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Based on review of medical records, policies and interviews, the facility failed to act upon a change in cardiac rhythm and escalate process of notification resulting in a patient death, and a risk of death in 2 (#1, #5) of 3 patients reviewed.

The facility failed to response to a change in cardiac rhythm for Patient #1, resulting in death.
The facility failed to implement orders for cardiac telemetry monitoring for Patient #3.
The hospital's action resulted in Immediate Jeopardy, starting 08/24/23. The Immediate Jeopardy was ongoing as of the exit date of 09/13/23. Refer to A144 (Standard).

Based on review of medical records, policies and interviews the facility failed to provide a safe setting for 2(#1, #5) out of 3 patients reviewed for telemetry. The facility's actions contributed to the death of Patient #1, which resulted in Immediate Jeopardy. Refer to A0115, Condition of Participation.

Findings included:

1) Patient #1 ' s medical record was reviewed. The patient arrived at the facility ED (Emergency Department) via EMS (Emergency Medical Services) on 8/24/2023 at 3:32PM with chief complaint of increased weakness and cough. The patient stated he was feeling achy and had a positive COVID-19 (Coronavirus Disease 2019) test. Vital signs were stable on arrival. Patient #1 had a medical history of Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), hypertension (high blood pressure), hypothyroid (the thyroid gland doesn't make enough thyroid hormones to meet the body's needs), pacemaker (implanted medical device that sends electrical pulses to the heart to help it beat at a normal rate and rhythm), cholecystectomy (removal of gallbladder), and Atrial Fibrillation (a type of arrhythmia, or abnormal heartbeat). Patient #1 received an admit order on 08/24/2023 at 8:18 PM. At 10:46 PM, a nurse' s note stated the patient had a temperature of 101.8 [degrees Fahrenheit] and had no treatment orders. In an effort to treat the fever, Staff B, RN (Registered Nurse) called the admitting physician for orders and was unable to contact anyone. Registration admitted the patient in the electronic bed assignment system, to an incorrect room at 9:25PM, resulting in the electronic bed assignment system showing him in a different room. Cardiac Telemetry monitoring was applied by the charge nurse in the emergency room with no documentation of the exact time this occurred. A review of the cardiac monitoring strips showed that on 8/24/2023 at 10:52 PM, right arm fail, leads off. At 8/24/2023 11:17 PM, Patient #1 ' s cardiac rhythm noted to be Ventricular Fibrillation (A serious heart rhytm problem in which the heart beats faster and out of rhythm).

On 8/24/2023 11:37 PM, a Code Blue (Cardiac arrest) was called by ED Staff after Staff B, RN went into the patient's room to administer medication and noted the patient lying across the bed, mouth open with the nasal cannula out of his nose. Staff B called the patient's name, performed a sternal rub, and noticed no chest rise and fall. Staff B did not feel a pulse and called a Code Blue and began chest compressions. Ultimately on 8/25/2023 at 12:00 AM Patient #1's time of death was declared.

In a telephone interview on 09/11/2023 7:21 PM with Staff A, monitor technician (MT), Staff A stated that Patient #1 was supposed to be in 2 West. Staff A was monitoring [cardiac telemetry] 2 West and 2 Central. Patient #1 started to have a lethal heart rhythm. Only one [cardiac] lead was on, and it looked like artifact (not a rhythm) or Ventricular Fibrillation. I called the nurse on the floor [2 West] and she said the patient wasn ' t there yet. I didn ' t know what to do at that time. It didn ' t seem reasonable to call a Code Blue to an empty room. Staff D, House Supervisor was there and I asked her what to do. We tried to locate the patient. He was supposed to be in ER [Room] X according to the electronic medical system. I called the ER and no one answered. "Me and the house [supervisor] didn' t know what to do. I didn' t know where the patient was. I knew he needed help. There was only one lead on." Staff A, MT stated she was trying to find information in the computer to locate the patient. About 5 to 6 minutes later she saw the Ventricular Fibrillation (fatal cardiac arrhythmia). She stated she called the nursing unit again, because her monitor showed the patient was on the unit. The nurse said the patient still hadn' t arrived. She stated she then called the ED and there was no answer, so she asked the supervisor what to do. She called the ED again and spoke to Staff C, ED CN (Charge Nurse) who said the patient had a nurse in the room with him. About 7 minutes later she heard a Code Blue (cardiac arrest) called and figured out it was for Patient #1. It was flat line (asystole - no heart beat)) before they called the Code Blue. We do have a policy to call a Code to the patient' s bedside. But there wasn' t a patient in the location the monitor showed he was in. Staff A said she also had 55 patients she was monitoring.

