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Based on observation, review of clinical records, review of facility policies and procedures, and interviews, the facility failed to honor patients' rights to receive care in a safe setting by failing to provide continuous cardiac monitoring for two (Patient #5, and #7) of three patients reviewed.

The hospital failed to ensure continuous cardiac monitoring at the cardiac telemetry (transmission of cardiac signals, electric or pressure derived, to a receiving location where they are displayed for monitoring) monitoring station for two patients (#5 and #7) reviewed for telemetric cardiac monitoring. (Refer to A0144) The noncompliance at the Condition of Participation of Patient Rights due to the hospital's failure to ensure that patients receive care in a safe setting resulted in Immediate Jeopardy. The Immediate Jeopardy began on 12/14/22. The hospital was informed of the Immediate Jeopardy on 1/6/23 at 11:00 a.m. and was ongoing as of the survey exit on 1/6/23. On 1/4/23 there were 42 patients on telemetry cardiac monitoring. Cross reference to Standard A0144.

Based on observation, review of clinical records, review of facility policies and procedures, and interviews, the facility failed to provide patient care in a safe setting for two (Patient #5 and #7) of three patients reviewed for incidents of serious life-threatening events. Two patients with physician ordered telemetric cardiac monitoring experienced cardiac arrest when they were not being monitored by hospital staff as required. One patient died the other survived.

The findings included:

Cross reference to Condition of Participation A0115.
1. The Cardiac Telemetry Monitoring Policy and Procedure, effective date 8/7/18, revised 6/2021 included the following: PURPOSE - To ensure patient safety and provide continuous cardiac monitoring and documentation guidelines for patients who have telemetry monitoring ordered. POLICY - B. The monitoring environment will be free from distractions (e.g., noise, performing clerical duties, answering phones for departments, tech.) as much as possible. Alarm volumes will be set at a reasonable level and monitoring personnel will be provided breaks to prevent alarm fatigue. E. If the rhythm is still transmitting to the central station but the monitor indicates battery low or lead off the monitoring technician must notify the Nurse. If there is no response, the situation is not responded to or if it is not resolved in 5 minutes a "Telemetry Alert" will be called. F. If the patient rhythm is not transmitting to the central station the monitoring personnel will call for immediate resolution by calling a "Telemetry Rapid Response" to the patient room and bed. TELEMETRY GUIDELINES - G. When the monitor tech is notified by the RN that a patient will be off the monitor the monitoring device should be placed in a "suspend" or "stand-by" mode. The monitor technician will contact the RN after 30 minutes to verify that the patient is still off the monitor and obtain an updated status. This information will be recorded on the Telemetry Notification Log. J. Telemetry Monitoring Centralized Station Alarms are to be set and maintained throughout the patient stay. K. Alarm volumes should be set at levels that enable personnel in the monitor bank areas in the centralized monitoring station to audibly detect the alarm. At no time during the monitoring should alarms be turned off or silenced. Any employee who disables an alarm is subject to disciplinary action up to and including termination. M. Daily Telemetry Notification Log will be used daily to record telemetry notifications by the Monitor Technician, calls placed to the care team and alerts or codes initiated from the monitoring station. MONITOR TECHNICIAN RESPONSIBILITIES - B. Personnel in the role of Monitor Technician will be responsible for monitoring cardiac telemetry, running documentation strips, and communicating to the nurse changes in patient's rhythm and when patients are off monitor or monitor indicating low battery or a lead is off. D. Patient rhythm viewable but monitoring system indicates low battery, lead off or artifact: 1) The Monitor Technician should notify the appropriate floor to alert them that the patient needs to have transmitter and leads checked. 2) Nursing personnel will check leads and/or batteries immediately. Nursing personnel should verify with the Monitor Technician that the issues is resolved. 3) If no response to notification or no resolution within 5 minutes the Monitor Technician will call a "Telemetry Alert" to the room/bed location of the patient. 4) The Monitor Technician will record the notification(s) on the Telemetry Notification Log

A review of an adverse incident with the Vice President (VP) of Quality and Patient Safety found Patient #5 presented at the Emergency Department (ED) on 12/7/2022. The patient was admitted from the ED to the Intensive Care Unit (ICU) with Sepsis and NSTEMI (non-ST heart rhythm interval-elevation myocardial infarction). After stabilization, the patient was transferred to the Progressive Care Unit (PCU) on 12/9/22 with physician orders for continuous cardiac monitoring. On the evening of 12/14/22, the patient was seen by the primary registered nurse (RN) and given nighttime medications at 8:55 p.m. The PCT [Patient Care Tech] reported checking on the patient at approximately 10:00 p.m. The VP said the signal was lost from all but one of the electric leads on the telemetry transmitter prior to 11:24 p.m. when the patient was found. When the leads failed, the monitor tech did not follow the policy for escalation. At 11:24 p.m., the primary RN and a PCT found the patient unresponsive. Code Blue was called. Per the Code Blue notes, the patient was found unresponsive and asystole (cessation of the electrical and mechanical activity of the heart - flatline) for an unknown down time. Resuscitation efforts ceased at 11:38 p.m. and patient expired.

