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Based on interview and record review, the hospital failed to ensure a performance improvement (Pl) project (use of rechargeable batteries in telemetry boxes) was overseen by the Quality Assessment Performance Improvement (QAPI) program committee for the hospital's patients. This failure placed the patients at risk for adverse outcomes.

Findings:

During an interview on 6/25/21, at 1:40 PM, with the Nurse Manager Central Telemetry 4 Tower (NM4T), NM4T stated, the charge nurse (CN4T) informed her Patient 1 had a cardiac arrest on 5/30/21 at 11:31 AM. NM4T stated, CN4T reported Patient 1's batteries had not been changed that morning and his telemetry box (a small box attached by wires to a patient which transmits vital signs [clinical measurements that indicate the status of the body's vital functions specifically pulse rate, temperature, respiration rate and blood pressure] and heart rhythms to a central station) was dead. NM4T stated, CN4T reported the telemetry box was not broken and began transmitting during the code blue (medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest) when new batteries were placed in the box. NM4T stated, the batteries should have been changed the previous night at 11 PM but a Certified Nursing Assistant (CNA 2) had floated from another floor the night before. NM4T stated, communication loss (loss of transmission of vital signs and heart rhythms to the central station) was not treated as an emergency and CNAs are taught to finish up what they are doing before checking on a communication loss from a telemetry box.

During an interview on 8/5/21, at 2 PM, with the Director of Clinical Engineering (DCE), DCE stated, an initial trial of rechargeable batteries for telemetry boxes was started in one patient room the end of January 2021, then was implemented on the Medical/Surgical Telemetry Unit (4T) around 2/9/21. DCE stated, "You would have not gotten a low battery indicator light, you would have just gotten a comm (communication) loss." DCE stated, "Notifications went out between me and leadership" regarding the lack of notification of "low battery" with the rechargeable batteries. DCE stated, I personally told a central telemetry lead, "Once we start implementing these batteries, battery would be full charge until we see comm loss" when the battery is dead. DCE stated, the vendor report following a cardiac arrest incident on 5/30/21 was sent via email and indicated the "GZ (type of telemetry box) battery was not charged for over 22 hours" and there was no failure of the (telemetry) machine.

During an interview on 8/10/21, at 10 AM, with CNA 2, CNA 2 stated, she had floated to 4T for night shift on 5/29/21. She had no orientation to the unit and she had worked with two other CNAs that night. CNA 2 stated, on her regular unit telemetry batteries are changed during their first rounds on patients at about 6 PM. CNA 2 stated, "I didn't change any batteries that night on the 4T unit." CNA stated, she didn't know there was anything different about the batteries and wasn't told there was anything different about the unit by the other CNA's, even though she had questioned them.

During a concurrent interview and record review on 8/20/21, at 1 PM, with the Nurse Manager Central Telemetry Unit (NMCTU), the hospital's policy and procedure (P&P) titled, "Cardiac Monitoring: Bedside & Telemetry ** Temporary**," date 12/7/20, was reviewed. The P&P indicated, "... E. The MT (Monitor Technician- staff trained to monitor, analyze, and report irregular or lethal heart rhythms, communication loss, and telemetry leads off) is responsible for calling the Registered Nurse (RN) with any of the following alerts. The RN is responsible for assessing/checking on the patient once alerted... 5. Patient off-line from monitoring. . ." NMCTU stated the MT's orientation packet indicated to review policy "PC-46 (Cardiac Monitoring: Bedside & Telemetry)" on the top line. NMCTU stated, she was not sure when the MTs were notified rechargeable batteries would indicate "comm loss" instead of giving a "low battery" warning. NMCTU stated, she had not sent out any formal education to the MTs and verified the P&P indicated to notify the RN in the event of a "comm loss." NMCTU stated, she would be concerned as a nurse knowing her patients were not being monitored. The only way the nurse would know a patient was not being monitored, unless the nurse was notified by the MT, would be to "wake up" the telemetry box attached to the patient by manually picking up the box. NMCTU stated, with the number of communication losses documented on 5/30/21, it was a lot of time that patients were not being monitored.

