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An Immediate Jeopardy (IJ) was identified beginning on 04/29/2021 and was determined to be on going at the time of survey exit. The facility failed to maintain an effective, ongoing, hospital wide, data driven quality assessment and performance improvement program.

Based on medical record reviews, staff interviews, policy and procedure reviews, and facility document reviews the hospital failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, including a complete analysis of an adverse event, development of an effective plan of correction, and measures in place to track performance and success, for Patient #4 who was ordered cardiac monitoring. The facility also failed to ensure quality indicator data related to continuous cardiac telemetry monitoring of patients in the Emergency Department (ED) was comprehensive to ensure the effectiveness and safety of services and that quality of care was monitored accurately to ensure quality patient care and improved patient safety (see A0286). ). Two ED patients (#7 and #13) were identified at the time of the survey with orders for continuous cardiac telemetry monitoring, but no documentation was provided to indicate the patients were being monitored which placed these patients at a likelihood of serious harm or death.


On 03/25/2022 at 4:49 PM, the Director of Risk Management and the Quality Director was informed of the Immediate Jeopardy (IJ) situation which began on 04/29/2021. The cumulative deficits placed the patients at risk for not having their needs met resulting in the Condition of Participation being out of compliance.
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Based on review of medical records, review of hospital policy and procedures, and staff interviews, it was determined the facility failed to ensure an established facility committee analyzed a patient mortality, identified a potential cause or delay in care, and implemented preventive actions that included learning throughout the hospital for an adverse event involving the death of Patient #4 and failed to implement two of five corrective actions for this event. The facility's failure put patients #7 and #13 at a likelihood of serious harm or death, as well as those who required cardiac monitoring that were not known at the time of the survey. This resulted in Immediate Jeopardy at the Condition of Participation of Quality Assurance and Performance Improvement.

The findings include:

1. Review of the medical record for Patient #4 revealed the patient presented to the Emergency Department (ED) via ambulance on 04/28/21 at 2:50 PM post syncope episode (loss of consciousness resulting from insufficient blood flow to the brain) at home. On 04/28/21 at 4:18 PM an Electrocardiogram (EKG) revealed a heartrate of 66 beats per minute with a left bundle branch block (a condition in which there is a slowing along the electrical pathway to the heart's left ventricle). On 04/28/21 at 5:11 PM a Computerized Tomography (CT) of the head without contrast revealed no evidence of an acute intracranial process. Patient #4 was in the ED for 12 hours and was stable. She was admitted with telemetry orders on 04/28/21 at 4:58 PM. There were no available inpatient beds at the time. The patient was placed into ED holding until a telemetry inpatient bed became available. Based on record review of Patient #4's cardiac monitoring, it was unable to be determined when the cardiac monitoring began due to lack of cardiac monitoring strip documentation. An initial assessment was completed by Employee A, Emergency Department Registered Nurse, on 04/28/21 at 7:00 PM which revealed Patient #4 was calm, alert, and oriented. Pulse oxygenation saturation was 98% on room air. There was no care plan initiated on admission regarding Patient #4's cardiac medical problem. On 04/29/21 at 1:25 AM Patient #4 requested to go to the bathroom. Employee A, Emergency Department Registered Nurse, assisted Patient #4 to the bathroom and returned the patient to bed at 1:30 AM.

On 03/24/22 at 10:30 AM an interview with Employee A revealed she escorted Patient #4 back to bed, but Employee A could not recall if she reconnected the cardiac monitoring leads to the patient.

Continued medical record review revealed that Employee A had to take another ED patient to an assigned inpatient room and left the ED. On 04/29/21 at 1:50 AM Employee A returned to the ED and checked on Patient #4. Employee A stated she discovered the patient in bed, unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated, and a Code Blue was called. Efforts to resuscitate Patient #4 were unsuccessful. The patient expired on 04/29/21 at 2:10 AM. An adverse event report was submitted to the Agency for Health Care Administration, the Florida State Survey Agency, on 05/12/21. The facility developed an initial plan of correction related to the incident. Education to the individual nurse, Employee A, was completed. Education to the ED staff included printing the cardiac monitoring telemetry strip every two hours while the patient was located in the ED. Learning points were shared throughout the other facilities within their system. The ED charge nurse must be notified of patients with cardiac monitoring telemetry orders holding in the ED. The complaint survey was conducted on 03/25/22. Eleven months after the event occurred, the facility failed to complete their action plan which included reeducation to all staff and the initiation of a cardiac monitoring telemetry ED logbook.

2. Record review of Patient #7 revealed he arrived at the Emergency Department (ED) on 03/22/22 at 8:28 AM for pneumonia and left forearm contusion. Electrocardiogram (EKG) was completed on 03/22/22 at 8:30 AM which revealed a right bundle branch block. A continuous cardiac telemetry monitoring order was placed on 03/22/22 at 8:39 AM. The patient transferred to an inpatient telemetry unit at 5:00 PM on 03/22/22. No additional continuous cardiac monitoring documentation was provided to the survey team to indicate the patient was being monitored.

