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Based on policy review, medical record review, observations and staff interview, it was determined the facility failed to ensure an RN (Registered Nurse) supervised and evaluated the care, per facility policy, for four (#3, #5, #7, #8) of eight patients sampled. Refer to A395.

Based on policy review, medical record review, observations and staff interview, it was determined the facility failed to ensure an RN (Registered Nurse) supervised and evaluated the care, per facility policy, for four (#3, #5, #7, #8) of eight patients sampled.

Findings included:

Review of the facility policy, "Assessment and Reassessment," dated 12/2019 page 36 of 39, Department Assessment and Reassessment, Table Emergency Department, the policy stated:
- Begin Initial Assessment within: Upon arrival, MSE [Medical Screening Examination] or Triage.
- Complete Initial assessment within: One [1] hour.
- Document Initial Assessment and Develop Plan of Care: During care episode.
- Reassessment Frequency:
" Every 60 minutes until MSE complete, After MSE:
" Level 1/Resuscitative will be performed continuously,
" Level 2/Emergency will be performed every 60 minutes,
" Level 3/Urgent will be performed every 4 hours,
" Level 4/Less Urgent will be performed prior to disposition or every 4 hours,
" Level 5/Non Urgent will be performed prior to discharge.

Review of Patient #5's medical record revealed the patient presented to the ED (Emergency Department) on 2/09/2021 at 4:53 am. The patient was triaged at 5:00 am and had a chief complaint of nausea and vomiting for 4 days. The patient's vital signs were Blood pressure 143/82, heart rate 78, respirations 18, temperature 96.2 degrees Fahrenheit, and oxygen saturation of 100 % on 2 liters via nasal cannula. The patient's Acuity level was documented as 3/Urgent.
A detailed review of the medial record failed to show documentation of continuous cardiac monitoring. The patient's vital signs were reassessed at 10:36 am. Review of the record revealed no documentation found why facility policy for reassessment not followed and 5.36 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 3/urgent should be reassessed every 4 hours. Patient #5 should have reassessed at 09:00 AM.

A review of Patient #7's medical record revealed the patient presented to ED on 2/10/2021 at 8:30 am with complaint of headache and chest pain. Documentation revealed the patient was triaged at 8:47 am with vital signs showing Blood Pressure 129/73, Heart rate 88, Respirations 16 Temperature 36.7 degrees Celsius and oxygen saturation 96% on room air and acuity level 2/Emergent.
The patient's vital signs were reassessed at 9:28 am. Review of the record revealed the next reassessment was completed at 4:55 PM. Review of the record revealed no documentation found why facility policy for reassessment was not followed and 7 hours elapsed before the patient was reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 2/emergent should be reassessed every 60 minutes. Patient # 7 should have been reassessed at 10:28 AM, 11:28 AM, 12:28 PM, 1:28 PM, 2:28PM, 3:28 PM, and 4:28 PM.

A review of Patient #8's medical record revealed the patient presented to ED on 4/07/2021 at 5:17 PM with chief complaint of seizures. Documentation revealed the patient was triaged at 5:17 PM with vital signs documented as blood pressure 125/62, Heart rate 61, Respirations 16, Temperature 36.6 degrees Celsius, oxygen saturation 100% on room air, and acuity level 2/Emergent.
A detailed review of the record revealed the patient's vital signs were reassessed at 7:14 PM. Review of the record revealed no documentation found why facility policy for reassessment not followed and 2 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 2/emergent should be reassessed every 60 minutes. Patient # 8 should have been assessed at 6:17 PM, and 7:17 PM.

Interview with Vice President (VP) Quality & Patient Safety on 4/16/2021 at 2:00 PM confirmed the above findings.

Review of Patient #3's medical record revealed the patient presented to ED via ambulance on 3/10/2021 at 1:33 PM. The patient was triaged at 1:38 PM and had a chief complaint of shortness of breath, coughing and congestion. The patient's vital signs were blood pressure 117/44, heart rate 107, respirations 32, temperature 98.6 degrees Fahrenheit, and oxygen saturation of 78% on room air. The patient's Acuity level was documented as 2/Emergent.