During a concurrent interview and record review on 8/25/21, at 1 PM, with NM4T, an email (email) titled "Weekly Communication 4/2/2021," dated 4/2/21, at 9:47 AM, was reviewed. The email indicated, "MANDATORY PROCESS. Effective 4/1/21. We are still having significant "communication loss" with our tele (telemetry) boxes. Clinical Engineering did and (sic.) audit and the majority are from dead batteries. Effective 4/1/2021 the batteries with (sic.) be changed at 11:00 and 2300 by the CNA assigned to that group. The Team Leads will be checking to make sure this is done. We all need to be diligent with this process for the safety of our patients. . . 4. Document that the batteries were changed when you document your vital signs for that patient in the Additional Information Section... What if I go to change the batteries and they still have a lot of charge left? CHANGE THEM ANYWAY. This ensures the changing schedule is not interrupted and reduces the frequency of communication loss resulting in patients being unmonitored. This is no longer an optional process . . ."NM4T stated, this "communication was only a request." NM4T stated, this was a unit manager and leadership decision but not a policy. NM4T stated, some of the CNAs documented and some did not.

During a review of the hospital record, an email (email) from vendor to Director of Clinical Engineering (DCE) , Director of Cardiac Critical Care Services (DCCCS), Nurse Manager Central Telemetry 4 Tower (NM4T), and other hospital administrators, titled "[Hospital]- Findings on incident," dated 7/29/21, at 2:56 PM, indicated, ". . .2. In the (vendor) investigation that found the GZ battery was not changed for over 22 hours. . ."

During an interview on 9/29/21, at 11:31 AM, with RN 1, RN 1 stated, the rechargeable battery trial did not work well. There was more communication loss, the rechargeable batteries were thrown away, and the CNA's did not change the batteries. RN 1 stated, she did not check the CNA's charting to ensure batteries were changed. She reported the issues to her unit manager and director.

During an interview on 9/29/21, at 11:53 AM, with DCCCS, DCCCS stated, the rechargeable battery trial began as an employee suggestion to go green. She stated, we took the idea to DCE. DCCCS stated, the only staff involved in the trial were NM4T and DCE. DCCCS stated, she did not inform her Vice President Chief Nursing Officer (VPCNO) of the trial. The training for the trial was done via email, huddles, and staff meetings. DCCCS stated, she was made aware the rechargeable batteries would have no warning when the battery was going to die, the monitors would just show communication loss. DCCCS stated, the CNAs were responsible for changing and recharging the batteries at 11 AM and 11 PM. DCCCS stated, they did not do any audits or collect data. As the director she had no safety concerns and no new safety measures were put in place. She stated, we thought the process was of high reliability and would be fine.

During an interview on 9/29/21, at 12:28 PM, with Nurse Manager Central Telemetry 4 Tower (NM4T), NM4T stated, no formal education was done for the rechargeable battery trial. She stated, training was done at huddles, and weekly emails. NM4T stated, training for battery change times was completed by Clinical Nurse Educator (CNE) when the telemonitors were rolled out to the whole hospital. NM4T stated, all departments utilized telemetry boxes and had the same battery change times 11 AM and 11 PM.

During an interview on 9/29/21, at 1:55 PM, with Director of Clinical Engineering (DCE), DCE stated, he spoke to the manufacturer, did his research, and found the manufacturer's recommendations for rechargeable batteries did not make sense; the battery life and recharge times were in excess. DCE stated, he selected lithium-ion rechargeable batteries after testing them in his shop. He stated, the lithium-ion rechargeable batteries lasted 18 to 24 hours depending on use. DCE stated, he informed DCCCS and NM4T the batteries would not give low batteries warning, the batteries would just stop working. He stated, he stressed the importance of ensuring the batteries were changed and recharged every 12 hours. DCE stated, if the rechargeable batteries were depleted it would show as communication loss on the telemonitors. The manufacturer's recommended rechargeable batteries did give off the warning alarm when battery life was low. DCE stated, the Chief Executive Officer (CEO) and Vice President Chief Nursing Officer (VPCNO) were not made aware of the rechargeable battery trial. DCE stated, he was never made aware of communication loss, nor did he collect or analyze data, nor was he involved in the staff training for the trial. DCE stated, any new product or piece of equipment that will touch a patient should go before the Value Analysis Committee (VAC).

