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Based on interview, record review and a review of facility documentation, the facility was out of compliance with 42 CFR 482.21 the Condition of Participation for the Quality Assurance Performance Improvement Program

Findings:

The facility failed to ensure that the Quality Assurance Performance Improvement Program included an ongoing program to address an adverse patient events in which there was no response from the monitor technician assigned to monitor 1 of 10 sampled patients (#1) during life threatening abnormal heart rhythms. As a result of this failure, the treatment was delayed and the patient died. The facility failed to identify a root cause of the monitor technician failure to identify and respond to abnormal heart rhythms. They did not implement performance improvement activities and preventive actions. This failure resulted in ongoing immediate jeopardy for residents receiving telemetry and being monitored by monitor technicians. Refer to A0286

Based on interview, observation, record review and a review of facility documentation, the facility failed to ensure that the Quality Assurance Performance Improvement Program included an ongoing program to address an adverse patient events in which there was no response from the monitor technician assigned to monitor 1 of 10 sampled patients (#1) during life threatening abnormal heart rhythms. The facility failed to identify a root cause of the monitor technician failure to identify and respond to abnormal heart rhythms. They did not implement performance improvement activities and preventive actions. This failure resulted in ongoing immediate jeopardy for patients receiving telemetry and being monitored by monitor technicians.


Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the facility on 1/16/15. A physician note of 1/17/15 read: "Admit the patient to ortho ... Place telemetry monitor on the patient." A nurse's note of 1/17/15 at 4:18 PM read: "Nurse notified, per RN direction, tele applied." Telemetry is when caregivers monitor the electrical activity of the heart for an extended time. A device sends information about the heart's electrical activity to a monitoring station. The care giver looks for problems or changes to see if a problem is likely to occur. (www.drugs.com)

Evidence of a monitor strip pulled close to the time of adverse cardiac readings on a remote cardiac monitor was found in the medical record of #1 in the form of a strip timed at 11:21 PM on 1/20/15. The monitor technician (MT)-A assigned to patient #1 on 1/20/15 was the technician who printed the strip at that time.

A review of facility policy "Continuous EKG (electrocardiogram) Monitoring by Telemetry" revision date April 2012, revealed the following: "A STAT (immediate) call via the direct line will be placed to the nurse for onset of potentially lethal dysrhythmias such as ... acute ST changes of ventricular tachycardia ... " A review of the position description for monitor technician revealed the following: "Responsible for continuous observation of the central telemetry screens for all patients requiring EKG monitoring and the documentation for each patient of baseline strips as well as all arrhythmias. ... Essential responsibilities: ... Immediately reports any changes in rhythm or other pertinent observations to charge nurse. Maintains clear communication with nurse until any problem or procedure is resolved." Thus, under certain circumstances as revealed by continuous remote monitor findings, an assigned monitor technician is required to notify a nurse.

A review of cardiac monitor strips for 1/20/15 produced retroactively from the monitor assigned to patient #1, was performed with Risk Manager (RM)-H on 4/07/15 at 11:50 AM. An additional evaluation of the retroactively produced monitor readings and a pulled monitor strip was performed with the physician Chief Quality Officer on 4/09/15 at 2:07 PM. Based on the results of the heart rhythm for those telemetry strips, RM-H said that the audible alarm indicating an arrhythmia would have sounded in the monitor room where MT-A was stationed at 11:19 PM or 11:24 PM on 1/20/15 and would have sounded unquestionably at 11:37 PM on 1/20/15, in a continuous manner. Both RM-H and the physician Chief Quality Officer agreed that when considering the monitor readouts and policy, the monitor technician should have called the nurse at least by 11:14 PM on 1/20/15 onward. In addition, the physician stated that the findings on the 11:21 PM pulled strip of 1/20/15, which MT-A pulled, would have also mandated a call to the nurse per facility policy. RM-H indicated that the monitor technician made no call to nursing during this time frame. There was no evidence in the record or from any other source for the evening of 1/20/15 of any call by MT-A to nursing during the entire time the arrhythmia occurred, before an eventual code incident at 11:45 PM in which the patient experienced cardiac arrest. The Discharge Summary, dictated on 3/03/15 at 11:40 AM read: "The patient, on 1/21/2015, had a cardiopulmonary arrest. Per notes, the patient was in ventricular fibrillation and CPR was given. The patient eventually was pronounced by the ER (emergency room) M.D. (medical doctor)"