Review of the record revealed at 1:45 PM the Respiratory Therapist (RT) (Staff J) completed an assessment of the patient and applied the BiPAP (Bilevel Positive Airway Pressure) to the patient. At 2:03 PM the RT (Staff J) reassessed the patient's pulse, oxygen saturation and respirations. The RN completed the initial assessment at 2:25 PM.

At 4:11 PM the RT (Staff J) approached the patient's room to reassess the patient and heard the BiPAP alarming inside the patient's room (door closed for isolation precautions). The RT (Staff J) entered the room and discovered the patient unresponsive and the BiPAP disconnected. The physician was called to the room and Code Blue initiated. The patient was resuscitated after 47 minutes, transferred to ICU (Intensive Care Unit), but expired on 3/12/2021. There was no evidence the nurse reassessed the patient after 2:25 PM. Review of the record revealed the patient was not reassessed the RN per facility policy. According to the Assessment and Reassessment policy (12/2019) a Level 2 should be reassessed every 60 minutes. Patient #3 should have been assessed no later than 3:25 pm by the RN.

An interview was conducted on 4/14/2021 at 2:45 PM with the VP of Quality & Patient Safety. The above findings were discussed and reviewed in detail and the VP of Quality & Patient Safety confirmed the findings.

Review of the facility policy, "Telemetry Monitoring," dated 2/2020 - NSH.PC.120, stated the purpose was to ensure patient safety and provide continuous cardiac monitoring and documentation guidelines for patients who have telemetry monitoring ordered. The policy stated, on page 2 of 10, POLICY (D) the RN is ultimately responsible for the interpretation of cardiac monitoring. They may delegate this task to personnel who have completed an approved Basic Arrhythmia Interpretation class and have demonstrated competency.

On page 5 of 10 of the policy it stated (Q) Areas Where Cardiac Telemetry Monitoring is Not Connected to Centralized Monitoring (i.e. ED) will (1) ensure appropriate continuous cardiac monitoring; (2) each area will ensure that arrhythmia competent staff are providing monitoring; and (3) guidelines related to protocols for cardiac monitoring, alarms, documentation, and competency of staff will be followed as per this policy.

Review of the medical record revealed at 2:25 PM the RN (Registered Nurse) conducted an initial nursing assessment. The RN noted the patient had BiPAP on and cardiac monitoring with a rhythm of ST (Sinus Tachycardia), no rate documented. This rhythm was different than the documented rhythm by the physician's interpretation of the ECG (electrocardiogram) at 1:37 PM. The physician noted the patient's rhythm was Afib (Atrial Fibrillation) with RVR (Rapid Ventricular Response) and a rate of 133.

Review of the facility policy, "Telemetry Monitoring," dated 2/2020, stated (I) rhythm strips are printed for the following events: rhythm changes and during code blue. There was no evidence the RN printed a telemetry strip of the patient's rhythm change or notified the physician of the change.

Observations and a tour were conducted in the ED on 4/14/2021 at 10:30 am. At the time of the tour there were currently four patients on continuous cardiac monitoring. There were two cardiac monitor screens observed in the nursing station. At the time of observation there was no staff member watching the monitors and the Charge Nurse (Staff G) was sitting with her back to the monitors.

An interview was conducted with the Charge Nurse (Staff G) on 4/14/2021 at 10:45 am. The Charge Nurse confirmed there was not a dedicated staff member assigned to watch the monitors. She stated the Charge Nurse sits near the monitors and listens for audible alarms at which time she or another staff member would respond. She confirmed the monitor will alarm for a cardiac arrhythmia, oxygen saturation less than 90%, and hypotension per set parameters.

