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Based on record review, policy review, and interview, it was determined, the facility failed to implement facility wide corrective action to minimize the risk of reoccurrence for one adverse event involving Patient #1, the facility failed to address staff competencies, a contributory factor to the incident.

The findings included:

Review of facility events revealed one entry related to Patient #1 dated 01/03/22.

Clinical record and administrative document reviews conducted on 01/31/22 and 02/01/22 disclosed Patient #1 experienced delay in care on 01/03/22 due to staff competency in recognizing the urgency of addressing critical laboratory results. The facility investigated the event and the analysis of the event indicated in addition to the delay in addressing critical results, the staff, the monitor technician, and the primary nurse, who cared for the patient the day before the event, failed to recognize changes in telemetry indicators (peaked T waves and changes in ST segment) and subsequently failed to notify the physician of those changes.

Further review of the clinical record also noted on 12/30/21 and 12/31/21, the nurses and the monitor technicians documented the wrong rhythm interpretation on the telemetry strip and on the shift nursing assessments. The staff documented Patient #1's rhythm as sinus instead of Atrial Fibrillation.

The corrective action implemented by the facility failed to address the staff competency in interpreting telemetry strips. There is no evidence the facility addressed the process failure as a systemic problem, at a hospital wide level, despite evidence that multiple nurses and telemetry technicians, had deficits in interpreting telemetry rhythm strips.

Interview with The Chief Nursing Officer (CNO) and The Director of Quality Management (DQM) conducted on 02/01/22 at approximately 10 AM revealed the facility did not provide telemetry, rhythm strip interpretation education to the monitor technicians and nurses after the facility had identified that Patient #1 had T waves and ST segment changes that were not identified by the staff and subsequently were not reported to the physician. The CNO and DQM confirmed the corrective action did not include education on rhythm interpretation.

Facility policy titled "Telemetry, Alarms, Prioritization last revised 01/22 documents "The Monitor Techs/Telemetry Techs (MT/TT): "Strips may be interpreted by a MT/TT or telemetry competent staff; however, all rhythm strips analyzed by a MT/TT must be validated and cosigned by the assigned nurse or charge nurse that is telemetry competent. Interpretations are to include heart rate, regularity, PR interval, QRS duration, QT interval, ST segment (elevated or depressed), rhythm interpretation, date, time, signature, and title. At the central monitoring station there should be calipers, an EKG reference and access to critical drips policies ... .....a change in rhythm will be captured on a strip, interpreted and the Nursing Supervisor notified."

Patient Safety Improvement and Risk management Program Plan dated January 2021 documents "The Patient Safety Improvement and Management Committee established appropriate mechanism for the review and analysis of incidents, near misses, serious events, sentinel events and infrastructures failures, including the appointment of teams to conduct root cause analysis.
Recommend corrective action resulting from review and analysis related to any type of event to the appropriate hospital and medical staff committees."

Based on clinical record review, administrative record review and interview, it was determined, the facility failed to ensure a registered nurse had the current specialized knowledge and certification to provide nursing care for patients requiring telemetry monitoring.

The findings included:

Clinical record review conducted on 01/31/22 and 02/01/22 revealed Staff A, a Registered Nurse, cared for Patient #1 on 01/03/22. The patient required telemetry monitoring.
Review of the nursing assessment dated 01/03/22 day shift, documents Patient #1 cardiac rhythm was normal sinus rhythm (NSR). Review of the telemetry strip dated 01/03/22 confirmed the nursing assessment was incorrect, Patient #1's heart rhythm was atrial fibrillation.

Review of the facility job description for Registered Nurses indicates ACLS (Advance Cardiac Life Support) is required six months from hire date.

Personnel review conducted on 01/31/22 revealed Staff A, ACLS expired in August 2021.

On 02/01/22 at approximately 12 PM, the Director of Quality Management (DQM) explained Staff A is no longer employed by the facility and the personnel file is not accessible to them. The DQM will request the pertinent records from the corporate office.

Phone interview with The Chief Nursing Office (CNO) and The DQM conducted on 02/03/22 at 11:30 AM revealed the facility was not able to locate Staff A's Advance Cardiac Life Support (ACLS) certification. The CNO explained Staff A was hired as a registered nurse intern and when she transitioned to the registered nurse position on June 19th, 2021, the system did not generate the tracking reminder for her certification. The facility requires ACLS certification six months after the successful completion of the internship program. Staff A was due to complete her ACLS certification by December 2021.