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The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for one (Patient #1) of 10 sampled patients that the Hospital provided care in a safe setting.

Refer to TAG: A-0144.

Based on observation, interviews and records reviewed, the Hospital failed to provide care in a safe setting for Patient #1 when he/she attempted to call for medical assistance through utilizing his/her call bell/light and when his/her monitor alarms were shut off at the central monitoring station.

Findings include:

Review of the Hospital's Patient Rights and Responsibilities Policy, dated 12/21/18 indicated that the Hospital's general procedure for Patient Rights is derived from the Massachusetts Patients' Bill of Rights. The Hospital website has posted the Patient Rights and Responsibilities and indicates that Patients have all reasonable requests responded to promptly and adequately within the capabilities of this facility.

Patient #1 was brought to the Emergency Department for evaluation of shortness of breath and altered mental status. Patient #1 has a history of hypotension, atrial fibrillation and end stage renal disease.

Review of Patient #1's Emergency Department Physician Provider Notes, dated 7/19/21, indicated that the patient was critically ill with hypotension and was being transferred to the critical care pod (Next Pod) of the Hospital's Emergency Department for continued care.

Review of Patient #1's Emergency Department Continuation of Care note, dated 7/19/21, indicated that Patient #1 had tested positive for COVID-19.

The Hospital reported to The Department of Public Health (DPH) that Patient #1 was found unresponsive in his/her room by a nurse and a code blue was activated, Patient #1's death was pronounced 30 minutes after the code was started. The report provided to DPH indicated that the Hospital's investigation discovered that the Patient's call light was not set up properly to ring at the nursing station for the emergency department's Next Pod in which he/she was being treated and was ringing in the North
Pod next to Patient #1's Pod.

Review of the Hospital's internal investigation indicated that not only was the call light ringing in a different Pod, but that Patient #1's telemetry alarms were silenced in his/her room and they were also shut off at the central monitoring station at the Next Pod nursing station, therefor any alarms to signal to the nurse that Patient #1 was in immediate need of nursing care was not audible to the nursing staff. Further, it was identified that Patient #1's call light was visible on the Next Pod, so the staff members working on the unit could see that the light was lit while Patient #1 was awaiting assessment and care.

During a tour of the Emergency Department on 8/19/21 the Senior Director of Emergency Medicine and Behavioral Health Services said that the call light for Patient #1 ' s room alarmed in the North Pod and not the Next Pod. He said that about two years ago, they reconfigured the Emergency Department and Patient #1 ' s Room was now part of Next Pod and used to be part of North Pod Extension.

During an interview on 8/20/21 at 8:30 A.M., Registered Nurse (RN) #1 said that she was aware that the call light system in Patient #1's room didn't ring in the Next Pod (critical care nursing station), but it rings in the North Pod Nursing station. RN #1 said that the staff members have complained about this for a while, but nothing was ever done about it. RN #1 said that the call light can be visualized on Next Pod, above the doors when it is lit as long as you see it from the right angle. RN #1 did acknowledge that she silenced Patient #1's bedroom monitor at the request of the patient because the alarms were bothering her. RN #1 said that when you silence the alarm at the bedside, it does not affect the alarms at the central monitor. She was not aware that the central monitor alarms had been turned off.

During an interview on 8/20/21 at 10:10 A.M., RN #2 said that he was the primary nurse for Patient #1 starting at 3:00 P.M. was aware that the call light for Patient #1's room sounded in another Pod, but that the light can be seen outside of the patient ' s room. Nurse #2 said that Nurse #3 told him that Patient #1 required attention, but he wasn't aware that there was an urgent need to go into the room immediately.

During an interview on 8/23/21 at 9:00 A.M. Nurse #3 said that he heard Patient #1's call bell alarm on North Pod even though Patient #1 was on Next Pod. Nurse #3 said that he went over to the Next Pod and saw that Patient #1 was on strict precautions. Nurse #3 said that he didn't go in the room because he wasn't sure if Patient #3 had COVID-19. Nurse #3 said that he put on an N-95 face mask and poked his head in the room. Nurse #3 doesn't recall if the patient spoke to him or just motioned that he/she needed assistance with the head of his/her bed. He said that he notified staff on Next Pod and that they said they would take care of it.