A review on 12/28/22 of the Telemetry Notification Log for 12/14/22, 7:00 p.m. to 7:00 a.m. shift, a handwritten documentation of monitor alarms occurring during each work shift maintained by the telemetry monitor tech, found an alarm documented for Patient #5 at 2300 (11:00 p.m.) indicating battery change needed. The monitor tech documented a PCT (not the tech assigned to the patient) was notified of the alarm. There were no other alarm occurrences for Patient #5 documented on the 12/14/22 Telemetry Notification Log. A lead failure alarm for Patient #5 was not document on the Telemetry Notification Log though lead failure was noted from the incident investigation as having occurred. There is no documentation of a response from nursing to the 11:00 p.m. alarm notification.

A review on 12/29/22 of the medical record for Patient #5 found; the patient arrived at the hospital Emergency Department on 12/7/22 at 8:45 a.m. Patient #5 was admitted through the ED and transferred to the ICU at 2:45 p.m. with Admitting Diagnoses of Septicemia, Altered Mental Status, and NSTEMI per the Emergency Department Physician. The Admitting Physician documented in progress notes additional diagnoses of Septic shock, UTI (urinary tract infection), Proteus ESBL bacteremia (a bacteria which causes UTI), dysphagia, Multiple sclerosis, aspiration pneumonia pneumonitis, LFT's elevation with Cirrhosis(elevated liver disfunction with liver damage), Hypokalemia (low potassium levels in the blood), Metabolic acidosis (excessive acid accumulation in the body), severe dehydration, elevated troponin (globular protein involved in muscle contraction elevated when a heart attack occurs) due to oxygen demand mismatch, multiple posterior pressure ulcers, urinary retention. The patient was downgraded and transferred from the ICU to PCU (Progressive Care Unit) on 12/9/22 at 11:55 a.m. The medical record documents reveiled that the telemetry monitoring started at 4:31 p.m. on 12/9/22. The patient remained on PCU until she coded on 12/14/22. She was in semi-private room without a roommate. The last vital signs were documented on 12/14/22 at 8:09 p.m. Pulse was 130 beats per minute, respirations 14 breaths per minute, Blood Pressure 92/63 mmHg, and pulse oximetry (blood oxygen saturation rate) 93%.

The last nursing progress note for Patient #5, documented by RN Staff B on 12/16/22 as a late entry for 12/14/22 at 11:30 p.m. reads, "This nurse entered patient's room with CNA in order to do a bed bath. Patient was found unresponsive and did not have pulse. Code blue called. This nurse started compressions". The last documented assessment of Patient #5 was on 12/14/22 at 9:00 p.m.

In an interview on 12/29/22 at 9:05 a.m., the VP of Quality and Patient Safety, RN, shared the findings of the Serious Event Analysis (SEA) for the adverse event of 12/14/22 unexpected death of Patient #5. The VP of Quality said Staff A was the monitor tech assigned to monitor Patient #5 on 12/14/22. She had been in that position for 6 to 8 months and had completed all required training for the position. The initial alarm went off at 9:15 p.m. that leads were disconnected. Staff A silenced the alarm at 9:16 p.m. At 11:00 p.m. the monitor indicated batteries needed to be changed. Staff A documented that the patient's care tech was notified. The patient care tech denied being notified by the monitor tech to change the batteries. The charge nurse and the primary nurse said they had not been notified of the alarm for Patient #5's monitor. The voice and text communication system used by the hospital for notification did not show any communication sent by Staff A. Staff A then changed the story saying that she verbally told the patient care tech. At 11:24 p.m. the nurse found the patient unresponsive. The VP of Quality said hourly rounding in utilized in the facility. The VP of Quality said there are typically 30 to 40 monitors in use on each shift; the maximum is no more than 60. The VP of Quality said staffing on the day of the incident was good. The VP of Quality said, since the incident, nursing leadership has provided in-service regarding telemetry and rounding. She said all nursing staff and monitor techs have signed off as attending the in-service. Data was reconciled with the event log at the monitor tech station for following; Tech or nurse informed for leads off/battery changes and Rapid Response call for rhythm changes.

In an interview on 12/29/22 at 10:15 a.m., Monitor Tech Staff F said she has been here for 4 years. She said she has 32 monitors on her board that she is monitoring at this time. She was shown the event log which records all events from batteries need changing, leads off, telemetry off for x-ray, etc. She said an overhead page is sent out for any disruptions to the monitoring. She said she never turns alarms off. She said she only put monitors on pause when instructed to by the nurse when the patient is showering or leaving the room for tests or procedures.