During a concurrent interview and record review on 9/29/21, at 3:08 PM, with Clinical Nurse Educator (CNE), CNE reviewed the "Telemetry Monitor Training (TMT) ," undated, the "TMT" indicated, "Batteries will need to be replaced at 24 hours or more frequently." CNE stated, all CNAs and RNs take this training. CNE stated, each unit made their own process for battery change times.

During an interview on 10/6/21, at 2:33 PM, with Director of Quality and Logistics (DQL), DQL stated, the Value Analysis Committee (VAC's) reviews and evaluates all new products, process changes, and equipment that touches a patient. DQL stated, VAC analyzes many factors; Is it clinically better for patients and staff? Is it safe? Is the idea financial solid? What is the protocol? How is staff going to be educated? How is it going to be monitored and managed? He stated, VAC helps makes the decision and evaluates and educates on it. We decide if we are going to trial the idea. DQL stated, the product champion fills out the request form and manages the trial with forms provided by VAC. The committee's job is to evaluate the product or change data and decided whether or not to approve. DQL stated, the VAC was not made aware of the rechargeable battery trial. DQL stated, VAC should have been made aware of any decision to go outside of manufacturer's recommendations.

During an interview on 10/6/21, at 3 PM, with Vice President Chief Nursing Officer (VPCNO), VPCNO stated, she was not made aware of the rechargeable battery trial. She stated, if a department wants to change any part of their equipment or supply, they should go to the Value Analysis Committee (VAC). VPCNO stated, the trial should have gone before the VAC because they are the group that would ask the important questions.

During a review of the "Nihon Kohden (manufacturer of medical electronic equipment) Operator's Manual (NKOM)," undated, the "NKOM" indicated, "Batteries ... Use either new alkaline batteries or fully charged rechargeable nickel-metal hydride (NiMH) batteries. Recommended Batteries Alkaline batteries: Medipower NiMH batteries: Panasonic BK-3HCC (GZ-120P/GZ-130P only) Panasonic BK-200AAB9B (GZ-140P only) ... Using unspecified batteries, previously used batteries that have been stored for long periods may result in short battery life or reduced performance resulting in unstable measurement. .. Situations Requiring Battery Replacement In any of the following cases the batteries have run out. Immediately replace the batteries with new ones. The "BATTERY WEAK" technical alarm is displayed. The "BATTERY WEAK" technical alarm is displayed on the central monitor."

During a review of the hospital's policy and procedure (P&P) titled, "Value Analysis Committee," dated 6/29/21, the P&P indicates, "The responsibility of the Value Analysis Committee (VAC) is to develop and implement an organized, systematic approach to determine the value of technology, products and services related to patient care - while simultaneously complementing process improvement, improved outcomes, safety and quality practices along with financial stewardship... Procedure: 1. The "New Product Request" (NPR) from (Attachment A) will be submitted to the committee Chairperson, Value Analysis Coordinator five business days prior to the scheduled VAC meeting by the product champion. . . 4. Either the product champion or a hospital representative will attend the VAC meeting to present the product for requesting department. . . 5. Upon VAC approval of product evaluation/trial, the duration of the· evaluation and determination of appropriate nursing units will be discussed during the committee meeting. . . 6 Upon completion of evaluation/trial, the product champion will forward the findings, data and reimbursement information (when appropriate) to the VAC Chairperson and attend the following meeting for final determination to accept or reject the product. 7. . . The product champion will collaborate with Materials Management , Clinical Education and department manager to provide the appropriate staff education."

During a review of the hospital's P&P titled, "Quality Improvement Plan (QIP)," dated 5/25/21, the "QIP" indicated, "Medical Staff The Medical Staff, in accordance with currently approved medical staff bylaws, shall be accountable for the quality of patient care. The Board delegates authority and responsibility for monitoring, evaluation and improvement of medical care to the Professional Staff Quality Committee "Prostaff', chaired by the Vice Chief of Staff delegates accountability for monitoring individual performance to the clinical Department Chiefs. Prostaff shall receive reports from and assure the appropriate functioning of the Medical Staff committees. "Prostaff: provides oversight for medical staff quality functions including peer review."