Additional observations were conducted in the ED on 4/16/2021 at 9:20 am. Upon arrival to the ED there was no staff observed at the cardiac telemetry monitor area. Interview with the ED Director stated the Charge Nurse was in a patient's room. At the time of the tour there were four patients with orders for continued cardiac monitoring. Staff were observed near the monitors but there was no visual monitoring of any of the patient's on cardiac monitoring. The Charge Nurse (Staff M) returned to the monitor area approximately five minutes later and was interviewed. The Charge Nurse was asked what her responsibilities were as the Charge Nurse. She stated providing resources to ED nurses and other staff, hands on tasks to ensure proper flow, timely placement of patients, ensure physicians evaluate patients in a timely manner, and assist in the monitoring of behavioral health patients. The Charge Nurse was asked if she was responsible to monitor the cardiac monitors. She confirmed it was her responsibility and stated it was all staff's responsibility to respond to the alarms.

The facility conducted a review of the Code Blue event for Patient #3 but failed to identify the facility policy, "Telemetry Monitoring," (2/2020) was not followed for patients located in the ED. Observations and interviews confirmed the facility's ED Charge Nurse is responsible for continuous cardiac monitoring of patients in the ED. Interview confirmed the Charge Nurse has multiple tasks in the department and does not continuously view the telemetry monitors. Interview confirmed the Charge Nurse relies on audible alarms to trigger a warning for the Charge Nurse or other staff in the area to assess the reason for the alarm. This jeopardizes the safety of patients located in the ED with orders for continuous cardiac monitoring and places patients at risk of serious adverse outcomes. Interview with the ED Medical Director was conducted on 4/15/2021 at 1:05 PM and confirmed the above findings. The ED Medical Director reported that it was his expectation for the patient's cardiac rhythm to be monitored and addressed when necessary.

Based on staff interviews, policy and procedure reviews, observations and medical record reviews, the medical staff failed to ensure policies governing medical care provided in the Emergency Department (ED) were followed for continuous cardiac telemetry monitoring. The facility failed to ensure the provision of services, equipment, personnel and resources to ED patients was provided timely to protect the health and safety of all patients located in the hospital's ED. Refer to A1104.

There was ongoing failure to follow physicians' orders for continuous cardiac telemetry monitoring. The facility failed to ensure patients at risk of cardiac decompensation were continuously monitored to ensure no delay in treatment or possible death. These systemic failures constituted an Immediate Jeopardy (IJ) situation, which has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient.

On 4/16/2021 at 3:35 p.m., the Vice President of Quality & Patient Safety and the Risk Coordinator were informed of the ongoing IJ situation which began on 3/10/2021. The cumulative deficits placed the patient's safety at risk for not providing timely treatment which resulted in the Condition of Participation being out of compliance.

Based on policy review, medical record review, observations and staff interview, it was determined the medical staff failed to ensure policies governing medical care provided in the Emergency Department (ED) were followed for continuous cardiac telemetry monitoring. The facility failed to ensure the provision of services, equipment, personnel and resources to ED patients was provided timely to protect the health and safety of all patients located in the hospital's ED for one (#3) of eight sampled patients. The facility failed to ensure policies governing medical care provided in the ED were followed for reassessment for four (#3, #5, #7, #8) of eight patients sampled.

Findings included:

Review of the medical record for patient #3 revealed on 3/10/2021 a 69-year-old female with a recent diagnosis of COVID-19 presented to the facility ED at 1:33 PM via ambulance with complaints of shortness of breath, coughing and congestion. The patient's vital signs at the time of arrival were oxygen saturation of 78%, blood pressure of 117/44, respirations of 32 per minute, and heart rate of 107 beats per minute (bpm).

Review of the physician's evaluation, dated 3/10/2021 at 1:37 PM, revealed the patient's shortness of breath was worse on exertion and she had chest tightness. Physician documentation revealed EMS (Emergency Medical Services) personnel found the patient with oxygen saturation in the 40's which improved to the 70's with oxygen via face mask. EMS personnel noted the patient had one syncopal episode in route to the ED.

The physician reviewed the ECG (Electrocardiogram) and noted the patient's rhythm was Afib (Atrial Fibrillation) with RVR (Rapid Ventricular Response) and a rate of 133. The physician ordered continuous cardiac monitoring at 1:41 PM.

