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Based on interview and record review, the facility failed to ensure interventions were implemented, for one patient (Patient 20), when Patient 20 had multiple episodes of decreased oxygen saturation (SPO2, level of oxygen in the blood) and decreased heart rate, which were not addressed timely, in accordance with the facility's policies and procedures (Refer to A 0398).

The cumulative effects of this systemic failure resulted in a delay of treatment for Patient 20 and could have contributed to Patient 20's death.

Based on interview and record review, the facility failed to ensure interventions were implemented, for one patient (Patient 20), when Patient 20 had multiple episodes of decreased oxygen saturation (SPO2, level of oxygen in the blood) and decreased heart rate (HR), which were not addressed timely, in accordance with the facility's policies and procedures.

This failure resulted in a delay of treatment for Patient 20 and could have contributed to Patient 20's death.

Findings:

On February 26, 2023, an unannounced visit was conducted at the facility for a complaint validation survey.

During a record review conducted with the Patient Safety Director (PSD) on February 28, 2024, at 1:15 p.m., the facility document titled, "History & (and) Physical," dated November 19, 2022, indicated, "...male with past medical history...for new onset of paraplegia (paralysis of the lower half of the body and legs) and possible quadriplegia (paralysis of arms and legs)...complaining of upper bilateral extremity (both arms) pain and forehead pain...states he cannot feel below his nipple line and cannot move his lower extremities..."

A review of the facility document titled, "Clinical Documentation Record," dated December 30, 2022, at 5 p.m., indicated, "...Pulse 79 [normal range in adults is 60 to100 beats per minute]...Respiratory rate: 24 [normal range in adults is 12 to 18 breaths per minute]...Blood Pressure 108/57 [normal is 90/60 to 120/80 in adults]...SPO2 % [percent]: 97...Oxygen delivery devices: Ventilator [machine connected to the patient tube to assist in breathing through a breathing tube]..."

A review of the facility document titled, "Code Blue [a hospital code for a patient needing resuscitation] Record," dated December 30, 2022, at 5:58 p.m., indicated, "...1759 (5:59 p.m.)...pulse...no...Rhythm...paced...PEA [Pulseless Electrical Activity, a condition where your heart stops because the electrical activity in your heart is too weak to make your heart beat]..."

A review of the facility document titled, "Code Blue Note," dated December 30, 2023, at 6:50 p.m., indicated, "...Code Blue called overhead for PEA arrest [when the heart stopped beating]. RN [registered nurse] had seen patient [Patient 20] 1 [one] hour prior...transferred to MICU [Medical Intensive Care Unit, unit for critically ill patients] where he would arrest again..."

A review of the facility document titled, "Dischage Summary," dated January 4, 2023, at 5:06 p.m., indicated, "...Discharge diagnosis: Hypoxemic [low level of oxygen] brain injury due to multiple cardiac [pertaining to the heart] arrests...Code Blue called again for PEA arrest on 12/30 [December 30, 2023]...Pt. [Patient 20] condition on discharge: expired..."

A review of the email sent by RN 2 to the Director of Intermediate Care (Director 1) and other staff was conducted with the PSD. The email indicated, "...Subject: CODE BLUE/TELEMONITORING," dated December 30, 2022 at 7:40 p.m., indicated, "...JUST WANTED TO FORWARD...THE VIGILANZ [SIC] MADE AND ADD MORE DETAILS REGARDING THE CODE BLUE IN [Patient 20's room number]...AT [sic] 12/30/22 [December 30, 2022 1758 [5:58 p.m.]...1715 [5:15 p.m.]: HR 82, SPO2 91%, RR [respiratory rate, normal is 12 to 18 breaths per minute in adults] 68. NO CALL [from the tele room, room where the patient's heart rate and rhythms were remotely monitored]...1740 [5:40 p.m.]: HR 60, SPO2 47%, RR 0. NOCALL OR CRITICAL ALARM...1755 [5:55 p.m.]: HR 23, NO SPO2, RR 0. NO CALL OR CRITICAL ALARM...1758 [5:58 p.m.]: HR0 [sic], NO SPO2, RR 0. CRITICAL ALARM ASYSTOLE, BUT STILL NO CALL FROM TELE ROOM...PT FOUND UNRESPONSIVE AND DISCONNECTED FROM VENT...CODE BLUE WAS CALLED..."

During a concurrent interview and record review conducted with the Patient Safety Director (PSD), the PSD stated there was no documented evidence Patient 20 was seen by staff between 5 p.m. to 5:58 p.m. on December 30, 2022. The PSD stated Registered Nurse (RN) 1 was assigned to Patient 20 and was in another patient's room during this time and did not hear Patient 20's alarm sounding. The PSD stated RN 2 was on modified duty and was assigned to the nurse's station desk. She further stated RN 2 sent out an email to Unit Director and Unit Manager after the code blue called for Patient 20. The PSD stated during this time the facility had several fire alarms going on at 5:07 p.m. and at 5:32 p.m. which triggered the unit fire doors and two patient doors to automatically close. She further stated the door to Patient 20's room was a door which automatically closes during a fire alarm. The PSD stated these events made it difficult for staff to hear any patient alarms on the unit. The PSD stated during this time the facility did not have a designated telemetry monitor technician (tele tech) assigned to this unit. She stated the RNs were responsible for monitoring their own patients. She stated the tele techs did have access to patient monitors for this unit but only called the registered nurse for red codes (when the vital signs are outside of the set perimeters). The PSD stated the facility is unable to locate the tele tech log for December 30, 2022.

