HospitalInspections.org

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the §482.23 Condition of Participation: Nursing Services was out of compliance.

A-0395- Standard: A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review the facility failed to ensure patients were monitored via continuous cardiac telemetry, and/or pulse oximetry, according to policy and physician orders and failed to ensure staff responded timely to these changes in one of nine patients who were ordered continuous monitoring (Patient #3). The facility also failed to ensure the immediate availability of cardiac telemetry and pulse oximetry monitoring equipment when ordered for patients.

Based on interviews and document review the facility failed to ensure patients were monitored via continuous cardiac telemetry, and/or pulse oximetry, according to policy and physician orders and failed to ensure staff responded timely to these changes in one of nine patients who were ordered continuous monitoring (Patient #3). The facility also failed to ensure the immediate availability of cardiac telemetry and pulse oximetry monitoring equipment when ordered for patients.

The failure resulted in a patient going unmonitored. While the patient was unmonitored she suffered cardiopulmonary arrest. The patient was found to have a hypoxic brain injury, required life support measures, and ultimately expiring during her hospital stay.

Findings include:

Facility policy:

The system-wide policy, Cardiac Monitoring- Adult, read the policy applied to all patient care areas with the capacity to provide cardiac monitoring. The licensed independent practitioner (LIP) places orders in the electronic health record (EHR) for continuous cardiac and/or pulse oximetry monitoring. Place the patient on the cardiac monitor as soon as possible upon the patient's arrival to the unit. Verify the patient's rhythm and/or oxygenation values are visible and audible with the correct patient name, room number, and transmitter number on the Telemetry Monitoring Unit (TMU). Respond to alarms in an urgent and immediate fashion. Staff will minimize the patient's unmonitored time.

The policy, Telemetry and Pulse Oximetry Monitoring Procedures published on 3/4/19, outlined "the required procedures necessary to safely and effectively monitor patients with remote telemetry and pulse oximetry monitoring." When addressing alarms, all telemetry/pulse oximetry (SPO2) issues would be called to the primary registered nurse (RN). The telemetry technician was responsible for documenting all communication on the Telemetry Call Log. The RN was responsible for responding "appropriately and timely" to all Telemetry Technician calls. The telemetry technician would follow a specific escalation process for pulse oximetry found between 86%-90%, and a more stringent escalation process for oxygen saturation levels found to be less than 85%.

According to the document, Telemetry and Pulse Oximetry Monitoring Procedure Changes, all telemetry and pulse oximetry (SPO2) issues would be called to the primary RN or another RN if the primary RN cannot respond. The RN had 3 minutes to fix the concern before the monitor technician would escalate the call to the next level, which could include notification to the charge RN or the facility's rapid response team.

1. The facility failed to ensure the nursing staff responded to cardiac telemetry and pulse oximetry changes in the patient.

a. On 4/10/19 at 1:12 p.m. an interview was conducted with a registered nurse (RN #1). RN #1 stated if cardiac telemetry and SPO2 were ordered and not monitored continuously it could lead to an unsafe situation where staff could miss an abnormal, or potentially lethal change in the patient's cardiopulmonary (heart and lungs) status.

b. A review of Patient #3 medical record revealed, Patient #3 was admitted on 2/24/19. According to the Emergency Department (ED) provider note at 3:40 p.m., Patient #3 had oxygen saturation levels in the "60's" while on room air. The provider on 2/25/19 at 6:28 a.m. admitted the patient for treatment of pneumonia (an infectious respiratory illness) and acute respiratory failure. According to the Orders on 2/24/19 at 3:52 p.m. the patient was ordered continuous oxygen via nasal cannula and continuous pulse oximetry (SPO2) monitoring for Patient #3. The monitoring was done via the telemetry technician.

c. Review of the Telemetry Call Log from 2/25/19 at 6:51 a.m. to 2/26/19 at 1:49 a.m. was reviewed for Patient #3. The log documented communication between the telemetry technician and the nursing staff related to abnormal changes in the patient's cardiac telemetry and oxygen saturation (the amount of oxygen in the bloodstream. Normal range was 95-100 percent, with values under 90 considered low) levels. The log included the time a call was placed by the telemetry technician to the nursing staff, the patient's room number, the reason for the call, and the "time fixed."