During an interview on 8/23/21 at 10:00 A.M. Patient Care Assistant (PCA) #1 said that she was working in the North Pod on 7/19/21. She said that she could hear Patient #1's call bell alarming on the North Pod call system. She said that the staff all know that this Next Pod bedroom call light alarms on the North Pod system. She said that when you work on the Next Pod, you are taught that the call light alarm rings in the North Pod for that room. PCA #1 said that even thought it alarms in the North Pod, you can still see and hear it from Next Pod so it shouldn't go unanswered.

During an interview on 8/23/21 at 10:30 A.M. the Unit Secretary on Next Pod said that she was working on 7/19/21 and at 5:00 the call bell was going off. She said that she overheard another nurse ask Nurse #2 if he wanted her to go in to check on Patient #1. She said that Nurse #2 said that he would go in shortly as he was caring for another patient. The Unit Secretary then said that PCA #1 came over and asked if anyone was going to answer the call light that was ringing in the Next Pod for Patient #1. The Unit Secretary told PCA #1 to go over to the call light system on North Pod and pick up the phone to tell the Patient that someone will be right in. The Unit Secretary then said about 5 minutes later Patient #1's daughter called the nursing station and told her that Patient #1 has been ringing for help. The daughter told the Unit Secretary that Patient #1 sounded like he/she was drowning and can't breathe. The Unit Secretary then hung up the phone and announced to the nursing staff and PCA #2 that was at the desk that Patient #1 can't breathe. The Unit Secretary said multiple people were there and could hear her. The Unit Secretary said that PCA #2 responded to her by saying, of course she can't breath, she has COVID. She said that moments passed and then a nurse got up to answer the call light and when she entered the room, the code blue was called. The Unit Secretary said that Hospital staff are trained to know that the call bell for Patient #1's room sounds on Next Pod. She said that although it sounds on North Pod, you can still hear and see the call light from Next Pod.

During an interview on 8/23/21 at 9:30 A.M., the Sr. Director of Emergency Medicine and Behavioral Health Services said that he didn ' t know that the call light for Patient #1's room rang in the North Pod and not in Next Pod.

During an interview on 8/23/21 at 9:30 A.M. the Assistant Nurse Manager said that there is a need for culture change and that this was a preventable problem. He said that basic nursing safety practice is that call bells need to be answered and monitor alarms shouldn ' t be shut off. He said that specific culture changes are being worked on.

Review of the Hospital's internal investigation indicated that the Patient's daughter called and told the Unit Secretary that she knows that nursing staff are busy, but Patient #1 had activated the call light and it was going off for at least 20 minutes without a response.

The Hospital failed to provide care in a safe setting when a Hospital Nurse failed to respond timely to requests by Patient #1 for help.

The Condition of Participation of Quality Assessment & Performance Improvement Program was not met.

Findings included:

The Hospital failed to identify opportunities for improvement, consider the incidence, prevalence, and severity of problems and implement changes that will lead to improvement for 1 (Patient #1) of 10 patient records reviewed.

Refer to TAG: A-0286.

Based on interviews and records reviewed, the Hospital failed to provide system wide implementation of preventative actions after Patient #1 was found unresponsive in his/her room following a medical emergency that went undetected due to nursing staff not responding to assess Patient #1 when he/she uitilized his/her call light to request nursing assistance and when a staff member silenced the central monitor alarm at the nursing station.

Findings include:

Review of the Hospital's Quality Assessment and Performance Improvement Plan, dated March 2020, indicated that the Hospital's Quality and Safety plan facilitates a multidisciplinary, systematic performance inprovement approach to identify and persue improved patient outcomes and reduce the risks associated with patient safety.

Patient #1 was brought to the Emergency Department for evaluation of shortness of breath and altered mental status. Patient #1 has a history of hypotension, atrial fibrillation and end stage renal disease.

