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Based on observation, interview, and record review, the facility failed to provide organized nursing services for one of 17 patients (Patient 1) on the telemetry unit (a unit where patients are under constant electronic monitoring) who were receiving telemetry monitoring (a portable device that measures the hearts electrical activity to continuously track heart rate and rhythm) when:

1a. On 1/16/23 the facility failed to implement its "Telemetry Monitoring: Application of and Care and Assessment of the Patient Monitor" policy when nursing staff did not respond to Patient 1's telemetry monitor alarms during 13 priority alarm events occurring over five consecutive minutes. These alarm events indicated Patient 1 was experiencing severe changes in heart rate or heart rhythm. As a result, Patient 1 did not receive a nursing assessment, nursing interventions, or potential emergency treatment during the five minutes that preceded Patient 1's cardiac arrest (the sudden loss of heart function). This failure caused or contributed to a delay of care in Cardiopulmonary Resuscitation (CPR) and emergency medical interventions to Patient 1, who was later determined to have severe anoxic encephalopathy (a complete loss of brain function due to no oxygen) and turned over to the organ donor network on 1/17/23. Refer to A 398 finding 1a.

1b. On 1/16/23 the facility failed to implement its "Telemetry Monitoring: Application of and Care and Assessment of the Patient Monitor" policy when nursing staff did not respond to Patient 1's telemetry monitor recordings that indicated Patient 1 was disconnected from two telemetry leads and the remaining three leads had poor quality signals with interrupted electrical artifact (a distortion in the telemetry monitoring that can be caused by a loose lead, body tremors, body movement, shaking, or shivering). As a result, Patient 1 did not receive a nursing assessment to troubleshoot the placement and integrity of the telemetry leads or to identify if Patient 1 had an abrupt change in physical condition, physical activity, or movement. This failure compromised Patient 1's safety, and potentially contributed to a delay of care, when Patient 1's telemetry monitor had interrupted signals for several minutes before it was able to detect severe changes in heart rate. Refer to A 398 finding 1b.

1c. On 1/15/23 - 1/16/23 The facility failed to implement its "Provision of Patient Care, Plan for Telemetry" policy when nursing staff did not provide Patient 1 with the appropriate ongoing patient assessments, including obtaining vital signs (heart rate, blood pressure, blood oxygen saturation, and temperature), health screenings, or hourly nursing rounds (hourly screenings that include patient observation to address a patient's personal needs, positioning and turning, safety needs, and fall risk precautions). This failure resulted in Patient 1 not receiving nursing services or assessments that identified a change in patient needs, a change in physical condition, or potential patient decline during the six hours that preceded Patient 1's cardiac arrest. Refer to A 398 finding 1c.

1d. On 1/15/23 - 1/16/23 the facility failed to implement its "Staffing Plan for Telemetry" policy when it did not maintain a nurse-to-patient ratio in Telemetry unit of 1:4 at all times. This failure caused, or contributed to, Patient 1 not receiving nursing services preceding their cardiac arrest. Refer to A 392 finding 1a.

1e. The facility failed to implement its staffing plan for the medical/surgical unit when it did not maintain a nurse-to patient ratio of 1:5 on 1/29/23. Refer to A 392 finding 1b.

1f. The facility failed to implement its "Staffing Plan for Telemetry" policy when it did not maintain a nurse-to-patient ratio on 1/29/23. Refer to A 392 finding 1c.

1g. The facility failed to implement its staffing plan for the critical care unit on 1/29/23. Refer to A 392 finding 1d.

The cumulative effect of these systemic problems resulted in the hospital's inability to comply with the statutory mandated Condition of Participation: Nursing Services.

Based on interview and record review, the facility failed to have adequate numbers of nurses and other staff to provide assessments, safe and effective care as needed by the patients, and implement its staffing policies to patients in the Telemetry unit (Tele, continuous remote monitoring of the patient's heart rate and rhythm), the Medical and Orthopedics Unit (a general medical unit), and Intensive Care Unit when:

1a. The facility failed to implement its "Staffing Plan for Telemetry" policy when it did not maintain a nurse-to-patient ratio in Telemetry unit of 1:4 at all times on 1/15/23 - 1/16/23. This failure caused, or contributed to, Patient 1 not receiving nursing services preceding her cardiac arrest.

1b. The facility failed to implement its "Staffing Plan for Surgical/Ortho Neuro " policy when it did not maintain a nurse-to-patient ratio in the Medical and Orthopedics Unit of 1:4 at all times on 1/29/23. This failure had the potential to cause, or contribute to inadequate nursing services and patient safety issues.

1c. The facility failed to implement its "Staffing Plan for Telemetry" policy when it did not maintain a nurse-to-patient ratio in Telemetry unit of 1:4 at all times on 1/29/23. This failure had the potential to cause, or contribute to inadequate nursing services and patient safety issues.

1d. The facility failed to implement its "Staffing Plan for Intensive Care Unit" policy on 1/29/23. This failure had the potential to cause, or contribute to inadequate nursing services and patient safety issues.