Review of the facility policy, "Telemetry Monitoring (02/2020)," NSH.PC.120, stated the purpose was to ensure patient safety and provide continuous cardiac monitoring and documentation guidelines for patients who have telemetry monitoring ordered. The policy stated, on page 5 of 10, (Q) areas where cardiac telemetry monitoring is not connected to centralized monitoring (i.e. ED) will (1) ensure appropriate continuous cardiac monitoring; (2) each area will ensure that arrhythmia competent staff are providing monitoring; and (3) guidelines related to protocols for cardiac monitoring, alarms, documentation, and competency of staff will be followed as per this policy.

Review of the medical record revealed at 1:45 PM on 3/10/2021 the RT (Respiratory Therapist) (Staff J) conducted an initial assessment of the patient and placed the patient on BiPAP (Bilevel Positive Airway Pressure). BiPAP is a treatment that uses air pressure to keep airways open. The RT (Staff J) documented the patient's pulse as 104 bpm, oxygen saturation of 94% on BiPAP, and respiratory rate 49 breaths per minute. At 2:03 PM the RT (Staff J) reassessed the patient and noted the patient's pulse as 107 bpm, oxygen saturation of 94%, and respiratory rate 53 breaths per minute.

RN (Registered Nurse) documentation at 2:25 PM on 3/10/2021 revealed an initial nursing assessment was performed. The RN noted the patient had BiPAP on and cardiac monitoring with a rhythm of ST (Sinus Tachycardia), no rate documented.

Review of the physician's re-evaluation, no time noted, revealed the patient was placed on a trial of BiPAP, received albuterol treatment and steroids. Her respiratory status improved significantly, and the patient stated she felt better and would like to continue the mask, refusing endotracheal intubation. Her respiratory rate and work of breathing had improved while on BiPAP.

Review of the medical record revealed a Code Blue was initiated on 3/10/2021 at 4:11 PM. Review of the physician's re-evaluation note revealed while the patient was waiting for admission, the RT (Staff J) notified the physician the patient was found unresponsive and disconnected from the BiPAP. The physician documented ACLS (Advanced Cardiac Life Support) resuscitation was initiated, the patient was in PEA (Pulseless Electrical Activity), then VFib (Ventricular Fibrillation), she received medications to aid in resuscitation, and was intubated endotracheally. The patient had ROSC (Return of Spontaneous Circulation) as a result of the treatment and transferred to ICU (Intensive Care Unit).

Review of the medical record for telemetry monitoring revealed no evidence a telemetry strip was in the medical record and the staff could not present one. Review of the facility policy, "Telemetry Monitoring," (02/2020) stated (I) rhythm strips are printed for the following events: rhythm changes and during code blue; (L) in the event that a Code Blue is called on a monitored patient, the monitor technician will print telemetry rhythm to capture pre-code, during code, and post code events. The policy further states (II)(B) personnel in the role of monitor technicians will be responsible for monitoring cardiac telemetry, running documentation strips, and communicating to the nurse changes in the patient's rhythm.

Review of the medical record revealed a note by the RT (Staff J) which was documented on 3/10/2021 at 5:25 PM (post event). The RT note stated upon nearing the patient's room the BiPAP alarm could be heard alarming in the room (door was closed for isolation precautions). Upon entering the room, the BiPAP circuit was disconnected from the patient's mask. The circuit was immediately reconnected, the RT (Staff J) performed a sternal rub on the patient and verbally called the patient with no response. The RT (Staff J) noted the patient's heart rate on the monitor was in the 50's and immediately alerted the physician and resuscitation efforts began.

An interview was conducted on 4/14/2021 at 3:00 PM with the Charge Nurse (Staff E) for the day of the event. It was confirmed the Charge Nurse is responsible for monitoring the cardiac telemetry monitors of the patients in the ED. The Charge Nurse (Staff E) was asked if patient #3 had any changes in cardiac rhythm, rate or oxygen saturation while she was monitoring the patient on 3/10/2021. She stated there were no changes and there were no alarms on the telemetry monitor prior to the event.

