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Based on policy review, cardiac monitor operations manual review, observation, medical record review, staffing assignment review, staff and physician interviews and review of an administrative investigation, the hospital leadership failed to provide oversight and have systems in place to ensure the protection of patients' rights and an organized nursing service to ensure that patients on cardiac monitors in the emergency department were evaluated and assessed when cardiac monitor alarms activate.

The findings include:

1. The hospital's nursing staff failed to protect and promote patients' rights for a safe environment for patients on cardiac monitors in the emergency department as evidence by failing to monitor, evaluate and assess cardiac status when cardiac monitor alarms activated signaling changes in the patient's cardiac status.

~cross refer to 482.13 Patient Rights' Condition: Tag A0115

2. The hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure patients on cardiac monitors were monitored, evaluated and assessed for changes in cardiac status when cardiac monitor alarms were activated warning of changes in cardiac status.

~cross refer to 482.23 Nursing Services Condition: Tag A0385

Based on policy review, cardiac monitor operations manual review, observation, medical record review, staffing assignment review, staff and physician interviews and review of an administrative investigation, the hospital's nursing staff failed to protect and promote patients' rights for a safe environment for patients on cardiac monitors in the emergency department as evidence by failing to monitor, evaluate and assess cardiac status when cardiac monitor alarms activated signaling changes in the patient's cardiac status.

The findings include:

The hospital failed to ensure a safe environment for the delivery of care to emergency department patients on cardiac monitors as evidenced by failing to ensure continuous supervision of cardiac monitors, response to cardiac monitor alarms and assessment of a patient when a cardiac alarm warned of a change in the patient's cardiac status.

~cross refer to 482.13(c)(2) Patients' Rights Standard: Tag A0144

Based on policy review, cardiac monitor operations manual review, observation, medical record review, staffing assignment review, staff and physician interviews and review of an administrative investigation, the hospital failed to ensure a safe environment for the delivery of care to emergency department patients on cardiac monitors as evidenced by failing to ensure continuous supervision of cardiac monitors, response to cardiac monitor alarms and assessment of a patient when a cardiac alarm warned of a change in the patient's cardiac status for 1 of 4 sampled patients on a cardiac monitor (#4).

The findings include:

Review of the Emergency Department "Continuous Cardiac Monitoring Protocol" revised April 2012 revealed "... Procedure: Critically ill patients presenting to the emergency department will have continuous cardiac monitoring. ... The monitors will be directly observed by a staff member competent in dysrhythmia interpretation. ... Changes in cardiac rhythm or rate, with clinical significance or changes in hemodynamic status, will be communicated to the physician immediately...."
Review of the Emergency Department policy "Assessment and Reassessment" revised December 2009 revealed "...Unstable patients should be reassessed as frequently as needed in order to assess the patient's condition and response to interventions...."

Review of the hospital's "Hand-Off Communication" policy revised November 1, 2008 revealed "Purpose: To provide consistent interactive communication between staff (hand-offs), including the opportunity to ask and respond to questions when a patient/client leaves one department/unit to go to another, transfers from one location to another and/or whenever there is a change in the care provider and/or Licensed Independent Practioner (LIP).... B. Direct communication must occur between staff whenever care is turned over to another provider. It includes, but is not limited to: ...2. Relief for staff leaving the unit for lunch or breaks. 3. Transfer level of care - patients leaving one nursing unit to move to another nursing unit..."

Review of the Operations Manual for the cardiac monitoring equipment (Spacelab) used in the emergency department (ED) revealed "...Higher priority alarms relate to changes in the patient's condition. Lower priority alarms typically relate to changes in signal quality. Higher priority alarms always override lower priority alarms. ... Events that can cause an ECG (electrocardiogram) alarm include: high or low rate, ventricular fibrillation, asystole ... Alarm condition are visually and audibly prioritized as high, medium, or low...." Further review of the Operations Manual revealed a "High" priority alarm tone type includes "two bursts of five tones every 15 seconds, or continuous tone until the alarm condition is resolved, the alarm is suspended, or the tone is reset." Review revealed the audible alarm is accompanied by a visual flashing red alert message that appears on the monitors. Review of the manual revealed an "asystole alarm" is a "High" priority alarm.