In a telephone interview on 9/11/23 7:47 PM with Staff B, RN , she said she was on a different assignment and switched with one of the nurses, and took over the assignment at around 9:00 PM. She did a set of vitals on Patient #1 right after report. He was awake, alert, oriented. She checked his temperature, and it was 101.2 degrees Fahrenheit. She called the attending doctor and did not get an answer. She then sent a text and didn' t get an answer. Then she attempted to contact the on- call physician and his phone was off. She went to the ED doctor and told them he had been "admitted for hours and didn't have one prn" (as needed) order. The practitioner gave orders for Tylenol and Rocephin (an antitibiotic). Staff B stated that it took about 15 minutes for the orders to be processed. So around 11:00PM, Staff B pulled the medication from the dispensing system and went into the room and called Patient #1' s name. He didn't respond, so she did a sternal chest rub. He still didn't respond. Staff B called a Code Blue and started CPR (Cardio Pulmonary Resuscitation). "He was down for 20 minutes before CPR was started."

In a telephone interview with Staff D, House Supervisor (NS) on 09/12/2023 at 10:05 AM she stated she was in the cardiac monitor room rounding. She looked at the logs and the trees. She looked at Staff A,MT's screen and saw Patient #1 was in distress and asked Staff A, MT about it. Staff A said Patient #1 has been doing that [questionable irregular rhythm] for a while and Staff A was unable to contact the nurse because she didn't know where Patient#1 was. Staff A told Staff D, House Supervisor, that she had called the floor and the ED and spoke to Staff C,Charge Nurse who stated the patient wasn't there. Staff A said she called the floor again and they said Patient #1 was not there. "So, we were talking, and I said maybe he is in transit. I wasn't sure what was going on, I didn't like it [the cardiac rhythm on the screen]. Staff A said it was just artifact. When the patients move around a lot it can cause artifact." Staff D stated she asked Staff A what she had done to find the patient. "The rhythm was changing. I was not sure what was going on. I wasn ' t there from the onset. I didn ' t know if he was moving while he was in transit. She said she was following what she was supposed to do. I thought well ok, if you're following what your protocol is. The protocol is to call a rapid response or a Code. According to her it wasn't a lethal rhythm. I am ok with rhythm strips. Not like I was a few years ago. I would reach out to an ICU nurse or if necessary, a doctor or resident. No code was called, no. The patient was registered into the wrong room, and they moved the patient to the room upstairs for monitoring prior to the patient leaving the ER. "

In an interview with Staff C, ED Charge Nurse on 09/12/2023 at 5:40 AM she stated Patient #1 was on a cardiac monitor and his information was faxed to the telemetry monitoring room; however, Staff C had to attend to an emergency and could not bring Patient #1 upstairs right away. Staff C remembered the monitor technician was trying to find the patient. When Staff C received the call, the monitor technician said Patient #1 was in room X, but there was not a patient in that room. We then found the patient in [another] room Y in cardiac arrest. A Code was called. Staff C stated she was the assigned charge and acting as secretary that night. Staff C stated she is often playing a dual role. "They have been saying since last October that we are getting a monitor technician for the ED, and we still don't have one." She stated the ED "gets extremely busy, and we can't always bring them upstairs right away. The other night we had 8 ICU [patient] holds and 4 of them were vent [ventilator] patients. There were no ICU (Intensive Care Unit) beds, so the nurses down here had at least 1 ICU patient along with their other case load. We have no staff. Take last night. We had 24 ER holds with 7 nurses after 1 AM. I am in charge, have patients, and the ED secretary. The 2 trauma nurses have assigned patients as well and they should only float, so they are available for traumas." She further stated the ED Manager does his best to help us out, but the [Emergency Department] Director doesn't answer his phone and is very difficult to get a hold of.