In an interview on 12/29/22 at 10:20 a.m., Primary Nurse RN Staff G, who has been with the hospital for 9 months, said that she receives notification of monitor alarms by phone call or text message. She displayed her phone and said all nurses, PCTs, and monitor techs are issued work phones as the method of communication between staff and other departments. She said the messages stay on the phone for about 24 hours before dropping off.

A review on 1/3/22 of the Telemetry Machine data record, a screen print of the central monitor for Patient #5 of monitored cardiac rhythms on 12/14/22 during the 7:00 p.m. to 7:00 a.m. shift showed the following: The initial alarm went off at 9:15 p.m. that the leads were off. At 9:16 p.m. the monitor was placed on "pause/standby". After 9:16 p.m. the monitor was never restored to active status. No rhythms were recorded for Patient #5 after 9:16 p.m. At 9:51 p.m. and again at 11:40 p.m. the telemetry machine sent an alert to change battery. The monitor was on pause/standby for two hours and eight minutes when the patient was found by nursing to be unresponsive. There were no rhythms being monitored, as ordered, to detect a life-threatening cardiac event.

In an interview on 1/3/23 at 2:30 p.m., Primary Nurse RN Staff B said the evening of 12/14/22 was a normal busy shift with many admissions. She said she starts her shift taking patient's vital signs and then passing medications. RN Staff B said she assessed Patient #5 around 9:00 p.m. and did not find the patient to be in distress. She said the patient was calm and though not very communicative was responding to questions. RN Staff B said she went on to complete the admission process for a new patient and then check four other patients. She said she and the PCT were planning to go back to Patient #5 later and provide a bath. RN Staff B said she was never notified of a monitor alarm for a loose lead or a battery change. She said she was at the nursing station several times that evening but not informed of alarms by the monitor tech. She said she did not notice which if any monitors were offline on standby. RN Staff B said when she and the PCT entered the patient's room at 11:24 p.m., the patient was unresponsive with no pulse. She said she called Code Blue and initiated CPR (cardiopulmonary resuscitation). She said the patient remained asystole. RN Staff B said she expects to be notified every time there is a monitor alarm for any of her patients. She said when she entered the room at 11:24 p.m. the leads were attached to the patient.

In an interview on 1/4/23 at 10:10 a.m., Clinical Nurse Coordinator (CNC) RN Staff C said she is responsible to oversee the monitor techs and cover them for breaks. She said that on 12/14/22 Monitor Tech Staff A did not notify her of any alarms or irregularities. CNC Staff C said she was busy assisting on the floor but was in and out of the nursing station where central telemetry monitoring is located. She said she did not notice that one or more monitors where on standby. She said the first she knew there was an issue was when she heard the Code Blue paged.
In an interview on 1/4/23 at 11:10 a.m., PCT Staff E said there were two PCTs on duty the evening of 12/14/22 and that they split the unit each taking half of the patients. She said Patient #5 was a total care patient and was fine when the nurse was administering medications early in the shift. PCT Staff E said she had been caring for Patient #5 for the past couple of nights. She said she had not been notified that Patient #5's monitor alarmed. She said she was not aware of the loose lead. PCT Staff E said when she and the nurse entered the room at 11:24 p.m. the cardiac monitor leads were attached to the patient. She said that at the bedside she is not likely to know if a lead is loose unless it is visibly disconnected. She said nursing relies on the monitor techs to notify them of an alarm.

Observation on 1/5/23 at 10:00 a.m. of the telemetry monitoring station found that when an alarm sounds the patient's monitored rhythm field is highlighted and an audible alarm sounds. The monitor tech can activate a silence button which turns off the audible alarm for 10 seconds. This gives the monitor tech time to notify nursing personnel. After 10 seconds the audible alarm starts again and will keep sounding until the trouble is cleared and the monitor is functioning properly. To silence a continuous alarm the monitor tech must hit the silence button every 10 seconds, or the alarm may be silenced by changing the monitor setting to put the monitor on pause/standby. This requires deliberate action and can only be reversed by changing the monitor settings to place the monitor on active status. The monitor tech demonstrated that when a monitor is placed on pause, the rhythm field on the monitor for that patient is circled in yellow and stays yellow until the monitor is reactivate. Looking at the display of monitors, one can tell which monitors are offline on pause.

