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Based on facility policy, medical record review, observation, and interviews it was determined the facility failed to provide safe setting for patients on continuous cardiac telemetry monitoring in one (Patient #1) of one hundred and fifty-one patients on cardiac telemetry monitors on 08/1/2022 and three [Cardiovascular Intensive Care Unit (CVICU), 5 North Burn Intensive Care Unit (ICU), 5 South Trauma Medical ICU] hospital Units of 11 units with patients on cardiac monitoring. Refer to A0144.

Based on facility policy, medial record review, observation and interviews it was determined that the facility failed to ensure patients received continuous telemetry monitoring in a safe setting in one (Patient #1) of one hundred and fifty-one patients on cardiac telemetry monitors and in 3 [Cardiovascular Intensive Care Unit (CVICU), 5 North Burn Intensive Care Unit (ICU), 5 South Trauma Medical ICU] hospital units of 11 units being monitored.

Findings included:

Review of the facility Policy and Procedure titled, "Cardiac Telemetry Monitoring", #WFD.PC.023, Revised 09/15/2021 ...Patient being monitored on continuous telemetry will be observed by a telemetry technician or nurse ... who is competent in cardiac rhythm interpretation & arrhythmia detection ... changes in life-threatening arrhythmia or dysrhythmia ... suspected life threatening rhythm is detected the ...telemetry technician will immediately initiate the following process- activate a code blue response to the patient's bedside, notify the primary RN [Registered Nurse] or charge RN[CNC], document on the facility approved process for recording telemetry event notifications, print copy of disclosure with interpretation and send to unit ...non-lethal arrhythmia is detected ...the monitor tech will call the primary nurse,, if no contact made or no response immediately escalate to the CNC. Within 2 minutes a nurse should assess the patient and contact the monitor technician and give an update on patient status and/or assure the patient' rhythm is being transmitted ... Second notification: if not resolution from a nurse within 2 minutes from time of initial notification, the monitor tech should call the units CNC and enter the notification time in log. The CNC should assess the patient status or assure the patient status is assessed and contact the monitor technician and given ... Third notification if no response within 4 minutes from time of initial notification, the monitor technician should initiate a Telemetry Alert ...overhead broadcasting should be used as a last resort ...At no time during the monitoring phase should alarms be turned off or silenced.
Review of Patient #1 medical record reveals:
1. On 08/01/2022 at 18:01 PM the telemetry strips showed Atrial/ Ventricular (AV) paced cardiac rhythm with ST elevation (2 points recognized in a heartbeat that when elevated can indicate Myocardial ischemia or infarction also known as a heart attack).
2. On 08/01/2022 at 6:18 PM the telemetry strips showed an agonal rhythm (abnormally slow heart rhythm that occurs at the end of life. It should be regarded as asystole (no electrical activity of the heart) and should be treated with Cardiopulmonary resuscitation.)
3. The telemetry strips reviewed for Patient #1 from 08/01/2022 at 6:01 PM through 08/01/2022 at 6:42 PM reveals the alarms were off on 13 telemetry strips and silenced on 6 telemetry strips out of 23 telemetry strips reviewed for Patient #1. This indicates that the audible alarms notifying the telemetry technician of an abnormality in the heart rhythm were silenced or turned off.

Review of facility documents reveals that there is no evidence of the telemetry log being completed on 08/01/2022 from 6:00 AM through 6:30 PM for 3rd floor medical surgical unit, in which Patient #1 was present. A log was started at 6:30PM with the oncoming shift and, the telemetry log reveals that on 6:32 PM the telemetry tech attempted to notify nursing Staff M with no answer by the RN. The telemetry tech attempted to call the nursing station at 6:32 PM with no answer. On 6:33 PM the telemetry tech had done an overhead broadcast to check Patient #1. At 6:36 PM the telemetry tech did an overhead page again. At 6:40 PM a rapid response was called to Patient #1's room and at 6:47 PM a code blue called to Patient #1's room. Patient #1 expired at 6:54 PM.