Findings:

1a. A review of the facility's policy and procedure titled, "Telemetry Unit- Structure Standards", revised 06/22, indicated that the Telemetry Unit is a 36-bed unit that provided care and telemetry monitoring to patients with major diagnosis that included cardiac surgery (surgery on the heart or heart's blood vessels), cardiac interventional procedures (nonsurgical heart procedures that repair the heart's vessels or arteries), cardiac failure (a condition the heart does not pump blood as well as it should), and respiratory failure (a condition when lungs can't get enough oxygen into the blood).

A review of the facility's policy and procedure titled, "Staffing Plan for Telemetry", revised 9/18, indicated that the licensed nurse-to-patient ratio in Telemetry shall be no greater than 1:4 at all times (one licensed nurse to four telemetry patients). Patients that required mechanical ventilation (a machine that assists with breathing), Bipap (a machine that delivers high pressurized air into the lungs through a face mask to help open the lungs), certain intravenous (IV, to provide access directly into a vein and directly into a bloodstream) medications, and hemodynamic (the measurement of blood flow through the vessels) support shall be staffed at a 1:3 nurse-to-patient ratio or higher based on acuity.

A review of the facility's document titled " Telemetry Unit Daily Assignment Sheet-Night Shift", dated 1/15/2023, indicated that the telemetry unit had eight telemetry staff nurses and one telemetry charge nurse providing patient care. Five of the eight nurses were at a 1:5 ratio, a ratio that exceeds the telemetry staffing policy standards. Two of the eight nurses were at a 1:4 ratio, and one nurse was at a 1:3 ratio. The charge nurse, RN 30, was assigned a 1:3 patient ratio after midnight.

During an interview on 2/08/23, at 4:53 pm, Registered Nurse (RN) 34 stated that she has been a telemetry nurse for four years and worked at the facility as a telemetry travel nurse (a registered nurse that provides temporary nursing services to facility) for approximately six weeks. RN 34 stated that the telemetry unit's staff assignments frequently did not follow the telemetry staffing plan policy. On several occasions telemetry nurses were assigned to care for more than four patients. RN 34 reported she was familiar with Patient 1 because she worked the shift that Patient 1 coded and assisted Patient 1's nurse with administering IV medications. RN 34 stated the unit was "severely short staffed" on 1/15/23 and "everyone was spread thin".

During a concurrent interview and record review on 2/27/23, at 4:05 pm, RN 30 reviewed the staff assignment sheets for 1/15/23 and verified that the staffing plan was not consistent with the facility's policy when five of eight telemetry nurses were working at a 1:5 patient ratio. RN 30 stated the telemetry night shift was short-staffed, and "becoming a revolving door for travel nurses". RN 30 confirmed that Patient 1's nurse, RN 32, was a travel nurse assigned to a 1:5 patient load. RN 30 reported she had a patient load of 1:3 after midnight because a day shift telemetry nurse working overtime had to go home. After midnight, RN 30 relieved Telemetry Tech (TT) 1 for a night break because she was the only staff member that was trained on the telemetry monitoring system that could provide break relief. Usually a patient care technician cross-trained on the telemetry monitoring system would be scheduled so the charge nurses do not have to provide TT's with break or lunch relief. RN 30 did not delegate her patient load to another telemetry nurse when she provided the TT break relief because the unit was already out of ratio and a resource nurse was not scheduled. RN 30 remained in the tele chamber at all times during TT 1's break and assumed that the other telemetry nurses would notify her if her patients needed nursing care. RN 30 verified that while she was in the tele-chamber when Patient 1 developed heart rate and rhythm changes and sustained a cardiac arrest.

During a concurrent interview and record review on 2/27/23, at 12:00 pm, Telemetry Unit Director (TD) verified that the night shift telemetry unit staffing sheet, dated 1/15/2023, did not follow the facility's staffing policy.


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1b. A review of the facility's document entitled "Staffing Plan for Surgical/Ortho Neuro" dated 4/2021 indicated that "The licensed nurse-to-patient ratio in Medical, Surgical, Ortho and Neuro shall be no greater than 1:5 at all times". It further indicates that "Pediatric and Telemetry monitored patients shall be staffed at a 1:4 nurse-to-patient ratio".

During an interview on 2/21/23 at 2:45 pm, the Director of Medical Surgical and Orthopedics (OND) reviewed the staffing sheets for 1/29/23 night shift and stated that RN 30 received a telemetry admission from the Emergency Department at 8:10 pm that night. RN 30 already had 4 telemetry status patients and was given a fifth, this new admission from the Emergency Department. OND stated that a nurse with 4 telemetry status patients should not have been given a 5th because that then put her out of compliance with state mandated ratios and department policy. OND acknowledged that the assignment was out of ratio and he did not know why the charge RN, who only had 2 telemetry patients did not take the new admission instead.

OND stated that on the night of 1/29/23 there had been 2 nurses who called in sick. One from the telemetry unit and one from critical care. He stated that all the charge nurses on Telemetry, Intensive Care Unit and Surgical unit had patients that night. OND stated that when the charge nurse has a patient assignment, the staff nurses do not get breaks and instead are paid for missed break or meal penalty. OND stated he thought this shortage was due to some travelers leaving before their contract had ended.