During a review of the hospital's Bylaws titled "(Hospital's name] District Bylaws," dated August 23, 2021, the Bylaws indicated, "The publicly elected Governing Body is responsible for the safety and quality of care, treatment, and services, establishes policy, promotes performance improvement, and provides for organizational management and planning ...Section 4 ... 2) Evaluate proposals brought to the Board to ensure that they are consistent with the mission statement. Monitors programs and activities of the hospital and subsidiaries to ensure mission consistency. . . A. QUALITY PERFORMANCE RESPONSIBILITIES - THIS Board has the final moral, legal, and regulatory responsibility for everything that goes on in the organization, including the quality of services provided by all individuals who perform their duties in the organization's facilities or under Board sponsorship. To exercise this quality oversight responsibility, the Board must: ... 6) Fully understand the Board's responsibilities and relationships with the Medical Staff and maintain effective mechanisms for communicating with them. . . 8) Adopt a Performance Improvement Plan and Risk Management Plan for the District and provide for resources and support systems to ensure that the plans can be carried out. .. 11) Monitor programs and services to ensure that they comply with policies and standards relating to quality... Article VII Performance Improvement (Pl) Section 1 The Governing Body requires that the Medical Staff and Health Care District staff implement and report on activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying and resolving problems, and for identifying opportunities to improve patient care within the District."

Based on observation, interview, and record review, it was determined the hospital did not meet the Condition of Participation (COP) for Nursing Services as evidenced by:

The hospital failed to ensure the Team Lead (TL [Registered Nurse RN- who perform the same role as charge nurse]) supervised and monitored the Certified Nursing Assistants (CNA's) and ensure there was an effective communication among TL-RN, CNA and Telemetry Monitor Technician (MT) using telemetry boxes (small box attached to patients by wires that transmits vital signs [clinical measurements that indicate the status of the body's vital functions specifically pulse rate, temperature, respiration rate and blood pressure] and heart rhythms to a central station) in providing patient care for five of 11 sampled patients (Patient 1, Patient 26, Patient 27, Patient 28, and Patient 29). This failure resulted in Patient 1 to suffer an unrecognized lethal heart rhythm due to the dead battery of a telemetry box and had the potential for Patient 26, Patient 27, Patient 28 and Patient 29's heart rhythms to go unmonitored and adversely affect their health conditions. (Refer to A 0395).

The cumulative effect of this systemic failure resulted in negatively impacting the safety and quality of care, treatment, and services to Patient 1, Patient 26, Patient 27, Patient 28 and Patient 29.

Based on observation, interview and record review, the hospital failed to ensure the Team Lead (TL [Registered Nurse RN]- who performs the same role as charge nurse) supervised and monitored Certified Nursing Assistants (CNA's) and there was an effective communication among TL-RN, CNA's, and Telemetry Monitor Technician (MT-staff trained to monitor, analyze, and report irregular or lethal heart rhythms, communication loss, and telemetry leads off) using telemetry boxes (small box attached to patients by wires that transmits vital signs [clinical measurements that indicate the status of the body's vital functions specifically pulse rate, temperature, respiration rate and blood pressure] and heart rhythms to a central station) for five of 11 sampled patients (Patient 1, Patient 26, Patient 27, Patient 28, and Patient 29) in providing patient care. This failure resulted in Patient 1 to suffer an unrecognized lethal heart rhythm due to the dead battery of a telemetry box and had the potential for Patient 26, Patient 27, Patient 28 and Patient 29's heart rhythms to go unmonitored and adversely affect their health condition.

Findings:

During a review of the hospital record, an email (email) from Director of Clinical Engineering (DCE) to Nurse Manager of 4 Tower (NM4T) and Materials Management staff (MMS), titled "Feb 9 - Waiting Issuance . . . Rechargeable Battery Kits . . . ," dated 2/9/21, at 3:11 PM, indicated, ". . . We are broadening our trial of a specialized Lithium Cobalt 1.5 V [volt- a unit of measure] Rechargeable battery on 4T [unit/station] for use with the new Nihon Kohden [manufacturer/distributor of medical electronic equipment] Telemetry Transmitters. . .While these rechargeable batteries are great performers, there is a drawback which could be a safety concern if a routine change of battery is not established. . . At the end of that life, the battery turns off. While the telemetry box will display Comm Loss (communication loss- loss of the transmission of vital signs and heart rhythms to the central monitoring station) at the Central Telemetry Monitoring and remote Nurse Stations, no alarm will sound and no waveforms (heart rhythms) or vitals information will be recorded until the battery set is changed. . .The new rechargeable batteries will show a full charge level until exhausted and then drop to 0. Building a planned battery change per shift will help greatly to ensure this situation does not occur. . ."