Facility documents revealed staff O, who was monitoring Patient #1's cardiac telemetry from 6:45 AM to 6:30PM, had no current competency for basic cardiac arrhythmias.

Interview on 08/30/2022 at 10:20 AM with staff B reveals that Staff member O has been removed from the cardiac telemetry monitoring position.

Staff B interview on 08/31/2022 at 12:00 PM revealed the telemetry does not alarm for ST changes or ST elevation (2 points recognized in a heartbeat that when elevated can indicate Myocardial ischemia or infarction also known as a heart attack.)

Observation on 08/30/2022 at 12:35 PM reveals there were 3 telemetry monitor technicians in the telemetry monitoring room. There were 3 stations of telemetry monitors with 3 monitor screens on the right and left with the middle station having 4 screens. Staff F on the middle screens left the room and returned approximately 2 minutes later. Observed 3 monitor screens with ICU on the back wall with no technician monitoring them nor any chair in front of them. (Photo evidence obtained.)

On 08/30/2022 at 12:50 PM an interview with Staff B confirms no one was watching the Intensive Care Units (ICU) monitors. Staff B stated if the alarms go off the nurse in ICU will answer it at bedside.

On 08/30/2022 at 1:35 PM an interview with Staff I confirms no telemetry tech is assigned to watch ICU monitors.

On 08/31/2022 at 12:00 PM an interview with Staff B confirms that there is no person watching the telemetry monitors in ICU's. Staff B disclosed ICU's have a charge nurse who sits at the desk, but she has extra duties and will leave the nursing station to provide care.

Based on facility documents, Quality and Patient Safety Plan, and interviews the facility failed to ensure that clear expectations for patient safety were implemented by a Quality Assurance Performance Improvement (QAPI) program unique to the hospital . The QAPI system failed to react to adverse incidents and failed to develop and implement measures to prevent further occurrences after multiple systemic process failures that resulted in deaths of patients related to telemetry recognition and nursing notification of lethal cardiac rhythms. Refer to A0321.

The condition is not met due to the systemic failure to maintain a functioning QAPI system to investigate, track and trend, and implement measures to prevent harm to patients in their facility based on adverse events.

Based on facility document, Quality and Patient Safety Plan, and interviews the facility failed to implement an effective Quality Assessment and Performance Improvement (QAPI) program unique to the hospital to prevent multiple systemic process failures in one of one QAPI program.

Findings included:

Review of the facility QAPI program reveals the program in place does not take into account the unique circumstances of services offered to focus on improved health outcomes related to continuous telemetry monitoring.

Review of the 2022 Quality & Patient Safety Plan ...the quality improvement plan (QI) provides an organization-wide systemic approach to plan, measure, evaluate and improve clinical outcomes and operational performance ...signed on 05/02/2022 by the Chief Executive Officer (CEO), the Chief Medical Officer (CMO), the Vice President (VP) of Quality, and the Chairman Board of Trustees.

On 08/31/2022 at 3:00 PM Interview with the Director of Quality reveals the facility had failed to trend and analyze the reported incidents from 3 deaths in the last 12 months related to cardiac telemetry monitoring for patient care, patient safety, notifications, and outcomes.

Based on observation, medical record reviews, facility policy review, and interviews it was determined the facility failed to provide:

A. Immediate nursing care for a patient with a change in cardiac rhythm on telemetry monitoring resulting in the patient's death.
Refer to A0392

B. Qualified nursing personnel for telemetry monitoring. Refer to A0397.

Based on facility policy, medical record review, facility documents, observation and interviews it was determined the facility failed to provide immediate care for a patient on cardiac monitoring that had a change in heart rhythm in one (Patient#1) out of one hundred and fifty-one on cardiac telemetry being monitored on 8/1/2022.