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1 c. During a concurrent review of staffing sheets and interview on 2/21/23 at 2:55 pm, OND confirmed all the charge nurses in Telemetry, Intensive Care Unit (ICU), and Medical surgical units had patients and all these units were out of ratio and not within their staffing policies. He said some traveler nurses (nurses who work at a temporary assignment for a certain number of weeks) have left after rate reduction and that could be the reason for the short staffing but on this night, there were also regular staff that called in sick. He said when the charge nurse takes patients then the nurses don't get a break but get paid overtime for those breaks.

During a concurrent review of staffing sheets and interview on 2/27/23 starting at 12 pm, the TD said, on 1/29/23 on night shift the charge nurse had four patients and the other nurses had five patients.

1. d. A review of the facility's "Staffing Plan for Critical Care" policy, dated 4/2021, indicated, the licensed nurse-to-patient ratio in Critical Care shall not be more than 1:2 at all times. . .. Assignments for the shift will be determined by the Charge Nurse. The Charge Nurse will not routinely assume a patient assignment but will be available to provide assistance to and relief for the licensed nurses with patient assignments. . .. If the Charge Nurse assumes a patient assignment, whenever, possible, a RN who has demonstrated competence to provide care to the individual's patient for whom he/she is providing relief, will be available during the lunch hours.

A review of the facility's "Adult & Pediatric Emergency Policy" policy, dated 5/2021, indicated the Code Blue team members included the Critical Care RN. The Code Team Member responsibilities included: The Code Blue Team Leader (Critical Care RN or Emergency Department RN) directs the code blue until the Emergency Department physician or primary care physician arrives to assume direction of the team.

A review of the ICU staffing sheets on 1/29/23 showed the charge nurse had two patients on night shift. The other nurses had two patients or 1 very critical 1:1 patient on that shift.

During an interview on 2/21/23 at 6 pm, RN 12 said when he is charge nurse, he has to respond to code blues (patient needs immediate lifesaving resuscitative efforts due to no pulse or respirations) and help with rapid responses (members including the ICU Charge nurse that assess and treat deteriorating patients to prevent further decline), so if he's charge nurse and has patients he can't respond as he should.

During an interview on 2/28/23 at 11:40 am, the above staffing was discussed with the ICU Director (ICUD). She confirmed it was not ideal when the charge nurse has a full patient load at the start of shift and if there's a code blue or rapid response on the Medical surgical or Telemetry floor then that patient would be transferred to ICU and the ICU nurses would have to assume care of that patient even though staffing was not adequate.

Based on observation, interview, and record review, the facility failed to provide organized nursing services for one of 17 patients (Patient 1) on the telemetry unit (a unit where patients are under constant electronic monitoring) who were receiving telemetry monitoring (a portable device that measures the hearts electrical activity to continuously track heart rate and rhythm) when:

1a. On 1/16/23 the facility failed to implement its "Telemetry Monitoring: Application of and Care and Assessment of the Patient Monitor" policy when nursing staff did not respond to Patient 1's telemetry monitor alarms during 13 priority alarm events occurring over five consecutive minutes. These alarm events indicated Patient 1 was experiencing severe changes in heart rate or heart rhythm. As a result, Patient 1 did not receive a nursing assessment, nursing interventions, or potential emergency treatment during the five minutes that preceded Patient 1's cardiac arrest (the sudden loss of heart function). This failure caused or contributed to a delay of care in Cardiopulmonary Resuscitation (CPR) and emergency medical interventions to Patient 1, who was later determined to have severe anoxic encephalopathy (a complete loss of brain function due to no oxygen) and turned over to the organ donor network on 1/17/23.

1b. On 1/16/23 the facility failed to implement its "Telemetry Monitoring: Application of and Care and Assessment of the Patient Monitor" policy when nursing staff did not respond to Patient 1's telemetry monitor recordings that indicated Patient 1 was disconnected from two telemetry leads and the remaining three leads had poor quality signals with interrupted electrical artifact (a distortion in the telemetry monitoring that can be caused by a loose lead, body tremors, body movement, shaking, or shivering). As a result, Patient 1 did not receive a nursing assessment to troubleshoot the placement and integrity of the telemetry leads or to identify if Patient 1 had an abrupt change in physical condition, physical activity, or movement. This failure compromised Patient 1's safety, and potentially contributed to a delay of care, when Patient 1's telemetry monitor had interrupted signals for several minutes before it was able to detect severe changes in heart rate and resulted in Patient 1 being discovered hunched over the edge of bed, with feet dangling, unresponsive, and without a pulse.

1c. On 1/15/23 - 1/16/23 The facility failed to implement its "Provision of Patient Care, Plan for Telemetry" policy when nursing staff did not provide Patient 1 with the appropriate ongoing patient assessments, including obtaining vital signs (heart rate, blood pressure, blood oxygen saturation, and temperature), health screenings, or hourly nursing rounds (hourly screenings that include patient observation to address a patient's personal needs, positioning and turning, safety needs, and fall risk precautions). This failure resulted in Patient 1 not receiving nursing services or assessments that identified a change in patient needs, a change in physical condition, or potential patient decline during the six hours that preceded Patient 1's cardiac arrest.