Observation during tour of the emergency department on 10/22/2013 at 1345 revealed a total of 26 beds and 20 cardiac (telemetry) monitored beds. Observation revealed the 20 cardiac monitored beds had bedside monitor screens with visual and audible alarms. Observation revealed a central monitor station located at the end of a centrally located nursing station that displayed data from each patient that was on a cardiac monitor in the ED. Observation of the central monitor station revealed visible and audible alarms were seen and heard at the central monitor station and within the ED area. Observation revealed another monitor screen that was located on a wall visible to the nursing station. Observation revealed the monitor screen displayed all patients that were on a cardiac monitor in the ED.

Closed record review on 10/23/2013 of Patient #4 revealed a 66 year-old female that presented to the emergency department on 08/25/2013 at 1048 via EMS (ambulance transport) with a chief complaint of low blood sugar and altered mental status. Review of the EMS trip report revealed the patient had a blood sugar level of 16 (critical low) upon arrival to the patient's residence and the patient received treatment for the low blood sugar en route to the ED. Review of the triage notes at 1049 revealed the patient was awake, sleepy and disoriented with a blood sugar of 69 on arrival. Review of the notes at 1050 revealed the patient's temperature was 97.6 Fahrenheit, pulse 86, respiratory rate 16, blood pressure 103/56 and oxygen saturation 94% on room air. Review of physician's notes revealed the patient was evaluated at 1100 and lab studies, EKG, chest x-ray and CT of the head and abdomen were ordered. Review of nursing notes at 1100 recorded the patient had a blood sugar of 65 and was given orange juice at 1112. Review of nursing notes revealed the patient was placed on oxygen at 2 liters per nasal cannula and a cardiac monitor at 1113. Nursing notes documented the patient was in normal sinus rhythm at 1113. Notes revealed the patient ate a few bites of a meal at 1130 with a repeat blood sugar result of 63 at 1158. Review of nursing notes at 1228 revealed a critical lab result of "glucose 46 (low)" was reported to the physician. Nursing notes documented by RN #1 (primary nurse) at 1327 recorded "Patient report provided to (RN #2)." Nursing notes documented by RN #1 at 1357 recorded "Upon returning to department, in room to evaluate pt (patient) due to alarm sounding. Pt lying supine with head turned to side, and head of bed elevated. Monitor showing asystole. Pt carotid checked for palpable pulse. Chest checked for resp (respiration). No pulse was palpable. No rise and fall of chest noted. Called for help, and chest compressions initiated." Review of the notes revealed the code ended at 1426 and the patient expired. Review of cardiac monitor strips revealed "1344 (13 minutes before RN #1 assessed the patient) HR (heart rate) 0 **ALARM** ASYSTOLE (lethal cardiac rhythm)."

Review of ED staffing on 08/25/2013 between 1300 and 1400 revealed the following: one physician (MD #3); one physician's assistant (PA #10); six registered nurses (RN#1, RN #2, RN #4, RN #5, RN #7 and RN #9); one nursing assistant (NA #8) and one unit secretary (staff #6). Additionally there was one physician's assistant; three registered nurses and one patient care assistant in the triage area.

Telephone interview on 10/23/2013 at 1415 with RN #1 revealed he remembered Patient #4 and he was her primary nurse. The nurse stated the patient was unstable and he had placed her on a cardiac monitor to monitor her closely. The nurse stated he was also monitoring her blood sugar levels. The nurse stated "It was time to go to lunch. I reported off to (RN #2) regarding the patient's status. She (Patient #4) was on the monitor and she would need a fingerstick blood sugar before I returned. I returned from lunch. I came in through the back door and heard an alarm sounding. I looked at the monitor to see where it was coming from. It was asystole, room CT3 (Patient #4's room). I entered the room, asked are you okay?, got no response, checked pulse, saw no chest rise and fall. There was no pulse and no respiration. I called for help and we coded the patient. (RN #5) and (RN #4) arrived first, then (MD #3). After the code was called I did an event review (review of cardiac monitor strips). I talked with the charge nurse because it looked like the patient had been in asystole 5 minutes or longer before I came back from lunch. There was a discrepancy between the monitor time and the computer time. I talked with (RN #2). She had left the unit to take another patient to an inpatient unit. She had not given a report to anyone before she left the ED. The charge nurse (RN #5) was at lunch and RN #4 was covering her." The nurse stated is was the responsibility of the nurse assigned to the patient to watch the cardiac monitor. He stated "We all watch those monitors. If an alarm sounds, we are supposed to assess the patient."