In an interview on 1/5/23 at 12:50 p.m., Monitor Tech Staff A said on 12/14/22 during the 7:00 p.m. to 7:00 a.m. shift the monitor alarm sounded for Patient #5. She said she placed the monitor on pause/standby. Monitor Tech Staff A confirmed she did not use electronic communication to notify nursing of the alarm. She said she told a passing PCT that a lead was off on Patient #5 and said she told the CNC of the monitor alarm. Monitor Tech Staff A said she was busy and got distracted doing clerical work charting, setting up charts for new admissions, deconstructing charts of discharged patients, and answering phone calls. She said she did not realize how much time had passed and was not aware the monitor for Patient #5 had remained on standby until she heard the overhead page for Code Blue. She looked up and realized there were no cardiac rhythms for Patient #5 on the monitor. Monitor Tech Staff A said that as a matter of work routine she did not document all alarms and notifications. Monitor Tech Staff A said that if the monitor alarmed for a lead being off was corrected immediately, then she did not document the alarm on the Telemetry Notification Log. Monitor Tech Staff A acknowledged she did not document a response from nursing staff that they had received the notification of the alarm. She said there were no rhythms for the monitor to detect a life-threatening cardiac event.

2. A review of the medical record for Patient #7 was conducted on 12/29/22 at 11:15 a.m. with the VP of Quality and Patient Safety. Patient #7 was admitted to the hospital on 9/12/22 with complaint of shortness of breath. The patient was admitted to the PCU and placed on telemetric cardiac monitoring. Patient #7 had prolonged QT (heart's electrical signal/rhythm made up of five waves designated P, Q, R, S, T- measured interval Q to T spread widened out of normal range) on monitor. The VP of Quality said the Serious Event Assessment (SEA) found that during the time Patient #7 was on PCU the Telemetry Monitor Tech needed relief for a break. The VP of Quality said the Clinical Nurse Coordinator for the unit is the designated relief person for the Monitor Tech. The SEA concluded the Monitor Tech left the monitoring station without ensuring the nurse was in place to observe the monitors. The monitors were unattended for five minutes. During the time the monitoring station was not covered, Patient #7 had a life-threatening cardiac event. The monitor alarm sounded for V tach (ventricular tachycardia - rapid heartbeat in the lower chambers). A nurse who happened to be at the nursing station near where the telemetry monitors are located responded to the alarm and called a Code Blue. The patient survived and was moved to the ICU. The patient was transferred to another facility for invasive procedures.

The Serious Event Assessment mitigation plan was implemented on 10/31/22 regarding monitors left unattended including completion of staff education, new staff hired (a secretary for 7:00 p.m. to 11:00 p.m.) to free the charge nurse from some paperwork allowing the charge nurse to assist with monitoring and proper handoff for breaks and monitoring effective handoff of the monitor tech to the nurse covering for breaks for 4 months.

In an interview on 1/4/22 at 10:20 a.m., the Chief Nursing Officer (CNO) said the CNCs have direct responsibility for the monitor techs during their shift. The CNO said the monitor techs have no clerical responsibilities. She said the monitor tech is not to leave the monitor station until the CNC has taken the chair in front of the monitors and is functioning as a monitor tech. the CNO confirmed the CNCs are not to be distracted while functioning as relief for the monitor tech and are to document all monitor alarms and notify nursing personnel.

Based on record review, interviews, review of facility documents, and review of policy and procedure, the hospital failed to ensure that clear expectations for patient safety were implemented by the Quality Assurance and Performance Improvement (QAPI) Program. The QAPI system failed to develop and implement effective measures to audit compliance with the performance improvement plans for two of three adverse incident events reviewed. The facility could not ensure telemetry monitor technicians and nursing personnel were following the requirements for continuous cardiac monitoring with a patient found unresponsive.

The condition is not met due to the systemic failure to maintain a functioning QAPI system to investigate, track and trend, implement measures to ensure continuous cardiac monitoring. The Chief Quality Officer failed to ensure that serious adverse/sentinel event interventions and auditing of interventions to prevent the opportunity for further unobserved cardiac rhythm change that caused Immediate Jeopardy to the safety of patients on telemetric cardiac monitoring. This resulted in Immediate Jeopardy at the Condition of Participation of QAPI. The Immediate Jeopardy began on 12/14/2022. The hospital was informed of the Immediate Jeopardy on 1/6/23 at 11:00 a.m. and was ongoing as of the survey exit on 1/6/2023. On 1/4/23 there are 42 patients on telemetry cardiac monitoring. (Refer to A0286, A0144, A0395).

Based on record review, staff interview and observation the facility failed to develop and implement effective measures to audit compliance with the Performance Improvement Plans (PIP) for two of three adverse incident events reviewed. The facility could not ensure telemetry monitor technicians and nursing personnel were following the requirements for patient care in a safe setting. Cross reference to A0115, A0286, and A0395

The findings included:

1. Record review of the medical record for Patient #5 12/7/22 through 12/14/22, the review of an incident reported 12/27/22, the Serious Event Assessment and interviews with facility staff regarding the unexpected death of the patient revealed the following: A Telemetry Monitor Technician failed to perform duties as required during which time Patient #5 experienced an undetected life-threatening cardiac event. The patient died.