Review of Patient #1's Emergency Department Physician Provider Notes, dated 7/19/21, indicated that the patient was critically ill with hypotension and was being transferred to the critical care pod (Next Pod) of the Hospital's Emergency Department for continued care.

Review of Patient #1's Emergency Department Continuation of Care note, dated 7/19/21, indicated that Patient #1 had tested positive for COVID-19.

The Hospital reported to The Department of Public Health (DPH) that Patient #1 was found unresponsive in his/her room by a nurse and a code blue was activated, Patient #1's death was pronounced 30 minutes after the code was started. The report provided to DPH indicated that the Hospital's investigation discovered that the Patient's call light was not set up properly to ring at the nursing station for the emergency department's Next Pod in which he/she was being treated and was ringing in the North Pod, next to Patient #1's Next Pod.

Review of the Hospital's internal investigation indicated that not only was the call light ringing in a different Pod, but that Patient #1's telemetry alarms were silenced in his/her room and they were also shut off at the central monitoring station at the Next Pod nursing station, leaving any alarms to signal to the nurse that Patient #1 was in immediate need for nursing care were not audible to the nursing staff. Further, it was identified that Patient #1's call light was visible on the Next Pod, so the staff members working on the unit could see that the light was lit while Patient #1 was awaiting assessment and care. The Hospital also identified that the nurse ' s responsible for Patient #1 should have set the telemetry monitors to Patient #1's specific parameter's so that the alarm wouldn't sound as often as it did.

Review of the Hospital ' s report to DPH indicated that the telemetry monitor ' s were able to capture vitals at 5:00 P.M. for Patient #1 that would have alerted the Nurse that Patient #1 required immediate attention had the alarms not been silenced at the central monitor in the nursing station. The records reflect that Patient #1 ' s vitals at 5:00 P.M. were as follows: Heart rate 108, Oxygen Level 86 % (The report indicated on room air, but the medical record indicated that the patient was on 3 liters of Oxygen at 4:42 P.M. when last assessed by Registered Nurse #2.) Blood Pressure was low at 85/47 and the respiratory rate was 25.

Review of the Hospital's Corrective Action Plan following the Root Cause Analysis indicated that the Hospital would: review in staff huddles the importance of responding to call bells and ensuring safe monitor settings, explore the ability to lower volume of alarm vs. turning off in patient room when disruptive, investigate the ability to prevent the central alarm from being turned off, develop in the computer system a bedside checklist to review settings for patients on monitors, review the algorithm for all alarm settings and create and assign a learning module in e-learning to review checklist, alarm configuration and protocols for responding to patient call lights.

Review of the huddle notes and the emails sent to Nursing staff as a result of the RCA indicated that the Hospital has informed the Emergency Department nursing staff not to turn off alarms at the central monitor and has created a paper checklist for the nurses to utilize to be sure their alarms are on and functioning. There is no mention in the education that the nurses have been retrained on the monitors and how to set the proper parameters for specific patient needs or discussion about responding timely to patient ' s call lights.

During an interview on 8/20/21 at 8:30 A.M. Nurse #1 said that Patient #1 asked if the alarms could be silenced in the room so that he/she wasn't disturbed. Nurse #1 said that she was able to silence the monitor alarms in the room but that the central monitor at the nursing station isn't silenced as a result of the bedroom monitor being silenced. Nurse #1 said the alarms were going off a lot. She doesn't feel comfortable as a nurse setting a patient's alarm parameter's too low.

During an interview on 8/20/21 at 9:10 A.M., the Senior Director of Emergency Medicine and Behavioral Health Services said that nurses should be checking to be sure their alarms are working properly and are adequately set to patient's clinical needs. He said that because of the parameters set on Patient #1's monitor, the alarms were going off quite frequently and the Patient requested Nurse #1 silence them in the room. He said that had the parameters been set according to Patient #1's clinical status, the alarms would have likely not been so bothersome or frequent.

During an interview on 8/20/21 at 12:00 P.M. the Risk Manager said that as a result of the Hospital investigation, the Hospital was supposed to retrain the nurses on setting parameters for the monitor alarms and the need for monitor training was identified as a result of the investigation.

