HospitalInspections.org

Based on interview, record review, and policy review the facility failed to ensure that:
- Patients were safe from an undetected abnormal heart rate and/or rhythm when the telemetry monitoring system (special equipment to track a patient's heart rate and rhythm through wires attached to the skin of the patient) had frequent radio frequency (RF, a type of energy which is measured in frequency or wavelengths per second) interference that resulted in a total loss of signal of the patient's telemetry reading.
- Patients were safe from falls after staff identified that bed alarms (bed and/or chair alarms, a system used to assist with reduction of falls in patients identified at risk for falling by alerting staff when a patient attempts to get up from a bed/chair without assistance) were either not turned on, functioning properly or not plugged into a power source for three discharged patients (#60, #63, and #64) of five discharged patients reviewed and two current patients (#75 and #78) of 20 current patients reviewed that were identified at high risk for falls.
These failures had the potential to place all patients monitored by telemetry and at risk for falls at increased risk for their health and safety. (A-0144)

These deficient practices resulted in the facility's non-compliance with specific requirements found under 42 CFR 482.13 Condition of Participation: Patient's Rights. The facility census was 79 with 46 patients on telemetry monitoring. The facility census was 74 at the time of the re-entrance.

The severity and cumulative effect of these practices had the likelihood to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 05/16/19, after the survey team informed the facility of the IJ, the staff put into place interventions to ensure the safety of the patients who were on telemetry.

As of 05/16/19, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- All patients with telemetry orders were consolidated to the units of Intensive Care Unit (ICU) that was a hardwired (cables directly connected to telemetry) unit that had no RF interference. The ICU had a total capacity for 16 patients.
- 2 North Critical Care Unit (CCU) would have a nurse to patient ratio of 1:4, with a total capacity of 19 patients. The unit would be staffed with two additional staff 24/7 whose only responsibility would be to respond to patients whose telemetry signal experience RF interference. Each staff would carry a phone and would stay with the patient, and view the cardiac rhythm on telemetry pack until notification from the monitor technician (tech) that the signal was received and visible. If the roaming staff already dedicated to a room and another room lost signal, the registered nurse (RN) assigned to that room would be contacted by the monitor tech to respond. Each RN would be assigned a buddy RN to respond in the event the patient RN was otherwise detained.
- 3 West would have a nurse to patient ratio of 1:4; total capacity of 16 patients. This unit would be staffed with two additional staff 24/7, whose only responsibility would be to respond to patients whose telemetry signal experienced RF interference. Each staff would carry a phone and would stay with the patient and view the cardiac rhythm on the telemetry pack until notification from the monitor tech that the signal was received and visible. If the roaming staff was already dedicated to a room and another room lost signal, the RN assigned to that room would be contacted by the monitor tech to respond. Each RN would be assigned a buddy RN to respond in the event the patient RN was otherwise detained.
- All cardiologists, hospitalists and admitting providers would be informed of the current telemetry RF interference issue and of the detailed plan to assure patient safety through medical staff office email distribution.
- All telemetry patients that were on 4 West were either discharged from the hospital or transferred to 2 North or 3 West for continued telemetry monitoring.
- A document in flyer style would be authored for all telemetry patients with the detail on current RF interference issue and the detail on the new process of monitoring, responding and keeping the patient safe with an explanation of why they may experience staff frequently coming into their room to check their telemetry.
- Assure staff phones were charged every shift and phones were verified as functional at the beginning of the shift.

As of 05/30/19, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Hourly rounding on all high risk fall inpatients, (excluding the Senior Behavior Health Unit) using the fall protocol audit form.
- Charge Nurse identifies and communicates the high risk patient to the rounder beginning now and thereafter, at the beginning of each shift.
- All deviations of fall protocol will be corrected upon discovery, and documented on the hourly rounding sheet in the comment section for follow up by the Unit Manager.
- Unit Manager/House Supervisor to review audit tools daily and follow up with staff as appropriate on the day shift 05/30/19.
- Immediate reassessment of ALL inpatients for appropriate fall risk score and appropriate interventions including operational bed/chair alarms including battery function/charge.
- Hourly rounding to be done by nursing staff (nurses, certified nurse assistants, technicians) who have received the fall prevention education.
- Education to be provided to ancillary staff (transporters, physical therapy) related to the bed/chair alarm process and equipment by 06/15/19. Until education is completed, unit staff will be responsible for placing patient on bed/chair alarm as indicated.

Based on interview and record review, the facility failed to provide the required notice to appeal a discharge for four current patients (#67, #68, #69, and #70) of 12 current patients reviewed. This failed practice had the potential to prevent patients the knowledge of a formalized appeal process for premature discharge. The facility census was 74 at the time of re-entrance.

Findings included:

1. Even though requested, the facility failed to provide a policy regarding the appeal process for discharge.

Review of Patient #67's History and Physical (H&P, a document in a patient's medical record that contains the physician's initial assessment and treatment plan) showed the patient was admitted on 05/27/19 for difficulty swallowing.

Review on 05/29/19 of Patient #67's medical record showed no evidence of a discharge appeal form.

Review of Patient #68's H&P dated 05/22/19 showed the patient was admitted on 05/21/19 for complaints of shortness of air and decreased appetite.

Review on 05/29/19 of Patient #68's medical record showed no evidence of a discharge appeal form.

Review of Patient #69's H&P showed the patient was admitted on 05/25/19 for left hip pain.

Review on 05/29/19 of Patient #69's medical record showed no evidence of a discharge appeal form.

Review of Patient #79's H&P showed the patient was admitted on 05/19/19 for generalized weakness.

Review on 05/29/19 Patient #79's medical record showed an order for discharge on the same day. There was no evidence of a second discharge appeal form within the medical record.

During an interview on 05/29/19 at 9:20 AM, Patient #79 stated that the physician told him yesterday that he would be discharged today and would go to a rehabilitation facility (the action of restoring someone to health or normal life after illness or injury). He stated that he had not received his second discharge appeal form to sign.