Review of the log 2/25/19 from 6:28 p.m. to 11:09 p.m. revealed Patient #3 experienced multiple abnormal changes and a lack of monitoring of her oxygen saturation levels, to include the following:

On 2/25/19 at 6:28 p.m., the telemetry technician placed a call to the Registered Nurse (RN) #9, due to Patient #3's oxygen saturation level at 60's. According to the log, RN #9 did not answer the call.

At 6:32 p.m., the telemetry technician placed another call to RN #9. The call was not answered.

At 6:46 p.m., the telemetry technician attempted a third call to the nurse staff due to Patient #3's oxygen saturation in the 60's. Again, the call was unanswered.

At 6:47 p.m., the telemetry technician attempted a fourth call to RN #9, which was not answered. On the fifth call at 6:47 p.m., to the unit, the desk personnel said, "she'll check".

At 7:00 p.m., 14 minutes later, the telemetry technician documented Patient #3's oxygen saturation was "still in the 60-70's". RN #9 said, the "patient keeps taking off oxygen".

On review of the log from 6:28 p.m., until 7:00 p.m., there was no evidence the nurse or unit staff responded to the patients low oxygen saturation levels in an urgent and immediate fashion as required by policy.

Subsequently, on 2/25/19 at 8:05 p.m. and 8:06 p.m., the telemetry technician placed two phone calls, one to RN #9 and one to nurse staff in regards to Patient #3's oxygen saturation "dips into the 60's". Neither of these phone calls were answered.

At 9:24 p.m., 9:25 p.m., and 9:34 p.m., three calls were placed to the nursing staff to alert them to patient's oxygen saturations "dip's to the 60's". There was no documented evidence the staff answered the phone or resolved Patient #3's low oxygen saturation level.

On review of the log from 8:05 p.m. until 9:34 p.m., there was no evidence Patient #3's abnormal oxygen saturation levels were resolved or staff followed the Cardiac Monitoring in Adults policy, which required staff to respond to alarms in an urgent and immediate fashion.

Again, on 2/25/19 at 10:38 p.m., 10:39 p.m., 10:53 p.m., and 11:09 p.m. four separate attempts were made to the nursing staff to alert them Patient #3's pulse oximeter (equipment used to monitor oxygen saturation) was off. There was no documented evidence the telemetry concerns were resolved.

At 11:09 p.m., the telemetry technician documented a code blue (an emergency announced when a patient was in cardiopulmonary arrest) was called for Patient #3.

Review of the log from 2/25/19 at 6:28 p.m. until 11:09 p.m., revealed 12 of the 14 calls placed by the telemetry technician to the nurse staff to notify them of abnormal oxygen saturation levels for Patient #3 showed no evidence the calls were answered and/or of a timely response for the nurse staff to the alarms. This was in contrast with the policy, Cardiac Monitoring in Adult, which read staff were to respond to alarms in an "urgent and immediate fashion", and minimize the patient's unmonitored time.

d. On 4/9/19 at 12:03 p.m., an interview was conducted with the telemetry technician (Tech #3). Tech #3 stated she was aware of Patient #3's incident on 2/25/19. Tech #3 stated the incident occurred due to a lack of continuous pulse oximetry monitoring after the SPO2 probe was removed by the patient, nursing staff not answering calls by the telemetry technician who attempted to report abnormal oxygen saturation levels, and the telemetry technician who did not escalate concerns with the abnormal oxygen saturation levels in a timely manner.

e. Continued review of Patient #3's medical record revealed, on 2/26/19 at 1:15 a.m., RN #9 documented in the Nurse Note a summary of the code blue incident for Patient #3. According the nurse note, she entered Patient's #3's room just after the staff alert button was activated. The certified nurse aid (CNA) stated the telemetry technician had just called and stated the patient had taken off her pulse oximeter again. Upon entering the room the patient was unresponsive.
Staff rolled Patient #3 onto her back and was noted to be cyanotic (blue) to the lips and finger tips.