During an interview on 6/23/21, at 3 PM, with the Director of Cardiac Critical Care Services (DCCCS), the DCCCS stated, the monitor technician (MT) saw "comm loss" (communication loss) from Resident 1's telemetry box on 5/30/21, at 11:12 AM. DCCCS stated, Telemetry Monitor Technician (MT) called CNA (Certified Nursing Assistant) 1 on 4T (unit/station) to report the communication loss. DCCCS stated, MT would see "low battery" when the battery is low on the box versus "comm loss." DCCCS stated, CNA 1 had checked on Patient 1 at 11 AM but was busy with patient care duties in the room next to Patient 1 when he was notified of the "comm loss." CNA 1 had not changed the batteries yet. DCCCS stated, family of Patient 1 came to the nurse's station at 11:30 AM stating, "Something is wrong with my dad." Registered Nurse 1 called a code blue (medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest) at 11:31 AM for Patient 1.

During a review of Patient 1's Medical Record (MR) titled, "Discharge Documentation," dated 5/30/21, at 3:11 PM, the MR indicated, "Discharge Diagnoses: 1. STEMI (heart attack). 2. CAD (coronary [heart] artery [blood vessel] disease- triple vessel disease (three blood vessels in the heart were blocked). 3. SVT (supraventricular tachycardia- abnormally fast heart rhythm). 4. AKI (acute kidney disease) on CKD (chronic kidney disease). 5. Acute on chronic anemia (disease of lacking enough red blood cells to carry oxygen). 6. Adenocarcinoma of lung (a type of cancer of the lung) . . . Patient is a 71 y/o (year old) male with adenocarcinoma . . He was admitted with an anterior (front side of the body) STEMI . . . the patient underwent cardiac angiogram (procedure to open blood vessels in the heart). He was found to have triple vessel disease. Multiple attempts were made to open the LAD (left anterior descending artery- largest and most important artery in the heart) but was unsuccessful. . . Cardiothoracic (heart) surgeon was consulted but felt that he was not a surgical candidate. . . He was downgraded to Med (medical)/surg (surgical) telemetry on 5/26. . . On 5/29 overnight, pt (patient) developed SVT HR (heart rate) 180s, broke with vagal maneuver (an action used to slow down heart rate). . . In the morning of 5/30, a code blue was called after the patient went into VF (ventricular fibrillation- a dangerous heart rhythm) arrest. The patient had blood pouring out from his oropharynx (mouth) and advanced airway was therefore unsuccessful by two physicians. After multiple rounds of CPR (chest compressions and breathing) the code was called." The MR indicated Patient 1 expired on 5/30/21.

During a concurrent observation and interview on 6/23/21, at 3:25 PM, with Director of Cardiac Critical Services (DCCCS), the Main Nurse's Station Telemetry monitor screen on the Health Unit Coordinator's (HUC) desk in 4T (unit/station) was observed. DCCCS stated, this telemetry station is not 100 percent monitored and the HUC is not a trained MT who would be observing the monitor for communication loss and reporting it to the Registered Nurse.

During an interview on 6/25/21, at 1:05 PM, with Telemetry Monitor Technician (MT) 1, MT 1 stated, she called CNA 1 (5/30/21 at 11:12 AM) when the telemetry monitor read "comm loss."