During an interview on 05/29/19 at 9:30 AM, Staff NNN, Registered Nurse (RN) stated that she thought the admitting nurse would give the discharge appeal form to the patient upon their admission then the nurse that discharged the patient would give the second form prior to discharge. She stated that she was assigned to care for Patient #79 for today.

During an interview on 05/29/19 at 9:48 AM, Staff Y, RN, stated that she wasn't sure what the discharge appeal form was or who was responsible for giving it to the patient. She stated that she thought the nurse gave it to the patient upon admission then again with the discharge instructions prior to discharge.

During an interview on 05/30/19 at 8:40 AM, Staff B, Chief Nursing Officer, (CNO) stated that the discharge appeal forms were given to the patients by the nursing staff on admission and she thought that case management was responsible for the second form prior to discharge.

The facility had no policy or process how the discharge appeal form was provided, when it should be provided or what staff was responsible for providing it to the patient.

Based on observation, interview, record review and policy review the facility failed to:
- Ensure that telemetry (special equipment to track a patient's heart rate and rhythm through wires attached to the skin of the patient) monitored patients were safe from a possible undetected heart rate and/or heart rhythm abnormalities for the current patients in 13 rooms (200, 208, 211, 215, 217, 218, 361, 362 [Patient #43], 363, 454 [Patient #42], 456, 458 [Patient #44] and 460) of 46 current patients on telemetry, and one discharged patient (#19, in room 458) of one discharged patient reviewed, when the telemetry monitoring system had frequent and intermittent radio frequency (RF, a type of energy which is measured in frequency or wavelengths per second) interference that resulted in a total loss of signal of the patients' telemetry readings.
- Identify the reason for the telemetry RF interference and correct in a timely manner.
- Recognize that patients who were placed on telemetry monitors in the South Emergency Department (ED) did not have trained staff assigned to monitor the telemetry readings for nine current patients (#13, #30, #32, #33, #34, #36, #37, #38 and #39) of nine current ED patients reviewed during a 24 hour period when the ED underwent a construction renovation.
- Ensure that staff followed ED department expectations for one discharged patient (#22) of one discharged patient reviewed, when staff in the ED failed to deliver critical diagnostic test results to the physician in a timely manner and failed to place patient on telemetry monitoring.
- Strategically put into place interventions and or measures to prevent patient falls after staff identified that bed alarms (bed and/or chair alarms, a system used to assist with reduction of falls in patients identified at risk for falling by alerting staff when a patient attempts to get up from bed/chair without assistance) were either not turned on, functioning properly or not plugged into a power source for three discharged patients (#60, #63 and #64) out of five discharged records reviewed and for two current patients (#75 and #78) of 20 current patients reviewed that were identified at high risk for falls.
- Ensure staff utilized a gait belt (an adjustable cloth belt, used as an assistive safety device, which is placed around a patient's waist so staff can hold onto it to provide steadiness) to prevent an injurious fall for one discharged patient (#74) of 20 patients reviewed that were identified at high risk for falls by staff.

These failures had the potential to place all patients admitted to the facility at risk for their health and safety. The facility census was 79. The facility census on re-entrance was 74.

Findings included:

1. Review of the facility's policy titled, "Patient Rights & Responsibilities," revised 12/01/16 showed that patients were to be treated in a safe setting.

Review of the facility's policy titled, "Guidelines for Admissions to a Telemetry Unit," dated 07/2011, showed that indications for telemetry monitoring were:
- Atrial Fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow);
- Post-operative patients with cardiac changes, or a history of cardiac diagnostic procedures, surgery or intervention;
- Drug toxicity (level that can cause injury to the body or death of organs) with arrhythmia (irregular heartbeat);
- Acute myocardial infarction (sudden onset heart attack), chest pain, rule out myocardial infarction or unstable angina;
- Decompensated (where the body looses its ability to sustain life without intervention) congestive heart failure (CHF, where the heart muscle doesn't pump blood as well as it should);
- Symptomatic bradycardia (unusual slow heartbeat) or symptomatic tachycardia (rapid heartbeat);
- Cardiac contusion (bruise of the heart muscle);
- Ischemic (restriction in blood supply to tissues, causing a shortage of oxygen needed to keep tissue alive) or hemorrhagic stroke (death of brain tissue cause by bleeding in the brain); and
- Step down from intensive care with recent cardiac arrest (when the heart suddenly stops beating) respiratory arrest (suddenly stopped breathing).

Review of Patient #19's History and Physical (H&P, a document in a patient's medical record that contains the physician's initial assessment and treatment plan) showed the following:
- He was a 62 year old male who presented by ambulance to the ED on 02/18/19 at 8:58 PM, with chest pain and nausea.
- A recent hospital admission 10 days prior for gastroparesis (a condition that affects the stomach muscles and prevents proper stomach emptying).
- A past medical history included hypertension (high blood pressure), myocardial infarction (MI, heart attack), hyperlipidemia (high level of fat in the blood), Insulin Dependent Diabetes Mellitus (IDDM, a disease characterized by high blood sugar levels that can potentially lead to life threatening conditions if untreated), end stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for regular or long-term dialysis [clinical purification of the blood by dialysis, as a substitute for the normal function of the kidneys] or a kidney transplant to maintain life) on dialysis Monday, Wednesday and Friday (MWF).
- He was assessed with chest pain with probable relation to the patient's gastro-esophageal reflux disease (GERD, a digestive disease in which stomach acid or bile irritates the food pipe lining) and possible pneumonia.
- The plan was to treat the patient with antibiotics, repeat a chest x-ray the following day, ESRD with dialysis on MWF and IDDM with sliding scale insulin (insulin therapy that is determined by the patient's blood sugar levels).

Review of Patient #19's medical record showed the following documentation:
- He was admitted to the medical-telemetry unit on 02/19/19 at 1:17 AM for chest pain.
- He was alert and oriented throughout most of the day on 02/19/19.
- The patient became agitated and a room change was planned to move the patient closer to the nurses' station. (exact time not documented)
- The Patient Care Assistant (PCA) went to check on the patient at approximately 4:53 PM and found the patient unresponsive.
- A code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond with a process specific to restore the heartbeat or breathing) was called and resuscitation efforts (attempts to restore heartbeat or breathing) were stopped at 5:13 PM.
- The patient was pronounced dead at approximately 5:15 PM on 02/19/19.