Findings:

1a. A review of the facility's policy and procedure titled, "Telemetry Monitoring: Application of and Care and Assessment of the Patient Monitor", revised 6/22, indicated that the policy's purpose was to provide a guideline for nursing staff on the care and monitoring of the patient on a telemetry monitor. The telemetry technician's duties included, to "monitor the patient's rhythm at all times and notify the nurse IMMEDIATELY" of any patient dysrythmia or ectopy. The patient's primary care RN duties included, to "PROMPTLY assess the patient, including vital signs, upon notification by the Telemetry Technician of any new or changed dysrhythmias (an abnormal or irregular heartbeat)".

A review of Patient 1's emergency room provider record, dated 1/14/23, at 7:08 pm, indicated that Patient 1 arrived by ambulance to the facility's emergency department (ED) with symptoms of shortness of breath, cough, back pain, and acute exacerbation of chronic obstructive pulmonary disease (severe worsening of a lung disease that blocks airflow making it difficult to breathe). ED labs indicated that Patient 1 had severe hypoxia (a lack of oxygen to support bodily functions), an elevated D-dimer (a blood measurement that may indicate a blood clotting disorder), and an elevated white blood cell count (WBC, a blood measurement that may indicate infection). An electrocardiogram (EKG, an electrical recording of the hearts rate and rhythm) indicated Patient 1 was in normal sinus rhythm (a healthy heart rhythm that usually has a heart rate of 60-100 beats per minute) with a heart rate of 91. A computed topography (CT, diagnostic imaging that produces images of inside the body) of Patient 1's chest and pulmonary arteries (arteries of the lungs) showed signs of a left pulmonary artery embolus (PE, a blood clot that may block one or more pulmonary arteries). Patient 1 was subsequently admitted to the facility's telemetry unit for further evaluation and treatment.

A review of medical doctor's (MD 1) progress note, dated 1/15/23, at 6:16 pm, indicated that Patient 1's interventions on the telemetry unit included: Intravenous (IV, to provide access directly into a vein and bloodstream) heparin (a medication that helps prevent blood clots) to reduce Patient 1's risk from the PE, telemetry monitoring for continued cardiac monitoring, IV antibiotic therapy for a WBC count elevation, IV Lasix (a diuretic medication that decreases the amount of fluid through the veins and arteries), oxygen, and Bipap (a machine that delivers high pressurized air into the lungs through a face mask to help open the lungs). MD 1 reported that Patient 1's condition was guarded (high risk for becoming clinically unstable).

A review of the facility's document titled "Tele Unit Assignment List", dated 1/15/23, at 6:29 am, indicated that Patient 1 was assigned to Telemetry Room #3018 A and placed on Telemetry Unit #20 for continuous telemetry monitoring.

A review of the facility's document titled "All Codes Record", dated January 2023, indicated that the facility's switchboard operator called an overhead code blue (a hospital emergency code indicating cardiac or respiratory arrest) for Room 3018 A, Patient 1's room, on 1/16/23 at 1:57 am.

During an interview, records request, and review on 1/27/23, at 5:20 pm, the facility's Director of Performance Improvement (DPI) verified they provided a complete copy of Patient 1's telemetry rhythm strips and audible alarm events (an event record that documents the time and reason why a patient's telemetry alarm was triggered) that occurred on 1/16/23. DPI stated that Patient 1's electronic health record (EHR) had documentation of only two audible alarm events that occurred at 1:57 am and 1:59 am on 1/16/23.

During an interview, records request, and record review on 2/22/23, at 9:45 am, the Health Information Management Lead (HIML) provided a second complete record of Patient 1's monitoring strips. HIML verified that Patient 1's record only contained two strips on 1/16/23 that were timed at 1:57am and 1:59 am. HIML was asked if there were any more strips stored in the Tele monitor or kept in the facility's cloud based EHR system. HIML stated there were no other stored rhythm strips on Patient 1. HIML confirmed that if she was presented with a court order to provide a copy of Patient 1's Tele strips these were the Tele strips she would provide.

During a record review of Patient 1's Full Disclosure of Telemetry Audible Alarm Events Report (a second by second continuous telemetry report of a patient's heart rate and rhythm, that records all triggered alarms, and the reason for the alarms), that was retrieved from the facility's information technology staff collaborating with the telemetry monitor manufacturer, dated 1/16/23, indicated that Patient 1's telemetry unit, Tele # 20, triggered a total of 13, separate, priority alarm events, starting at 1:54:00 am. These events included alarms at the following times: 1:54:00 am Sinus Tachycardia (heart rate over 100), 1:54:25 am extreme bradycardia ( heart rate below 40), 1:54:49 am bradycardia, 1:55:12 am extreme bradycardia, 1:55:53 am bradycardia, 1:56:31 am bradycardia, 1:56:39 extreme bradycardia, 1:57:05 am 'paused alarm' for bradycardia, 1:57:08 am extreme bradycardia, 1:57:32 am 'paused alarm" for bradycardia, 1:57:33 am extreme bradycardia, 1:59:20 ventricular fibrillation/ tachycardia (VFIB, a life-threatening rhythm). At 1:59:40 am the telemetry leads were removed from Patient 1 and CPR was initiated.