Patient #3's oxygen was under her hip and her pulse oximeter was on the side of the bed. Patient #3 remained unresponsive, pulseless, and cardiopulmonary resuscitation (CPR) was initiated.

At 11:36 p.m., according to the provider's Progress Note, the patient was intubated (the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway so a patient can be placed on a ventilator to assist with breathing during anesthesia, sedation, or severe illness) for respiratory support.

At 11:47 p.m., the patient was transferred to ICU for further medical management and life support measures.

On 3/6/19 at 3:00 a.m., according to the Discharge Summary documented by the provider, Patient #3 suffered a anoxic brain injury (a type of brain injury that occurs when the brain is deprived of oxygen and a large number of brain cells die simultaneously, causing diminished brain function). Comfort care (a medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort) measures were initiated, and the patient was pronounced dead on 3/6/19 at 2:55 a.m.

Review of the medical record for Patient #3 revealed no evidence the nursing staff responded to each of the patient's episodes of oxygen desaturations as noted on the 2/25/19 Telemetry Call Log. There was also no evidence the nursing staff resolved SPO2 monitoring after the pulse oximetry wasn't in place and the patient remained unmonitored.

f. On 4/10/19 at 9:52 a.m., an interview was conducted with an acute care unit registered nurse (RN #2) who stated she was aware of the incident on 2/25/19 for Patient #3. RN #2 stated cardiac telemetry and SPO2 monitoring compliance on the unit had been "a problem for a while." RN #2 stated there was a lack of nursing staff and telemetry technician accountability on the unit in regard to compliance with telemetry monitoring and responsiveness to changes in cardiac telemetry (telemetry) and/or SPO2. RN #2 stated continuous telemetry and SPO2 monitoring was important in order for staff to identify and respond to a patient's cardiac rhythm changes, oxygen desaturations, or potentially lethal cardiopulmonary changes.

RN #2 said she reported her concerns to the unit's previous director over the past year, but stated no formal change in process was put in place to ensure staff were reporting and responding to telemetry and SPO2 changes in a timely manner.

g. On 4/9/19 at 12:03 p.m., an interview was conducted with the telemetry technician (Tech #3). Tech #3 stated she had identified concerns with the lack of nursing staff responsiveness to telemetry technician phone calls to report telemetry and SPO2 changes. Tech #3 stated she reported her concerns to the previous unit director, but had not received feedback on how to improve the process.

h. A continued review of the Telemetry Call Log from 2/1/19 to 3/3/19 revealed similar findings of inconsistent telemetry and SPO2 monitoring for other patients and a lack of timely response from the nursing staff regarding abnormal changes in a patient's telemetry or SPO2. Examples included:

On 2/13/19 at 11:30 a.m., the telemetry technician documented an unsuccessful phone call to the nursing staff because patients in Room 354 and 358 SPO2 were not monitored. At 12:00 p.m., 30 minutes later, a second phone call was attempt to the RN. Each of the patient's SPO2 was unmonitored for 30 minutes.

On 2/13/19 at 8:07 p.m., the telemetry technician documented a phone call to the nursing staff due to the patient in Room 337 not being monitored. There was no documented evidence the nursing staff responded and resolved the concern on the patient not being monitored.

On 2/19/19 at 10:51 a.m., the telemetry technician documented a call to the nursing staff reporting the SPO2 for the patient in room 329 was not being monitored. The lack in SPO2 monitoring was not documented as resolved, or "fixed", until 11:27 a.m. According to the log, the patient's SPO2 was unmonitored for approximately 35 minutes.

On 3/3/19 there were three entries in the log in which nursing staff failed to respond to the telemetry technicians attempts to notify them of abnormal and/or lack of SPO2 monitoring for the patients. These included:

i. At 6:55 p.m. and 7:12 p.m., the telemetry technician called the nursing staff to report the patient in Room 335, SPO2 was unmonitored. There was no evidence on the log, for either of the phones calls, nursing staff members responded to and resolved the patient's lack in SPO2 monitoring.

ii. At 8:25 p.m., the telemetry technician documented a call was placed to the nursing staff because the oxygen saturation for the patient in room 349 decreased to the "70's". There was no evidence a nurse responded to the patient's drop in oxygen saturation.

iii. At 9:31 p.m., the telemetry technician attempt to call nursing staff to report the oxygen saturation for the patient in Room 348 had decreased to 82%. There was no evidence nursing staff responded to and resolved the patient's decrease in oxygen saturation.