3. Record review of Patient #13 revealed she arrived at the Emergency Department (ED) on 03/22/22 at 10:07 AM for dizziness and blurred vision. Electrocardiogram (EKG) was completed on 03/22/22 at 10:56 AM which revealed atrial fibrillation. A continuous cardiac telemetry monitoring order was placed 03/22/22 at 10:23 AM. The patient was discharged home on 03/22/22 at 4:38 PM. No additional continuous cardiac monitoring documentation was provided to the survey team to indicate the patient was being monitored.


On 03/22/22 at 11:00 AM an interview was conducted with Employee B, Emergency Department Registered Nurse. She was unaware that the continuous cardiac monitoring strips were to be printed, interpreted, and posted in the patient medical record. She was unable to provide an alternate way of verifying ED patients were being monitored.

On 03/24/22 at 11:00 AM an interview was conducted with Employee C, Emergency Department Charge Nurse. She confirmed that Employee A had left the ED to transport another patient to an inpatient bed. She confirmed that she was working as charge nurse in the ED the night of the incident. She could not recall seeing Patient #4 on the cardiac monitor. She confirmed when the code team arrived in Patient #4's room, the cardiac monitoring leads were not attached to the patient.

On 03/24/22 at 11:30 AM an interview was conducted with Employee D, Emergency Department Director. He confirmed that telemetry education was conducted to the ED staff. The education included printing continuous cardiac monitoring strips every two hours or with any change in rate/rhythm. The telemetry strips should be printed and placed on monitor sheets. He confirmed that there were no audits conducted after the plan of correction was developed. He also confirmed that the ED cardiac monitoring telemetry logbook was not completed.

On 03/25/22 at 10:20 AM an interview with the Hospital Quality Director stated that the Quality department was not following the incident that occurred with Patient #4. She confirmed there was not a quality project from the adverse incident with Patient #4.

On 03/25/22 at 10:51 AM an interview with the Vice President of Nursing confirmed that the facility failed to track, trend, and analyze the data from Patient #4's adverse incident that occurred in April of 2021.

On 03/25/22 at 1:00 PM an interview with the manager of Risk Management confirmed that there were no cardiac monitor strips or additional documentation for Patient #4, Patient #7, or Patient #3 to indicate that the continuous cardiac telemetry was initiated and continuously monitored.

On 03/25/22 a review of the facility's Policy and Procedure on Telemetry Monitoring with a last approval date of 03/2022 stated, "monitoring strips will be printed and posted on admission to the unit, at the beginning of each shift, with any rhythm change, prior to being transferred to a higher level of care, when requested by RN, or following a code blue." The Policy and Procedure stated following a Code Blue or transfer to a higher level of care the monitor technician will:
a. Review all classes in the monitor memory and print the 4 most recent strips
b. Print out any abnormal rhythms or beats that occurred in the last 24 hours prior to the event, if available
c. Review the strips with the RN prior to the patient being removed from the monitor making sure no additional information or strips are needed for documentation.
d. Place the strips on the patient's telemetry log sheet
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An Immediate Jeopardy (IJ) was identified beginning on 04/29/2021 and was determined to be ongoing at the time of survey exit. Failure to ensure Registered Nurses (RN) verified and implemented physicians' orders for cardiac monitoring was identified.

Based on medical record reviews, staff interviews, policy and procedure reviews, the hospital failed to ensure policies governing cardiac monitoring of patients were followed for assessment and monitoring of patient's cardiac rhythm and failed to ensure the provision of services was provided timely to protect the health and safety of all patients. This resulted in the death of Patient #4, the likelihood of serious harm or death to Patients #7 and #13, as well as other patients who required cardiac monitoring that were unknown at the time. (see A0396).

On 03/25/2022 at 4:49 PM, the Director of Risk Management was informed of the IJ situation which began on 04/29/2021. The cumulative deficits placed the patients at risk for not having their needs met resulting in the Condition of Participation being out of
compliance.
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Based on review of medical records, review of hospital policy and procedures, and staff interviews, it was determined the facility failed to ensure that the staff cardiac monitoring care plan was continuously implemented by the nursing staff for 3 of 3 patients sampled for cardiac monitoring. (Patients #4, #7 & #13) The facility's failure contributed to Patient #4's death and put Patients #7 and #13 at a likelihood of serious harm or death, as well as those who required cardiac monitoring that were not known at the time of the survey. This resulted in Immediate Jeopardy at the Condition of Participation of Nursing Services.

