HospitalInspections.org

Based on record review, interview, and observation, the provider failed to ensure timely communication and response to cardiac telemetry signal loss and/or fatal arrhythmia for 1 of 4 patients (Patient #1) reviewed for cardiac telemetry (continuous monitoring of heart rhythm and rate).

The findings included:

The provider's Policy and Procedure titled "Telemetry Monitoring of the Adult Patient" documents the Purpose, "To ensure safe telemetry monitoring practices and establish timely communication for patients on telemetry monitoring" and under Procedure, "In the event that the ECG (electrocardiogram) tracing becomes unreadable (loss of signal/electrical interference), the monitor technician will:
1. notify the primary nurse, charge nurse or other designee.
2. Initiate a red alert chain of command if unable to speak with the assigned RN or charge nurse.
3. Activate a Rapid Response if unable to speak with a RN" and "For any sudden changes in ECG rhythm, or rate, the monitor technician will notify the assigned nurse, and/or charge nurse, who will immediately assess the patient."

Review of the clinical record reveals Patient #1 was admitted via the Emergency Department on 03/25/23 with problems that included heart attack and confusion. Review of Patient #1's "Orders - Electronic" reveals an order on 03/25/23 at 1:44 PM for "Cardiac monitor", an order on 03/25/23 at 5:15 PM to admit Patient #1 to telemetry; and an order on 03/25/23 at 5:16 PM for "Cardiac Telemetry Monitoring" that remained active until after the end of care on 03/29/23.

A one-page print out of Patient #1's telemetry monitoring on 03/29/23 for 3:51 PM to 4:10 PM documents the waveform on "Lead II" became a flat line at 3:58 PM and the print out switched to "Lead VI" at 3:59 PM which was also a flat line and remained a flat line to the end of the page at 4:10 PM. Patient #1's 6-lead telemetry print out on 03/29/23 at 3:58:06 (hours:minutes:seconds) PM documents a waveform was present on all 6 leads before it became a flatline within that same minute. Patient #1's 6-lead telemetry print out on 03/29/23 at 4:12:11 PM documents a waveform was again present, approximately 14 minutes after it had become a flat line.

During interview on 04/19/23 beginning at 12:50 PM, Monitor Tech, Staff A confirmed she was responsible for monitoring Patient #1's telemetry during the day shift (7 AM to 7 PM) on 03/29/23 and stated Patient #1 had a flat line since around 4:00 PM which she had assumed meant he was "off the monitor," that she told a Patient Care Assistant once to replace the leads but he never had a rhythm on the monitor again after that, and that she did not tell the nurse (Staff B) that he remained off the monitor until Staff B happened to come in the monitoring room for another reason around 5:30 PM.

During interview on 04/18/23 beginning at 2:35 PM, Assistant Nurse Manager, Staff B interpreted Patient #1's printed telemetry rhythm from 03/29/23 at 4:12:11 PM as "sinus rhythm going into V tach" (ventricular tachycardia). During this same interview on 04/18/23 beginning at 2:35 PM, the Chief Nursing Officer interpreted Patient #1's printed telemetry rhythm from 03/29/23 at 4:33:36 PM as ventricular fibrillation, from 03/29/23 at 4:40:36 PM as ventricular fibrillation, and from 5:28:56 PM as ventricular tachycardia. Ventricular tachycardia and ventricular fibrillation are lethal arrhythmias. During ventricular tachycardia, the lower chamber of the heart beats too fast to pump blood well and the body does not receive enough oxygenated blood. During ventricular fibrillation, the deadliest of heart rhythms, the heart muscles quiver instead of pumping blood normally. These two rhythms cause most cases of sudden cardiac death and prompt intervention maximizes the chance of patient survival.

A Nurse's Note from 03/29/23 at 5:29 PM documents the Monitor Tech asked the nurse to check on Patient #1 who was then found unresponsive and pulseless, and CPR (cardiopulmonary resuscitation) was started. Patient #1 was pronounced dead on 03/29/23 at 5:46 PM.

During interview on 04/19/23 beginning at 12:50 PM, Monitor Tech, Staff A reported Patient #1's telemetry displayed only a flat line from around 4:00 PM until she asked the nurse to check on him around 5:30 PM; denied ever seeing that Patient #1 had ventricular tachycardia or ventricular fibrillation; and denied any alarms going off to alert her of these dysrhythmias or of silencing those alarms.

During an interview on 04/19/23 at 1:20 PM, the Chief Nursing Officer reported Staff A was responsible for sixty-four patients on telemetry on 03/29/23.

During telephonic interview on 04/19/23 beginning at 11:47 AM, Registered Nurse, Staff B confirmed she took care of Patient #1 on 03/29/23 from 7:00 AM until his death; that she was not notified he was not on the monitor until she happened to enter the monitoring room for another reason; that she was never notified he was off the monitor; was not notified he had ventricular tachycardia or ventricular fibrillation; that had she been aware of this she would have immediately called a Code Blue; and that upon learning he was off the monitor she immediately went to his room where she found him unresponsive and pulseless and initiated the Code Blue and Advanced Cardiovascular Life Support protocol.

During observation of the centralized telemetry monitoring room on 04/18/23 beginning at 11:33 PM, 3 Monitor Techs were present for 111 monitored patients, and, of these, Staff A was responsible for fifty-four patients on four displays. During the observation, Staff A squarely faced the two left-most displays and occasionally turn to look at the displays on her right, which were at right angles to the first two and positioned such that they were not both in her field of vision while directly facing the other displays as she sat.

During interview on 04/18/23 at 2:35 PM, the Chief Nursing Officer stated she had told management to put in a fourth Monitor Tech and did not know until this day that it was not done; that there was a limit of 50 patients per Monitor Tech before Patient #1's death, but they had since decided to decrease it to 40 patients per Monitor Tech; and that they had not yet reconfigured the hardware to uncouple 2 displays to enable more even division of the workload among 3 Monitor Techs, which was the reason she had directed to add a fourth Monitor Tech.