These findings were in contrast with the policy, Cardiac Monitoring in Adult, which read staff were to respond to alarms in an "urgent and immediate fashion", and minimize the patient's unmonitored time.

i. A continued review of the Telemetry Call Log from 3/4/19 to 4/5/19 was conducted. Similar findings of inconsistent telemetry and SPO2 monitoring for patients, a lack of timely response from the nursing staff regarding abnormal changes in a patient's telemetry or SPO2, and lack of escalation of the concern by the telemetry technician were found. These findings were in contrast to the policy, Telemetry and Pulse Oximetry Monitoring Procedures published on 3/4/19.

Examples included:

On 3/28/19 at 6:06 p.m., the telemetry technician documented a call to the nursing staff to report a lack of SPO2 monitoring for the patient in Room 329. According to the "time fixed" documentation, the SPO2 monitoring was not resolved until 6:55 p.m., leaving the patient unmonitored for approximately 49 minutes.

On 3/28/19 at 11:44 p.m., the telemetry technician called the nursing staff to report the patient in Room 326 was de-saturating (a reduction in blood oxygen levels below normal parameters, or less than 90%). This call was not answered. A second attempt to contact the nursing staff was documented at 12:12 a.m. The issue was not resolved until 12:27 a.m., approximately 41 minutes after the initial call was placed.

On 4/1/19 at 10:30 a.m., the telemetry technician documented a call to nursing and reported the patient's SPO2 in Room 329 was currently unmonitored. The "time fixed" was not documented until 11:15 a.m., approximately 45 minutes of unmonitored time per the Telemetry Call Log.

On 4/5/19 at 4:19 p.m., the telemetry technician called nursing to report the patient in Room 350 had a telemetry box that was off. The telemetry technician attempted a second call at 4:28 p.m., which was documented as unanswered. A third attempt phone call was documented as unanswered at 4:29 p.m. There was no evidence nursing staff responded to and resolved the lack of telemetry monitoring for this patient in a timely manner.

The findings were in contrast to the, Telemetry and Pulse Oximetry Procedure Changes document, which read the RN, had three minutes to fix reported concerns before the monitor technician would escalate calls to a "next level", to include calling the charge RN or the Rapid Response Team to the patient's room.

j. On 4/15/19 at 1:40 p.m., an interview was conducted with the director of quality and patient safety (Director #6), as well as the chief nursing officer (CNO #5). Director #6 confirmed Patient #3's incident on 2/25/19 prompted the facility to conduct an investigation, review their telemetry monitoring policies and procedures, and began to implement a written telemetry process for staff to follow.

However, Director #6 stated the facility had not established a process to ensure staff compliance after the changes were put in place.

Director #6 stated leadership "oversight of the call log was not great", and telemetry technicians were inconsistent with documentation in the log. Director #6 was unable to provide evidence of staff re-education related to the gaps in compliance noted on the Telemetry Call Logs from February to April.

According to CNO #5, there was not a formal process in place to assess staff compliance to the changes but in place since 3/4/19 for the telemetry procedure process. CNO #5 was unable to provide evidence continued staff non-compliance identified in the Telemetry Call Logs were reviewed, investigated, analyzed for process improvement opportunities, and completed prior to the survey.

