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Based on review of facility policies, observations, medical records reviews, and staff interviews, the facility failed to provide care in a safe setting for patients with continuous cardiac monitoring orders in six (1, 7, 8, 12, 13, & 14) of six sampled telemetry patients, and failed to recognize a lethal cardiac telemetry rhythm due to cardiac monitoring not being applied in one (#1) of six (1, 7, 8, 12, 13, & 14) patients, resulting in death, which was identified as Immediate Jeopardy.. Refer to tag A0144. Cross reference to A0263 and A0365.

An Immediate Jeopardy action removal plan provided by the facility on 01/12/2023 which included:

All nursing staff and cardiac monitoring unit (CMU) staff are required to review the cardiac telemetry monitoring procedures and policies which began 1/11/2023 via Safety Tiered Huddles. All Registered Nurses (RN) and CMU staff will be educated prior to starting their shift. This was completed with staff onsite and observed by surveyors. Education for additional staff prior to working is ongoing. Review of documentation and attestation of staff was completed.

Beginning 1/12/23 at 7am and continuing until further notice, the CMU will have an additional individual to assist with breaks and clerical duties. Observation of telemetry monitoring room was done.

When a new telemetry order is entered, the Telemetry Protocol is followed by the bedside nurse. The Charge Nurse will verify new telemetry orders and complete a second reconciliation with CMU. Began 01/11/2023. Education ongoing. Verification with staff completed.
Leadership rounding will occur every shift to verify team member's knowledge and compliance with policies and processes. Rounding will continue daily for 4 weeks, or until leadership is able to prove staff competency. Began 1/12/2023 and verified by surveyors.

Effective immediately, admission of patients from the ED who require telemetry will be transported with a portable monitor and accompanied by a licensed professional. A warm handoff will occur at the bedside and the ED nurse will stay at the bedside until telemetry box is placed on the patient and reconciliation with CMU is complete. Verified onsite with surveyor observation.
A review of our adverse event reporting process was conducted. There will be a 100% review of the monitoring techs auditing process with the goal of greater than or equal to 90% compliance. Results of monitoring of compliance with the telemetry process will be reported weekly to First Focus for three months, starting 1/13/23.

All Quality and Risk Management staff will be re-educated on the review of adverse events. Education began 01/12/2023 to include the need for immediate investigation, Root Cause Analysis, and development of action plans.

Based on verification of the facilities immediacy removal action plan, verification of education based on staff interviews and observation on 01/12/2022 at 4:56 PM, this resulted in the Immediate Jeopardy being removed.

Based on review of facility policies, observation, medical records reviews, and staff interviews it was determined the facility failed to provide care in a safe setting and failed to follow facility telemetry policy for continuous cardiac monitoring for patients, contributing to Patient #1's death, in six (1, 7, 8, 12, 13, & 14) of six sampled telemetry patients.

Findings included:

Review of the facility policy & procedure title, "Cardiac Monitoring", # NCL0100 . . . PURPOSE: Provide a continuous picture of the patient's cardiac electrical activity . . . An "Off telemetry for test(s)" order, is required for a patient to be transported without continuous monitoring. If provider order requires patient to be on telemetry monitoring for patient transport and test(s), patient must be monitored for test(s) and transported with appropriate telemetry credentialed team members . . . After telemetry box is placed on patient, call monitor tech to verify capture. Follow this process anytime the telemetry box is removed and reapplied. Verify assigned box, with patient ID and box number at least once per shift. Confirm telemetry box number and document in medical record ... When the monitor tech identifies that a patient is off the monitor and no prior notification has been received, the MT immediately calls the patient's nurse and/or Patient Care Tech. If no response from nurse or PCT the MT will contact the Charge Nurse. b. When the leads are reattached the team member calls the MT to confirm capture, including patient's name, room number and telemetry box number before leaving the room ...