An electrocardiogram (EKG, ECG) is a test that measures the electrical signals that control heart rhythm. The test measures how electrical impulses move through the heart muscle as it contracts and relaxes.
The electrocardiogram translates the heart's electrical activity into line tracings on paper. The spikes and dips in the line tracings are called waves. The P wave is a record of the electrical activity through the upper heart chambers (atria). The QRS complex is a record of the movement of electrical impulses through the lower heart chambers (ventricles). The ST segment shows when the ventricle is contracting but no electricity is flowing through it. The ST segment usually appears as a straight, level line between the QRS complex and the T wave. The T wave shows when the lower heart chambers are resetting electrically and preparing for their next muscle contraction. (www.webmd.com)



A nurse's note of 1/20/15 at 11:45 PM by a Registered Nurse Rapid Response Team member read: "Rapid Resp Team. Comment: call to assess pt (patient) for EKG (electrocardiogram) changes just prior to entering room code blue 90 called. CPR (Cardio Pulmonary Resuscitation) in progress. Please see code sheet for progress." Code sheet documentation indicated that the EKG changes were not recognized until 11:45 PM on 1/20/15. The alarm would have sounded at 11:37 PM on 1/20/15. It would have been audibly sounding in the monitor room, in the presence of MT-A, for at least eight minutes.

Observations of the monitor room on 4/07/15 at 3:30 PM revealed that 2 monitor technicians reviewed an array of monitors which were appropriately angled towards the seated monitor technicians; two to the left, two to the right and a central screen used for pulling strips. The monitor technicians sat about five feet apart from one another. Observations did not reveal any distractions: no TV, book reading, radio, cell phone use, staff interruptions, loud noises from outside. The door to the room was closed. During interview of MT-B on 4/8/15 at approximately 6:46 PM via telephone he indicated, as for breaks, the charge nurse would come in and temporarily replace the monitor technician.

During an interview of RM-I on 4/07/15 at 12:51 PM, the monitor station enabled remote monitoring of patients in different units of the entire hospital, with the exception of the emergency room. MT-A had responsibility for monitoring patient #1 on 1/20/15. He stated that during a previous interview of MT-A she revealed that she did not respond to what was on the screen. He stated MT-A would not attest to what was visible on the screen at the time of the arrhythmia and that no definitive or conclusive response could be obtained from her. During an interview of the Director of Clinical Care on 4/07/15 at 4:30 PM, she stated that MT-A said that she did not hear the alarm or discern any abnormalities on the screen. The failure to report adverse findings revealed on the remote monitor screen and the pulled monitor strip as specified in the above stated policy and position description, "Continuous EKG (electrocardiogram) Monitoring by Telemetry" revision date April 2012, was a violation of these requirements.

An interview of MT-A was performed on 4/08/15 at approximately 6:15 PM. She stated that she could not recall having heard the alarm go off for patient #1. She stated that she did not note any abnormalities with the cardiac rhythm for patient #1 per visual examination of the monitor on 1/20/15. MT-A said in her interview that she was present in the room on 1/20/15 when patient #1 experience heart rhythm abnormalities, as reported to her later, and her next break was scheduled for 1:00 AM later that shift.

During an interview on 4/09/15 at 4:20 PM, RM-I stated they looked into the incident that occurred on 1/20/15. RM-I said they did not perceive the above mentioned incident with patent #1 is as a matter of competency with MT-A, due to there being no prior history of a similar nature with this employee and she has been a full time employee since July 2012. Since the incident, the facility had not instituted any type of program of close supervision with MT-A or other monitor technicians.

During that same interview, RM-I said the Director of Clinical is responsible for supervising the monitor technicians, but she does not stay in the monitoring room with the monitor technicians to verify they are detecting abnormal heart rhythms as they are occurring. Each screen has a maximum capacity of 16 patients and each monitor technician is responsible for 4 screens for a maximum of 64 patients at one time. The RM-I said 2 MTs work 12-hour shifts. The shifts run from 6 AM to 6 PM and 6 PM to 6 AM. All of the patients in the hospital on telemetry with the exception of the emergency room, are monitored by 2 MTs in the monitor room. Thus, the 2 MTs have the responsibility for monitoring all telemetry patients in the hospital, excluding the ER. He said no evidence was uncovered to indicate that MT-A or MT-B were on break during the incident on 1/20/15.