Review of Patient #19's telemetry recordings for room #458, dated 02/19/19 and timed 2:49 PM to 4:45 PM, showed RF interference from 3:36 PM until 4:45 PM, a total of one hour and nine minutes in duration.

Prior to when Patient #19 was found unresponsive, there was one hour and nine minutes of RF interference that resulted in a continuous signal loss. The patient's room (#458) had a known history of RF interference.

During an interview on 05/15/19 at 9:55 AM Staff G, Registered Nurse (RN), Unit Manager, stated that the PCA had gone into Patient #19's room to obtain a blood sugar when she found him unresponsive. She stated that she overheard the code blue and remembered when she arrived at his room there was a large amount of bloody vomit next to the patient, on the floor and even out into the hallway. She stated she was so concerned that something had gone wrong on behalf of her staff that she asked the Chief Nursing Officer (CNO) and Risk Manager to complete a root cause analysis (RCA, a method of problem solving used for identifying the root cause of faults or problems) but they refused.

2. Review of the facility's document titled, "Regional Staff Meeting," dated 02/25/19, showed that during a round table discussion, they spoke about the RF interference between the call light system and the telemetry monitors.
Although it was discussed in the meeting on 02/25/19, the facility failed to diagnose and correct the interference.

During an interview on 05/15/19 at 9:55 AM, Staff G, RN, Unit Manager, stated that the telemetry monitoring system had frequent RF interference shortly after the system was replaced, approximately two years ago. She stated that the RF interference occurred daily on three of the five units that had telemetry, affected multiple patient rooms, was worse during storms and that sometimes the interference caused a complete signal loss of the patient's telemetry reading for 20 minutes or greater. She stated that leadership was aware of the problem but that it had not been fixed, and that they continued to say the problem was with the patient's nurse call button (also referred to as call light) and the proximity of them in relation to the patient's telemetry. She stated that she was very concerned for the safety of the telemetry patients.

Review of five emails dated 01/21/19 through 03/04/19 showed that unit managers communicated RF interference issues to leadership staff including Staff B, CNO and Staff FF, Regional Bio-Medical Manager.

During an interview on 05/15/19 at 1:51 PM, Staff FF, Regional Bio-Medical Manager stated that the facility changed from their previous telemetry monitoring system to another company approximately two years ago and that over the last "couple" of months, nursing staff had reported issues with RF interference. She stated that the equipment itself looked good and that the functioning was good but there was some interference from an unknown external source. Staff FF stated that a representative from the telemetry company visited the facility in 01/2019 or 02/2019 after staff had reported the RF interference. She stated that the telemetry company had evaluated the system and replaced every telemetry lead (wires affixed to the skin for heart monitoring) within the facility.

Review of a typed report prepared by the regional service manager for the telemetry company, and addressed to the facility, showed that they had arrived on-site on 01/07/19 and made observations of signal loss of three to five seconds with the telemetry system at intermittent intervals across the entire system. Observations were again made the week of 01/29/19 with the same issues as observed during the week of 01/07/19. The conclusion stated that due to the intermittent nature of the RF interference, they were unable to locate the source and fix the problem. The recommendation was for the facility to reach out to a third party specializing in RF troubleshooting to locate the source.

Review of handwritten notes provided by Staff FF, Regional Bio-Medical Manager dated 11/30/2018 to 05/15/19 showed 23 handwritten notes regarding RF interference for various patient rooms/units. The first documented RF interference issue was dated 12/13/18.

Review of the facility's undated document titled, "Clinical Work Orders," showed the following online work orders (request for maintenance or repair of something broken or that does not work right) were sent to Biomedical Engineering:
- 03/11/19 at 8:07 AM, 2 North, Cardiac Care Unit (CCU), Telemetry Pack (a portable heart monitor worn around your neck or in the pocket of a hospital gown that track heart rhythm problems and send to a receiving location for display for monitoring);
- 03/11/19 at 11:43 AM, 2 North, CCU, Telemetry Pack;
- 03/22/19 at 1:50 PM, 2 West, Telemetry Pack;
- 04/01/19 at 3:16 PM, 3 West, Telemetry Pack;
- 04/02/19 at 10:25 AM, 3 West, Telemetry Pack;
- 04/10/19 at 10:38 AM, Biomed, Telemetry Pack;
- 04/17/19 at 1:23 PM, 2 North, CCU, Telemetry Pack;
- 04/30/19 at 12:22 PM, 3 West, Telemetry Pack; and
- 05/06/19 at 2:34 PM, 2 North, CCU, Telemetry Pack.

During an interview on 05/16/19 at 3:55 PM, Staff OO, Chief Medical Officer (CMO), stated that:
- He was made aware of the interference with the telemetry over the last two months.
- He was not aware the telemetry signal was interrupted for more than a few seconds at a time.
- The patients should have been moved if the interruption was more than a few seconds.
- The Patient Care Technicians (PCT's) and the nurses had shown their frustration with the RF interference.

During an interview on 05/15/19 at 3:07 PM, Staff HH, RN, Unit Manager, stated that she was aware of the telemetry RF interference and that it had been happening for approximately two months. She also stated that there was no audible alarm when the RF interference occurred and that she had contacted the CNO regarding the room with the most interference, room #208.

During an interview on 05/16/19 at 3:30 PM, Staff PP, RN, stated that the RF interference had been a problem for over a year and she had to move 10 patients one shift in January due to the telemetry not reading accurately. She also stated that all of the physicians had complained to the administration, and that the House Supervisors had been told to place the less critical (lower risk for poor outcomes) cardiac patients in Room #208.

All patients with a cardiac diagnosis were high risk and unpredictable with a need for accurate telemetry.