In an interview on 09/12/2023 5:53 AM with Staff P, MT she stated Patient #1 was on the ER screen [the ER screen in the cardiac telemetry unit] and being transferred to his room. She stated that when they receive a text message, they are to transfer the patient to the tree [the unit's cardiac monitoring screen]. After Patient #1 was transferred to the tree (2West), the monitor was showing only 1 lead in use and Staff A, MT knew something was wrong, and it needed attention. She called the ER, and they told her the patient went upstairs. She called the floor, but the floor said the patient was not there either. She called the ED again to tell them the patient was not on the floor and the leads needed to be fixed. But the ED said they could not find the patient. Later, the ED called back and said they found the patient and an RN was with him. She stated they realized after the fact; our screen showed the patient was in room Y in the (charting system) but the patient was actually in [another] room X; that's why no one could find him. Then a Code Blue was called. The House Supervisor was in the telemetry monitoring unit with us during that entire time. The telemetry policy came out in January 2023, and it stated the patient stays on the ER tree until the patient goes to the floor to the bed they are assigned to, and the bedside nurse confirms the patient made it to the floor. She stated they were taught a different process. They were taught that when they receive a texted picture of the patient label and telemetry box number from the ED, they move the patient to the room that was assigned to them. "But now we must follow the policy. We had emails sent out regarding reviewing the policy and education. The policy is also printed out and placed in our tele monitor unit for us to review and we need to sign a sign in sheet stating we reviewed it. Then our manager did come to us and ask us if we had any questions regarding the policy. I mentioned, in the policy on page 2 #4 and 5, it is confusing and vague. I pointed out in the policy it does not specify what room or which they are referring to. When I started, I do not recall even seeing or being given a copy of the policy; so, I ' ve been working the way they taught us which is the wrong way. "



2) Review of Patient #5 ' s medical record, showed Patient #5 was admitted to the facility on 08/29/2023 for postop medical management of total right knee arthroplasty (surgical procedure to restore function of a joint). Patient #5 has a past medical history of hypertension, hyperlipemia, and hypothyroidism. A telemetry order was placed for Patient #5 on 08/29/2023 at 1:30 PM.

Review of the telemetry event log dated 08/29/2023 revealed a notation that Patient #5 was received to the nursing unit at 3:17 PM, not put on cardiac monitor until 10:01 PM, approximately 7 hours later.

In an interview on 09/13/2023 at 3:22PM with Staff S, Nurse Manager she revealed Patient #5 came back from PACU (Post Anesthesia Care Unit) on 08/29/2023 at 9:35PM with the cardiac telemetry monitoring on. The monitor tech got confused and thought the patient had discharge orders. She asked another monitor technician to go take the telemetry box off Patient #5. Then later in the shift the monitor tech realized she made a mistake; Patient #5, did not have discharge orders. She told the other monitor technician to put the telemetry box back on the Patient #5. After that incident happened, she educated the monitor technicians on the process of double checking the patients ' name and room number with the orders that are printed out. Also, before taking the box off the patient, they must ask the PCT (Patient Care Technician) working the nursing unit, and then the RN if the telemetry box can be removed from the patient.



3) Review of the policy, Cardiac Telemetry Monitoring, effective 02/16/2023, revealed "Patients on cardiac telemetry will have their rhythm continuously monitored by a telemetry technician or nurse who is competent in cardiac rhythm interpretation. The rhythm will be documented at predetermined intervals as per applicable facility standards. . .

Staff will respond immediately to any significant rhythm change or loss of signal. A defined notification and escalation pathway is used to reliably ensure timely communication and treatment. . . All changes in telemetry monitoring (e.g., room changes, patient transfers, telemetry box changes) must be verified by nursing and should be immediately communicated to the telemetry technician. . . Procedure: If during transport (including transfer from the emergency department) the patient is monitored on a portable heart monitor, then a nurse must accompany the patient. If, however, central monitoring continues during transport, then there is no telemetry related requirement for a nurse to accompany the patient. All patient transfers must be timely communicated to the telemetry technician. . .Rhythm Changes: The telemetry technician must immediately notify the nurse of any significant change in cardiac rhythm. Telemetry technician will record the notification on the telemetry notification log. . .Telemetry notification and escalation process:
Life-threatening arrhythmia -In the event of a potentially life-threatening arrhythmia the telemetry technician will initiate the following procedure: immediately activate 'Code Blue' response to the patient 's bedside, notify the patient 's nurse, document the event on the facility log, print strip with interpretation and send to unit."