During an interview on 6/25/21, at 1:15 PM, with CNA 1, CNA 1 stated, we change batteries on the telemetry boxes at 11 AM and 11 PM during our shift. CNA 1 stated, "All patients are on telemetry. I don't remember them (MTs - Telemetry Monitor Technician) calling me about this patient (Patient 1) that day (5/30/21)." CNA 1 stated, "They call us throughout the day to check communication loss." CNA 1 stated, "all day long" when asked approximately how many times per shift he gets called by MTs for communication loss. CNA 1 stated, he had checked on Patient 1 approximately 30 minutes prior to the code blue. CNA 1 stated he heard the code blue call for Patient 1 and immediately went into the room to start chest compressions.

During an interview on 6/25/21, at 1:25 PM, with Registered Nurse (RN) 1, RN 1 stated she was caring for Patient 1 on 5/30/21. RN 1 stated, Patient 1's son came out of his room and said, "I'm not sure if my dad is breathing." RN 1 stated she immediately went into the room and discovered Patient 1 not breathing. RN 1 stated she pressed the code blue button and CNA 1 started chest compressions. RN 1 stated she checked the tele (telemetry) box because a rhythm will show on the box and it was completely dead. RN 1 stated, "I don't know what happened with the box. I told the charge nurse that 'when I walked in to check to see what rhythm he was in and the box was dead.'"

During an interview on 6/25/21, at 1:40 PM, with Nurse Manager Central Telemetry 4 Tower (NM4T), NM4T stated, the charge nurse (CN4T) informed her Patient 1 had a cardiac arrest on 5/30/21 at 11:31 AM. NM4T stated, CN4T reported Patient 1's batteries had not been changed that morning and his telemetry box (a small box attached by wires to a patient which transmits vital signs and heart rhythms to a central station) was dead. NM4T stated, CN4T reported the telemetry box was not broken and began transmitting during the resuscitation when new batteries were placed in the box. NM4T stated, no one could remember who changed the batteries during the code. The batteries should have been changed the previous night at 11 PM but a CNA 2 had floated from another floor the night before. NM4T stated, communication loss (loss of transmission of vital signs and heart rhythms to the central station) was not treated as an emergency and CNAs are taught to finish up what they are doing before checking on a communication loss from a telemetry box.

During an interview on 6/25/21, at 3:55 PM, with Director of Cardiac Critical Care Services (DCCCS), DCCCS stated, there would have been a low battery indicator light on the telemetry monitor in Central Telemetry Station (CTS), 4T telemetry monitoring station, and the telemetry box itself. DCCCS stated, there was no report of a low battery indicator.

During an interview on 8/5/21, at 2 PM, with Director of Clinical Engineering (DCE), DCE stated, "Notifications went out between me and leadership" regarding the lack of notification of "low battery" with the rechargeable batteries. DCE stated, I personally told the central telemetry lead, "Once we start implementing these batteries, battery would be full charge until we see comm loss" when the battery is dead. DCE stated, the vendor report following a cardiac arrest incident on 5/30/21 was sent via email and indicated the "GZ (type of telemetry box) battery was not charged for over 22 hours" and there was no failure of the (telemetry) machine.

During an interview on 8/10/21, at 10 AM, with CNA 2, CNA 2 stated, she had floated to 4T (unit/station) for night shift on 5/29/21. CNA 2 stated, she had no orientation to the unit. She had worked with two other CNAs that night. CNA 2 stated, on her regular unit telemetry batteries are changed during their first rounds on patients at about 6 PM. CNA 2 stated, "I didn't change any batteries that night" on the 4T unit. CNA 2 stated, she didn't know there was anything different about the batteries and wasn't told there was anything different about the unit by the other CNAs, even though she had questioned them.

During a concurrent interview and record review on 8/20/21, at 1 PM, with Nurse Manager of Central Telemetry Unit(NMCTU), the hospital's policy and procedure (P&P) titled, "Cardiac Monitoring: Bedside & Telemetry ** Temporary**," date 12/7/20, was reviewed. The P&P indicated, ". . . E. The MT (Telemetry Monitor Technician - staff trained to monitor, analyze, and report irregular or lethal heart rhythms, communication loss, and telemetry leads off) is responsible for calling the Registered Nurse (RN) with any of the following alerts. The RN is responsible for assessing/checking on the patient once alerted. . . 5. Patient off-line from monitoring. . ." NMCTU stated the MT's orientation packet indicated to review policy "PC-46 (Cardiac Monitoring: Bedside & Telemetry)" on the top line. NMCTU stated, she was not sure when the MTs were notified rechargeable batteries would indicate "comm loss" instead of giving a "low battery" warning. NMCTU stated, she had not sent out any formal education to the MTs and verified the P&P indicated to notify the RN in the event of a "comm loss." NMCTU stated, she would be concerned as a nurse knowing her patients were not being monitored. NMCTU stated, the only way the nurse would know a patient was not being monitored, unless the nurse was notified by the MT, would be to "wake up" the telemetry box attached to the patient by manually picking up the box. NMCTU stated, with the number of communication losses documented on 5/30/21, there were a lot of times that patients (Patient 1, Patient 26, Patient 27, Patient 28, Patient 29) were not being monitored.