A. Review of Patient #8's medical record shows that on 09/05/2022 Patient #8 was admitted to the hospital with a diagnosis of chest pain. Past medical history of three cardiovascular stents (a tubular support placed temporarily inside a blood vessel, canal, or duct to aid healing or relieve an obstruction) placed, high blood pressure, and coronary artery disease. An interview on 1/10/2023 at 11:00 AM with the Regional Risk Manager revealed that on 09/06/2022 the transporter arrived at Patient #8's room to transport the patient to the cardiac catheterization lab for a heart catheterization (insertion of a narrow tube into the heart through an artery to examine how well the heart is functioning). The RN (Registered Nurse) removed the telemetry box without physician orders for telemetry to be removed for transport. Patient #8 transported without cardiac monitoring. Further review of Patient #8 medical record revealed the Ticket to Ride (facility form to be filled out for patient to be transported to other areas of the hospital) with the destination as the cardiac catheterization lab and the telemetry area blank. Physician orders on 09/05/2022 at 7:47 PM included telemetry and to maintain cardiac monitoring when patient is bathing.

B. A review of the medical record for Patient #12 showed he was admitted to the hospital from the emergency department on 9/9/22 with a diagnosis of acute compression fracture and a relevant medical history of hypertension. Review of a physician's order in the medical record dated 9/9/22 9:22 AM reflected "place in observation." Telemetry: yes (telemetry is cardiac monitoring) Further review of the physician's orders dated 9/9/22 9:22 AM revealed an order for telemetry. The documentation reflected it had been acknowledged (signed) by an RN at 9:23 AM. A review of the History and Physical dated 9/9/22 9:57 AM reflected the following: Plan: admit to inpatient observation, telemetry monitor. A review of the Emergency Department Ticket to Ride (communication tool) dated 9/9/22 reflected no indication the patient had an order for telemetry, or cardiac rate and rhythm communication. Upon review of the admission database dated 9/9/22 11:40 AM, there was no indication the patient was on telemetry or any documentation reflecting a cardiac rate and rhythm. Review of the 9/9/22 shift assessment, 8:20 PM, revealed Patient #12 did not have his telemetry implemented. The box for cardiac monitor was checked "no." Upon review of the cardiac rhythm strip dated 9/10/22 5:10 AM, documentation on the strip reflected it was "relabeled to admit strip." Patient #12 was without cardiac monitoring for seventeen hours and 30 minutes; from the time the admission assessment was documented until the next morning.

C. On 1/10/23 at 11:00 AM an interview was conducted with the regional Risk Manager. She disclosed that when Patient #12 was admitted to the nursing unit on 09/09/2022, nursing did not call to put the telemetry on as per protocol. The Cardiac Monitoring Unit (CMU) technician called the charge nurse to verify that the patient was supposed to be on cardiac monitoring and was informed that the patient was supposed to be on telemetry. The primary RN called the CMU tech and informed them that the patient had been in the room since the beginning of their shift at 7:00 PM without a cardiac monitor on and will go put the cardiac monitor on now. Cardiac monitoring did not begin until 5:08 AM on 9/10/22.

D. On 09/17/2022 Patient #13's medical record revealed he was admitted to the hospital with diagnosis of sickle cell pain. On 09/17/2022 physician orders for "telemetry may be off for tests and bathing." An interview on 01/10/2023 at 11:00 AM with the Regional Risk Manager revealed that Patient #13 refused to wear telemetry for day shift on 09/17/2022, CMU tech called the night shift charge nurse to find out who was the nurse for patient #13. The charge nurse informed CMU tech that the patient was transferred to another room during the day shift. The day shift nurse did not call to notify CMU of the transfer. Further review of Patient #13's medical record showed that the Ticket To Ride form for the destination of another room with no information on cardiac monitoring and the Ticket To Ride form for an additional destination of a room on another unit with no information on telemetry. No evidence found that the Physician was notified of Patient #13's refusal to wear the cardiac monitor. The order for cardiac telemetry monitoring was still in place.