During an interview on February 28, 2024, at 2:40 p.m., conducted with RN 3, RN 3 stated the unit did not have an assigned tele tech to watch the monitors for their patients. RN 3 stated the telemetry [remote monitoring of patient's heart rates and rhythms] alarms usually go off for SPO2 below 88, but on this day, the fire alarms were going off and were very loud making it hard to hear any other alarms. RN 3 stated they heard an alarm for low oxygen at the nurse's station monitors and RN 4 went to Patient 20's room to investigate after she was notified by RN 2 of the heart rhythm change RN 2 saw on the tele monitor. RN 3 stated RN 4 noticed Patient 20's trachea tubing was detached from the ventilator and then called a Code Blue.

During a concurrent interview and record review on February 29, 2024, at 9:30 a.m., conducted with Manager 1, Manager 1 stated the tele techs do not print any rhythm strips or change of oxygen. She further stated the RN would be responsible for interpreting and printing their own patients' telemetry strips (recording of the heart rate and rhythm on a special type of paper). Manager 1 stated during this time there was no organized way for tele techs to document these events or who they contacted for telemetry alarms and no tele logs have been located for December 30, 2022.

During a concurrent interview and record review on February 29, 2024, at 9:40 a.m., conducted with Manager 2, Manager 2 stated the expectation is for the unit RNs to print the tele strips for their patients every four hours and when there is a rhythm change, then the RN is to notify the physician. She stated the RN is expected to contact the physician if there is a prolonged or sustained oxygen event. Manager 2 stated there was no documentation Patient 20's sustained oxygen event was addressed nor was it reported to the physician.

During a concurrent interview and record review on February 29, 2024, at 10 a.m., conducted with Tele Tech 1, Tele Tech 1 stated, during this event the tele techs were not responsible for this unit and the tele techs were only there as "second eyes" and would contact the RN if there was a red alarm. Tele Tech 1 stated, if the patient's oxygen went below the parameters, they would have seen a red alarm and called the RN. She stated she was not sure about this event without looking at the log.

During a concurrent interview and record review on February 29, 2024, at 10:16 a.m., conducted with Director 1, Director 1 stated there were multiple fire alarms going on December 30, 2023, and the unit did not receive any calls from a tele tech for the change in Patient 20's status. Director 1 stated the RN assigned to the patient should print an event change, then communicate the change to the physician.

During an interview and record review on February 29, 2024, at 11:01 a.m., conducted with RN 4, RN 4 stated she came to the nurse's station to chart and heard an alarm at the monitor located in the nurse's station. RN 4 stated the alarm was for oxygen saturation drop. She stated she went into Patient 20's room and noticed his ventilator tubing was disconnected. RN 4 stated Patient 20's monitor indicated a rhythm change to asystole (condition where the heart stopped beating) she then started cardiopulmonary resuscitation (chest compressions) and called a Code Blue.

During a concurrent interview and record review on February 29, 2024, at 11:15 a.m., conducted with the Respiratory Technician Manager (RT Manager), the RT Manager stated the ventilator alarm settings are always set to the highest volume possible. The RT Manager stated the ventilator would have started to alarm when Patient 20's ventilator tubing became disconnected. The RT Manager further stated the RN should have been able to hear the alarm through a closed door but it may have been difficult with a closed door and fire alarms going off.

During an interview on February 29, 2024, at 1:30 p.m., conducted with the Assistant Chief Nursing Officer (ACNO), the ACNO stated, on December 30, 2022, during a fire alarm, nursing staff should have walked around the unit to check on the patients to ensure their safety. The ACNO stated the patient monitor settings are set to alarm when the patient's oxygen level falls below 90%. She further nursing staff should have responded to this alarm timely.

A review of the undated facility document titled, "Telemetry Safety Bundle: Practice Standards & [and] Communication," was conducted. The document indicated, "...Staff Roles and Responsibilities...Registered Nurses...Ensure patient is appropriately monitored at all times...Telemetry Technicians...Notify Primary RN promptly of rhythm changes and/or alarms requiring ventilation. Document method of notification and time of alarm resolution...Record alarm notification in a facility-specific Telemetry Notification Log..."

A review of the facility's policy and procedure titled, "Clinical Alarm System Efficacy for Patient Care," dated July 22, 2020, was conducted. The policy indicated, "...All clinical staff and contract employees assigned to clinical areas...Alarms on clinical monitoring and interventions systems will be maintained in the "on" position and will be sufficiently audible to staff...Alarm volumes will be set at a level so that staff can hear them. If there is competing noise in the area, or the patient is housed at some distance from the staff, then the volume of the alarms will be high enough or augmented in a manner that allows staff to hear them above the competing noise...Clinical staff will provide the following assessment...Under reasonable and predictable extremes of environmental conditions the alarm can be heard (including ambient noise levels)..."

A review of the facility policy and procedure titled, "Far West Division Cardiac Telemetry Monitoring," dated June 23, 2021, was conducted. The policy indicated, "...Patients being monitored on continuous telemetry will be observed by a Telemetry Technician or Nurse who is competent in cardiac rhythm interpretation & arrhythmia detection. Rhythm changes, life-threatening arrhythmias, and/or loss of signal will be responded to in an immediate manner...Patients requiring telemetry will have their cardiac rhythm continuously monitored and documented each shift and PRN with cardiac rhythm changes...The Telemetry Technician should immediately notify the RN of changes in patient's rhythm...Monitor strips will be run to capture changes in rate or rhythm...The RN is responsible to notify the Provider of changes in patient's cardiac rhythm/condition...If no resolution from a nurse within 2 minutes from time of initial notification, the monitor tech should call the unit's charge nurse and enter the notification time on the log...If no response within 5 minutes from time of initial notification, the monitor tech should initiate a "Telemetry Alert" broadcast to the unit staff which will automatically notify the Charge Nurse and House Supervisor by sending a broadcast through immobile..."