A review of Patient 1's telemetry technician record entered by Telemetry Technician (TT, a technician responsible for independently observing and interpreting a patient's heart rate and rhythm) 1, dated 1/16/23, at 1:59 am, indicated that Patient 1's heart rate decreased to the 30's. The telemetry unit charge nurse (RN 30) went to Patient 1's room to perform a nursing assessment and immediately instructed TT 1 to page a code blue. Patient 1's telemetry monitor appeared to show VFIB. Patient 1's telemetry leads were removed, and CPR was initiated, approximately five minutes after Patient 1's first telemetry alarm was triggered.

During an interview on 2/8/23, at 5:54 pm, TT 1 stated she has been employed as a certified TT (a certification to monitor vital signs and heart rhythm remotely from special telemetry equipment) at the facility for four years and confirmed she was working on the telemetry unit when Patient 1 coded. TT 1 stated telemetry charge nurses are cross- trained to work in the tele chamber (a small room within the telemetry unit equipped with four desktop monitors that display live- time continuous telemetry monitoring of over 46+ patients). Cross-trained staff understand the chamber is to never be unmanned and that they are observe the monitors at all times, analyze patient rhythms, and respond to all alarms. Before Patient 1's code blue, TT 1 was relieved by the telemetry unit charge nurse (RN 30) from the tele chamber for a 10-15-minute break. After break, TT 1 returned to the chamber and found RN 30 analyzing an enlarged version of Patient 1's live-time telemetry monitoring. Patient 1's heart rate was severely bradycardia, "then bouncing back up". TT 1 assisted RN 30 by pulling up a history function on the telemetry system that displayed an enlarged, continuous progression, of Patient 1's heart rate history. TT 1 identified that Patient 1's heart rate had been fluctuating between sinus tachycardia and extreme bradycardia, and instructed RN 30 to go "get eyes on the patient". After RN 30 entered Patient 1's room she yelled out for TT 1 to call a code blue. When TT 1 paged for a code blue she noticed that Patient 1's rhythm appeared to display V fib, followed by Patient 1's leads being removed for CPR. TT 1 was not aware that Patient 1's monitor had been alarming for several minutes before the code blue because the continuous patient history function did not display the alarm events. TT 1 stated that telemetry chamber staff would be expected to request an immediate nursing assessment of Patient 1 at the first triggered alarm and receive a nurse report on the patient within one minute. If a report is not received, and priority alarms continue to trigger, TT 1 would yell for the charge nurse (CN, a registered nurse who oversees a department of nurses) to delegate a patient assessment stat (a medical word for urgent or rush).

During a concurrent interview and record review on 2/27/23, at 4:00 pm, Registered Nurse (RN) 30 stated that she has been a CN on the facility's telemetry unit for approximately five years and confirmed she received training on the facility's telemetry monitoring equipment and procedures. RN 30 verified she worked the night of Patient 1's code and provided relief for TT 1 during her early morning break. During TT's break RN 30 remained in the tele chamber at all times, even though she had three telemetry patients assigned to her for nursing care. RN 30 verified that Patient 1's monitor displayed an alarm at 1:54:00 am for sinus Tachycardia. During that alarm, RN 30 yelled for someone to go and check on the patient. RN 30 assumed a licensed nurse heard her request and went to immediately assess Patient 1. RN 30 confirmed Patient 1's monitor continued to trigger multiple priority alarms following the 154:00, but she had assumed a nurse was already with the patient. At 1:57 RN 30 observed an extreme bradycardia also, so she "yelled again for someone to go check on the patient". When TT 1 returned from break, they analyzed Patient 1's strips together, and TT 1 verified that the extreme bradycardia "was real". RN 30 left the tele chamber, went to Patient 1's room, and discovered Patient 1 on the edge of her bed, with her feet hanging off, likely attempting to sit up. A second nurse was assisting RN 30 and confirmed that Patient 1 had no carotid pulse. RN 30 yelled out for TT 1 to page a code blue. The two nurses transferred patient 1 to their back, removed the leads, and began CPR. When RN 30 was asked what occurred between Patient 1's 1:54:00 alarm and 1:57:25 alarm, RN stated there were several travel nurses (licensed nurses that take temporary positions in hospitals) working this shift, and they were unwilling to help or provide patient care if an issue doesn't involve their patient.

During an interview on 2/14/23 at 11:15 am, RN 31 stated she has been a critical care nurse (a nurse who provides specialized care to very ill patients) for five years and worked at the facility as a travel telemetry nurse for approximately five weeks. RN 31 reported she was familiar with Patient 1 because she was assigned to her roommate in 3018 B on the night of Patient 1's cardiac arrest. RN 31 reported on 1/16/23, during the early morning hours, she observed that room 3018's call light was on. When RN 31 walked toward room 3018 to answer the call light, she noticed that RN 30 was trailing behind her. RN 31 stated she was unaware that RN 30 was responding to priority alarms from Patient' 1's telemetry unit. RN 31 thought RN 30 was responding to the call light as well, since RN 30 was not walking urgently, and laughing while having a conversation with another nurse. When RN 31 entered the room, Patient 1's roommate pointed to the curtain that separated the two patients. RN 31 discovered Patient 1 up in bed, hunched over the edge, with her legs dangling, and eyes closed. Patient 1 did not respond to RN 31's voice or physical stimuli. RN 31 checked Patient 1's carotid pulse and confirmed there was no pulse. RN 30 yelled out for TT 1 to page a code blue, and RN 31 and RN 30 grabbed Patient 1's legs, pivoted her body back in bed, and confirmed that Patient 1 was still without pulse. RN 31 stated many staff members began to enter Patient 1's room, so she exited and resumed providing care to her patients. RN 31 did not observe CPR being administered to Patient 1.