E. Review of Patient #1's medical record revealed on 12/01/2022 admitting diagnosis as shortness of breath, community acquired pneumonia right middle (lung) lobe, hypertensive urgency, and anemia. On 12/01/2022 at 10:53 PM physician orders for telemetry included, may be off for test, bathing/ showers. On 12/06/2022 at 2:13 AM Central Monitor Unit (CMU) tech notified the RN for Patient #1 that the patients leads were off. The CMU tech called again on 12/06/2022 at 2:30 AM to notify the nurse that the patients telemetry leads were still off. On 12/06/2022 at 02:33 AM a Code Blue (cardiac arrest response) was called for Patient #1. The patient transferred to ICU and the brain MRI results were consistent with brain death, and ultimately Patient #1 expired.

F. Patient #14 medical record review showed on 01/03/2023 at 3:52 PM Patient #14 was admitted to a hospital room for syncope episode (fainting or passing out) and bradycardia (low heart rate). An interview on 01/10/2023 at 11:00 AM with the Regional Risk Manager revealed that the nurse placed the telemetry unit on the patient but did not call CMU to complete the process (verifying capture of the heart rhythm in the CMU). This was not caught during the telemetry rounding process at 10:00 PM where all telemetry units are verified. Further review of the patient medical record reveals that the admission cardiac strip was captured on 01/04/2023 at 11:13 AM. Patient #14 physician orders revealed that on 01/03/2023 at 3:52 PM telemetry, may be off for bathing and test. The patient was not monitored for 19 hours and 21 minutes.

G. A tour was conducted on 01/09/2023 at 10:20 AM on the Central Monitoring Unit. Upon entering the secured room, surveyor observed 3 cardiac monitor towers (towers 2,3, & 4) with no staff in front of the screens, monitoring the telemetry rhythms.

H. During a tour of the CMU observed Patient #7 off (showing leads off/ asystole (a condition in which the heart stops beating)) the cardiac monitor screen on 01/09/2023 at 10:43 AM in the CMU. The CMU tech called the nurse for patient #7 to notify that patient was off telemetry monitoring, and again at 10:50 AM the patient was still off telemetry monitoring, CMU tech called to inform the nurse that Patient #7 was still not on cardiac monitoring. Cardiac monitoring resumed on 01/09/2023 at 10:56 AM, according to confirmation with CMU tech.

I. On 1/11/23 at 2:15 PM a tour of the emergency department (ED) was conducted. At 2:16 PM an interview was conducted with Staff K, RN traveler (contract nurse). Staff K said if there is a situation in which it's an abdominal pain with telemetry ordered, then "I don't know if they have to be on a monitor for transport." If the patient is going to a telemetry floor and we don't have a monitor, then we can put them on a Zoll (defibrillator with monitor) or a life pack. Otherwise, they will stay here until a monitor is available. "If I am bringing them to the floors, I bring them in the room and wait until I see the nurse, verify they are on a monitor and have a rhythm transmitting."

J. On 1/11/23 at 2:23 PM an interview was conducted with Staff L, RN traveler. She said transport takes the patients to the floors. If they are not on a cardiac drip then a nurse doesn't have to go. The transporter takes the patient and the Ticket to Ride to the floor. The nurse on the floor can see the admission orders, and that's how she knows if they are on a cardiac monitor.

K. At 2:30 PM on 1/11/23 an interview was conducted with Staff M, RN. Staff M said if they're [patients] not on a drip, transport or techs can take them. "We call the nurse on the floor to tell them what's going on with the patient."

L. On 1/11/23 at 2:33 PM an interview was conducted with Staff N, RN. Staff N said the nurse goes with the patient if they are on a cardiac drip. "It depends on the circumstances. If you feel like it's necessary. The orders have telemetry monitoring and we do call report periodically. If they're going to telemetry, then they know they will need a monitor."

M. A tour was conducted on the telemetry unit, Swann 5 on 1/11/23 at 2:30 PM. During the tour, an interview was conducted with Staff O, RN at 2:35 PM. Staff O said the nurses receive a page [pager call] when a patient is coming, with their name, diagnosis, age, and assigned telemetry box. Nurses call CMU (central monitoring unit) and tell them the room number and name of the patient, and when the telemetry box is placed, the nurse calls CMU and verifies the rhythm, name, room number, and box number. Transporters bring them up. "Patients don't come to the floor on a monitor unless they are open heart [surgery patients]."