2. The facility failed to ensure the immediate availability of cardiac and pulse oximetry equipment when ordered for patients.

a. Document review was conducted of the facility's occurrence log, which identified three events from March to April related to a lack of immediately available telemetry monitoring equipment after the physician ordered it. In the occurrence, staff reported patients were ordered, or admitted to the unit, for cardiac telemetry or oxygen saturation (SPO2) monitoring but was not done due to lack of telemetry equipment.

i. On 3/2/19 at 5:52 a.m., an occurrence was completed which documented three patient incidents were orders for SPO2 monitoring were placed but "not enough equipment to monitor them" was available. The patients were identified in Rooms 332, 349, and 353. According to the occurrence, staff were instructed to "place patients on [portable vital sign machines] and listen for alarms from nurse's station." However, staff reported the patients in Room 349 and 353 were not close enough to the nurse's station to hear alarms in the room. According to the occurrence, staff were unable to remove telemetry monitors from any other patient and were in an "unsafe situation with inadequate monitoring capabilities."

ii. On 3/3/19 at 6:42 a.m. an occurrence was completed which read a patient arrived to the unit with a diagnosis of pneumonia. The patient was ordered continuous SPO2 monitoring. The registered nurse (RN) called the telemetry technician for an SPO2 telemetry monitor but was told "we don't have anymore" and to see if a telemetry monitor could be removed from another patient.

iii. On 4/3/19 at 7:13 a.m., an occurrence report was completed. According to the occurrence on 4/2/19 at 3:38 p.m., patient (Patient B) was ordered continuous SPO2 monitoring. On 4/3/19 at 5:00 a.m., 13.5 hours later, Patient B was found without the continuous pulse oximetry monitor during shift change. The telemetry technician was called to request a pulse oximetry monitor but stated "no [telemetry monitors] available right now." According to the occurrence, staff had to find another patient (Patient A) on the unit using telemetry equipment which "wasn't needed" in order to remove it from Patient A and use it for Patient B.

b. On 4/10/19 at 9:52 a.m., an interview was conducted with a registered nurse (RN #2). RN #2 stated the unit's previous director had instructed her to use a portable vital sign machine as a substitute for the telemetry equipment when the telemetry equipment was not immediately available for patient use. RN #2 stated she was not aware of any process improvement activities to prevent further occurrences of patients not having the telemetry equipment available when ordered.

c. On 4/11/19 at 9:39 a.m., an interview was conducted with the telemetry technician (Tech #4). Tech #4 stated the facility "definitely runs out of telemetry [equipment]" when they are needed. Tech #4 stated in the last year she was "constantly" asked for telemetry equipment by nursing, but none was available. She stated over time the telemetry equipment "disappeared" off the unit or were undergoing repair and not available for patient use. If an RN requested telemetry equipment and none were available, she would request the Charge RN "troubleshoot" by attempting to identify any other patients, which could discontinue their telemetry monitoring in order to make equipment available for the unmonitored patient.

Tech #4 stated situations could still occur where telemetry and SPO2 monitoring are ordered but the equipment would not be immediately available on the unit. She stated the facility had ordered more telemetry monitoring equipment and as of 4/11/19, had not arrive.

Tech #4 stated the use of a portable vital sign machine would not be considered telemetry monitoring because the telemetry technician did not remotely monitor the values, cardiac rhythms are not monitored on those types of equipment, and alarms could be missed if no one was directly in the room with the patient.

Tech #4 stated telemetry monitoring should be initiated immediately after it was ordered to ensure staff could identify and respond to any concerning changes in the patient's heart rhythm, heart rate, or oxygen saturation in a timely manner.

She stated her leadership had not provided guidance to the telemetry technicians regarding process improvement activities, which would ensure the immediate availability of telemetry and SPO2 monitoring equipment when ordered for patients on the unit.

d. On 4/10/19 at 1:12 p.m. an interview was conducted with a registered nurse (RN #1). RN #1 stated she had had use a portable vital sign machine to monitor a patient because continuous telemetry and SPO2 monitoring equipment was unavailable. She stated the risk with using the portable vital signs machine was the machine was unable to analyze cardiac rhythms and was not centrally monitored by the telemetry technician who would be responsible for identifying and reporting abnormal telemetry and SPO2 changes to the RN.

RN #1 stated all patients ordered telemetry and SPO2 monitoring should have the proper equipment in place to ensure staff were able to identify and address any of the patient's abnormal cardiopulmonary findings.

RN #1 stated she had not received any specific guidance from her leadership related to process improvement activities to ensure there were telemetry and SPO2 monitoring equipment immediately available for all patients after it was ordered, or when admitted for continuous monitoring.