During a concurrent interview and record review on 8/25/21, at 1 PM, with NM4T, an email (email) titled "Weekly Communication 4/2/2021," dated 4/2/21, at 9:47 AM, was reviewed. The email indicated, "MANDATORY PROCESS. Effective 4/1/21. We are still having significant "communication loss" with our tele (telemetry) boxes. Clinical Engineering did and (sic.) audit and the majority are from dead batteries. Effective 4/1/2021 the batteries with (sic.) be changed at 11:00 and 2300 by the CNA assigned to that group. The Team Leads will be checking to make sure this is done. We all need to be diligent with this process for the safety of our patients. . . 4. Document that the batteries were changed when you document your vital signs for that patient in the Additional Information Section. . . What if I go to change the batteries and they still have a lot of charge left? CHANGE THEM ANYWAY. This ensures the changing schedule is not interrupted and reduces the frequency of communication loss resulting in patients being unmonitored. This is no longer an optional process . . ." NM4T stated, this "communication was only a request." NM4T stated, this was a unit manager and leadership decision but not a policy. NM4T stated, some of the CNAs documented and some did not.

During an interview on 8/25/21, at 1:15 PM, with the CN4T, CN4T stated, "Yes" she was told when the rechargeable batteries went dead there would be a communication loss but doesn't remember how she was informed. CN4T stated, the 11 AM and 11 PM battery changes were implemented to ensure that the box did not go dead. CN4T stated, the CNAs were supposed to document the battery change in "IView (computer charting program)," but this was not a requirement.

During an interview on 8/25/21, at 2:20 PM, with Director of Cardiac Critical Care Services (DCCCS), DCCCS stated, the nurse cannot see the patient's heart rhythm when the patient is off-line from monitoring, as in communication loss, and could be 15 minutes where "nobody has eyes on the patient." DCCCS stated, a low battery alarm would give the CNA time to change the battery and the nurse or MT would be able to continue to view the patient's heart rhythm.

During an interview on 9/29/21, at 11:31 AM, with Registered Nurse (RN) 1, RN 1 stated, the rechargeable battery trial did not work well. She stated, there was more communication loss, the rechargeable batteries were thrown away, and the CNAs did not change the batteries. RN 1 stated, she did not check the CNA's charting to ensure batteries were changed. She reported the issues to her unit manager and director.

During an interview on 9/29/21, at 11:39 AM, with Charge Nurse (CN) 2, CN 2 stated, "I wasn't told there was any difference" in the rechargeable batteries.

During an interview on 9/29/21, at 12:28 PM, with Nurse Manager Central Telemetry 4 Tower (NM4T), NM4T stated, no formal education was done for the rechargeable battery trial. She stated, training was done at huddles (gather together), and weekly emails. NM4T stated, training for battery change times was completed by Clinical Nurse Educator (CNE) when the telemonitors were rolled out to the whole hospital. NM4T stated, all departments utilized telemetry boxes and had the same battery change times 11 AM and 11 PM.

During an interview on 9/29/21, at 12:30 PM, with Director of Cardiac Critical Care Services (DCCCS), DCCCS stated, no audits were done regarding compliance with battery changes in the telemetry boxes because the assumption was made CNA's were "doing what they were supposed to do." DCCCS stated, "(We) did not educate it out to (inform) nurses to check after CNA's."

During an interview on 9/29/21, at 12:38 PM, with Director of Cardiac Critical Care Services (DCCCS), DCCCS stated, staff education regarding battery changes was provided during impromptu huddles on the unit and by email. DCCCS stated, the education provided in huddles was not documented.