The facility reported that on 12/14/22 at 9:15 p.m., the telemetry monitor for patient #5 alarmed warning loss of a lead. The 9:15 p.m. alarm is not documented on the Telemetry Notification Log for 12/14/22, 7:00 p.m. to 7:00 a.m. shift as required by policy. Monitor Tech Staff A placed the monitor for Patient #5 on auto pause/standby silencing the alarm at 9:16 p.m. The pause was not released, and the monitor was not placed back online. Staff A did not notify nursing staff of the alarm. The procedure is to document on the Telemetry Notification Log the time of the alarm and the name of the nursing staff member notified. A review of the printout of the machine data found at that at 9:51 p.m. and again at 11:40 p.m. the monitor machine data recorded an alert to change the battery in the telemetry transmitter for Patient #5. The Telemetry Notification Log documents at 11:00 p.m. the monitor gave an alert to change batteries. Staff A documented on the Telemetry Notification Log that the Patient's nurse was notified. The patient care tech denied being notified by the monitor tech to change the batteries. The text message notification system used by the hospital did not show any notification communications regarding Patient #5 were sent by Staff A on 12/14/22. When questioned, Staff A then changed the story, according to the Vice President (VP) of Quality and Patient Safety, that she verbally told the Patient Care Technician (PCT) that batteries needed changing for Patient #5. In interviews on 1/4/23 the PCT, the primary nurse Registered Nurse (RN), and the charge nurse Clinical Nurse Coordinator (CNC) who were on duty on 12/14/22 all said they were not notified either verbally or by text of the monitor alarm. At 11:24 p.m. on 12/14/22, RN Staff B and PCT Staff E entered the patient's room to give a bath and found the patient unresponsive. A Code Blue was initiated by the nurse. The patient was not able to be revived. The telemetry monitor had been offline for 2 hours and 9 minutes and not able to alarm a life-threatening cardiac event. Per Code sheet record, Code CPR (Cardiopulmonary Resuscitation) started at 11:25 p.m. Patient #5 was in asystole (cessation of the electrical and mechanical activity of the heart - flatline). CPR maintained. Meds given during code included 4 rounds of Epinephrine 9 (also known as adrenaline is a medication injected into the heart during cardiac arrest to stimulate heart activity), 1 sodium bicarbonate, and 1 calcium. Time of death called at 11:38 p.m. by the in-house doctor. The Last vital signs were documented at 8:09 p.m.; Pulse was 130 beats per minute, respirations 14 breaths per minute, Blood Pressure 92/63 mmHg, pulse oximetry (blood oxygen saturation rate) 93%. Last progress notes were documented by the RN on 12/16/22 as a late entry for 12/14/2022 at 11:30 p.m. reads, "This nurse entered patient's room with Certified Nursing Assistant (CNA) in order to do a bed bath. Patient was found unresponsive and did not have a pulse. Code blue called. This nurse started compressions." The last nursing assessment was documented on 12/14/22 at 9:00 p.m. by RN Staff B.

A Serious Event Assessment (SEA) regarding the unexpected death of Patient #5 was conducted on 12/15/22. The monitor tech did not perform duties as required. The monitor tech silenced the alarm without notifying nursing staff of the issue. In an interview on 12/28/22 the VP of Quality and Patient Safety said the monitor tech silenced the alarm when the lost lead alarm was enunciated. The VP said she presumed the monitor tech kept silencing the alarm every time it started back to alarm. A test of the telemetry monitor alarm on 1/3/23 found that activation of the alarm silencer only lasts for 10 seconds, and the alarm sound returns. A review of the printout of the machine data on 1/4/23 found the monitor tech had placed the monitor for Patient #5 on pause taking the monitor offline and thus not reporting cardiac events. Putting the monitor on "Auto Pause" is a deliberate activity requiring the monitor tech to change the settings.

The hospital developed risk mitigation strategies and implemented these strategies beginning on 12/16/22:
A) Credentials checked prior to floating staff to the Progressive Care Unit (PCU).
B) Audit telemetry log each shift - Number of telemetry monitored patients/number of alerts.
C) Reiterate the importance of following telemetry policy - Reeducation by Patient Safety Director.
D) Reiterate importance of following telemetry policy - Start of shift huddles by Nurse Manager.

Conclusions of SEA: Hourly rounding is utilized in the facility. Per VP of Quality and Safety, there are typically 30 to 40 total patients on monitors; standard is no more than 60. Per VP, staffing on the day of the incident was good. Per VP, since incident, have in-serviced staff regarding telemetry, rounding and all staff have signed off. Data was reconciled with the event log at monitor tech station. Tech or nurse informed for leads off/battery changes. Rapid response call for rhythm changes.