Based on review of Plan of correction, facility documents and interviews, the hospital failed to maintain an effective ongoing, data driven quality assessment and performance improvement program.
Due to the facilities inaction with continuing to ensure compliance with previous identified problems with cardiac telemetry orders and escalation, patients were put at risk, and Patient #1 expired.

The hospital's action resulted in Immediate Jeopardy, starting 08/24/23. The Immediate Jeopardy was ongoing as of the exit date of 09/13/23. Refer to A0283, Standard..

Based on review of previous plan of correction dated 11/22/2022 for an Immediate Jeopardy cited for A0115, A0283, and A0385 (refer to the CMS-2567 Statement of Deficiencies for Event ID 71EF11, dated 10/28/22), facility document review, and interviews the facility failed to ensure that actions for identified concerns with cardiac telemetry monitoring were effective and sustained in preventing serious harm or likely serious harm to patients on cardiac monitoring for 2 (#1, #5) of 3 patients reviewed. The facility's actions contributed to Patient #1's death, which resulted in Immediate Jeopardy. Refer to A0263, Condition of Participation.

Findings included:

Review of the Plan of Correction, submitted to the Agency for Healthcare Administration (AHCA) on 11/22/2022 included Performance Indicators which included timely telemetry response and staffing safety. It revealed a measure including targeted education regarding Cardiac Telemetry Workflow to be within the expected standards of practice for safe care of all telemetry patients on telemetry monitoring completed by 11/01/2022.

During an interview conducted with the Director of Patient Safety/Risk Manager on 09/12/2023 at 1:39 PM regarding Patient #1, he revealed they identified human factor, policy and procedure, training and competency as issues in telemetry monitoring incidents. Factors noted were Staff A, MT inattention to detail, and the registrar who registered the patient into the wrong room, and lack of complex thinking by Staff D, House Supervisor. An action plan was developed, and education was done with a read and sign escalation protocol of lethal rhythms, equals Code Blues immediately, as well as Monitor Tech staff must document all notification on logs as they occur. Education was completed on 09/08/2023.

The Director of Patient Safety/Risk Manager further stated, audits of the telemetry logs for any deviation from policy for the registrars began. We did a read and sign specifically about admission bed placement making sure that it ' s accurate where they ' re placing the patient. He disclosed that weekly tests of the system are performed. We disconnect the patient from telemetry and wait to see how the escalation goes.

During an interview conducted at 2:25 PM 09/13/2023 regarding Quality Assurance Process Improvement with Vice President of Quality (VPQ), Emergency Department Manager, Staff S, Progressive Care Unit manager, Assistant Chief Nursing Officer), and the VP of Operations. The staff presented a Power Point presentation. The VPQ stated that the facility continued to track and trend our telemetry logs, stating that they have been at 95% from the date of the event to present. The VPQ stated that after Patient #1's death, immediate education began for the Nursing supervisor, registration, monitor technicians and transport personnel. On 08/29/2023 they began additional education to all the inpatient units.

The ED Manager stated there has been a decrease in ER hold hours of about 30 minutes (How long the patient waits in the ED prior to room placement), and a decrease in the patients length of stay.

The ED Manager stated that 91% of ED staff have completed the education.

Staff S, Manager of Telemetry, PCU and Float Pool stated according to the current telemetry algorithm, if a life threatening arrhythmia is detected, they call a Code Blue (cardiac arrest response) overhead immediately, and then the notifications they have made including the Code Blues, rapid responses or the tele alerts (overhead paging notification) are written on the telemetry notification log and they do not call a unit or the nurse. Monitor Technicians are to immediately call a Code Blue (overhead paging) for a lethal rhythm for life threatening conditions of asystole (no heart beat), ventricular tachycardia (fast heart beat rhythm of the ventricles, the lower chambers of the heart), or 3 or more consecutive PVCS (premature contractions/ineffective heart muscle contractions occurring before the ventricle has refilled with blood) that are rate 142 to 150, ventricular fibrillation (fast abnormal heart rhythm), severe bradycardia (low heart rate) and severe tachycardia (fast heart rate). That's currently our policy. They are familiar with our escalation, and the managers tested them and all of them received 100% on the test.

During an interview conducted with Staff I, MT at 11:19 AM on 9/11/23, Staff I said "if the patient is having a serious rhythm, call the nurse, then the charge [nurse]. If they don't answer call a Code overhead." This is contrary to the policy and management interviews.