During that same interview, RM-I said there have been no reviews of strips that the monitor technicians, including MT-A, have pulled. He stated: "There is nothing to believe with her (MT-A) history that this is a competency issue." He said all monitor technicians underwent additional training and testing in March of 2015, from 3/13/15 to 3/31/15. However, the training did not start until 52 days after the MT failed to identify, respond, and notify the nurse of a life threatening arrhythmia. MT-A had her final test on 3/31/15 and had remained working with patients with telemetry since, 1/22/15, 2 days after the day after patient #1 died on 1/20/15. RM-I did not indicate that any form of heightened oversight or observation of monitor technician activities or accuracy of their findings had been instituted since the incident on 1/20/15, other than the above mentioned testing. The testing completed in March did not include looking at monitors to identify abnormal rhythms or verify the monitor technicians ' accuracy in identifying potentially lethal dysrhythmias.

In addition, Risk Manager #I indicated in an e-mail communication of 4/12/15 that MT-A returned to work on her next regularly scheduled shift of 1/22/15 and that counseling took place, 16 days after patient #1 died, on 2/05/15. He stated that the facility investigation was completed as of 2/05/15. MT-A continued to work in the monitor room with patients on telemetry when she had not been re-educated or counseled and while the investigation was still in progress.

Based on interview, record review and a review of facility documentation, the facility was out of compliance with 42 CFR 482.23 the Condition of Participation for Nursing Services.


Findings:

The facility failed to ensure the provision of effective nursing services for monitor technicians providing care to patients in the form of required cardiac monitoring and appropriate intervention when a life threatening arrhythmia occurs on a continuous basis for 1 of 10 sampled patients (#1). This failure resulted in a delay in emergency lifesaving treatment for patient #1 and the patient died. Refer to A-392

Based on interview, record review and a review of facility documentation, the facility failed to ensure the provision of effective nursing services for monitor technicians providing care to patients in the form of required cardiac monitoring and appropriate intervention on a continuous basis for 1 of 10 sampled patients (#1). This failure resulted in a delay in emergency lifesaving treatment for patient #1 and the patient died.

Findings:

A review of the medical record of patient #1 revealed the patient was admitted to the facility on 1/16/15. A physician order of 1/16/15 read: "Consult: cardio." The patient's discharge diagnosis as indicated on the Discharge Summary dictated on 3/03/15 read: "Right intertrochanteric hip fracture, status post intramedullary nailing. Coronary artery disease, status post coronary artery bypass graft (from a prior admission). Tachycardia-bradycardia syndrome. Sick sinus syndrome, status post permanent pacemaker (from a prior admission). Paroxysmal atrial fibrillation. Hypertension. Dyslipidemia. Carotid disease. History of pulmonary fibrosis. Chronic left bundle branch block." An Operative Note indicated the performance of surgery on 1/18/15 for the above mentioned hip fracture. A physician note of 1/17/15 read: "EKG (electrocardiogram): Sinus rhythm with incomplete right bundle branch block and left anterior fascicular block, rate 65 ... Admit the patient to ortho ... Place telemetry monitor on the patient." A nurse's note of 1/17/15 at 4:18 PM read: "Nurse notified, per RN (registered nurse) direction, tele applied." Telemetry is when caregivers monitor the electrical activity of the heart for an extended time. A device sends information about the heart's electrical activity to a monitoring station. The care giver looks for problems or changes to see if a problem is likely to occur. (www.drugs.com) Nurse's notes from 1/17/15 through 1/20/15 reflected the continued performance of remote cardiac monitoring.