A review on 12/29/22 of the auditing process of the Telemetry Notification Logs found data collected and the event comparison could not determine that the monitor techs are following the Cardiac Telemetry Policy or reporting all alarms. The auditing tool compared the alarms documented on the Telemetry Notification Log and the Overhead paging of alarms. This does no assure that all alarms are documented on the Log. The Overhead paging of alarms is a second level notification and does not capture first notifications by voice or text communication. There was no reconciliation of the Telemetry Notification Log with a machine data printout of alarms to prove all alarms are documented by the monitor tech. There was no reconciliation of the Telemetry Notification Log with a printout of the memory of the telecommunication devices used to call or text notice of an alarm to the nursing staff to prove that all alarms are communicated by the monitor tech to the nursing staff. The Telemetry policy establishes time frames for notification and response to alarms. The Telemetry Notification Log did not capture the times of nursing response, the time of escalation to the next level of notification, and the time the issue resolved. The performance improvement plan was not adequate to ensure monitor techs were performing as required.

In an interview on 1/3/23 at 12:54 p.m., the VP of Quality and Patient Safety and the facility Director of Patient Safety discussed the adverse incident involving Patient #5 including the event investigations and mitigation strategies developed from investigation.

Per Director of Patient Safety plan is to audit the telemetry monitor logs daily. Review overhead paging logs and compare to handwritten monitor tech logs in order to identify discrepancies. Asked how based on the current monitor tech telemetry logs how the leadership team knows that the staff followed policy in escalating the alert based on no response or delayed response since the response times to the notification was not charted. Director of Patient Safety agreed that there was no way to confirm that the monitor tech had escalated if needed within the 5 minutes as required by policy. VP of Quality and Patient Safety said it was a system form that could not be altered without approval. Chief Nursing Officer joined the interview at this time. She stated staff education for monitor techs was completed as a computer-based training with annual refresher for all nurses (PCU/ ICU) and all monitor techs. Education information is kept on HealthStream transcripts. Then the new monitor techs are paired with a mentor for a few weeks. The CNO agreed the telemetry monitor logs were completed inconsistently. The CNO said that at her previous organization she had a template that she could use to educate the monitor techs on how to complete the log more accurately.

2. Patient #7 was admitted to the hospital on 9/12/22 with complaint of shortness of breath. Patient placed on telemetry cardiac monitoring. Patient had prolonged QT (heart's electrical signal/rhythm made up of five waves designated P, Q, R, S, T- measured interval Q to T spread widened out of normal range) on the monitor. The Telemetry Monitor Tech needed relief for a break. The tech left without ensuring the nurse was in place to observe the monitor. The monitors wee left unattended for five minutes. The patient coded and an alarm sounded for V tach (ventricular tachycardia - rapid heartbeat in the lower chambers). A nurse who happened to be at the nursing station where the telemetry monitors are located responded to the alarm and called a code. The patient survived and was moved to the ICU. The patient was then transferred to another facility for invasive procedures.

The Serious Event Assessment was implemented on 10/31/22 which included the following: Conclusion - monitors left unattended for five minutes, alarm did go off and was responded to. Event did occur with cardiac code. Patient survived and was transferred.
Corrective action - Staff education completed, new staff hired (secretary for 7p to11p) to free charge nurse from a portion of paperwork so charge nurse can assist with monitoring and proper hand off for breaks. Monitoring effective hand-off of the monitor tech to the nurse covering for breaks for 4 months.

A review of the audit report on 12/29/22 found that there was no data collected of the monitor tech to nurse hand-off for breaks. The nursing manager gave a verbal report to the VP of Quality and Safety that she had observed appropriate hand-off on several occasions. There was no documentation of times or participants of the observed hand-offs. There was no documentation of frequency of observations. The monitoring of the Performance improvement Plan (PIP) is not adequate to ensure the safety of the patients or the effectiveness of the procedure that were implemented.

Based on observation, clinical record review, review of facility policies and procedures, and interviews, the facility failed to ensure cardiac telemetry monitor techs were supervised and performing their required responsibilities by licensed nurses competent to assess telemetry monitors. This lack of supervision resulted in a cardiac monitor with alarms disengaged offline for an extended time period for Patient #5 on 12/14/22. During which time the patient had a cardiac event which was not detected. Patient #5 coded and died. Also, on 9/13/22 the telemetry monitors were left unattended with nursing leadership not ensuring coverage while the monitor technician was on a break. During which time Patient #7 had a cardiac event which resulted in a code. The patient survived.

There was inadequate nursing oversight of telemetric cardiac monitoring for Patient #5 and Patient #7 during which changes in cardiac rhythms occurred. (Refer to A0286, A0395, and A0144)

The hospital's noncompliance with the Conditions of Participation of Nursing Services due to the hospital's failure to provide appropriate nursing oversight resulted in Immediate Jeopardy. The Immediate Jeopardy began on 12/14/22. The hospital was informed of the Immediate Jeopardy on 1/6/23 at 11:00 a.m. and was ongoing as of the survey exit on 1/6/23. On 1/4/23 there are 42 patients on telemetry cardiac monitoring. Cross reference to A0115, A0286, and A0395.

