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Based on interviews and records reviewed the Hospital failed for one (Patient #3) patient of 10 sampled patients to provide implementation of preventative actions to all nursing staff after Patient #3 returned to the nursing unit requiring cardiac telemonitoring that was not properly connected to the central monitor which resulted in the unexpected death of Patient #3.

Based on interviews and records reviewed the Hospital failed for one (Patient #3) patient of 10 sampled patients to provide implementation of preventative actions to all nursing staff after Patient #3 returned to the nursing unit requiring cardiac telemonitoring that was not properly connected to the central monitor which resulted in the unexpected death of Patient #3.

Patient #3 was admitted to the Hospital in March of 3021 from an outside hospital for coronary catheterization after having chest pressure radiating to left arm that was associated with nausea.

Review of the Nursing Note dated 3/17/21 at 7:34 P.M., indicated that RN #1 assumed care at 7:00 P.M. Patient #3 was alert and oriented to person, place, time and situation. Patient #3 was telemonitored and denied chest pain or shortness of breath.

Review of the Hospital Discharge Summary dated 3/1indicated that on 3/17/21 Patient #3 underwent a cardiac catheterization. Patient #3 was transferred to 5 West with no issues after the procedure. The registered nurse noted that the patient had a possible right radial hematoma. Charge nurse went to check on Patient #3 who was found unresponsive and pulseless. Cardiopulmonary resuscitation (CPR) was initiated, initial rhythm was asystole (represents the cessation of electrical and mechanical activity of the heart).

Review of the Nursing Note dated 3/17/21 indicated that 7:00 P.M. Patient #3 was alert and oriented to person, place, time and situation. Patient #3 was telemonitored and denied chest pain or shortness of breath.

During an interview on 5/19/21 at 12:30 P.M. Unit Manager #1 said that the Patient came back with a telemonitoring box on, but the telemonitoring box was never set up to the central monitor. Unit Manager #1 said that the Charge Nurse was very busy, assisting another patient on the unit and was not aware that Patient #3 had returned from the cardiac catheterization lab. Nurse #1 didn't connect the telemonitor to the central monitor, which is located at the nurse's station, so the monitor did not sound in the nurses station to alert the charge nurse that Patient #3 was having a medical emergency.

Unit Manager #1 said that during her investigation, it was determined that the Charge Nurse was never notified that the patient returned and that she was caring for a behavioral patient who was very intrusive and other contributing factors were taking place on the unit which lead to the lack of communication and central monitor set up. The Unit Manager performed daily huddles with the nursing staff on 5 West indicating that communication with the Charge Nurse is necessary upon patient return. Furthermore, a blast email was sent to all Hospital nursing staff to educate them on cardiac telemonitoring communication among staff expected to be caring for and monitoring patients.

Review of the Hospital's internal investigation indicated that on 5/1/21 the hospital found they failed to identify that the transportation department was provided with the blast email that went out regarding appropriate communication regarding patients on telemonitors. A patient was transported to 5 West and left without nursing knowledge. Another email went out to transportation staff on 5/4/21 to address this.

During an interview on 5/19/21 at 12:30 p.m. the Director of Quality and Patient Safety, said the Hospital did not track who received the "blast email". She said their corrective actions did not include re-education to Hospital Staff and that there is no way to determine if all staff members read and acknowledged the "blast" email.

The Hospital failed to provide documentation and evidence that the Hospital staff have been properly educated to prevent a like occurrence from happening again.