In an interview on 9/13/2023 at 3:22PM with Staff S, Nurse Manager she revealed Patient #5 came back from PACU (Post Anesthesia Care Unit) on 8/29/2023 at 9:35 PM with the cardiac telemetry monitoring on. The monitor tech got confused and thought the patient has discharge orders. She asked another monitor technician to go take the telemetry box off Patient #5. Then later in the shift the monitor tech realized she made a mistake; Patient #5, did not have discharge orders. She told the other monitor technician to put the telemetry box back on the Patient #5. After that incident happened, Staff S/Nurse Manager educated the monitor technicians on the process of double checking the patients ' name and room number with the orders that are printed out. Also, before taking the tele box off the patient, they must ask the PCT (Patient Care Technician) working the nursing unit, then the RN [Registered Nurse] if the telemetry box can be taken off the patient.

Based on review of facility staffing, staffing grids, staffing schedules, medical records, and interviews, the facility failed to provide immediate nursing care for a patient with a change in cardiac rhythm on telemetry monitoring resulting in the patient's death in 1( #1) of 3 patients reviewed for telemetry.

The facility failed to identify, locate and rescue a patient in a lethal cardiac rhythm, ultimately ending in the death of Patient #1.
The facility failed to ensure that Patients being cared for in 2 of 3 units were appropriately staffed to ensure their continued safety.

The hospital's action resulted in Immediate Jeopardy, starting 08/24/23. The Immediate Jeopardy was ongoing as of the exit date of 09/13/23. Refer to tag A0392, Standard.

Based on facility staffing grid, the ICUs (Intensive Care Units) and PCU (Progressive Care Unit) staffing schedules and interviews it was determined that the facility failed to ensure that sufficient staffing with an immediate availability of Registered Nurse (RN) in the Surgical Intensive Care Unit (SICU)/Trauma Unit, and Progressive Care Unit (PCU) for 1 of 3 Units reviewed for staffing.

Based on review of medical records, facility documents, and interviews, the facility failed to ensure that patients on telemetry were provided life saving measures in the event of a fatal cardiac arrhythmia (abnormal heart rhythm) in 1 (#1) of 3 patients reviewed for cardiac telemetry services, and failed to provide continuous telemetry monitoring for 2 (#1, #5) of 3 patients reviewed.

The facility's actions contributed to Patient #1's death, which resulted in Immediate Jeopardy. Refer to A0385, Condition of Participation.


Findings include:

1)

a) Review of facility ICUs staffing grid revealed the SICU ratio was one RN (Registered Nurse) to two patients with the Clinical Nurse Coordinator/Charge Nurse (CNC/CN) having no patients. The facility PCU staffing grid revealed the PCU ratio was one RN to four patients with the Clinical Nurse Coordinator/Charge Nurse having no patients.

b) Review of the facility staffing schedules for SICU from 09/01/2023 to 09/11/2023, revealed the following:

On 09/01/2023 at 7AM, CN with 2 patients assignment;

On 09/03/2023 at 7AM, CN with 3 patients assignment;

On 09/03/2023 at 7PM, CN with 1 patients assignment;

On 09/06/2023 at 7PM, CN with 1 patients assignment, and 1 RN with 3 patients assignment;

On 09/07/2023 at 7PM, CN with 1 patients assignment;

On 09/08/2023 at 7AM, CN with 1 patients assignment;

On 09/08/2023 at 7PM, CN with 2 patients assignment, and 3 RNs with 3 patients assignment;

On 09/09/2023 at 7PM, CN with 2 patients assignment, and 6 RNs with 3 patients assignment;

On 09/10/2023 at 7AM, CN with 1 patients assignment, and 1 RN with 3 patient assignment;

On 09/10/2023 at 7PM, CN with 2 patients assignment, and 1 RN with 4 patients assignment;

On 09/11/2023 at 7AM, CN with 2 patients assignment, and 1 RN with 3 patients assignment.