An electrocardiogram (EKG, ECG) is a test that measures the electrical signals that control heart rhythm. The test measures how electrical impulses move through the heart muscle as it contracts and relaxes.
The electrocardiogram translates the heart's electrical activity into line tracings on paper. The spikes and dips in the line tracings are called waves. The P wave is a record of the electrical activity through the upper heart chambers (atria). The QRS complex is a record of the movement of electrical impulses through the lower heart chambers (ventricles). The ST segment shows when the ventricle is contracting but no electricity is flowing through it. The ST segment usually appears as a straight, level line between the QRS complex and the T wave. The T wave shows when the lower heart chambers are resetting electrically and preparing for their next muscle contraction. (www.webmd.com )

The Discharge Summary dictated on 3/03/15 at 11:40 AM read: "The patient, on 1/21/2015, had a cardiopulmonary arrest. Per notes, the patient was in ventricular fibrillation and CPR (cardiopulmonary resuscitation) was given. The patient eventually was pronounced by the ER (emergency room) M.D. (medical doctor)" The patient did not survive. Ventricular tachycardia is a fast heart rhythm that starts in the lower part of the heart (ventricles). If left untreated, some forms of ventricular tachycardia may get worse and lead to ventricular fibrillation, which can be life-threatening. (www.webmd.com )

A review of cardiac monitor strips for 1/20/15, produced retroactively from the monitor assigned to patient #1, was performed with Risk Manager (RM)-H on 4/07/15 at 11:50 AM. At 11:13 PM on 1/20/15 the patient's heart rate showed irregularities; the QRS interval was wider and the heart rate was slowing down. At 11:14 PM on 1/20/15, there was more slowing and a changing from atrial rhythm to junctional rhythm (the SA node or sinoatrial node firing is either blocked or it is not firing at all). At 11:24 PM on 1/20/15 the patient was in ventricular rhythm. At 11:37 PM, the patient went into ventricular tachycardia and remained in this. The patient coded and was removed from this monitor while under this rhythm. During an interview with RM-H again on 4/08/15 at approximately 4:22 PM, she stated that the audible alarm would have gone off depending on the heart rate or certain rhythms. In the case of patient #1, she stated that it most likely sounded briefly at around 11:19 PM on 1/20/15 or 11:24 PM on 1/20/15, due to a low heart rate. She stated that it would, without question, have sounded continuously by 11:37 PM on 1/20/15 when the patient went into ventricular tachycardia. Further evaluation by Risk Manager #H at 2:24 PM on 4/09/15 revealed that with respect to the retroactive monitor readouts, the nurse should have been called when the patient had an elevated ST segment, in accordance with policy, at 11:14 PM. She confirmed that there was no evidence in the record or elsewhere of this having been done. She confirmed that there was an elevated ST segment at 11:14 PM and there was no later improvement in the patient ' s heart rhythm.

An additional evaluation of a retroactively produced monitor reading was performed with the physician Chief Quality Officer on 4/09/15 at 2:07 PM. He stated that the 11:21 PM strip on 1/20/15 which the MT pulled, indicated a wide QRS and an elevated ST segment. He stated that due to the ST elevation and the fact that it reflected a significant change since a normal strip at from 7:00 PM on 1/20/15, the nurse should have been called. He classified the strip as showing "accelerated idioventricular rhythm." A review of the strips which were retroactively obtained from the monitor revealed the following per the physician Chief Quality Officer. At 11:13 PM on 1/20/15, the ST segment was elevating. At 11:14 PM on 1/20/15, the QRS widened to 0.1 seconds, thus it was no longer in the normal range. From 11:14 PM onward on 1/20/15, there was a widened QRS and an elevated ST segment above the baseline. He stated that, per policy, this was an acute ST change and would have mandated a call to the nurse. At 11:21 PM on 1/20/15, the physician indicated that the QRS was even wider and the ST was still elevated. There was no P wave. At 11:37 PM - 11:38 PM on 1/20/15, the patient went into ventricular tachycardia and remained there through the end of the strip at 11:47 PM, per the physician.

During an interview with RM-H on 4/07/15 at 11:50 AM, a review of the cardiac rhythm strips from the monitor for 1/20/15 from 11:13 PM until at least 11:45 PM, revealed the patient developed cardiac abnormalities which had not been detected by monitor technician #1 and reported to nursing when certain thresholds were encountered, as required in policy and the monitor technician's position description. During an interview of RM-I on 4/07/15 at 12:51 PM, RM-I said, the monitor station enabled remote monitoring of patients in different units of the hospital. Monitor Technician (MT)-A had coverage over the room with the monitor for patent #1. He stated that during a previous interview of MT-A, she revealed that she did not respond to what was on the screen. He stated that the MT would not attest to what was visible on the screen on 1/20/15 one way or the other and that no definitive or conclusive response could be obtained from her.