During an interview on 8/23/21 at 9:30 A.M., the Senior Director of Emergency Medicine and Behavioral Health Services indicated that the nursing staff has not had retraining on setting parameters because he didn't see a deficit with setting parameters.

During an interview on 8/23/21 at 9:30 A.M. the Assistant Nurse Manager said that there is a need for culture change and that this was a preventable problem. He said that basic nursing safety practice is that call bells need to be answered and monitor alarms shouldn't be shut off. He said that specific culture changes are being worked on.

During an interview on 8/23/21 at 10:30 A.M., the Director of Patient Safety and Regulatory Affairs said that she didn't know the central monitor alarms could be shut off. She said that the Hospital hasn't done a systemic review of the other departments to be sure that a like occurrence won't happen on another unit within the Hospital system. She also said that they have not checked the rest of the units in the Hospital system of call light discrepancies like the one they found as a result of this investigation on Next Pod.

The Hospital failed to implement changes and education to prevent a like occurrence from happening again when they didn ' t follow their own Root Cause Analysis' Corrective Action Plan and educate nursing staff on setting monitor parameters, re-educate staff on call light response expectations, and perform system wide audits to confirm the monitors and alarms all work as expected on all units.

The Condition of Participation of Nursing Services was not met.

Findings include:

The Hospital failed to ensure for one patient (Patient #1), out of 10 sampled patients that the Hospital supervised and provided assessment of each patient.

The Hospital failed to ensure for one patient (Patient #1), out of 10 sampled patients that the Hospital provided care in a safe setting.

Refer to TAG: A-0392

Based on observation, interviews and record reviews, the Hospital failed to provide adequate nursing care and assessment to a patient when their nursing staff failed to respond to Patient #1 ' s call for help and his/her daughter ' s call for help.

Findings include:

Patient #1 was brought to the Emergency Department for evaluation of shortness of breath and altered mental status. Patient #1 has a history of hypotension, atrial fibrillation and end stage renal disease.

Review of Patient #1's Emergency Department Physician Provider Notes, dated 7/19/21, indicated that the patient was critically ill with hypotension and was being transferred to the critical care pod (Next Pod) of the Hospital's Emergency Department for continued care.

Review of Patient #1's Emergency Department Continuation of Care note, dated 7/19/21, indicated that Patient #1 had tested positive for COVID-19.

The Hospital reported to The Department of Public Health (DPH) that Patient #1 was found unresponsive in his/her room by nursing staff and a code blue was activated and Patient #1's death was pronounced 30 minutes after the code was started. The report provided to DPH indicated that the Hospital's investigation discovered that the Patient's call light was not set up properly to ring at the nursing station in the emergency department's Next Pod in which he/she was being treated and was ringing in the North Pod next to Patient #1's Pod.

Review of the Hospital's internal investigation indicated that not only was the call light ringing in North Pod, but that Patient #1's telemetry alarms were silenced in his/her room and they were also shut off at the central monitoring station at the Next Pod nursing station, therefor any alarms to signal to the nurse that Patient #1 was in immediate need for nursing care was not audible to the nursing staff. Further, it was identified that Patient #1's call light was visible on the Next Pod, so the staff members working on the unit could see that the light was lit while Patient #1 was awaiting assessment and care.

During a tour of the Emergency Department on 8/19/21 the Senior Director of Emergency Medicine and Behavioral Health Services said that the call light for Patient #1 ' s room alarmed in the North Pod and not the Next Pod. He said that about two years ago, they reconfigured the Emergency Department and Patient #1's Room was now part of Next Pod and used to be part of North Pod Extension.

During an interview on 8/20/21 at 8:30 A.M., Registered Nurse (RN) #1 said that she was aware that the call light system in Patient #1's room didn't ring in the Next Pod (critical care nursing station), but it rings in the North Pod Nursing station. RN #1 said that the staff members have complained about this for a while, but nothing was ever done about it. RN #1 said that the call light can be visualized on Next Pod, above the doors when it is lit as long as you see it from the right angle. RN #1 did acknowledge that she silenced Patient #1's bedroom monitor at the request of the patient because the alarms were bothering her. RN #1 said that when you silence the alarm at the bedside, it does not affect the alarms at the central monitor. She was not aware that the central monitor alarms had been turned off.