N. At 2:54 PM on 1/11/23 an interview was conducted with Staff P, RN. Staff P said nurses get a text notification that they are receiving a patient from the emergency room. They tell us the name and room number. They notify us when the patient is here. It's either an ER (emergency room) tech or a transporter who bring the patients up. They don't come up on a monitor. The monitor is placed in the room and put on the patient when they arrive. Then we notify the monitor techs. The rate and rhythm are documented on the assessment with the box number.

O. At 3:05 PM on 1/11/23 an interview was conducted with the manager of Imaging Services. He disclosed that he is responsible for overseeing transportation of patients. Central transport takes patients to their destination. It depends on who is available to transport them. Primarily, it's transport. There is a list of things they can't transport like [patients receiving] cardiac drips. They have to have a nurse or qualified person for that. They call CMU if they are transporting a patient on a monitor.

P. On 1/12/23 at 10:10 AM an interview was conducted with the Director of Quality. The Director of Quality said they have four hours to implement admission orders. Telemetry is initiated on the floor unless they are in ED hold on telemetry. Then monitoring is continued from there. "We have been really looking at our policies and how to interpret them, and then how that gets communicated to the leadership out there. We are looking at the reconciliation of admission orders. Right now, orders are reconciled every twelve hours, but we don't have a process for reconciling admission orders. The cardiac policy says that if they have an order that says they can be off tele (telemetry) for bathing or tests then that includes for transport. It does not say that in the order, so we are looking at that."

Q. Review of the policy, Admission of Patient From Emergency Department, last reviewed 5/2022, revealed the following information: An emergency department nurse, emergency service technician, patient care technician/ patient service technician, or transporter (as determined by the primary nurse) accompanies the patient to the unit. The patient is transported with all necessary equipment . . . Reports are provided on all admitted patients following the facility's approved reporting process . . . D. Emergency Center Patient Admission Orders 4. All admit holds in the ED will have admission orders initiated within four hours.

Based on facility documents, medical record reviews, and staff interview it was determined that the hospital failed to ensure that the Quality Assurance Performance Improvement Program was implemented for investigation and determination of root cause of an adverse event involving continuous cardiac monitoring that contributed to the Patient #1's death. The hospital also failed to implement an immediate corrective action plan to prevent another cardiac telemetry related adverse event in 3 (#1, #2, & #11) of 4 adverse events.This resulted in Immediate Jeopardy. Refer to A0286. Cross reference to A0115 and A0365.

An Immediate Jeopardy action removal plan provided by the facility on 01/12/2023 which included:

All nursing staff and cardiac monitoring unit (CMU) staff are required to review the cardiac telemetry monitoring procedures and policies which began 1/11/2023 via Safety Tiered Huddles. All Registered Nurses (RN) and CMU staff will be educated prior to starting their shift. This was completed with staff onsite and observed by surveyors. Education for additional staff prior to working is ongoing. Review of documentation and attestation of staff was completed.

Beginning 1/12/23 at 7am and continuing until further notice, the CMU will have an additional individual to assist with breaks and clerical duties. Observation of telemetry monitoring room was done.

When a new telemetry order is entered, the Telemetry Protocol is followed by the bedside nurse. The Charge Nurse will verify new telemetry orders and complete a second reconciliation with CMU. Began 01/11/2023. Education ongoing. Verification with staff completed.
Leadership rounding will occur every shift to verify team member's knowledge and compliance with policies and processes. Rounding will continue daily for 4 weeks, or until leadership is able to prove staff competency. Began 1/12/2023 and verified by surveyors.