During concurrent interviews and record reviews on 1/27/23, at 11:22 am, 2/22/23, at 5:00 pm, and 2/27/23, at 9:20 am, TT 2 reported she is a certified TT tech that has worked at the facility for 1.5 years. TT 2 stated that telemetry monitor technicians and relief staff (staff that are cross- trained to work in the telemetry chamber) are trained to stay in the telemetry chamber at all times, focus on scanning the telemetry monitors, and responding to patient alarms. TT 2 stated that every alarm requires a nurse to follow up with a patient interaction. If a particular patient's telemetry monitor is constantly alarming, a licensed nurse can call the MD and request for a change in alarm parameters to reduce alarm fatigue (when medical professionals become desensitized to an increase in alarms, leading to missed alarms or delayed response). TT 2 was asked to analyze Patient 1's Total Alarm Event Disclosure and describe what actions or interventions they would take while working in the telemetry chamber. TT 1 stated they would "immediately alert nursing staff" to check on Patient 1 at the 1:54 alarm event because the rhythm was "severely lower" than Patient 1's typical rate of 70's-80's. Since Patient 1's room, room 3018 A, was very close to the tele chamber, TT 1 would expect a staff member to yell out that the event is cleared or request support for either a rapid response (a team that provides early emergency interventions to prevent cardiac arrest) or code blue within one minute. If TT 1 did not receive an update on Patient 1's status from a licensed nurse within one minute, she would repeat the request for an immediate nurse assessment. TT 1 would leave the tele chamber door open, "yell for an urgent nurse assessment", and request for the "telemetry unit charge nurse".

During concurrent interviews and record reviews on 2/21/23, at 9:23 am, and 2/27/23, at 10:30 am, TT 3 stated he has worked as a certified TT at the facility for over 20 years and acts as a preceptor for new TT staff. TT 3 was asked to analyze Patient 1's Full Alarm Event Disclosure and describe what actions they would take if they were working in the tele chamber during these events. TT 3 stated at Patient 1's first 1:54:01 am alarm he would request a licensed nurse to immediately assess Patient 1. TT 3 stated the alarm was "valid sinus bradycardia" rhythm because of the distance between each QRS complex (the tracing of each heartbeat seen on an EKG) on the rhythm strip. This alarm event was "even more concerning" because Patient 1 experienced sinus Tachycardia immediately prior to the sinus bradycardia alarm, which may indicate patient 1 "was struggling". During the 1:54:01 am alarm, TT 3 would open the tele chamber door, make eye contact with a licensed nurse, and request an immediate assessment of 3018 A for extreme bradycardia. Since room 3018 A is very close to the nurses' station, a licensed nurse should "respond immediately" and get "eyes on the patient" within 20-30 seconds. The event would either be cleared, or emergency intervention would be initiated within one minute of the 1:54 alarm. TT 3 verified that Patient 1's rhythm strips showed five minutes had passed from the first alarm event to Patient 1's leads being removed for CPR.

During a concurrent interview and record review on 2/27/23, at 11:55 am, the Telemetry Unit Director (TD) stated she has been the facility TD for five years and was a critical care nurse at the facility for approximately 43 years. TD reported that all telemetry nurses, technicians, and staff received training on the facility's telemetry monitoring system called MindRay. TD was asked to analyze Patient 1's Total Alarm Event Disclosure and explain the expectations of staff identifying and responding to telemetry alarm events. TD confirmed that Patient 1's Total Alarm Event Disclosure indicated that 13 separate, priority alarms, were triggered over five consecutive minutes. TD verified that Patient 1's first alarm was triggered at 1:54:01, and the code was not called until 1:57, and the leads were not disconnected for CPR until 1:59 am. TD stated that a nurse should have been assessing Patient 1's alarm immediately and could not offer an explanation for why emergency nursing services were not delivered within one minute of Patient 1's first alarm. TD stated it is her expectations, and the facility's policy, that staff in the chamber respond to all telemetry alarms. There are no alarm situations that should be ignored. If a patient's device seems to be alarming often, telemetry staff can request an MD order to change the alarm parameters. When a patient's telemetry monitor alarms, staff in the telemetry chamber are expected to notify licensed nurses of alarm events immediately, and nursing staff are expected to stop what they are doing and assess the patient. If the nurse determines emergency intervention is needed, the nurse should yell out for staff to call extension 777 (the facility's switchboard paging system) for either a rapid response or code blue. It is expected that this process be completed within one minute. TD verified that a delay of care occurred when Patient 1 did not receive a nursing assessment or emergency nursing services within one minute of their first alarm and confirmed that Patient 1's leads were not removed for CPR until five minutes after their first alarm.