During an interview on 05/15/19 at 3:20 PM, Staff II, PCT/Telemetry Technician, stated that the portable telemetry pack interrupted the telemetry's signal anytime a patient's cell phone or patient nurse call button was too close, or when the patient moved or turned over. She added that she completed a daily report sheet for the manager that documented what rooms were affected by the RF interference and for how long.

Review of four telemetry recordings dated 04/15/19 showed the following RF interference:
- Room #349 had 10 signal interruptions and/or complete signal loss ranging from three seconds to one minute within a 29 minute time frame.
- Room #354 had 22 signal interruptions and/or complete signal loss ranging from two seconds to one minute 11 seconds within a 30 minute time frame.
- Room #355 had 29 signal interruptions and/or complete signal loss ranging from one second to three minutes within a 30 minute time frame.
- Room #360 had 25 signal interruptions and/or complete signal loss ranging from three seconds to two minutes 35 seconds within a 31 minute time frame.
- Room #362 had 15 signal interruptions and/or complete signal loss ranging from one second to three minutes within a 30 minute time frame.

Review of telemetry recordings for 11 patient rooms (449, 451, 453, 454, 455, 456, 457, 458, 459, 461 and 464) showed 106 RF interferences and/or complete signal loss for 05/09/19 from 7:18 PM through 05/10/19 at 6:09 AM (approximately 11 hours). These signal losses ranged from 30 seconds to one hour and 30 minutes in duration.

Review of facility's documents dated 05/13/19, showed that all rooms on the CCU had RF interference throughout the day. Most RF interference ranged from one to five minutes and the following times were longer:
- Room #217, RF interference, 20 minutes;
- Room #200, RF interference, 15 minutes;
- Room #215, RF interference, 15 minutes;
- Room #211, RF interference, 10 minutes;
- Room #200, RF interference, 19 minutes;
- Room #208, RF interference, four hours;
- Room #217, RF interference, one hour;
- Room #218, RF interference, 18 minutes; and
- Room #208, RF interference, 14 minutes.

Observation on 05/16/19 from 11:45 AM to 12:00 PM showed rooms on 4 West had the following telemetry monitor alert with "No RF Signal":
- Room 454 had 13 alerts;
- Room 456 had five alerts;
- Room 458 had three alerts; and
- Room 460 had three alerts.

During an interview on 05/16/19 at 12:00 PM, Staff MM, Unit Secretary, stated that:
- The unit had issues with the "No RF Signal" since approximately 10:00 AM, when the system starting displaying the alert.
- There was no predictability with the RF interference, and for the most part, it occurred daily.
- She was to log daily on a flowsheet, the date, time and duration when the "No RF Signal" displayed on the telemetry monitor.

Observation on 05/16/19 from 12:15 PM to 12:30 PM showed the rooms on 3 West had the following telemetry monitor alert with "No RF Signal":
- Room 361 had two alerts;
- Room 362 had 26 alerts; and
- Room 363 had three alerts.

During an interview on 05/16/19 at 12:15 PM, Staff NN, Unit Secretary, stated that:
- From approximately 10:30 AM to 11:00 AM, the "No RF Signal" began to alert (highlighted bar noted on the telemetry monitor), and had frequent alerts since that time.
- Staff were to log the RF interference occurrences daily.
- When the telemetry monitor showed a low or high heart rate, the actual heart rate might not be what was recorded on the telemetry monitor because of the RF interference.
- When the telemetry monitor recorded low or high heart rates, staff would go to the patient's room to confirm if the heart rate was what showed on the telemetry monitor.
- There was no consistency as to when or why the RF interference occurred.

Review of Patient #42's medical record showed:
- The patient was admitted on 05/12/19 at 12:18 PM, to room 454 on the Medical-Surgical Unit, for complaints of suicidal ideation (thoughts of harming self), unwitnessed ingestion (to eat or drink something that can harm the body) of possibly 20 razor blades and vomiting blood.
- The patient's admission orders showed that the patient was admitted from the ED for inpatient care to the Medical-Surgical Unit with telemetry monitoring.
- The patient's telemetry recordings dated 05/16/19 from 10:27 AM to 11:58 AM, showed RF interference for a total of approximately 22 minutes.

Review of Patient #43's medical record showed:
- The patient was admitted to on 05/15/19 at 1:20 PM, to room 362 in the CCU with complaints of CHF and hypoxia (not enough oxygen reaching the cells and tissues in the body).
- The patient's admission orders showed that the patient was admitted from the ED to the Critical Care Unit with telemetry monitoring for CHF and hypoxia.
- The patient's telemetry recordings dated 05/16/19 from 10:26 AM to 12:20 PM, showed RF interference for a total of approximately 31 minutes.

Review of Patient #44's medical record showed:
- The patient was admitted on 05/15/19 at 8:21 PM, to room 458 on the Medical-Surgical Unit for complaints of hypokalemia (low levels of potassium, which can affect the heart rhythm).
- The patient's admission orders showed that the patient was admitted from the ED to the Medical-Surgical Unit with telemetry monitoring.
- The patient's telemetry recordings dated 05/16/19 from 10:26 AM to 11:25 AM, showed RF interference for a total of approximately six minutes.

The telemetry company made recommendations for the facility to reach out to a third party that specialized in the RF troubleshooting as they were unable to locate the source. This recommendation was noted on 01/2019. Current RF interference occurred on multiple units in multiple patient rooms as observed by the survey team. The lack of immediacy to find a solution placed all patients on telemetry at an increased risk for their health and safety and even possible death.

3. Observation on 05/13/19 at 2:13 PM with concurrent interview, showed that the facility's ED was currently undergoing renovations to ED rooms. Staff S, RN, Unit Manager, stated that the renovations started 05/13/19 .

Observation on 05/14/19 at 10:12 AM, showed that the patient rooms on the south side of the ED did not have an assigned staff responsible for monitoring the telemetry monitor. The telemetry monitor screen was located in the hallway across from the south side ED nurses' station and displayed four patients on telemetry, however, no staff monitored the telemetry monitor.