Based on observations, interviews, records review and hospital policy reviews the hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for each patient. The hospital failed to ensure the Monitor Techs (MT) responsible for monitoring patients on continuous cardiac telemetry monitoring were supervised appropriately. This lack of supervision resulted in one patient, Patient #5, having cardiac telemetry monitor alarms deactivated against policy for two hours and nine minutes. The deactivated alarms were identified when patient was found unresponsive, coded and died. The facility failed to notify physicians for episodes of increase heart rate for 4 (Patient #5, #8, #9, and #10) of 5 patients reviewed for elevated heart rates documented on Telemetry Notification Log or in clinical records. Nursing leadership failed to ensure continuous coverage of the telemetric cardiac monitor station resulting in the monitor station being left unattended for five minutes. Cross reference to A0385.

The findings included:

Review of hospital policy titled, Cardiac Telemetry Monitoring, revised 6/2021 which stated:
Purpose: To ensure patient safety and provide continuous cardiac monitoring and documentation guidelines for patients who have telemetry monitoring ordered.

Policy: Section C. The cardiac telemetry monitoring alarms have been determined to be high-risk medical equipment where there is serious injury or death to a patient if the alarm/ equipment were to fail. Section D. The Registered Nurse (RN) is ultimately responsible for the interpretation of cardiac monitoring. Section E. If the patient rhythm is still transmitting to the central station but the monitor indicates battery low or lead off the monitoring technician must notify the Nurse. If there is no response, the situation is not responded to or if it is not resolved in 5 minutes a "Telemetry Alert" will be called.
Procedure: Section K. At no time during monitoring should alarms be turned off or silenced. Any employee who disables an alarm is subject to disciplinary action up to and including termination.
Nursing (RN) Responsibilities: Section B. The Registered Nurse is responsible to ensure that the patient is being appropriately monitored at all times. Telemetry verification is conducted as part of the cardiac assessment.

Review of hospital policy titled Modified Early Warning System (MEWS) reviewed 1/11/22 which stated:
Purpose: The purpose of the Modified Early Warning Systems (MEWS) is to augment early recognition, intervention, and stabilization or patients experiencing unexpected clinical deterioration.
Required Response: Licensed caregiver - reassess patients-documents notification of score in Electronic Medical Record (EMR) physician notification screen- activate rapid response team if clinical judgement deems necessary- notify physician as indicated. Charge Nurse- Round on identified patients with primary nurse to determine if additional monitoring or intervention is needed.

1. Clinical records reviewed for Patient #5 documented admission to the hospital on 12/7/22. Patient was transferred from the Intensive Care Unit (ICU) to the Progressive Care Unit (PCU) on 12/9/22 with ordered continuous telemetry monitoring. On 12/14/22 at 8:09 p.m. RN, Staff B, documented vital signs including a pulse rate of 130 beats per minute and a MEWS score of 4. Printed cardiac rhythm strip for 8:10 p.m. showed heart rate at 130 beats per minute. There was no documented notification to the physician or interventions for the elevated heart rate in the clinical record. Central telemetry monitoring documented an alarm for leads fail with no visual cardiac pattern on telemetry 12/14/22 at 9:15 p.m. At 9:16 p.m. the monitor data showed continued alarm for leads fail with no visual cardiac pattern on telemetry with monitor placed on "Auto Pause". MT Staff A deactivated the audible alarm and indicated Patient #5 was off unit. Patient #5 was bedbound and was not out of the unit for any procedures. At 9:51 p.m. the monitor data shows continued monitor alarm for leads fail, no visual cardiac pattern on telemetry and new notification to change battery for telemetry. On 12/14/22 at 11:24 p.m. RN, Staff B, and Patient Care Technician (PCT) Staff E entered Patient #5's room and found patient unresponsive. Code Blue was initiated and continued until 11:38 p.m. when resuscitation efforts were ended, and Patient #5 was declared deceased.

On 1/3/23 at 12:55 p.m., interviewed Vice President (VP) of Quality and Patient Safety who confirmed the MT works under the supervision of the charge nurse for the shift assigned.

On 1/3/23 at 1:45 p.m., Chief Nursing Officer (CNO) said they have a chain of command for the monitor techs. The charge nurse supervises their daily work, each shift has a house supervisor who checks on the staff and currently there is an interim manager covering the PCU department.

On 1/3/23 at 3:05 p.m., interviewed MT Staff F, who said she works day shift and the immediate go to person would be the charge nurse, each shift also has a house supervisor.

On 1/4/23 at 9:10 a.m., phone interview with RN Staff B, Patient #5's primary nurse on 12/14/22 nightshift. RN Staff B said the nurses obtain the first set of vital signs on the shift. She did not recall Patient #5 having a heart rate of 130 beats per minute. She said, "normally if I saw that I would recheck it." Regarding communication with the MT during the shift., RN Staff B replied, "I had no communication for this patient or any other patients from the MT that shift. I was in and out of the nurses' station several times and the MT never said anything to me that there was something wrong with the monitoring."