Findings included:

Review of the facility Policy and Procedure title, "Cardiac Telemetry Monitoring", # WFD.PC.023, Revised 09/15/2021 ...Rhythm changes is detected ...the monitor tech will call the primary nurse, if no contact made or no response immediately escalate to the Clinical Nurse Coordinator (CNC). Within 2 minutes a nurse should assess the patient and contact the monitor technician and give an update on patient status and/or assure the patient' rhythm is being transmitted ...Second notification: if not resolution from a nurse within 2 minutes from time of initial notification, the monitor tech should call the units CNC and enter the notification time in log ... Third notification if no response within 4 minutes from time of initial notification, the monitor technician should initiate a Telemetry Alert ...overhead broadcasting should be used as a last resort ...At no time during the monitoring phase should alarms be turned off or silenced.

A.
Review of Patient #1 medical record that on 08/01/2022 at 6:33 PM a telemetry alert sent via hospital provided phone and at 6:41 PM a rapid response was called to patient #1 room. On 08/01/2022 at 6:42 PM a code blue was initiated. Patient #1 expired at 6:54 PM.

Review of the facility documents revealed that staff M failed to complete a nursing assessment of Patient #1 during the 8/1/2022 7am -7pm (12-hour shift). On 08/01/2022 at 5:30 PM the Patient Care Technician (PCT) informed staff M that Patient #1 was short of breath and the PCT applied oxygen on Patient #1. Staff M failed to reassess the patient. Further review of the facility documents reveals that the facility provided phone was not answered when the telemetry technician called for notification of status change in Patient #1 condition.

B.
The cardiac telemetry strips reviewed for Patient #1 from 08/01/2022 at 6:01 PM through 08/01/2022 at 6:42 PM reveals the alarms were turned off on 13 telemetry strips and silenced on 6 telemetry strips out of 23 telemetry strips reviewed for Patient #1.

Review of Patient #1 Telemetry notification log reveals that there is no evidence of log being completed on 08/01/2022 from 6:00 AM through 6:30 PM. Patient #1 telemetry log reveals that on 6:32 PM the telemetry technician attempted to notify Staff M with no answer by the RN. The telemetry technician attempted to call the nursing station at 6:32 PM with no answer. On 6:33 PM the monitor tech had done an overhead broadcast to check the tele patient #1. At 6:36 PM the monitor tech did an overhead page again. At 6:40 PM a rapid response was called to Patient #1 room and at 6:47 PM a code blue called to Patient #1 room.

Observation on 08/30/2022 at 12:35 PM reveals there were 3 telemetry monitors technicians in the telemetry monitoring room. There were 3 stations of telemetry monitors with 3 monitor screens on the right and left with the middle station having 4 screens. Staff F on the middle screens left the room and returned approximately 2 minutes later. Observed 3 monitor screens on the back wall with no technician monitoring them nor any chair in front of them. (Photo evidence obtained)

On 08/30/2022 at 12:50 PM an interview with Staff B confirms no one was watching the Intensive Care Units (ICU) monitors along the back wall. Staff B stated if the alarms go off the nurse in ICU will answer it at bedside.

On 08/30/2022 at 1:35 PM an interview with Staff I confirms no telemetry tech is assigned to watch ICU monitors.

On 08/31/2022 at 12:00 PM an interview with Staff B confirms that there is no person watching the telemetry monitors in ICU. Staff B disclosed ICU have a charge nurse who sits at the desk, but she has extra duties and will leave the nursing station to provide care.

Staff B interview on 08/31/2022 at 12:00 PM revealed the telemetry does not alarm for ST changes ((2 points recognized in a heartbeat that when elevated can indicate Myocardial ischemia or infarction also known as a heart attack.)

Based on facility policy, medical record review, facility documents, and interviews the facility failed to have qualified staff to monitor the cardiac telemetry monitors. In one (staff O) out of four staff files reviewed.

Findings included:

Review of the facility policy and procedure title, "Cardiac Telemetry Monitoring", # WFD.PC.023, Revised 09/15/2021 ...Monitor Technician responsibilities a. patient will be monitored by a Monitor Technician or someone with equivalent competencies of basic arrhythmias ...

Facility documents revealed no evidence that staff O is competent in cardiac rhythm interpretation & arrhythmia detection.

Interview on 08/30/2022 at 10:20 AM with staff B reveals that Staff member O has been removed from the cardiac telemetry monitoring position.