During an interview on 05/14/19 at 10:12 AM, Staff S, RN, Unit Manager, stated that:
- She verified and acknowledged that the south side ED did not have assigned staff responsible for monitoring the four current patients on telemetry.
- The telemetry monitor alarms were on, but staff would probably not be able to hear the alarm if it sounded, if staff were not in close proximity of the monitor.
- She acknowledged that if a patient went into a lethal heart rhythm (arrhythmia, abnormal heart rhythm that can result in death) staff might not be aware of the arrhythmia for several seconds since no staff were assigned or responsible to monitor the four patients currently on telemetry.
- Normally the south side ED was connected to the central telemetry monitoring system located on the north side ED but the central telemetry monitoring system was not able to monitor the south side since the start of renovations that started 05/13/19.
- The south side ED was without an assigned staff responsible to monitor patients on telemetry for approximately 24 hours (from 05/13/19 at 8:00 AM to 05/14/19 at 10:12 AM).
- The facility discussed a plan for the telemetry monitoring, but staff did not strategically plan or put into place measures to monitor the telemetry patients on the south side during renovations.

Review of medical records showed the following patients admitted to the south side ED without an assigned staff responsible for monitoring their telemetry:
- Patient #36 was in the ED from 05/14/19 at 12:27 AM until 05/14/19 at 6:28 AM (approximately six hours), and was placed in a room on the south side ED and on telemetry. The patient's VS were: B/P - 179/91 (normal range between 90/60 and 120/80), Pulse - 115 (heart rate, normal range between 60 to 100 beats per minute) and Temperature - 103.1° (normal range between 97° and 99°). Laboratory testing showed that the patient's Lactic Acid (a chemical seen with severe infection [sepsis, a life-threatening condition when the body's response to infection injures its own tissues/organs] or shock [critical condition brought on by a sudden drop in blood and oxygen flow throughout the body], high levels can cause life-threatening conditions) returned with a critical level of 4.3, and the patient was admitted to the Intensive Care Unit (ICU, a unit where the more critically ill patients are cared for), with continued telemetry, in serious condition.
- Patient #13 was in the ED from 05/13/19 at 3:03 PM until 05/13/19 at 8:11 PM (approximately five hours), and was placed in a room on the south side ED with telemetry monitoring. Magnetic resonance imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) of the head showed that the patient had an acute stroke, and the patient was admitted for his diagnosis of stroke, with continued telemetry monitoring.
- Patient #32 was in the ED from 05/13/19 at 5:28 PM until 05/13/19 at 10:53 PM (approximately five hours) and was placed in a room on the south side ED with telemetry monitoring. The patient scored a two on the National Institutes of Health Stroke Scale (NIHSS, clinical tool used to assess and evaluate the neurological status in a stroke patient and used to measure the severity of the stroke) which indicated he had suffered a minor stroke, and was admitted for inpatient care for further evaluation.
- Patient #30 was in the ED from 05/13/19 at 4:07 PM until 05/13/19 at 9:51 PM (approximately five hours), and was placed in a room on the south side ED with telemetry monitoring for chest pain. The patient was discharged home after a cardiac workup (diagnostic tests to determine is the patient is having a heart attack).
- Patient #33 was in the ED from 05/13/19 at 7:33 PM until 05/13/19 at 9:16 PM (approximately an hour and a half), and was placed on the south side ED with telemetry monitoring for chest pain. The patient was discharged home after a cardiac workup.
- Patient #34 was in the ED from 05/13/19 at 7:38 PM until 05/14/19 at 1:17 AM (approximately five hours), and was placed in a room on the south side ED with telemetry monitoring. The patient's electrocardiogram (EKG, test that checks for problems with the electrical activity of your heart) showed showed sinus tachycardia with a rate of 114, and the patient's potassium (a mineral and electrolyte that helps your muscles work that includes the muscles that control your heartbeat and breathing) level returned at a critical level of 2.9. The patient was discharged home after examination and treatment with potassium administration.
- Patient #37 was in the ED from 05/14/19 at 7:59 AM until 05/14/19 at 2:00 PM (approximately six hours), and was placed in a room on the south side with telemetry monitoring due to uncontrolled bleeding from a post-surgical finger amputation (removal of). The patient's EKG showed A-fib with a rate of 131. After treatment for the bleeding, the patient was discharged home.
- Patient #38 was in the ED from 05/14/19 at 8:51 AM until 05/14/19 at 11:44 AM (approximately three hours), and was placed in a room on the south side ED with telemetry monitoring for shortness of breath. After examination and treatment, the patient was discharged home.
- Patient #39 was in the ED from 05/14/19 at 9:47 AM until 05/14/19 at 2:00 PM (approximately four hours), and was placed in a room on the south side ED with telemetry monitoring for abdominal pain, headache, nausea, fatigue (extremely tired) and shortness of breath. The patient was discharged home after diagnostic testing, examination and treatment.

Facility staff failed to:
- Strategically plan and/or put into place measures to monitor the telemetry monitor when patients were placed on telemetry on the south side ED when telemetry was not available on the central monitoring system on the north side ED during renovations.
- Ensure staff were assigned and responsible to monitor patients placed on telemetry on the south side ED when the south side telemetry was not available on the central monitoring system on the north side ED during renovations.
- Recognize that all patients placed on telemetry on the south side ED were at increased risk for harm including death when staff were not assigned or responsible to monitor patients on telemetry during renovations.

4. Review of the facility document titled, "Job Description," revised 07/2017 showed that the ED RN was directly responsible and accountable for the care given to his/her patients in the ED. He/she was to communicate with the physician about the changes in the patient's clinical condition including results of the diagnostic studies and patient symptoms.