1b. A review of the facility's policy and procedure titled, "Telemetry Monitoring: Application of and Care and Assessment of the Patient Monitor", revised 6/22, indicated that the policy's purpose was to provide a guideline for nursing staff on the care and monitoring of the patient on a telemetry monitor. The telemetry technician's duties included, to monitor the patient's rhythm at all times and notify the nurse "IMMEDIATELY" of any poor quality or interrupted telemetry signal. The patient's primary care RN duties included, to "assess PROMPTLY" the integrity of the leads, wires, and battery status upon notification by the technician of any equipment dysfunction and perform a prompt assessment of the patient, including vital signs.

A record review of Patient 1's Full Disclosure Telemetry Report (a second-by-second continuous telemetry report of a patient's heart rate and rhythm), dated 1/16/23, indicated that Patient 1 was connected to a five-lead telemetry unit (a telemetry unit with five wires that connect to adhesive pads on a patient's chest). Two of the five telemetry leads (lead II and lead AVR) became disconnected from Patient 1, and displayed a poor signal with artifact, from 1:51:31 am. to 1:59:40 am, at which time all leads were removed to initiate CPR.

During concurrent interviews and record reviews on 1/27/23, at 11:22 am, 2/22/23, at 5:00 pm, and 2/27/23, at 9:20 am, TT 2 stated that a patient must have all five telemetry leads securely connected with a good quality signal for TT's to perform their job. The telemetry system does not produce an audible alarm if only one lead becomes disconnected, so it is important to constantly monitor for disconnected or disrupted leads. TT 2 stated "many non-alarm events may be red flags too." Patients may be attempting to remove the equipment, getting out of bed without assistance, or may be experiencing physiological changes that interrupt the telemetry signal. When a TT identifies that a lead is disconnected, or has a poor signal, they request for a nurse to immediately assess the patient's telemetry unit and physiological status. TT 2 verified that Patient 1's Full Disclosure Telemetry Report indicated the two main leads, lead AVR and lead II, became disconnected at 1:51.26 and 1:51:29, approximately six minutes before a nurse assessed Patient 1 and called a code blue, and approximately eight minutes before CPR was administered. TT 2 stated that the telemetry chamber staff should have alerted nursing staff to immediately assess Patient 1's telemetry unit and physiological status at 1:51 am.

During concurrent interviews and record reviews on 2/21/23, at 9:23 am, and 2/27/23, at 10:30 am, TT 3 stated that the telemetry monitoring system cannot discern artifact from true arrhythmia, or detect changes in a patient's baseline heart rate, if just one lead becomes disconnected. The facility trains telemetry technicians to notify nursing staff when one lead becomes disconnected from a patient, or if artifact is continually detected, because the unit will not be able to provide true information for analysis. TT 3 stated that patients are placed on telemetry monitors for a reason, and this disruption in monitoring places telemetry patients at risk. TT 3 analyzed Patient 1's Full Disclosure Telemetry Report and stated the first red flag was at 1:51 am, when leads II and AVR became disconnected and displayed a lot of artifacts. TT 3 stated at 1:51 am telemetry chamber staff should have requested that a nurse immediately check on Patient 1. TT 3 verified that five minutes went by from the time the two leads became disconnected with poor signals to the time a nurse assessed Patient 1 and paged a code blue, and approximately eight minutes passed until Patient 1's leads were removed for CPR administration.

During a concurrent interview and record review on 2/27/23, at 4:00 pm, RN 30 confirmed that she was working in the telemetry chamber on 1/16/23 at 1:51 am to relieve the scheduled TT for a break. RN 30 was asked to analyze Patient 1's Full Disclosure Telemetry Report and identify any non-alarm events that would trigger her to request nursing interventions. RN 30 stated she would enlarge Patient 1's telemetry disclosure on the chamber monitor to verify if a lead was disconnected or to determine if there was a lot of patient movement at 1:51 am. RN 30 stated she recalled identifying that Patient 1's leads were disconnected and requesting for a nursing staff member to assess Patient 1 and their monitor. RN 30 could not recall what nurse she delegated the assessment task to, or if a nurse even responded to her request. RN 30 stated the telemetry night shift nursing staff are a majority of travel nurses who are not willing to help out. RN 30 assumed a nurse went to assess Patient 1, despite not receiving a follow-up nurse report the telemetry monitor continuing to display disconnected leads and artifact.

During an interview on 2/14/23 at 11:15 am, RN 31 stated TT's frequently announce from the tele chamber that certain patients are "showing leads off". The patient's direct care nurse, or an available nurse at the nurse's station, will respond and notify the TT that they are in route to assess the patient. The nurse will circle back to the TT and give a status update. If a patient's leads remain disconnected, or show artifact, TT's will continue to yell from the tele chamber until the issue is fixed. RN 31 stated Telemetry nurses rely on TT's because they are the "eyes and ears of heart changes", so it is important that the person in the telemetry chamber announce when leads are off and that nurses quickly assess the situation. Otherwise, telemetry nurses assume that their patients' monitors are properly secured and displaying a safe rhythm. RN 31 reported she was familiar with Patient 1 because she was assigned to Patient 1's roommate in 3018 B on the night of Patient 1's cardiac arrest. RN 31 assisted Patient 1 to reposition in bed and observed Patient 1's telemetry unit in the front pocket of her gown. RN 31 verified Patient 1's leads were secured at that time, because Patient 1 was a large woman who had been moving around a lot. RN 31 reported Patient 1 became very restless late in the night and appeared uncomfortable and agitated. RN 31 tried to meet the patient's needs by providing Patient 1 with water, repositioning, and requested snacks. RN 31 stated Patient 1 ate and drank very little and continued to move around a lot in bed. RN 31 located Patient 1's assigned telemetry nurse, RN 32, and reported her observations.