Telephone interview on 10/24/2013 at 1040 with RN #2 revealed the nurse remembered the incident with Patient #4. The nurse stated "(RN #1) gave me report. He said she had a low blood sugar. He had fed her and she was talking. Her sugar was up and I needed to recheck a fingerstick blood sugar in 20 minutes. I decided to take my other patient upstairs and I don't think I told anyone I was leaving. No alarms were sounding when I left. When I returned everybody was in her (Patient #4) room. (RN #1) said he heard the alarm when he returned to the ED from lunch. The charge nurse was on lunch and nobody was watching the monitors. I have never been told at (name of hospital) who was supposed to watch the monitor. I don't know whose job that is. It (Central Monitoring Station) is in front of the charge nurse desk. I didn't realize how seriously sick this woman was."

Interview on 10/23/2013 at 1500 with MD #3 revealed he remembered Patient #4. The physician stated he was in the pit (center of the nursing station) and heard a nurse call out cardiac arrest. The physician stated the patient had no pulse and no spontaneous breathing when he arrived. The physician stated "There was monitor paper on the floor. That concerned me. I don't remember hearing an alarm. I didn't hear it going into the room. Nursing staff are responsible for watching the monitors. This situation should not occur. No one should be in asystole and no one know it for 10 minutes."

Interview on 10/23/2013 at 1510 with RN #4 revealed she remembered the incident with Patient #4. The nurse stated "The charge nurse had gone to lunch. She handed me the charge nurse phone and told me the next two rooms up (for patients). Nothing else was said. Typically we give patient report. I had no idea that patient was as critical as she was. I did not know the status of the patients or the nurses that had gone to lunch. (RN #2) had taken (RN #9's) patients because (RN #9) was tied up monitoring a one to one pediatric patient that had conscious sedation. (RN #1) had gone to lunch. (RN #2) was covering his patients. I was in the medication room with a pharmacy tech loading narcotics into the Omnicell (automatic dispensing medication system)." The nurse stated she was in and out of patient rooms and at the nursing desk area during the time she was covering for the charge nurse. Interview revealed "Typically the charge nurse was supposed to watch the monitor along with who ever else. Everybody is responsible to monitor the alarms. There were two nurses left in the ED (RN #7) and me. (RN #9) was tied up with a one to one monitoring. I don't remember hearing the alarm. When an alarm goes off, who ever hears it should assess the patient. The nursing assistant or unit secretary should notify somebody if they hear an alarm. I was not notified when (RN #2) left the ED."

Interview on 10/23/2013 at 1615 with RN #5 revealed she was the charge nurse on 08/25/2013 and remembered the incident with Patient #4. The charge nurse stated she had asked RN #2 to relieve RN #1 for lunch. The charge nurse stated RN #9 was monitoring one to one with a patient who had received conscious sedation. The charge nurse stated she went to lunch and gave a "quick and brief" summary to RN #4 before she left the ED. The charge nurse stated she returned from lunch and heard RN #1 calling for help in CT3 (Patient #4's room). The nurse stated "I did not hear an alarm. I went into the room and saw monitor paper all over the floor. It had been going for a few minutes. (RN #1) got the paper and found that the patient had been in asystole for some time. I don't remember how long. We discovered the time didn't match (cardiac monitor and computer). (RN #2) had gone to the floor and didn't give report. She should have checked with (RN #4 relief charge nurse) before she left the unit. There was a lack of communication and a lack of nursing judgement."

Interview on 10/23/2013 at 1809 with RN #7 revealed she remembered the incident with Patient #4. The nurse stated she didn't remember what she was doing before (RN #1) said he needed help. The nurse stated she was at the nursing station when RN #1 called for help. The nurse stated "No, I didn't hear an alarm. Bells are ringing all day. I can't confirm if it went off or not. The main monitor is located at the change nurse desk. She is not glued to that area. It was the responsibility of who ever relieved her to watch the monitors."