Review of Patient #22's medical record showed the following:
- The patient was a 43 year old male who presented to the ED on 03/09/19 at 8:46 PM for a chief complaint of chest tightness and abdominal fullness.
- At 8:52 PM an EKG was ordered by Staff VV, ED physician (per protocol) and performed by Staff EE, RN.
- At 8:56 PM, a cardiac monitor was ordered (per protocol) by Staff VV.
- At 8:59 PM, the patient was taken directly into a room, and Staff EE, RN documented that the EKG report was placed on top of the linen, as the physician was not at the desk or available to hand deliver the EKG to at that time.
- The EKG printed report dated 03/09/19 at 8:56 PM, showed an abnormal heart rhythm and that the patient had a heart rate of 70 beats per minute, was in a sinus rhythm (any cardiac rhythm that begins at the sinus node [the heart's natural pacemaker] it is sufficient but not necessary for electrical activity to flow within the heart), had multiple ventricular premature complexes (extra heartbeats that disrupt our regular heart rhythm) a inferoposterior infarct (tissue death due to inadequate blood supply located to the lower portion and backside of the heart muscle) and an anterolateral infarct, acute (infarct of the front and side surfaces of the heart).
- At 9:30 PM, the patient was placed on the telemetry monitor.
- At 9:50 PM, nursing documentation showed the patient was upright in bed, took oral medications without difficulty and intravenous (IV, in the vein) medications were administered. The patient's family was at the bedside.
- At 10:25 PM, the patient's spouse notified nursing that she was unable to get patient to respond. The nurse checked on the patient and notified the physician.
- At 10:30 PM, a code blue was called and resuscitative measures were initiated.
-Staff VV, ED physician documented that the EKG was handed to him and interpreted at approximately 10:35 PM, during the code blue.
- The patient was pronounced dead at 11:09 PM.

Patient #22 wasn't placed on a telemetry monitor until 44 minutes after he had presented to the ED with chest tightness. Staff EE, RN performed the EKG at 8:52 PM which showed the patient was having an MI. Staff EE failed to follow protocol and hand deliver the critical EKG result to the physician. The physician was not aware of the patient's condition until he reviewed the EKG report during the code blue.

During an interview on 05/15/19 at 9:23 AM, Staff S, RN Unit Manager, stated that Staff EE, RN had used her walkie talkie and relayed the EKG results to the primary care nurse and the physician but didn't realize it wasn't functioning so neither the primary care nurse or the physician received the messaged. Staff S stated that it was department protocol and the expectation for the nurse to hand deliver a critical diagnostic test such as the EKG or a critical lab result to the physician and make sure they were aware of the patient's condition immediately.

During a telephone interview on 05/22/19 Staff VV, ED physician, stated that patients who presented to the ED with any type of chest pain were automatically placed on the telemetry monitors per protocol, and the nursing staff did not need to wait for an order to do this. He stated that the first time he saw Patient #22 was when he was called to the patient's room when the code blue was called. He stated that after the Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professional when a patient's heartbeat or breathing stops) had begun, he asked to see the initial EKG reading, but his assistant wasn't able to locate it and it was found lying on top of the linen hamper inside the patient's room. He stated that when he looked at the EKG printout his heart "sunk" as the patient "clearly" had a "STEMI" (ST elevation myocardial infarction, a full-blown heart attack). Staff VV stated that this patient should have been recognized as a high risk for a STEMI based on his age, presenting symptoms and ethnicity (patient was African American).

Staff EE, RN failed to place Patient #22 on the telemetry monitor upon his arrival to the ED with the chief complaint of chest tightness. She also failed to follow department protocol and hand deliver the critical EKG report to the physician. These failures had a direct impact on Patient #22's fatal outcome.

5. Review of the facility's policy titled, "Patient Fall Prevention," dated 12/27/18, showed that a fall is defined as any unintentional and unanticipated downward displacement to the floor or any other lower surface. Fall precautions and interventions included the following directives for staff:
- Use bed/chair alarms;
- Stay with the patient (at arm's reach) when patient is toileting, showering or ambulating;
- Keep top two side rails up;
- Consider placing in room within sight of nursing station;
- Encourage the patient to call for assistance;
- Consider fall monitoring;
- Hourly rounding; and
- Fasten the gait belt around the patient when transferring, out of bed, or ambulating.
Post fall management included the following directions for staff:
- Assess for injury to include vital signs and neurological assessment (exam that focuses on brain function and nerves, for example, mental status, speech, vision, reflexes, coordination, gait and sensation, ability to feel things);
- Document circumstances of fall, post fall assessment and patient outcome in the medical record;
- Complete the post-fall huddle form;
- Complete an Event Report;
- Notify the physician; and
- Notify the family.

Review of discharged Patient #60's medical record showed that she was transferred from a nearby facility as a direct admit to the facility's CCU for a higher level of care on 03/13/19 at 10:33 PM with complaints of elevated Troponin (a blood test used to detect heart attack and/or injury) and hyperglycemia (high blood sugar).

Review of the patient's H&P dated 03/13/19 showed that the patient reported shortness of air, nausea, weakness with fatigue and that she had fallen earlier in the day. The patient has suffered two strokes that resulted in expressive aphasia (difficulty in expressing one's thoughts with words) and Maoyamoya disease (blocked arteries in the brain).

Review of the patient's CCU Admission Assessment dated 03/13/19 at 10:35 PM showed that:
- The

Based on observation, interview, record review and policy review the facility failed to:
- Document the consumption of an ordered nutritional supplement (a product, usually a liquid, taken orally which is intended to provide extra nutrients) for four patients (#54, #68, #79 and #80) of six patients reviewed with orders for supplements.
- Assess the weight of two patients (#54 and #81) even though these patients were identified as having a poor appetite with probable protein malnutrition (lack of proper nutrition, caused by not enough to eat or by not eating the right things) or/and at high risk for non-healing of five patients reviewed for weights.
- Document the consumption of meals for two patients (#54 and #81) of five patients reviewed.
These failures had the potential to affect all patients admitted allowing patients to potentially lose weight and/or not receive the proper nutrition for the healing process. The facility census was 74.

Findings included:

1. Review of the facility's undated policy titled, "Wound Assessment and Documentation," showed the following:
- Assess the nutritional status for wound healing.
- Dietary consult if the patient has a wound.
- Encourage a high protein diet.
- Consider supplements and monitor labs (albumin, measurement in the blood that can indicate malnutrition).