During a telephone interview on 2/17/23, at 6:00 pm, RN 32 stated she no longer works for the facility, declined to answer questions, and disconnected the call.

During a concurrent interview and record review on 2/27/23, at 11:06 am, DPI presented a copy of Patient 1's Full Disclosure Telemetry Report that was marked up with hand-written comments, and printed by the Chief Nursing Officer (CNO) for the survey team. DPI was unsure who marked-up the report or what the comments were intended for. DPI placed a telephone call to the CNO for clarification. CNO confirmed that he reviewed Patient 1's telemetry strips and made hand-written notes on the report to clarify that the flat lines were due to disconnected leads versus a dysrhythmia (abnormal heartbeat that is too slow or too fast). DPI confirmed that the CNO's notes verified Lead II became disconnected from Patient 1 at 1:51 am remained intermittently disconnected until 1:59 am, when they were removed for CPR.

During a concurrent interview and record review on 2/27/23, at 11:55 am, TD analyzed Patient 1's Full Disclosure Telemetry Report and identified that one or more leads became disconnected at 1:51 am. TD stated that disconnected leads, and leads with a lot of artifacts, are "a red flag", and disrupt TT's from doing their job. TD stated that a nurse should have "gotten eyes on" Patient 1 at 1:51 am to assess the patient and the telemetry unit set up. When telemetry chamber staff request that a nurse assess a situation, it is the TD's expectation, and facility policy, that nurses respond immediately.

1c. A review of the facility's policy and procedure titled, "Provision of Patient Care, Plan for Telemetry", revised 12/20, directed registered nursing staff to assess all telemetry patients on admission and reassess all patients at least every four hours to identify changes in patient care needs. Nursing assessment/reassessments included obtaining vital signs every four hours and screening patients to identify patient needs related to physical, psychosocial, nutritional, and functional care. Assessment data should be documented in the facility's Meditech Patient Care System (an electronic health record system).

A review of the facility's document titled "Daily Staff Assignment Sheet-Noc's", dated 1/15/23, indicated that RN 32 was assigned to provide nursing care to Patient 1 from 6:30 pm to 6:30 am.

On 1/30/23 at 11:55 am, a request was made to the RM for a complete copy of RN 32's nursing notes and nursing interventions administered to Patient 1 during the 1/15/23 night shift. RM stated RN 32 had only documented a physical health assessment at the start of shift and the administration of two IV antibiotic medications. RM stated there were no record of vital signs obtained by RN 32, no record of a physical reassessment, and no record of hourly nursing rounds.

During an interview on 2/15/23, at 4:21 pm, RN 1 stated she is an intensive care unit nurse (ICU, a nurse that provides care to patients with life-threatening conditions) at the facility and that she provided care to Patient 1 in the ICU after their cardiac arrest. RN 34 stated while she was reviewing Patient 1's health history in the EHR she discovered that RN 32 did not administer hourly nursing rounds, a nurse reassessment, or vials signs on Patient 1 prior to her cardiac arrest.

During an interview on 2/21/23, at 10:00 am, RN 33 reported she has been employed as a telemetry nurse at the facility for eight years. RN 33 stated that telemetry nurses are required to administer and document a head-to-toe physical assessment on their assigned patients at the start of every shift followed by reassessment screenings every four hours. Physical assessments include obtaining a complete set of vital signs. At the start of each shift the telemetry unit patient care tech (PCT) may obtain the first set of vital signs, however it is the nurses' responsibility to review this data and ensure the vital signs are completed. Telemetry nurses are also required to administer and document hourly round interventions on each patient. These interventions allow the telemetry nurses to get eyes on their patients and requires screening for patient safety, patient mobility, a change in patient's physical health status, and a change in patient needs. RN 33 stated that hourly rounds are only performed by licensed nurses to ensure patients are getting continually assessed. This intervention is a task that pops up hourly in every patient EHR for telemetry nurses to complete.

During a concurrent interview and record review on 2/27/23, at 4:05 pm, RN 30 reported that telemetry nurses are expected to do hourly rounds on all patients, which included at "the bare minimum" to stand at the bedside, check that the patients are breathing, verify the patient's tele box number and telemetry lead placement, and confirm that the patient's IV lines are opened and secured. RN 30 verified that telemetry nurses must administer a reassessment screening every four hours, which includes obtaining a complete set of vital signs. RN 30 was informed by a day shift charge nurse that RN 32 had not administered nursing assessments, medications, or IV fluids to other patients on a prior night shift. RN 30 stated she had a conversation with RN 32 and requested that she not leave work until all nursing interventions were implemented and documented. Due to a heavy workload, RN 30 did not have time to verify that RN 32 followed her instructions.

During concurrent interviews and record reviews on 2/14/23, at 11