Interview on 10/23/2013 at 1730 with staff #6 revealed the staff member is usually located at the nursing station desk area. The staff member stated she remembered the incident with Patient #4. The staff member stated "I don't remember alarms going off during the time (RN #1) was gone to lunch. He came back and went into CT3 and he yelled for help. I looked and he was doing chest compressions. I get a combination of alarms. The phone is ringing, printer is going, there is a lot of chatter. I can't say whether I heard an alarm or not. I don't know who was watching the monitors. If the charge nurse leaves, these is no one there to watch the monitor."

Interview on 10/24/2013 at 0910 with NA #8 revealed the staff member thought she remembered the incident with Patient #4. The staff member stated "I couldn't say if I heard an alarm or not. If I hear an alarm, I go check the patient to see if anything is loose or if the pulse oximeter probe is off the finger. I make sure they are breathing."

Telephone interview on 10/24/2013 at 1025 with PA #10 revealed he did not remember Patient #4 or any situation with delayed response to an alarm. The interview revealed the PA had started working at the hospital's ED the last week of July and did not remember any code blue situations since he had been there. Interview revealed the PA was able to hear alarms when he was located at the nursing station.

Review on 10/23/2013 of an administrative investigation (Root Cause Analysis) Timeline revealed "It is believed there was approximately 9-10 minutes before response to the alarms. The clocks on the computer and the monitor and the life pack are not synchronized." Review of the investigation revealed it was found that no one individual was responsible for watching the central monitor in the ED. The investigation revealed that RN #2 had left the unit to transport a patient to an inpatient unit and had failed to report to anyone that she was leaving the ED. Findings revealed the ED charge nurse had also gone to lunch at the same time as RN #1 and had failed to report off to the relief charge nurse.

Consequently, Patient #4 presented to the emergency department on 08/25/2013 at 1048 with hypoglycemia (low blood sugar) and altered mental status. The patient was unstable and placed on a cardiac monitor for close monitoring. The patient's primary nurse (RN #1) reported off to RN #2 at 1327 when RN #1 left the unit to go to lunch. RN #1 returned to the unit from lunch at 1357 (30 minutes later) and heard an alarm when he came through the ED unit doors. RN #1 viewed the cardiac monitor and saw it was Patient #4 in asystole (lethal cardiac rhythm). RN #1 assessed the patient and found she had no pulse and no respiration. Cardiopulmonary resuscitation (CPR) was started and ended at 1426 when the patient expired. Findings revealed the patient had been in asystole for 9-10 minutes with alarms sounding before a nurse responded and assessed the patient.

Based on policy review, cardiac monitor operations manual review, observation, medical record review, staffing assignment review, staff and physician interviews and review of an administrative investigation, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure patients on cardiac monitors were monitored, evaluated and assessed for changes in cardiac status when cardiac monitor alarms were activated warning of changes in cardiac status.

The findings include:

Emergency department nursing staff failed to evaluate and assess a patient when cardiac monitoring warning alarms sounded indicating a change in the patient's cardiac status.

~cross refer to 482.23(b)(4) Nursing Services Standard: Tag A0395

Based on policy review, cardiac monitor operations manual review, observation, medical record review, staffing assignment review, staff and physician interviews and review of an administrative investigation, emergency department nursing staff failed to evaluate and assess a patient when cardiac monitoring warning alarms sounded indicating a change in the patient's cardiac status for 1 of 4 sampled patient's on a cardiac monitor (#4).

The findings include:

Review of the Emergency Department "Continuous Cardiac Monitoring Protocol" revised April 2012 revealed "... Procedure: Critically ill patients presenting to the emergency department will have continuous cardiac monitoring. ... The monitors will be directly observed by a staff member competent in dysrhythmia interpretation. ... Changes in cardiac rhythm or rate, with clinical significance or changes in hemodynamic status, will be communicated to the physician immediately...."
Review of the Emergency Department policy "Assessment and Reassessment" revised December 2009 revealed "...Unstable patients should be reassessed as frequently as needed in order to assess the patient's condition and response to interventions...."