On 1/4/23 at 10:10 a.m., phone interview with Charge Nurse RN Staff C who was in charge on 12/14/22 nightshift. RN charge nurse said, "I had no communication for this patient or any other patients from the MT that shift. I was in and out of the nurses' station several times and the MT never said anything to me that there was something wrong with the monitoring. It was a busy shift. When I saw the Code Blue light in the charge nurse station I went to respond. This was the first time I was aware the patient was having any distress." The RN Charge Nurse Staff C said the monitor techs are to notify the charge nurse if they see anything off on the monitors.

On 1/4/23 at 10:50 a.m., phone interview with the On-call physician who was on call the night of Patient #5 death. He did not recall any communication about Patient #5 and confirmed he would expect to be notified for a patient with an increased heart rate of 130 beats per minute.

On 1/4/23 at 11:10 a.m., phone interview was conducted with PCT Staff E, assigned to patient #5 on 12/14/22 night shift, said she did not receive any calls or notification from the MT about leads off or batteries needing to be changed. PCT said she was with primary RN when they found the patient unresponsive and called the Code Blue.

On 1/4/23 at 11:45 a.m., during an interview, VP of Quality and Patient Safety said the absolute root cause of this event is that the MT failed follow policy. She said during the investigation the MT assigned told her she had silenced the alarm at 9:16 p.m. and that the yellow visual alarm stayed in place. The Director of Patient Safety said that she was not aware the MT could silence or pause the audible alarm indefinitely.

On 1/4/23 at 12:45 p.m., Patient #5 record reviewed for elevated heart rate 130 beats per minute documented on 12/14/22 at 8:09 p.m. VP of Quality and Patient Safety confirmed no physician notification, progress notes or interventions were documented. Further review also showed on 12/8/22 at 9:30 p.m. the patient had an elevated heart rate of 124 beats per minute. VP of Quality and Patient Safety confirmed no physician notification, progress notes or interventions were documented.

2. On 1/4/23 at 1:20 p.m. the survey team reviewed the previous 24 hours telemetry monitor log for patients identified with elevated heart rates for nursing notification and nursing documentation of physician notification. Patient #8 was documented as having heart rate between 120 and 140 beats per minute on 1/3/23. MT notified unknown nurse at 11:12 a.m., 11:59 a.m., 12:09 p.m., and 12:12 p.m. For Patient #9 the MT documented on 1/3/22 at 9:27 a.m. the patient's heart rate increased from 120 to 130 beats per minute since 8:06 a.m. and notified the patient's nurse three times. For Patient #10, on 1/3/23 at 9:58 p.m. the MT documented tachycardia (increased heart rate) on the notification log. The VP of Quality and Patient Safety confirmed no physician notifications, progress notes, or interventions were documented in the reviewed patient records. The VP of Quality and Patient Safety said there should be nursing documentation.

On 1/5/23 at 12:50 p.m. phone interview with MT Staff A confirmed she had paused the audible alarm for Patient #5. She said she had tried to call the PCT to check the leads but couldn't get through, so she told her when she saw her. MT Staff A said, "I put on the pause, usually I don't, after I told them the lead was off. Time got away and the next thing I knew the code was being called."

On 1/5/23 at 1:40 p.m., during interview the CNO confirmed that it was unacceptable for the charge nurse on the shift to not notice the telemetry monitor alarm paused for Patient #5 for 2 hours and 9 minutes. The charge nurse is responsible for the monitor techs and should be looking at the monitors as well.


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3. A review of the medical record for Patient #7 was conducted on 12/29/22 at 11:15 a.m. with the VP of Quality and Patient Safety. Patient #7 was admitted to the hospital on 9/12/22 with complaint of shortness of breath. The patient was admitted to the PCU and place on telemetric cardiac monitoring. Patient #7 had prolonged QT on monitor. The VP of Quality said the Serious Event Assessment (SEA) found that during the time Patient #7 was on PCU the Telemetry Monitor Tech needed relief for a break. The VP of Quality said the Clinical Nurse Coordinator for the unit is the designated relief person for the Monitor Tech. The SEA concluded the Monitor Tech left the monitoring station without ensuring the nurse was in place to observe the monitors. The monitors were unattended for five minutes. During the time the monitoring station was not covered, Patient #7 had a life-threatening cardiac event. The monitor alarm sounded for V tach (ventricular tachycardia - rapid heartbeat in the lower chambers). A nurse who happened to be at the nursing station where the telemetry monitors are located responded to the alarm and called a Code Blue. The patient survived and was moved to the ICU. The patient was transferred to another facility for invasive procedures. Nursing leadership did not ensure the cardiac monitoring station was properly covered.