During an interview on 8/20/21 at 10:10 A.M., RN #2 said that he was the primary nurse for Patient #1 starting at 3:00 P.M. and was aware that the call light for Patient #1 ' s room sounded in another Pod, but that the light can be seen outside of the patient's room. Nurse #2 said that Nurse #3 told him that Patient #1 asked for assistance, but he wasn't aware that there was an urgent need to go into the room immediately for an assessment.

During an interview on 8/23/21 at 9:00 A.M. Nurse #3 said that he heard Patient #1's call bell alarm on North Pod even though Patient #1 was on Next Pod. Nurse #3 said that he went over to the Next Pod and saw that Patient #1 was on strict precautions. Nurse #3 said that he didn ' t go in the room because he wasn ' t sure if Patient #3 had COVID-19. Nurse #3 said that he put on an N-95 face mask and poked his head in the room. He doesn ' t recall if the patient spoke to him or just motioned that he/she needed assistance with the head of his/her bed. He said that he notified staff on Next Pod and that they said they would take care of it.

During an interview on 8/23/21 at 10:00 A.M. Patient Care Assistant (PCA) #1 said that she was working in the North Pod on 7/19/21. She said that she could hear Patient #1's call bell alarming on the North Pod call system. She said that the staff all know that this Next Pod bedroom call light alarms on the North Pod system. She said that when you work on the Next Pod, you are taught that the call light alarm rings in the North Pod for that room. PCA #1 said that even thought it alarms in the North Pod, you can still see and hear it from Next Pod so it shouldn ' t go unanswered.

During an interview on 8/23/21 at 10:30 A.M. the Unit Secretary on Next Pod said that she was working on 7/19/21 and at 5:00 the call bell was going off. She said that she overheard another nurse ask Nurse #2 if he wanted her to go in to check on Patient #1. She said that Nurse #2 said that he would go in shortly as he was caring for another patient. The Unit Secretary then said that PCA #1 came over and asked if anyone was going to answer the call light that was ringing in the Next Pod for Patient #1. The Unit Secretary told PCA #1 to go over to the call light system on North Pod and pick up the phone to tell the Patient that someone will be right in. The Unit Secretary then said about 5 minutes later Patient #1's daughter called the nursing station and told her that Patient #1 has been ringing for help. The daughter told the Unit Secretary that Patient #1 sounded like he/she was drowning and can't breathe. The Unit Secretary then hung up the phone and announced to the nursing staff and PCA #2 that was at the desk that Patient #1 can't breathe. The Unit Secretary said multiple people were there and could hear her. The Unit Secretary said that PCA #2 said "of course she can't breath, she has COVID." She said that moments passed and then a nurse got up to answer the call light and when she entered the room, the code blue was called. The Unit Secretary said that Hospital staff are trained to know that the call bell for Patient #1's room sounds on Next Pod. She said that although it sounds on North Pod, you can still hear and see the call light from Next Pod.

During an interview on 8/23/21 at 9:30 A.M. the Assistant Nurse Manager said that there is a need for culture change and that this was a preventable problem. He said that basic nursing safety practice is that call bells need to be answered and monitor alarms shouldn't be shut off. He said that specific culture changes are being worked on.

Review of the Hospital ' s internal investigation indicated that the Patient's daughter called and told the Unit Secretary that she knows that nursing staff are busy, but Patient #1 had activated the call light and it was going off for at least 20 minutes without a response or nursing assessment.

Review of the Hospital's staffing schedule and assignment for 7/19/21 indicated that there were five nurses working, one patient care technician working and one unit secretary working at the time that Patient #1 was calling for help with no response to assess the patient's needs.

The nurses failed to respond to and meet the needs of Patient #1 when he/she utilized his/her call bell for nursing assistance.