Review of Patient #54's History and Physical (H&P, a document in a patient's medical record that contains the physician's initial assessment and treatment plan) dated 05/24/19 showed the following:
- The patient was admitted to 3 West on that date with diagnoses of diabetes (a disease when the body cannot rid itself of excess glucose/sugar in the blood and requires insulin [hormone]), and infection in the bone of her right foot.
- The patient reported severe weakness and a poor appetite.
- The patient's albumin level was low at 1.9 (normal = 3.4-5.0).
- The patient's total protein (a test that measures two protein levels in the blood, albumin and globulin) level was low at 6.3 (normal = 6.4-8.2).

Review of the patient's orders dated 05/24/19, showed a nutritional shake supplement twice daily.

Review of a consult dated 05/24/19, showed the following:
- The patient had a pressure injury (injury to the skin and/or underlying tissue, usually over a bony area) on her sacrum (triangular shaped bone which lies above the tailbone) and a deep tissue injury (intact or non-intact skin with localized area of discoloration that can be red, maroon, or purple in color that does not go away when pressure is applied. Skin in this area may feel soft, firm or mushy and underlying damage is usually present) on her left heel (wounds typically require increased protein in order for healing to occur). The consult showed concern for progression to further tissue loss/death.
- The patient suffered from moderate protein-calorie malnutrition (lack of proper nutrition specific to lack of protein and calories in the diet).
- A nutritional assessment and replenishment would be essential to wound healing and management of the diabetes.

Review of a nutritional assessment dated 05/25/19, showed the following:
- The patient had uncontrolled diabetes and increased nutrient needs related to skin compromise.
- The patient had upper body wasting, and the dietitian was in agreement with malnutrition.
- The patient was a high nutritional risk.
- The dietitian recommended meals, snacks and a nutritional shake supplement twice daily.
- Goals included 75% or better intake of meals, and 100% intake of the protein foods.

Even though requested, the facility failed to provide a policy regarding patient weights.

Review of the patient's nursing admission assessment dated 05/24/19, showed a weight of 142 (the patient was five foot nine inches tall). As of 05/30/19 at 8:40 AM, there were no further weights documented.

Even though requested, the facility failed to provide a policy regarding monitor/documentation of meal intake.

Review of the patient's meal intake from 05/24/19 through 05/30/19 showed only one meal documented (breakfast on 05/26/19). Staff failed to monitor/document the patient's meal consumption.

Even though requested, the facility failed to provide a policy regarding monitor/documentation of nutritional shake supplements.

Review of the patient's fluid intake documentation did not show any record for the amount of nutritional shake supplements that the patient drank throughout her admission.

Observation and concurrent interview on 05/29/19 at 2:47 PM, showed the patient was thin and weak. The patient said her appetite was "okay."

Review of Patient #68's H&P dated 05/22/19 showed that she was admitted to 4 West on 05/21/19 with diagnosis of pneumonia, decreased appetite and skin breakdown. The patient's admission albumin level was low at 2.7.

Review of the patient's orders showed for a nutritional shake supplement twice daily. A nutritional reassessment was completed on 05/28/19 and the nutritional shake supplement was increased to three times a day.

Review of the patient's fluid intake documentation did not show any record for the amount of nutritional shake supplements that the patient drank throughout her admission.

Review of Patient #79's H&P dated 05/19/19 showed the following:
- The patient was admitted to 4 West on that date with diagnosis of generalized weakness and urinary tract infection.
- The patient's albumin level was low at 2.3.
- The patient's total protein was low at 5.9.

Review of the patient's orders showed for a nutritional shake supplement at dinner time.

Review of the patient's fluid intake documentation did not show any record for the amount of nutritional shake supplements that the patient drank throughout his admission.

Review of Patient #80's H&P dated 05/28/19 showed the following:
-The patient was admitted to 4 West on that date with diagnosis of altered mental status, fever and severe protein-calorie malnutrition.
-The patient's total albumin level was low at 2.1.
-The patient's total protein level was low at 5.7.

Review of a nutritional consult dated 05/29/19 showed that the reason for the consult was due to wound on left buttocks and that the patient had little to no oral intake over the past two days. A nutritional shake supplement was ordered for all meals as a result of this consult.

Review of the patient's fluid intake documentation did not show any record for the amount of nutritional shake supplements.

Review of Patient #81's H&P dated 05/20/19 showed the following:
- The patient was admitted to 4 East with diagnoses of diabetes, renal failure and a non-healing wound that led to a toe amputation.
- The patient's albumin level was low at 2.2.
- The ordered patient's diet was a regular diet.

Review of the patient's Dietary Consult dated 05/21/19 at 1:00 PM showed the following:
- Renal diet appropriate due to abnormal renal labs.
- Continue to trend weights and intake due to these were highly variable.
- Add protein supplement when intake was less than 75% of his meals.
- Patient was a risk for low nutrition.

Review of the patient's medical record dated 05/30/19 showed the following:
- The staff failed to change the patient's diet to renal from regular diet.
- On 05/25/19, no intake for patient recorded.
- On 05/26/19, no intake or output recorded.
- The staff failed to follow weights and trend.

During an interview on 05/30/19 at 10:55 AM, Staff VVV, Dietitian, stated that since her note on 05/21/19, the only weights taken were on 05/25/19, 05/28/19 and 05/29/19.

These failures had the potential to have a detrimental effect on the patient's healing process and place all patients admitted to the facility at an increased risk of nutritional deficits.



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Based on interview, record review and policy review the facility failed to:
- Update the care plan for one discharged patient (#74) after an injurious fall, with interventions to prevent further falls, out of 10 care plans reviewed.
-Initiate fall interventions/precautions for one discharged patient (#60) that staff assessed at high risk for falls when the patient experienced a fall approximately 15 hours after being admitted to the facility.
-Initiate fall interventions/precautions for one current patient (#75) that was at high risk for falls.