c) On 09/11/2023 at 10:36 AM an interview with Staff H revealed he is Charge Nurse for the unit, caring for 2 patients and acting as the unit secretary. He also stated two ICU RNs are caring for 4 PCU patients each. "Night shift is extremely short; the staff is talking about how unsafe it is and are refusing to pick up extra shifts. One night shift RN will look at the schedule and if its short staffed, he will purposely call out because that is how unsafe it is. He refuses to work like that, so he calls out. The last 45 days have been horrible with staffing; we are back to charge RNs taking assignments along with acting as unit secretary for the unit. Staff H revealed the Chief Nursing Officer (CNO) said its ok for the ICUs to triple [the RN cares for 3 patients] their RNs if the ICU patients are not trauma patients. It's also ok for the charge RNs to take assignments now."



d) Review of the facility staffing schedules for Progressive Care Unit (PCU) from 09/01/2023 to 09/11/2023, revealed the following:

On 09/01/2023 at 7AM, CN with 4 patients assignment;

On 09/01/2023 at 7PM, CN with 4 patients assignment;

On 09/03/2023 at 7AM, CN with 4 patients assignment;

On 09/05/2023 at 7AM, CN with 4 patients assignment;

On 09/06/2023 at 7PM, CN with 4 patients assignment;

On 09/08/2023 at 7AM, CN with 4 patients assignment;

On 09/08/2023 at 7PM, CN with 4 patients assignment;

On 09/09/2023 at 7AM, CN with 4 patients assignment;

On 09/09/2023 at 7PM, CN with 4 patients assignment;

On 09/10/2023 at 7AM, CN with 4 patients assignment;

On 09/10/2023 at 7PM, CN with 4 patients assignment;

On 09/11/2023 at 7AM, CN with 4 patients assignment;

On 09/11/2023 at 7PM, CN with 6 patients assignment, and all RN assignments are 6:1.

e) On 09/12/2023 at 11:20 AM an interview with Staff T, CN revealed staffing on 09/11/2023 nightshift, the charge nurse cared for six patients and the other three RNs also cared for six patients each. Staff T, CN stated the charge RN frequently has an assignment caring for patients. We do what we can to make it work. There is no leadership higher than my manager that seems to care, we ask if we can block rooms and they tell us no, we must go up to 6 patients, if need be, we also have issues when a patient needs to leave the floor for a test, and we must go with the patient. When the charge RN has an assignment, she/he can't monitor/care for any other RNs patients, so we are having to team up and help each other. Staffing has definitely been a challenge this last month and appears to be worse now.

2)

a) Review of Patient #1's medical record was completed. The patient arrived at the facility ED (Emergency Department) via EMS (Emergency Medical Services) on 8/24/2023 at 3:32 PM with chief complaint of increased weakness and cough. The patient states he was feeling achy and had a positive COVID-19(Coronavirus Disease 2019) test. Vital signs were stable on arrival. Patient #1 had a medical history of Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), hypertension (high blood pressure, hypothyroid (the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), pacemaker (implanted medical device that sends electrical pulses to your heart to help it beat at a normal rate and rhythm), cholecystectomy (removal of gallbladder), and Atrial Fibrillation (a type of arrhythmia, or abnormal heartbeat). Patient #1 received an admit order at 08/24/2023 at 8:18 PM. At 10:46 PM, a nurse ' s note states the patient had a temperature at 101.8 [degrees Fahrenheit] and had no treatment orders. To treat the fever, Staff B, RN (registered nurse) called the admitting physician for orders and was unable to contact anyone. Registration personnel admitted the patient in the medical computer system into an incorrect room at 9:25 PM, resulting in the medical computer system showing him in a different room. Cardiac Telemetry monitoring was applied by the charge nurse in the emergency room with no documentation of the exact time this occurred. A review of the cardiac monitoring strips shows that on 8/24/2023 at 10:52 PM, the cardiac monitoring shows right arm fail, leads off. At 8/24/2023 at 11:17 PM, Patient #1's cardiac rhythm noted to be Ventricular Fibrillation (fatal arrhythmia). On 8/24/2023 11:37 PM, a Code blue (Cardiac arrest response) called by ED Staff after Staff B, RN went into the patients' room to administer medication and noted patient lying lateral in bed, mouth open with nasal cannula out of nares (nostrils). Staff B called the patient's name, performed a sternal rub, and noticed no chest rise and fall. Staff B did not feel a pulse and called a Code Blue and began chest compressions. Ultimately on 8/25/2023 at 12:00 AM Patient #1 expired.