Review of the hospital's "Hand-Off Communication" policy revised November 1, 2008 revealed "Purpose: To provide consistent interactive communication between staff (hand-offs), including the opportunity to ask and respond to questions when a patient/client leaves one department/unit to go to another, transfers from one location to another and/or whenever there is a change in the care provider and/or Licensed Independent Practioner (LIP).... B. Direct communication must occur between staff whenever care is turned over to another provider. It includes, but is not limited to: ...2. Relief for staff leaving the unit for lunch or breaks. 3. Transfer level of care - patients leaving one nursing unit to move to another nursing unit..."

Review of the Operations Manual for the cardiac monitoring equipment (Spacelab) used in the emergency department (ED) revealed "...Higher priority alarms relate to changes in the patient's condition. Lower priority alarms typically relate to changes in signal quality. Higher priority alarms always override lower priority alarms. ... Events that can cause an ECG (electrocardiogram) alarm include: high or low rate, ventricular fibrillation, asystole ... Alarm condition are visually and audibly prioritized as high, medium, or low...." Further review of the Operations Manual revealed a "High" priority alarm tone type includes "two bursts of five tones every 15 seconds, or continuous tone until the alarm condition is resolved, the alarm is suspended, or the tone is reset." Review revealed the audible alarm is accompanied by a visual flashing red alert message that appears on the monitors. Review of the manual revealed an "asystole alarm" is a "High" priority alarm.

Observation during tour of the emergency department on 10/22/2013 at 1345 revealed a total of 26 beds and 20 cardiac (telemetry) monitored beds. Observation revealed the 20 cardiac monitored beds had bedside monitor screens with visual and audible alarms. Observation revealed a central monitor station located at the end of a centrally located nursing station that displayed data from each patient that was on a cardiac monitor in the ED. Observation of the central monitor station revealed visible and audible alarms were seen and heard at the central monitor station and within the ED area. Observation revealed another monitor screen that was located on a wall visible to the nursing station. Observation revealed the monitor screen displayed all patients that were on a cardiac monitor in the ED.

Closed record review on 10/23/2013 of Patient #4 revealed a 66 year-old female that presented to the emergency department on 08/25/2013 at 1048 via EMS (ambulance transport) with a chief complaint of low blood sugar and altered mental status. Review of the EMS trip report revealed the patient had a blood sugar level of 16 (critical low) upon arrival to the patient's residence and the patient received treatment for the low blood sugar en route to the ED. Review of the triage notes at 1049 revealed the patient was awake, sleepy and disoriented with a blood sugar of 69 on arrival. Review of the notes at 1050 revealed the patient's temperature was 97.6 Fahrenheit, pulse 86, respiratory rate 16, blood pressure 103/56 and oxygen saturation 94% on room air. Review of physician's notes revealed the patient was evaluated at 1100 and lab studies, EKG, chest x-ray and CT of the head and abdomen were ordered. Review of nursing notes at 1100 recorded the patient had a blood sugar of 65 and was given orange juice at 1112. Review of nursing notes revealed the patient was placed on oxygen at 2 liters per nasal cannula and a cardiac monitor at 1113. Nursing notes documented the patient was in normal sinus rhythm at 1113. Notes revealed the patient ate a few bites of a meal at 1130 with a repeat blood sugar result of 63 at 1158. Review of nursing notes at 1228 revealed a critical lab result of "glucose 46 (low)" was reported to the physician. Nursing notes documented by RN #1 (primary nurse) at 1327 recorded "Patient report provided to (RN #2)." Nursing notes documented by RN #1 at 1357 recorded "Upon returning to department, in room to evaluate pt (patient) due to alarm sounding. Pt lying supine with head turned to side, and head of bed elevated. Monitor showing asystole. Pt carotid checked for palpable pulse. Chest checked for resp (respiration). No pulse was palpable. No rise and fall of chest noted. Called for help, and chest compressions initiated." Review of the notes revealed the code ended at 1426 and the patient expired. Review of cardiac monitor strips revealed "1344 (13 minutes before RN #1 assessed the patient) HR (heart rate) 0 **ALARM** ASYSTOLE (lethal cardiac rhythm)."