Effective immediately, admission of patients from the ED who require telemetry will be transported with a portable monitor and accompanied by a licensed professional. A warm handoff will occur at the bedside and the ED nurse will stay at the bedside until telemetry box is placed on the patient and reconciliation with CMU is complete. Verified onsite with surveyor observation.
A review of our adverse event reporting process was conducted. There will be a 100% review of the monitoring techs auditing process with the goal of greater than or equal to 90% compliance. Results of monitoring of compliance with the telemetry process will be reported weekly to First Focus for three months, starting 1/13/23.

All Quality and Risk Management staff will be re-educated on the review of adverse events. Education began 01/12/2023 to include the need for immediate investigation, Root Cause Analysis, and development of action plans.

Based on verification of the facilities immediacy removal action plan, verification of education based on staff interviews and observation on 01/12/2022 at 4:56 PM, this resulted in the Immediate Jeopardy being removed.

Based on facility documents, medical records reviews, staff interviews it was determined that the facility failed to track and trend adverse events, failed to determine a root cause analysis immediately after an adverse event and failed to have a corrective action plan to prevent the likelihood of serious harm or death in 3 (#1, #2, & 11) out of 4 adverse events reviewed. Refer to A0286.

Findings included:

A. Review of Patient # 1's medical record revealed on 12/01/2022 admitting diagnosis as shortness of breath, community acquired pneumonia Right Middle [lung] Lobe, hypertensive urgency, and anemia. On 12/01/2022 at 10:53 PM physician orders for telemetry inluded, may be off for test, bathing/ showers. On 12/06/2022 at 2:13 AM Central Monitor Unit (CMU) technician notified the RN (Registered Nurse) for Patient #1 that the patients leads were off. The CMU technician called again on 12/06/2022 at 2:30 AM to notify the nurse that the patients cardiac monitoring leads were still off. On 12/06/2022 at 02:33 AM a Code Blue (cardiac arrest response) was called for Patient #1. The patient transferred to ICU and brain MRI results were consistent with brain death, and ultimately Patient #1 expired.

B. Risk Management investigation of the event began 12/22/2023 (21 days after the event) when they were notified of the mortality review. The root cause analysis for Patient #1 was being completed on 01/10/2023 while the surveyors were conducting an investigation of Patient #1.
On 01/10/2023 at 11:57 AM an interview was conducted with the Nursing Director of Critical Care/Centralize monitor unit where it was disclosed the facility does not have a formal tracking and trending system for telemetry related issues other than PRISM (facility event reporting system).

C. Review of Patient #2's medical record revealed that the patient presented to the facility for gastroparesis (a condition that affects the stomach muscles and prevents proper stomach emptying). The record revealed the patient also has a history of pseudocholinesterase deficiency (disorder that makes you sensitive to certain muscle relaxants used during general anesthesia) and had a hard time waking up from anesthesia. On 11/02/2022 at 6:56 AM a consent was signed by the patient for a Esophagogastroduodenoscopy (A diagnostic procedure that uses a scope that examines the esophagus, stomach, and the beginning part of the small intestine) with injection therapy (Botox a drug prepared from the bacterial toxin botulin, used medically to treat certain muscular conditions). On 11/02/2022 at 8:38 AM the procedure started and was completed by 8:43 AM. Patient #2 was transported to the PACU (Post Anesthesia Care Unit) where anesthesia was stopped. On 11/02/2022 at 8:59 AM Patient #2 was taken back to the procedure room after it was realized that the Botox injection therapy was not given.

D. On 01/10/2023 at 2:00 PM an interview with the Former Risk Manager where she disclosed that she did not consider Patient #2 event a wrong procedure, but a medication omission and it went to the bottom of the pile.
Risk Management investigation of the event did not start until 12/29/2022 (57 days after event) for Patient #2. The root cause analysis for Patient #2 is to being completed on 01/18/2023. No corrective action plan in place for the adverse event.

