East (Ortho, Neuro-spine) shows that the Registered Nurse cared for greater than five patients 174 times.

Review of the job description for the Clinical Nurse Coordinator (CNC) reveals the Clinical Nurse Coordinator ensures and delivers high quality, patient centered care and coordination of all functions in the unit / department during the designated shift ...The CNC directs, monitors, and evaluates nursing care in accordance with established policies/ procedures, serves as a resource person for staff ...

Actual staffing schedule provided was 42 shifts, during the time period of October 01, 2022, through October 24, 2022, (days and nights shifts) shows that in the SICU (surgical Intensive care unit/Trauma unit) that the Nurse Coordinator /Charge Nurse (CNC) was assigned to care for patients 17 times.

Actual staffing sheets provided 36 shifts, during the time period of October 01, 2022, through October 24, 2022, days and nights shifts for 3 East (Ortho, Neuro-spine) shows that the Clinical Nurse Coordinator was assigned to care for patients 31 times.

Actual staffing sheets provided was for 46 shifts, during the time period of October 01, 2022, through October 24, 2022, days and nights shifts for MICU (Medical Intensive Care) shows the Clinical Nurse Coordinator was assigned to care for patients three times and was dedicated telemetry monitor one time.

On 10/25/2022 at 10:56 AM an interview was conducted with RN F who disclosed that the nurses have six patients all the time even weekends.
On 10/25/2022 at 11:04 AM an interview was conducted with CNC G. who disclosed that the nurses have six patients and yesterday she had a patient.
On 10/25/2022 at 11:35 AM an interview was conducted with RN J who disclosed that over the weekend the CNC had three patients in MICU. RN J disclosed that the ICU RN that has 3 patients cannot take a lunch because the patients are critical.
On 10/25/2022 at 11:20 AM an interview was conducted with RN L. who disclosed that she has have three patients, she has had triple patient a couple of times. RN L disclosed that she has had four patients assigned to her.
On 10/25/2022 at 12:05 PM an interview was conducted with RN M who disclosed that the CNC over the weekend had three ICU patients.
On 10/2/2022 at 2:10 PM a phone interview was conducted with RN R who disclosed that she had six patients when one of her patients was a code blue and that the CNC had patients that shift.
On 10/26/2022 at 3:49 PM a phone interview was conducted with RN CC who disclosed she had three patients while working in ICU.
On 10/26/2022 at 1:25 PM an interview conducted with Director X who disclosed that staffing is based on the staffing grid and acuity. This surveyor asked to see the policy on acuity and was informed they do not have one and the clinical nurse coordinator / charge nurse determine the acuity which is subjective and comes with experience.

Based on staff interviews, medical record reviews, and policy review, it was determined that the facility failed to ensure 1 Patient (#4) of 16 patients sampled, had correct verbal orders administered.
Findings included:

Review of the facility policy titled "Verbal orders." Reviewed 4/22 states,

E). "clarify verbal orders during readback for drugs."

F). "clarify dosages during readback."

G). "clarify and order."

Review of the medical record for Patient #4 revealed the patient presented to the facility ED on 1/16/2022 at 9:12 PM for a complaint of Left Flank pain. Review of the record revealed the patient was triaged by an RN (registered nurse) at 9:15 PM. The patient's vital signs were blood pressure 159/85, pulse 65 bpm, respiration rate 18, oxygen saturation 96 % on room air, temperature 98.3. Review of the triage assessment revealed the RN assigned the patient an acuity level of ESI - 2.

At 10:45 PM, Patient #4 received a CT (computed tomography) abdomen pelvis with contrast and subsequently developed chest pain, burning sensation and throat swelling concerning for suspected anaphylaxis due to the CT dye. The patient was prescribed and given IV (Intravenous) Solumedrol and IV Benadryl.

At 11:00 PM a verbal order from the physician to the nurse was given for IM epinephrine 0.5mvg. The nurse administered the epinephrine IV (intravenous) instead of IM (intramuscular) and the patient immediately went into ventricular tachycardia (VTach). Stat EKG was ordered and showed ST elevation in AVR (indicating a blockage of the involved coronary artery and that the heart muscle is currently dying), with ST depressions indicating ischemia. This persisted on repeat EKG' s.

At 01:15 AM, Patient was taken straight from the ER to the Cath Lab for emergency heart catheterization.

Pt was admitted to ICU following the procedure on 1/16/2022 for further monitoring.