An interview was conducted with the ED Medical Director (Staff I) (who was also the physician that provided care to patient #3 on 3/10/2021) on 4/15/2021 at 1:05 PM. The physician stated the patient's condition had improved and she responded well to the BiPAP, respiratory treatments, and steroids. The physician was asked to describe the current practice in the ED for when a patient is ordered continuous cardiac monitoring. He stated the cardiac monitors are located in the nursing station and clinical staff have access to view them. He stated the Charge Nurse monitors the cardiac monitors and alerts staff to alarms. The physician confirmed he was aware the Charge Nurse has other responsibilities and is not continuously watching the monitors. The physician confirmed this posed a risk in timely identifying a patient that is decompensating.

Observations and a tour were conducted in the ED on 4/14/2021 at 10:30 am. At the time of the tour there were currently four patients on continuous cardiac monitoring. There were two cardiac monitor screens observed in the nursing station. At the time of observation there was no staff member watching the monitors and the Charge Nurse was sitting with her back to the monitors. An interview was conducted with the Charge Nurse (Staff G) on 4/14/2021 at 10:45 am. The Charge Nurse confirmed there was not a dedicated staff member assigned to watch the monitors. She stated the Charge Nurse sits near the monitors and listens for audible alarms at which time she or another staff member would respond. She confirmed the monitor will alarm for a cardiac arrhythmia, oxygen saturation less than 90%, and hypotension per set parameters.

Additional observations were conducted in the ED on 4/16/2021 at 9:20 am. Upon arrival to the ED there was no staff observed at the cardiac telemetry monitor area. Interview with the ED Director (Staff E) stated the Charge Nurse was in a patient's room. At the time of the tour there were four patients with orders for continued cardiac monitoring. Staff were observed near the monitors but there was no visual monitoring of any of the patient's on cardiac monitoring. The Charge Nurse returned to the monitor area approximately five minutes later and was interviewed. The Charge Nurse (Staff M) was asked what her responsibilities were as the Charge Nurse. She stated providing resources to ED nurses and other staff, hands on tasks to ensure proper flow, timely placement of patients, ensure physicians evaluate patients in a timely manner, and assist in the monitoring of behavioral health patients. The Charge Nurse was asked if she was responsible to monitor the cardiac monitors. She confirmed it was her responsibility and stated it was all staff's responsibility to respond to the alarms.

The facility conducted a RCA (Root Cause Analysis) of the event but failed to identify the facility policy, "Telemetry Monitoring," was not followed for patients located in the ED. Observation conducted on 4/14/20 at 10:30 am, 4/16/2021 at 9:20 am, and interviews conducted on 4/14/21 at 10:45 am, 4/14/2021 at 3:00 pm, 4/16/2021 at 9:20 am confirmed the facility's ED Charge Nurse is responsible for continuous cardiac monitoring of patients in the ED. Interviews on 4/14/2021 at 10:45 am and 4/16/2021 at 9:20 am confirmed the Charge Nurse has multiple tasks in the department and does not continuously view the telemetry monitors. Interviews on 4/14/2021 at 10:45 am and 4/16/2021 at 9:20 am confirmed the Charge Nurse relies on audible alarms to trigger a warning for the Charge Nurse or other staff in the area to assess the reason for the alarm. This jeopardizes the safety of patients located in the ED with orders for continuous cardiac monitoring and places patients at risk of serious adverse outcomes. Despite aggressive treatment for patient #3 the patient expired on 3/12/2021.


Review of the facility policy, "Assessment and Reassessment (12/2019)," ##NSH.PC.009 page 36 of 39, Department Assessment and Reassessment, Table Emergency Department stated:
- Begin Initial Assessment within: Upon arrival, MSE [Medical Screening Examination] or Triage.
- Complete Initial assessment within: One [1] hour.
- Document Initial Assessment and Develop Plan of Care: During care episode.
- Reassessment Frequency:
" Every 60 minutes until MSE complete, After MSE:
" Level 1/Resuscitative will be performed continuously,
" Level 2/Emergency will be performed every 60 minutes,
" Level 3/Urgent will be performed every 4 hours,
" Level 4/Less Urgent will be performed prior to disposition or every 4 hours,
" Level 5/Non-Urgent will be performed prior to discharge.