This failure had the potential to affect all patients by not communicating current, applicable needs of their patients via the care plan interventions and goals. The facility census was 74.

Findings included:

1. Review of the facility's policy titled, "Plan of Care," revised 01/01/17 showed the following:
- A plan of care must be developed after the initial assessment of the patient, in order to address the comprehensive, holistic needs of the patient, in order to facilitate healing, comfort and safety.
- Each care plan problem must have a measurable goal and interventions should be realistic and specific.
- Evaluate and re-evaluate the care plan at each visit.

Review of the facility's policy titled, "Patient Assessment (Nursing)," revised 01/16/17, showed care plans will be modified to reflect current assessment and patient needs.

Review of the facility's policy titled, "Patient Fall Prevention," revised 12/27/18, showed:
- Care plan interventions will be planned, implemented and documented according to each patient's risk for falls and their individual needs.
- Revise and update the care plan if a patient's fall risk changes during hospitalization.
- After a fall, complete a post-fall huddle (an investigative tool) form, and modify/individualize the care plan as the patient conditions warrants.

Review of current Patient #75's medical record dated 05/24/19 at 4:13 PM, showed that the patient was a 71 year old female with congestive heart failure (CHF, where the heart muscle doesn't pump blood as well as it should), dementia, shortness of breath, weak, fatigue, poor appetite, nausea, light headed, dizziness and the patient was a high risk for falls with a score of "60."

Review of the patient's care plan in the medical record dated 05/29/19, showed that since the patient's admission on 05/24/19, the patient's fall intervention care plan was inactive.

Review of discharged Patient #74's History and Physical (H&P, a document in a patient's medical record that contains the physician's initial assessment and treatment plan) dated 04/17/19, showed the following:
- The patient was admitted on that date with diagnoses of diabetes (a disease when the body cannot rid itself of excess glucose/sugar in the blood and requires insulin [hormone] to control; uncontrolled diabetes may cause a disease of the blood vessels which can damage the kidneys, eyes, heart, and nerves) and related non-healing left foot ulcer and bone infection. The patient was noncompliant with her diabetic healthcare.
- The patient suffered from numbness and tingling related to her diabetes (can create instability while walking/standing).
- The patient also suffered from swelling of the left foot (can create instability while walking/standing).

Review of the patient's Discharge Summary (a document in a patient's record that contains the overall care while an inpatient and discharge plan) dated 04/24/19, showed she was discharged on that date after having a below knee amputation (BKA, loss of a limb portion can create instability and/or imbalances) on the left on 04/18/19, increasing risk for falls.

Review of the patient's fall risk assessment dated 04/21/19, at 8:00 AM showed a score of "70."

Review of a physician's progress note dated 04/21/19, showed the patient lost her balance and sustained a fall to the ground, suffering a small abrasion to her upper lip.

Review of the patient's fall risk assessment dated 04/21/19, after the fall, showed a score of "90."

Review of the patient's care plan initiated on 04/17/19, showed the following:
- The patient was a high fall risk.
- Staff should provide toileting.
- A post fall assessment should be done immediately after a fall.

During an interview on 05/29/19 at 3:10 PM, Staff HH, Registered Nurse (RN) 3 West Interim Manager, stated that there were no evident changes in the patient's care plan, after the fall on 04/21/19, to prevent further falls.

During an interview on 05/30/19 at 10:43 AM, Staff HH stated that care plan update information should come from the supervisor after the post-fall huddle form was completed. The RN responsible for the patient was ultimately responsible for assessment and review of the care plan for intervention additions.

Review of discharged Patient #60's medical record showed that she was transferred from a nearby facility as a direct admit to the facility's Cardiac Care Unit (CCU) for a higher level of care on 03/13/19 at 10:33 PM with complaints of elevated Troponin (a blood test used to detect heart attack and/or injury) and hyperglycemia (high blood sugar).

Review of the patient's H&P dated 03/13/19 showed that the patient reported shortness of air, nausea, weakness with fatigue and that she had fallen earlier in the day. The patient has suffered two strokes that resulted in expressive aphasia (difficulty in expressing one's thoughts with words) and Maoyamoya disease (blocked arteries in the brain).

Review of the patient's CCU Admission Assessment dated 03/13/19 at 10:35 PM showed that:
- The patient had a positive history for falling within the past three months (the patient had reported that she had fallen earlier that day).
- The patient was on bedrest and required assistance from staff.
- The patient required assistance from staff to complete activities of daily living (ADL, daily self-care activities, such as bathing, dressing and eating).
- The patient ambulated with an unsteady shuffling gait and required assistance from staff during transfers.
- Staff assessed the patient's risk for falling and the patient scored 80 on the fall risk tool (a total score of 45 or greater indicated the patient was at high risk for falling and staff were directed to activate the high fall risk plan of care).
- Fall precautions were put into place that included the call light was within reach of the patient.
- The patient was placed close to the nurse's station for close monitoring,

Review of the patient's Plan of Care dated 03/14/19 at 12:36 AM showed staff failed to initiate interventions that included for the top two side rails to be in the up position; bed alarm activated/on; and hourly rounding by staff to ensure the bed alarm was plugged in, on and functioning.

Review of the Post Fall Huddle Form dated 03/14/19 showed that the bed alarm had not been activated by staff.

Review of a facility report dated 03/14/19 showed that:
- The patient's bed alarm was not activated at the time of the fall.
- The patient was assessed at risk for falls and had a history for falls with a reported fall at home on 03/13/19.
- Recommendations for system improvement was made on 03/25/19 (11 days after the patient's fall) to include initiation for a new fall protocol initiative on the CCU to include hourly rounding to look specifically for bed/chair alarms and bed controls were plugged in.

During an interview on 05/29/19 at 2:40 PM, Staff A, Risk Manager, acknowledged that according to the report, the bed alarm was not turned on at the time of the patient's fall. At 3:50 PM, Staff A stated that after the patient's fall the facility did not do an Root Cause Analysis (RCA, a method of problem solving used to identify and uncover the causes of either a problem or event) of the incident.






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