Interview on 10/24/2022 at 2:20pm regarding Patient #4 with Staff B, Director of Patient Safety, he summarized the event as: Patient #4 had a CT with contrast which resulted in SOB and difficulty breathing. A verbal order was given for Epinephrine. An adverse reaction to receiving this medication occurred. The result was the incorrect route of mediation (epinephrine), which was given IV instead of IM. Patient developed multiple episodes of non-sustained V Tach on the monitor. The nurse that gave the medication was on orientation, but the preceptor was in the room at the time. The physician was in the room and noted the error. The patient was already on telemetry monitoring, an EKG was done immediately, ST elevation was noted (indicating a blockage of the involved coronary artery and that the heart muscle is currently dying). Patient taken to catheterization lab. Patient was admitted to ICU (Intensive Care Unit) for further monitoring and went home 4 days later. Staff B further stated he was not aware of any other issues when reviewing this chart. When asked if he noticed that no assessment or reassessment was completed on this patient in the ER other than on initial triage for approximately 4 hours, he stated he was aware, but does not know why he did not include it in your serious event analysis. He also stated that all involved in the event analysis were aware that the reassessment of vitals was not completed on this patient, therefore no further actions, or change in processes were completed to address the reassessment issue in the ER department.

Based on interview and record review the facility failed to maintain a clean and safe environment for Patient #15 when, a single use sonopet tip (a surgical instrument) was not disposed of and removed during decontamination and sterilization in one (#15) of one operating room case of 4 reviewed.

This failure resulted in the potential for patient infection or cross infection related to compromised surgical instrument and/or fragmentation during use for Patient #15.

Findings:

1. Patient #15's medical record was reviewed. Patient # 15 was 74 years old who was admitted to the facility on 10/6/2022 for Right frontal tumor (brain tumor). The "OPERATIVE REPORT" dated 10/11/2022 indicated, " ...Imaging showed a large right frontal lesion. It was decided that this should be resected ...The patient was intubated. He was positioned appropriately. He was registered to the image guidance system. Registration was deemed accurate. The area was prepped and draped in the usual manner. It was noted there was a contaminated instrument on the field, therefore the whole surgical field was changed ..."

2. 10/25/2022 at 10:10 AM the Infection Prevention Director (IPD) was interviewed. The IPD stated she was not aware of the infection control breach identified on 10/11/2022 during Patient #15's brain surgery. The IPD and the Director of Quality, who was also present in the room, confirmed there was no incident report or occurrence report submitted in connection to the infection control breach identified on 10/11/2022 during Patient #15's procedure.

3. On 10/25/2022 at 11:22 AM Surgical Technician 3 (ST3) and Registered Nurse Circulator (RNC) were interviewed. Both stated they were in the OR when the infection control breach was identified during Patient #15's procedure. Both stated that prior to starting the procedure a sonopet, a surgical instrument that aspirates fluid from the brain, had a used disposable tip attached to it. ST3 stated two other scrub technicians were involved in the preparation of the sterile filed/sterile instruments for Patient #15's procedure and that was why she was did not realize right away that the sonopet still had a used disposable tip attached. Both stated they reported the incident to the Charge Nurse, Operating Room Manager and Operating Room Director.

4. On 10/25/2022 at 11:55 AM, the Interim Sterilization Process Department Manager (SPDM) was interviewed. The SPDM stated the disposable tip should have been removed and discarded during the breakdown of the last procedure when the sonopet was used before sterilization. The SPDM stated SPD record indicated the sonopet was last sterilized on 6/29/2022. The SPDM stated he was not aware of any corrective activity initiated related to the infection control breach.

5. On 10/27/2022 at 11:36 AM, the Operating Room Director (ORD) was interviewed. There were multiple failures involved with the identified infection control breach during Patient #15's procedure. The ORD stated:
a. The sonopet disposable tip should have been removed after use in the OR by the Scrub Technician prior to being transported back to the decontamination room where surgical instruments are washed.
b. If the used disposable tip was not removed and disposed in the OR, it should have been identified during washing in the decontamination room and removed and disposed of before coming out into the clean side for assembly and sterilization by the Sterile Processing Technician.
c. If the instrument came out of the clean side with the used disposable tip still attached, it should have been identified during assembly prior to sterilization by the Sterile Processing Technician.

The ORD stated there are planned re-education and improvement actions related to the incident which are yet to be implemented.

6. Review of the facility policy and procedure titled "Decontamination Practices" last reviewed 10/21 indicated," ...PURPOSE: Standard precautions are enforced to protect patients and employees. Adherence to a clean, safe environment will be maintained in the Sterile processing Department ...Efficiency of Process for Future Availability of Instruments/Equipment A. Steps to decontamination process: 1. Sorting: begins at the point of use. 2. Transportation: from point of use in a puncture-resistant container with cover to Sterile Processing Department's decontamination room ...5. Following decontamination, the devices are transported to the clean assembling ..."

Based on staff interviews, medical record reviews, and policy review, it was determined that the facility failed to ensure stat orders were completed in 3 patients (#4, #7 and #8) of 17 patients sampled in the Emergency Department. Refer to A1103.

Based on staff interviews, medical record reviews, and policy review, it was determined that the facility failed to ensure 3 patients (#4, #7 and #8) of 17 patients sampled in the Emergency Department were reassessed.