The findings include:

1. Review of the medical record for Patient #4 revealed the patient presented to the Emergency Department (ED) via ambulance on 04/28/21 at 2:50 PM post syncope episode (loss of consciousness resulting from insufficient blood flow to the brain) at home. On 04/28/21 at 4:18 PM an Electrocardiogram (EKG) revealed a heart rate of 66 beats per minute with a left bundle branch block (a condition in which there is a slowing along the electrical pathway to the heart's left ventricle). On 04/28/21 at 5:11 PM a Computerized Tomography (CT) of the head without contrast revealed no evidence of an acute intracranial process. Patient #4 was in the ED for 12 hours and was stable. She was admitted with telemetry orders on 04/28/21 at 4:58 PM. There were no available inpatient beds at the time. The patient was placed into ED holding until a telemetry inpatient bed became available. Review of Patient #4's cardiac monitoring revealed it was unable to be determined when the cardiac monitoring began due to no cardiac monitoring strip documentation. An initial assessment was completed by Employee A, Emergency Department Registered Nurse, on 04/28/21 at 7:00 PM which revealed Patient #4 was calm, alert, and oriented. Pulse oxygenation saturation was 98% on room air. There was no care plan initiated on admission regarding Patient #4's cardiac medical problem. On 04/29/21 at 1:25 AM Patient #4 requested to go to the bathroom. Employee A, Emergency Department Registered Nurse, assisted Patient #4 to the bathroom and returned the patient to bed at 1:30 AM.

On 03/24/22 at 10:30 AM an interview with Employee A revealed she escorted Patient #4 back to bed, but Employee A could not recall if she reconnected the cardiac monitoring leads to the patient.

Continued medical record review revealed that Employee A had to take another ED patient to an assigned inpatient room and left the ED. On 04/29/21 at 1:50 AM, Employee A returned to the ED and checked on Patient #4. Employee A stated she discovered the patient in bed, unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated, and a Code Blue was called. Efforts to resuscitate Patient #4 were unsuccessful. The patient expired on 04/29/21 at 2:10 AM. An adverse event report was submitted to the Agency for Health Care Administration, the Florida State Survey Agency, on 05/12/21. The facility developed an initial plan of correction related to the incident. Education to the individual nurse, Employee A, was completed. Education to the ED staff included printing the cardiac monitoring telemetry strip every two hours while the patient was located in the ED. Learning points were shared throughout the other facilities within their system. The ED charge nurse must be notified of patients with cardiac monitoring telemetry orders holding in the ED. The complaint survey was conducted on 03/25/22. Eleven months after the event occurred, the facility failed to complete their action plan which included reeducation to all staff and the initiation of a cardiac monitoring telemetry ED logbook.

2. Record review of Patient #7 revealed he arrived at the Emergency Department (ED) on 03/22/22 at 8:28 AM for pneumonia and left forearm contusion. Electrocardiogram (EKG) was completed on 03/22/22 at 8:30 AM which revealed right bundle branch block. A continuous cardiac telemetry monitoring order was placed on 03/22/22 at 8:39 AM. The patient transferred to an inpatient telemetry unit at 5:00 PM on 03/22/22. No additional continuous cardiac monitoring documentation was provided to the survey team to indicate the patient was being monitored.

3. Record review of Patient #13 revealed she arrived at the Emergency Department (ED) on 03/22/22 at 10:07 AM for dizziness and blurred vision. Electrocardiogram (EKG) was completed on 03/22/22 at 10:56 AM which revealed atrial fibrillation. A continuous cardiac telemetry monitoring order was placed on 03/22/22 at 10:23 AM. The patient was discharged home on 03/22/22 at 4:38 PM. No additional continuous cardiac monitoring documentation was provided to the survey team to indicate the patient was being monitored.


On 03/22/22 at 11:00 AM an interview was conducted with Employee B, Emergency Department Registered Nurse. She was unaware that the continuous cardiac monitoring strips were to be printed, interpreted, and posted in the patient medical record.

On 03/24/22 at 11:00 AM an interview was conducted with Employee C, Emergency Department Charge Nurse. She confirmed that Employee A had left the ED to transport another patient to an inpatient bed. She confirmed that she was working as charge nurse in the ED on the night of the incident. She could not recall seeing Patient #4 on the cardiac monitor. She confirmed when the code team arrived in Patient #4's room, the cardiac monitoring leads were not attached to the patient.

On 03/24/22 at 11:30 AM an interview was conducted with Employee D, Emergency Department Director. He confirmed that telemetry education was conducted to the ED staff. The education included printing continuous cardiac monitoring strips every two hours or with any change in rate/rhythm. The telemetry strips should be printed and placed on monitor sheets. He confirmed that there were no audits conducted after the plan of correction was developed. He also confirmed that the ED cardiac monitoring telemetry logbook was not completed.

On 03/25/22 at 1:00 PM an interview with the manager of Risk Management confirmed that there were no cardiac monitor strips or additional documentation for Patient #4, Patient #7, or Patient #13 to indicate that the continuous cardiac telemetry was initiated and continuously monitored.

On 03/25/22 a review of the facility's Policy and Procedure on Telemetry Monitoring with a last approval date of 03/2022 stated, "monitoring strips will be printed and posted on admission to the unit, at the beginning of each shift, with any rhythm change, prior to being transferred to a higher level of care, when requested by RN, or following a code blue." The Policy and Procedure stated following a Code Blue or transfer to a higher level of care the monitor technician will:
a. Review all classes in the monitor memory and print the 4 most recent strips
b. Print out any abnormal rhythms or beats that occurred in the last 24 hours prior to the event, if available
c. Review the strips with the RN prior to the patient being removed from the monitor making sure no additional information or strips are needed for documentation.
d. Place the strips on the patient's telemetry log sheet.
.