Review of ED staffing on 08/25/2013 between 1300 and 1400 revealed the following: one physician (MD #3); one physician's assistant (PA #10); six registered nurses (RN#1, RN #2, RN #4, RN #5, RN #7 and RN #9); one nursing assistant (NA #8) and one unit secretary (staff #6). Additionally there was one physician's assistant; three registered nurses and one patient care assistant in the triage area.

Telephone interview on 10/23/2013 at 1415 with RN #1 revealed he remembered Patient #4 and he was her primary nurse. The nurse stated the patient was unstable and he had placed her on a cardiac monitor to monitor her closely. The nurse stated he was also monitoring her blood sugar levels. The nurse stated "It was time to go to lunch. I reported off to (RN #2) regarding the patient's status. She (Patient #4) was on the monitor and she would need a fingerstick blood sugar before I returned. I returned from lunch. I came in through the back door and heard an alarm sounding. I looked at the monitor to see where it was coming from. It was asystole, room CT3 (Patient #4's room). I entered the room, asked are you okay?, got no response, checked pulse, saw no chest rise and fall. There was no pulse and no respiration. I called for help and we coded the patient. (RN #5) and (RN #4) arrived first, then (MD #3). After the code was called I did an event review (review of cardiac monitor strips). I talked with the charge nurse because it looked like the patient had been in asystole 5 minutes or longer before I came back from lunch. There was a discrepancy between the monitor time and the computer time. I talked with (RN #2). She had left the unit to take another patient to an inpatient unit. She had not given a report to anyone before she left the ED. The charge nurse (RN #5) was at lunch and RN #4 was covering her." The nurse stated is was the responsibility of the nurse assigned to the patient to watch the cardiac monitor. He stated "We all watch those monitors. If an alarm sounds, we are supposed to assess the patient."

Telephone interview on 10/24/2013 at 1040 with RN #2 revealed the nurse remembered the incident with Patient #4. The nurse stated "(RN #1) gave me report. He said she had a low blood sugar. He had fed her and she was talking. Her sugar was up and I needed to recheck a fingerstick blood sugar in 20 minutes. I decided to take my other patient upstairs and I don't think I told anyone I was leaving. No alarms were sounding when I left. When I returned everybody was in her (Patient #4) room. (RN #1) said he heard the alarm when he returned to the ED from lunch. The charge nurse was on lunch and nobody was watching the monitors. I have never been told at (name of hospital) who was supposed to watch the monitor. I don't know whose job that is. It (Central Monitoring Station) is in front of the charge nurse desk. I didn't realize how seriously sick this woman was."

Interview on 10/23/2013 at 1500 with MD #3 revealed he remembered Patient #4. The physician stated he was in the pit (center of the nursing station) and heard a nurse call out cardiac arrest. The physician stated the patient had no pulse and no spontaneous breathing when he arrived. The physician stated "There was monitor paper on the floor. That concerned me. I don't remember hearing an alarm. I didn't hear it going into the room. Nursing staff are responsible for watching the monitors. This situation should not occur. No one should be in asystole and no one know it for 10 minutes."

Interview on 10/23/2013 at 1510 with RN #4 revealed she remembered the incident with Patient #4. The nurse stated "The charge nurse had gone to lunch. She handed me the charge nurse phone and told me the next two rooms up (for patients). Nothing else was said. Typically we give patient report. I had no idea that patient was as critical as she was. I did not know the status of the patients or the nurses that had gone to lunch. (RN #2) had taken (RN #9's) patients because (RN #9) was tied up monitoring a one to one pediatric patient that had conscious sedation. (RN #1) had gone to lunch. (RN #2) was covering his patients. I was in the medication room with a pharmacy tech loading narcotics into the Omnicell (automatic dispensing medication system)." The nurse stated she was in and out of patient rooms and at the nursing desk area during the time she was covering for the charge nurse. Interview revealed "Typically the charge nurse was supposed to watch the monitor along with who ever else. Everybody is responsible to monitor the alarms. There were two nurses left in the ED (RN #7) and me. (RN #9) was tied up with a one to one monitoring. I don't remember hearing the alarm. When an alarm goes off, who ever hears it should assess the patient. The nursing assistant or unit secretary should notify somebody if they hear an alarm. I was not notified when (RN #2) left the ED."