Review of patient #3's medical record revealed the patient presented to ED on 3/10/2021 at 1:33 PM. The patient was triaged at 1:38 PM and had a chief complaint of shortness of breath, coughing and congestion. The patient's vital signs were Blood pressure 117/44, heart rate 107, respirations 32, temperature 98.6 degrees Fahrenheit, and oxygen saturation of 78% on room air. The patient's Acuity level was documented as 2/Emergent.

Review of the record revealed the RN reassessed the patient at 2:25 PM. The patient's pulse, oxygen saturation and respirations were reassessed by the RT (Staff J) at 1:45 PM and 2:03 PM. The RT (Staff J) discovered the patient unresponsive at 4:11 PM. There was no evidence the nurse reassessed the patient after 2:25 PM. Review of the record revealed the patient was not reassessed timely and per facility, "Assessment and Reassessment," policy.

Review of the facility policy, "Telemetry Monitoring (02/2020)," NSH.PC.120, stated the purpose was to ensure patient safety and provide continuous cardiac monitoring and documentation guidelines for patients who have telemetry monitoring ordered. The policy stated, on page 2 of 10, POLICY (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; (D) the RN is ultimately responsible for the interpretation of cardiac monitoring. They may delegate this task to personnel who have completed an approved Basic Arrhythmia Interpretation class and have demonstrated competency.

Review of patient #5's medical record revealed the patient presented to ED on 2/09/2021 at 4:53 am. The patient was triaged at 5:00 am and had a chief complaint of nausea and vomiting for 4 days. The patient's vital signs were Blood pressure 143/82, heart rate 78, respirations 18, temperature 96.2 degrees Fahrenheit, and oxygen saturation of 100 % on 2 liters via nasal cannula. The patient's Acuity level was documented as 3/Urgent.
A detailed review of the medial record failed to show documentation of continuous cardiac monitoring. The patient's vital signs were reassessed at 10:36 am. Review of the record revealed no documentation found why facility policy for reassessment not followed and 5.36 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 3/urgent should be reassessed every 4 hours. Patient #5 should have reassed at 09:00 AM.

A review of patient #7's medical record revealed the patient presented to ED on 2/10/2021 at 8:30 am with complaint of headache and chest pain. Documentation revealed the patient was triaged at 8:47 am with vital signs showing Blood Pressure 129/73, Heart rate 88, Respirations 16 Temperature 36.7 degrees Celsius and oxygen saturation 96% on room air and acuity level 2/Emergent.
The patient's vital signs were reassessed at 9:28 am. Review of the record revealed the next reassessment was completed at 4:55 PM. Review of the record revealed no documentation found why facility policy for reassessment not followed and 7 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 2/emergent should be reassessed every 60 minutes. Patient # 7 should have been reassed at 10:28 AM, 11:28 AM, 12:28 PM, 1:28 PM, 2:28PM, 3:28 PM, and 4:28 PM

A review of patient #8's medical record revealed the patient presented to ED on 4/07/2021 at 5:17 PM with chief complaint of seizures. Documentation revealed the patient was triaged at 5:17 PM with vital signs documented as blood pressure 125/62, Heart rate 61, Respirations 16, Temperature 36.6 degrees Celsius, oxygen saturation 100% on room air, and acuity level 2/Emergent.

A detailed review of the record revealed the patient's vital signs were reassessed at 7:14 PM. Review of the record revealed no documentation found why facility policy for reassessment not followed and 2 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 2/emergent should be reassessed every 60 minutes. Patient # 8 should have been assessed at 6:17 PM, and 7:17 PM.

Interview with VP Quality & Patient Safety (Staff A) on 4/16/2021 at 2:00 PM confirmed the above findings.