b) In a telephone interview on 9/11/23 at 7:47 PM with Staff B, RN (Registered Nurse), she said she was on a different assignment and switched with one of the nurses and took over the assignment at around 9:00PM, and the patient was on telemetry. She did a set of vitals on Patient #1 right after she received report on the patients. He was awake, alert, oriented. She checked his temperature, and it was 101.2 degrees Fahrenheit. She called the attending doctor and did not get an answer. She then sent a text and didn't get an answer, then she attempted to contact the on-call physician and his phone was off. She went to the ED doctor and told them he had been "admitted for hours and didn't have one prn" (as needed) order. The practitioner gave the orders for Tylenol and Rocephin (antibiotic). Staff B stated that it took about 15 minutes for the orders to be processed. Around 11:00PM, Staff B pulled the medication from the dispensing system and went into the room and called Patient #1's name. He didn't respond, so she did a sternal chest rub. He didn't respond to it. Staff B called a code blue (cardiac arrest) and started CPR (Cardiopulmonary Resuscitation). "He was down for 20 minutes before CPR was started."

c) In a telephone interview with Staff D, Nursing Supervisor (NS) on 9/12/23 at 10:05 AM she stated she was in the cardiac monitor room rounding. She looked at the logs (telemetry monitor logs) and the trees (computer screen showing cardiac telemetry strips). She looked at Staff A, Monitor Tech's (MT screen and saw Patient #1 was in distress and asked Staff A, MT about it. Staff A said Patient #1 has been doing that [questionable irregular rhythm] for a while and Staff A was unable to contact the nurse because she didn't know where Patient#1 was. Staff A told her that she had called the floor and the ED and spoke to Staff C, Charge Nurse who stated the patient wasn't there. Staff A said she called the floor again and they said Patient #1 was not there. "So, we were talking, and I said maybe he is in transit. I wasn't sure what was going on, I didn't like it [cardiac rhythm on the screen] She said it was just artifact (not a rhythm). When the patients move around a lot it can cause artifact." She stated she asked Staff A what she had done to find the patient. "The rhythm was changing. I was not sure what was going on. I wasn't there from the onset. I didn't know if he was moving while he was in transit. She said she was following what she was supposed to do. I thought well ok, if you're following what your protocol is. The protocol is to call a rapid or a Code. According to her it wasn't a lethal rhythm. I am ok with rhythm strips. Not like I was a few years ago. I would reach out to an ICU (Intensive Care Unit) nurse or if necessary, a doctor or resident. No Code was called, no. The patient was registered into the wrong room, and they moved the patient to the room upstairs for monitoring prior to the patient leaving the ER. "

d) In an interview with Staff C, ED Charge Nurse (CN) on 9/12/23 at 5:40AM, she stated Patient #1 was on a cardiac monitor and his information was faxed to the telemetry monitoring room, however, Staff C had to attend to an emergency and could not bring the Patient #1 upstairs to his assigned room right away. Staff C remembered the monitor technician was trying to find the patient. When Staff C received the call, the monitor technician said Patient #1 was in room X, but there was not a patient in that room. We then found Patient #1 in room Y in cardiac arrest. A Code was called. Staff C states she was the assigned charge and acting as secretary that night. Staff C stated she is often playing a dual role. "They have been saying since last October that we are getting a monitor technician for the ED, and we still don't have one." She states the ED "gets extremely busy, and we can't always bring them upstairs right away. The other night we had 8 ICU [patient] holds and 4 of them were vent [ventilator] patients, there were no ICU beds, so the nurses down here had at least 1 ICU patient along with their other case load. We have no staff. Take last night we have 24 ER holds with 7 nurses after 1 AM. I am in charge, have patients and the ED secretary. The 2 trauma nurses have assigned patients as well and they should only float, so they are available for traumas."

e) Review of Patient #5 ' s medical record, showed Patient #5 was admitted to the facility on 08/29/2023 for postop medical management of total right knee arthroplasty (surgical procedure to restore function of a joint) with past medical history of hypertension, hyperlipemia, hypothyroidism. A telemetry order was placed for Patient #5 on 08/29/2023 at 1:30 PM.

f) Review of the telemetry event log dated 8/29/2023 revealed a notation that Patient #5 was received to the nursing unit at 3:17 PM, not put on cardiac monitor until 10:01 PM, approximately 7 hours later.