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Based on obsrvation, interview and record review, the hospital failed to ensure nursing services was provided in a safe manner.

Findings:

1. On the transitional care/neurosurgery unit (TCNU) a monitor technician failed to implement a policy and procedure for the notification of nursing staff during a medical emergency (see A-386).

2. The hospital failed to ensure staffing guidelines on the TCNU included an acuity system to determine the maximum/minimum work load for monitor technicians (see A-397).

3. The hospital failed to develop a policy and procedure to direct staff on how and when to respond to the ventilator alarms when activated (see A-386).

The cumulative effect of these systemic problems resulted in the hospital's failure to provide safe nursing care to patients.

Based on observation, documentation and interview, staff failed to implement a hospital policy and procedure in regards to notifying licensed nursing staff of a medical emergency. In addition the hospital failed to develop a policy and procedure for unit clerks on the transitional care/neurosurgery unit (TCNU) in responding to ventilator alarms.

Findings:

1. A review of Patient 1's medical record on 2/24/12 revealed the following event.

Patient 1 was admitted to the hospital's transitional care/neurosurgery unit (TCNU) on 2/15/12 after being seen in the emergency room for shortness of breath, swelling of her extremities (edema) and decrease in urine output. Initial patient assessment revealed Patient 1 was alert and oriented but ventilator dependent (unable to breathe without mechanical assistance due to chronic respiratory problems) due to her respiratory status. She was placed on a mechanical ventilator that was connected to her tracheostomy tube (insertion of a tube into the patient's trachea through an opening in the neck, to facilitate passage of air) to support her breathing.

Further review of the chart indicated on 2/18/12 at approximately 10:25 a.m., the patient's ventilator became disconnected from her airway activating an alarm intended to alert staff of the problem. Nursing failed to respond to the alarm until 10:33 a.m., a period of 8 minutes. When staff responded, the patient was found unresponsive to verbal commands and pain. A code blue (medical emergency) was called at 10:44 a.m. and a medical team arrived. Patient 1 was stabilized and transferred to the hospital's intensive care unit for further care. The physician on the unit wrote, "Patient altered mental status is likely secondary to anoxic brain injury post disconnect from the ventilator...".

A review of the hospital investigation report on 2/24/12 found that a monitor technician (Tech A) was responsible for overseeing the cardiac monitors and the ventilator alarms. Tech A noted Patient 1's ventilator alarm had been activated which indicated the patient was off the ventilator. Tech A attempted to contact the nurse (Nurse B) assigned to Patient 1 via vocera (a two way voice activated communication device carried by staff) but got no response. After an unknown amount of time Tech A paged the nurse on an overhead paging system.

A review of the hospital policy and procedure for alarm notification was reviewed on 2/24/12. The policy indicated monitor technicians should notify the nurse of an alarm via vocera to check the patient immediately. If the nurse does not respond or the vocera does not reach the nurse, the monitor technician escalates the process by immediately calling the Charge Nurse via vocera or telephone. In step 3, in the event the Charge Nurse does not respond to the call immediately, the monitor technicians are to overhead page and broadcast "nurse assist stat" to the room.

On 2/24/12 a statement by Tech A was reviewed regarding her involvement with Patient 1's ventilator alarm. Tech A indicated that Patient 1's ventilator alarm went off at approximately 10:30 to 10:35 a.m. on the morning of 2/18/12. She further indicated she called the nurse on the vocera but got no response. She then "forgot" to proceed with the hospital's alarm notification procedure. She further stated she did not call the charge nurse because of all the "commotion" around her.

Time data recorded from the mechanical ventilator (time sequence when the patient is on or off the ventilator) connected to Patient 1 was reviewed on 3/2/12. The ventilator data revealed Patient 1 was off the ventilator from 10:25 a.m., until 10:33 a.m., a period of 8 minutes in which the patient was not breathing.

A visit was made to the TCNU on 2/24/12 and 3/2/12. It was found the ventilator alarms were connected to a patient call box system. The call box and ventilator alarms sound outside the rooms and at the monitor technicians' rooms. The ventilator alarm has a distinguished high pitch sound when activated, as when a patient is off the ventilator.

Failing to implement a policy and procedure in responding to a patient care alarm places patients at risk for potential injury.

2. On 6/26/12 at 11:15 a.m. the manager of TCNU was interviewed. She stated after the patient event on 2/18/12 when nursing staff failed to respond to a ventilator alarm in a timely manner, the ventilator alarms were relocated. Instead of being in the monitor room with the monitor technicians, the ventilator alarms were relocated to the nurse stations. Hospital administration determined through their own assessment, the monitor technicians had too many distractions while performing their duties therefore removed the ventilator alarms from the monitor room.

During an interview with the TCNU manager on 6/26/12 and prior to a unit visit, the manager stated all 4 nurse stations were equipped with the ventilator alarms system. A visit was made to the TCNU on 6/26/12 at 1:30 p.m. with the interim Chief Nursing Officer and TCNU manager. Three of the 4 nurse stations were visited. It was observed the first nursing station had no staff present. At the second station, the ventilator alarm was placed on a low volume making it impossible to hear unless sitting next to the call box. The third station had plenty of staff but according to the medical unit clerk (MUC), the station can become noisy and the alarm could be missed even though activated. When asked, the MUC stated she would overhead page the nurse if the ventilator alarm sounded. The MUC did not know of a policy for responding to the ventilator alarm as the initial policy regarding ventilator alarm notification was written for the monitor technicians and nurses. The unit manager stated there was no policy for MUC responding to the ventilator alarm.

Failing to develop a policy and procedure for MUCs responding to ventilator alarms did not promote a safe environment for patients, as the MUCs would be likely first responders to the alarm due to the amount of time spent on the nurse station.

Based on interview and record review, the hospital failed to have a specific job description and system in place to measure the amount of work a monitor technician performs. Findings:

On 6/27/12 the transitional care/neurosurgery unit (TCNU) monitor technician's job description was reviewed. The document revealed the monitor technician job was integrated with the functions performed by nurse aides (HSA). According to administrative staff (TCNU Manager) the HSA duties were not required for monitor technicians, although it was in the job description.

On 6/27/12 at 10 a.m. during a review of the TCNU staffing schedule for the month of February 2012, it was noted that although the monitor technicians were included in the staffing matrix there was no patient to monitor technician ratio. The hospital staffed TCNU with one monitor technician regardless of the patient census/workload. The hospital lacked an acuity system for staffing monitor technicians.

On 6/26/12 at 1:55 p.m. during an interview with monitor technician B, she stated her typical workload consisted of monitoring the cardiac activity of 36 - 38 patients, although the number could go up to 49 patients. In addition to monitoring the patient's cardiac rhythms, the monitor technicians are expected to "run" and read (printout a cardiac strip and interpret the rhythm for each patient) the patient's cardiac rhythms once a shift. Furthermore, the monitor technicians are responsible for the "King of Hearts." The "King of Hearts" is an outpatient program in which outpatients have a cardiac monitor and are instructed to call the monitor technician during an episode of perceived cardiac abnormality. If the call is made the technician is responsible for printing out the cardiac rhythm during the time of abnormality. In addition to the above duties the monitor technicians are also responsible for monitoring the "sitter" cameras. The cameras are used for patients who are at high risk for falls and are "trying to get out of bed". The technician must notify nursing when the patient is trying to get out of bed. There are 4 sitter camera/monitors.

Failing to develop a system to determine a safe workload for monitor technicians does not promote a safe environment as alarms could be missed (see A-386).