Findings included:

Review of the facility policy titled "Assessment and Reassessment" last revised on 01/11/2022 states, "Emergency Room reassessment are performed by RN's according to acuity level: b) level 2/Emergent will be performed every 60 minutes." "Medical-Surgical initial assessments are performed within: 30 mins."

Interview with Staff (A), RN Director of Emergency Department 10/25/2022 at 10:00 AM, confirmed the Emergency Department's standard for assessment/reassessment was every hour.

Review of the medical record for patient #4 revealed the patient presented to the facility ED(Emergency Department) on 1/16/2022 at 9:12 PM for a complaint of Left Flank pain. Review of the record revealed the patient was triaged by an RN (registered nurse) at 9:15 PM. The patient's vital signs were blood pressure 159/85, pulse 65 bpm, respiration rate 18, oxygen saturation 96 % on room air, temperature 98.3. Review of the triage assessment revealed the RN assigned the patient an acuity level of ESI - 2.

At 10:45 PM, Patient received a CT (Computerized Tomography) abdomen pelvis with contrast and subsequently developed chest pain, burning sensation and throat swelling concerning for suspected anaphylaxis due to the CT dye. The patient was prescribed and given IV Solumedrol and IV Benadryl. At 11:00 PM a verbal order from the physician to the nurse was given for IM (intramuscular) epinephrine 0.5mvg. The nurse administered the epinephrine IV (intravenous) instead of IM, and the patient immediately went into ventricular tachycardia (VTach - an abnormal heart rhythm that occurs when the lower chamber of the heart beats too fast to pump well and the body doesn't receive enough oxygenated blood). Stat (right away) EKG (Echocardiogram) was ordered and showed "ST elevation in AVR, with ST depressions" (indicates ischemia).
At 01:15 AM, Patient was taken straight from the ER (Emergency Room) to the Catheterization (Cath) Lab for emergency heart catheterization.
Review of the record reveals during this time in the ER no further vital signs, assessment or reassessment of the patient for the duration of 4 hours, from triage (9:15PM) to Cath Lab (01:15AM).


Review of the medical record for patient #7 revealed the patient an 82 year old woman with a past medical history of CHF (congestive heart failure) and hypertension was brought in by EMS (Emergency Medical Services) as a trauma on 10/8/2022 at 04:33 AM for a complaint of a fall at home. Review of the record revealed no triage assessment was completed. Patient was assigned an acuity level 1 - trauma on the Medical Screening Exam and trauma sheet.
The patient was placed on continuous cardiac monitoring whilst in the trauma unit from 04:33 AM till 06:30 AM. During this time the patient vitals were taken every 5 mins the first hour and 10 mins the second hour and patient remained in constant tachycardia of 125 BPM.
Review of orders revealed at 06:30 AM the patient was downgraded from a trauma and transferred into the care to the ED physician. At 06:38 AM orders for stat Troponin was placed. At 07:00 AM orders for telemetry, continuous cardiac monitoring and medical admission where also placed.
At 08:20 AM patient was transferred to the ER holding room (CDU) at 8:20 AM. At 10:52 AM patient was found Asystole, code blue called, patient expired at 11:12 AM.
Review of the medical record revealed the last vital signs were completed at 06:30AM. From 06:30AM to death at 11:12 AM, (4.5 hrs) no assessment or reassessment of patient and no vital signs were completed, Stat labs were not drawn. Further review failed to find any orders or documentation for EKG whilst the patient in the ER, failed to find any treatment for the tachycardia, and failed to place the patient on telemetry as ordered by physician.
Review of the facility policy titled "Stat orders." Reviewed 3/22 states, "stat orders should only be used in cases of extreme emergency or for life threatening situations." 2. Laboratory orders: the lab will respond within 15-30 minutes for stat orders.
Interview with the ER medical director, treating ED physician, ER nursing director, Risk Manager, VP of Quality and director of quality all acknowledged being aware of these findings at the time of the incidents and not taking any further action to address, correct or accurately documenting these findings in the facilities review processes.



Review of the medical record for Patient #8 revealed the patient a 79 year old female past medical history significant for atrial fibrillation on Eliquis was brought in as a stoke alert by EMS on 10/13/2022 at 5:41 PM, for evaluation of altered mental status with aphasia and confusion and right sided weakness prior to a ground level fall.
Further review of the patients' medical record failed to find any triage assessment, any vital signs or any reassessments. At 5:44 PM order for cardiac continuous monitoring was placed. Patient was not placed on telemetry. At 9:05 PM, Patient was placed on a ventilator, 3.5 hours after arriving. One set of vitals were documented at 9:10 PM, Temp 36.4, P 79, RR 18, BP 156/85, O2 100%, patient on ventilator. No other vitals were documented, and the patient was transferred to ICU (Intensive Care Unit) at 10:30 PM.
Interview with Staff (II) MD, Medical Director of Emergency Department, Staff (A), RN Director of Emergency Department, Staff (B) Risk Manager and Staff (JJ) VP Quality on 10/25/22 at 3:00 PM verified the above findings.