A nurse's note of 1/20/15 at 11:45 PM by a Registered Nurse (RN) Rapid Response Team member read: "Rapid Resp Team. Comment: call to assess pt (patient) for EKG (electrocardiogram) changes just prior to entering room code blue 90 called. CPR (Cardio Pulmonary Resuscitation) in progress. Please see code sheet for progress." Code sheet documentation indicated that the event was recognized at 11:45 PM on 1/20/15. Since the alarm on the cardiac monitor sounded at 11:37 PM on 1/20/15, it was audibly sounding in the monitor room, in the presence of monitor technician #A, for at least eight minutes.

The record revealed that monitor tech #A had pulled a strip at 11:21 PM on 1/20/15. There was no evidence in the record or from any other source for the evening of 1/20/15 of any call to nursing by MT staff before an eventual code to begin CPR at 11:45 PM.

A review of facility policy "Continuous EKG Monitoring by Telemetry" revision date April 2012, revealed the following: "A STAT call via the direct line will be placed to the nurse for onset of potentially lethal dysrhythmias such as ... acute ST changes of ventricular tachycardia ... " A review of the position description for monitor technician revealed the following: "Responsible for continuous observation of the central telemetry screens for all patients requiring EKG monitoring and the documentation for each patient of baseline strips as well as all arrhythmias. ... Essential responsibilities: ... Immediately reports any changes in rhythm or other pertinent observations to charge nurse. Maintains clear communication with nurse until any problem or procedure is resolved." Under the circumstances as revealed by continuous remote monitor findings, an assigned monitor technician is required to notify a nurse.

An interview was performed on 4/08/15 at 4:05 PM with RN-C, who was patient #1's nurse on 1/20/15. She stated that another nurse, RN-D had gone by the monitor shortly before the time of the eventual performance of a Code and noticed an elevated heart rate in the 180's or so. She and RN-D then went to the room of patient#1 and started CPR and awaited arrival of Rapid Response and also the Code Team.

An interview of RN-D was performed on 4/09/15 at approximately 10:15 AM. She stated that the nursing station was empty just prior to the incident, as nurses had been with patients. She sat in the monitor area and as soon as she sat down, she looked over to the monitor and noted an abnormal heart rate with #1. There had been no notification by the MT of any discrepancies with the patient.

During an interview of the Director of Clinical Care on 4/7/15 at 4:30 PM, she stated that the MT-A said that she did not hear the alarm or discern any abnormalities on the screen.

An interview of MT-A was performed on 4/08/15 at approximately 6:15 PM. She stated that she could not recall having heard the alarm go off for patient #1 on 1/20/15. She stated that she had pulled a strip on this patient and other patients that evening. She said the strip of patient #1 was pulled during the time which she later understood as being shortly prior to when #1 had begun to experience significant cardiac abnormalities. She stated that she did not note any abnormalities with #1 per visual examination of the monitor at the time of the initial abnormal heart rhythms, nor when the patient experienced sustained ventricular tachycardia.


The act of pulling strips is required each shift per policy. Facility policy "Continuous EKG Monitoring by Telemetry" revision date April 2012 read: "The MT (monitor tech) ... sends each strip-recording print job directly to unit printers at the scheduled times. ... The bedside nurse is responsible for ... initialing the lower right hand corner of the strip print-out, and then placing it in the physical chart." Evidence of a strip pulled close to the time of the incident with patient #1 was found in the medical record of #1 in the form of a strip timed at 11:21 PM on 1/20/15. As indicated above, this 11:21 PM strip for #1 had abnormalities which, per policy as quoted above, would have required a call. Also as indicated above, MT-A did not call nursing at any point during the time frame in which reportable abnormalities were visible on the monitor, which included the strip pull time of 11:21 PM on 1/20/15. MT-A pulled the monitor strip of 11:21 PM on 1/20/15. The failure to report adverse findings revealed on the remote monitor screen and the pulled monitor strip at a certain level as specified in the above stated policy and position description was a violation of the requirements in the policy for Continuous EKG Monitoring by Telemetry.

During an interview of the RM-I at approximately 5:30 PM on 4/09/15, he confirmed the preceding.