Interview on 10/23/2013 at 1615 with RN #5 revealed she was the charge nurse on 08/25/2013 and remembered the incident with Patient #4. The charge nurse stated she had asked RN #2 to relieve RN #1 for lunch. The charge nurse stated RN #9 was monitoring one to one with a patient who had received conscious sedation. The charge nurse stated she went to lunch and gave a "quick and brief" summary to RN #4 before she left the ED. The charge nurse stated she returned from lunch and heard RN #1 calling for help in CT3 (Patient #4's room). The nurse stated "I did not hear an alarm. I went into the room and saw monitor paper all over the floor. It had been going for a few minutes. (RN #1) got the paper and found that the patient had been in asystole for some time. I don't remember how long. We discovered the time didn't match (cardiac monitor and computer). (RN #2) had gone to the floor and didn't give report. She should have checked with (RN #4 relief charge nurse) before she left the unit. There was a lack of communication and a lack of nursing judgement."

Interview on 10/23/2013 at 1809 with RN #7 revealed she remembered the incident with Patient #4. The nurse stated she didn't remember what she was doing before (RN #1) said he needed help. The nurse stated she was at the nursing station when RN #1 called for help. The nurse stated "No, I didn't hear an alarm. Bell are ringing all day. I can't confirm if it went off or not. The main monitor is located at the change nurse desk. She is not glued to that area. It was the responsibility of who ever relieved her to watch the monitors."

Interview on 10/23/2013 at 1730 with staff #6 revealed the staff member is usually located at the nursing station desk area. The staff member stated she remembered the incident with Patient #4. The staff member stated "I don't remember alarms going off during the time (RN #1) was gone to lunch. He came back and went into CT3 and he yelled for help. I looked and he was doing chest compressions. I get a combination of alarms. The phone is ringing, printer is going, there is a lot of chatter. I can't say whether I heard an alarm or not. I don't know who was watching the monitors. If the charge nurse leaves, these is no one there to watch the monitor."

Interview on 10/24/2013 at 0910 with NA #8 revealed the staff member thought she remembered the incident with Patient #4. The staff member stated "I couldn't say if I heard an alarm or not. If I hear an alarm, I go check the patient to see if anything is loose or if the pulse oximeter probe is off the finger. I make sure they are breathing."

Telephone interview on 10/24/2013 at 1025 with PA #10 revealed he did not remember Patient #4 or any situation with delayed response to an alarm. The interview revealed the PA had started working at the hospital's ED the last week of July and did not remember any code blue situations since he had been there. Interview revealed the PA was able to hear alarms when he was located at the nursing station.

Review on 10/23/2013 of an administrative investigation (Root Cause Analysis) Timeline revealed "It is believed there was approximately 9-10 minutes before response to the alarms. The clocks on the computer and the monitor and the life pack are not synchronized." Review of the investigation revealed if was found that no one individual was responsible for watching the central monitor in the ED. The investigation revealed that RN #2 had left the unit to transport a patient to an inpatient unit and had failed to report to anyone that she was leaving the ED. Findings revealed the ED charge nurse had also gone to lunch at the same time as RN #1 and had failed to report off to the relief charge nurse.

Consequently, Patient #4 presented to the emergnecy department on 08/25/2013 at 1048 with hypoglycemia (low blood sugar) and altered mental status. The patient was unstable and placed on a cardiac monitor for close monitoring. The patient's primary nurse (RN #1) reported off to RN #2 at 1327 when RN #1 left the unit to go to lunch. RN #1 returned to the unit from lunch at 1357 (30 minutes later) and heard an alarm when he came through the ED unit doors. RN #1 viewed the cardiac monitor and saw it was Patient #4 in asystole (lethal cardiac rhythm). RN #1 assessed the patient and found she had no pulse and no respiration. Cardiopulmonary resuscitation (CPR) was started and ended at 1426 when the patient expired. Findings revealed the patient had been in asystole for 9-10 minutes with alarms sounding before a nurse responded and assessed the patient.

NC00092364