During a concurrent interview and record review on 9/29/21, at 3:08 PM, with Clinical Nurse Educator (CNE), CNE reviewed the "Telemetry Monitor Training (TMT)," undated, the "TMT" indicated, "Batteries will need to be replaced at 24 hours or more frequently." CNE stated, all CNAs and RNs take this training. Each unit made their own process for battery change times. CNE stated, for a CNA floating to another unit, the process could potentially be different on each unit.

During a concurrent interview and record review on 9/30/21, at 1:40 PM, with Telemetry Monitor Technician (MT) 2, MT 2's "Daily log (log)," dated 4/2/21, was reviewed. The "log" indicated, MT 2 called a Certified Nursing Assistant (CNA) for "comm loss" at 3:28 PM for rooms 3, 5, 6, and 8 on 4T unit. MT 2 stated, for "comm loss" we call the CNA to change the batteries. MT 2 stated, comm loss "is the same as a dead battery." MT 2 stated, with the trial of rechargeable batteries, there was no indication the battery was draining. MT 2 stated, she voiced her concerns to DCE and felt it was a patient safety issue. MT 2 stated, "I didn't think it was a good idea."

During an interview on 9/30/21, at 2:26 PM, with Director of Cardiac Critical Care Services (DCCCS), DCCCS stated, "Absolutely the policy says to call the nurse" for communication loss.

During an interview on 9/30/21, at 3:11 PM, with Telemetry Monitor Technician (MT) 4, MT 4 stated, "'Comm loss' right now has to do with the battery" and the CNA is called.

During an interview on 10/4/21, at 2:05 PM, with Charge Nurse 2 North (CN2N), CN2N stated, "We changed the batteries once per shift, with the second or third set of vital signs, at either midnight or three or four in the morning. I don't know if it is standardized yet." CN2N stated, "I'm not sure if CNAs have something in their charting. The Registered Nurses are responsible to make sure CNAs are doing their job."

During a concurrent interview and record review, on 10/5/21, at 8:56 AM, with Team Lead 4T (TL4T), Nurse Manager Central Telemetry 4 Tower (NM4T), and Clinical Risk Manager (CRM), the "Additional Information" in the Medical Record (MR), dated 5/29/21 and 5/30/21, and Telemetry Monitor Technician (MT) 1's Daily log (log), dated 5/30/21, for Patient 1, Patient 26, Patient 27, Patient 28, and Patient 29, were reviewed. Patient 1's MR indicated, no CNA documentation for telemetry battery changes on 5/29/21 at 11 AM or 11 PM. MT 1's log indicated, Patient 1's telemetry monitor had "comm loss" on 5/30/21, at 11:12 AM. "Comm loss" verified by NM4T. Patient 26's MR indicated, no CNA documentation for telemetry battery changes on 5/30/21 at 11:00 AM. MT 1's log indicated, Patient 26's telemetry monitor had "comm loss" on 5/30/21 at 12:17 AM. "Comm loss" verified by NM4T. Patient 27's MR indicated, no CNA documentation for telemetry battery changes on 5/30/21 at 11 AM or 11 PM. MT 1's log indicated, Patient 27's telemetry monitor had "comm loss" on 5/30/21, at 7:40 AM, 9:20 AM, and 12:15 AM. "Comm loss" verified by NM4T. Patient 28's MR indicated, no CNA documentation for telemetry battery changes on 5/29/21 at 11 PM or 5/30/21 at 11 AM. MT 1's log indicated Patient 28's telemetry monitor had "comm loss" on 5/30/21 at 2:12 PM. "Comm loss" verified by NM4T. Patient 29's MR indicated, no CNA documentation for telemetry battery changes on 5/30/21 at 11 AM. MT 1's log indicated, Patient 29's telemetry monitor had "comm loss" on 5/30/21 at 1:38 PM. "Comm loss" verified by Clinical Risk Manager (CRM). TL4T stated, he "mainly looks at the monitor in front of me" to determine if telemetry boxes are working. TL4T stated, he does not review the CNA's charting in the medical record. TL4T verified MR findings.