E. A review of the Discharge Summary in the medical record for Patient #11, dated 6/10/22 revealed she was readmitted to the hospital on 5/26/22 with diagnoses of Persistent MRSA (Methicillin-resistant Staphylococcus aureus - a multi-drug resistant organism) bacteremia (bacteria in the blood) and right cubital vein thrombosis rule out septic thrombophlebitis. The discharge disposition indicted Patient #11 was deceased. At 11:30 AM on 1/11/23 an interview was conducted with the supervisor of clinical risk management (regional risk manager). The regional risk manager disclosed that Patient #11 was discharged on 5/24/22 and readmitted on 05/26/2022 with sepsis and positive blood culture of bacteremia. On the 5/20/2022 she came to Emergency Department (ED) via Emergency Medical Services Ambulance (EMS). She fell at home, and they brought her in. We believe the IV line was where the infection started. The EMS line had not been discontinued (from the 20 to 24th admission). If the field IV site had been discontinued per policy the patient may not have been readmitted with a health care acquired blood stream infection. Root Cause Analysis (RCA) was done on 7/8/22 (28 Days after patients death).

Based on facility policies, medical record reviews, observations, and staff interviews it was determined the facility failed to ensure the supervision of nursing staff in the delivery of care of patients on continuous telemetry monitoring in six (1, 7, 8, 12, 13, & 14) of six sampled telemetry patients and contributing to the death of Patient #1. This resulted in Immediate Jeopardy. Refer to A0398. Cross reference to A0115 and A0263.

An Immediate Jeopardy action removal plan was provided by the facility on 01/12/2023 which included:

All nursing staff and cardiac monitoring unit (CMU) staff are required to review the cardiac telemetry monitoring procedures and policies which began 1/11/2023 via Safety Tiered Huddles. All Registered Nurses (RN) and CMU staff will be educated prior to starting their shift. This was completed with staff onsite and observed by surveyors. Education for additional staff prior to working is ongoing. Review of documentation and attestation of staff was completed.

Beginning 1/12/23 at 7am and continuing until further notice, the CMU will have an additional individual to assist with breaks and clerical duties. Observation of telemetry monitoring room was done.

When a new telemetry order is entered, the Telemetry Protocol is followed by the bedside nurse. The Charge Nurse will verify new telemetry orders and complete a second reconciliation with CMU. Began 01/11/2023. Education ongoing. Verification with staff completed.
Leadership rounding will occur every shift to verify team member's knowledge and compliance with policies and processes. Rounding will continue daily for 4 weeks, or until leadership is able to prove staff competency. Began 1/12/2023 and verified by surveyors.

Effective immediately, admission of patients from the ED who require telemetry will be transported with a portable monitor and accompanied by a licensed professional. A warm handoff will occur at the bedside and the ED nurse will stay at the bedside until telemetry box is placed on the patient and reconciliation with CMU is complete. Verified onsite with surveyor observation.
A review of our adverse event reporting process was conducted. There will be a 100% review of the monitoring techs auditing process with the goal of greater than or equal to 90% compliance. Results of monitoring of compliance with the telemetry process will be reported weekly to First Focus for three months, starting 1/13/23.

All Quality and Risk Management staff will be re-educated on the review of adverse events. Education began 01/12/2023 to include the need for immediate investigation, Root Cause Analysis, and development of action plans.

Based on verification of the facilities immediacy removal action plan, verification of education based on staff interviews and observation on 01/12/2022 at 4:56 PM, this resulted in the Immediate Jeopardy being removed.

Based on facility policies, medical record review, observation, and staff interviews it was determined that facility failed to provide adequate supervision to nursing personnel to ensure hospital policy and procedures were followed regarding cardiac (telemetry) monitoring in six (1, 7, 8, 12, 13, & 14) of six sampled telemetry patients.

Findings included:

A. Review of the facility policy & procedure title, "Cardiac Monitoring", # NCL0100 ... PURPOSE: Provide a continuous picture of the patient's cardiac electrical activity ... An "Off telemetry for test(s)" order, is required for a patient to be transported without continuous monitoring. If provider order requires patient to be on telemetry monitoring for patient transport and test(s), patient must be monitored for test(s) and transported with appropriate telemetry credentialed team members ...After telemetry box is placed on patient, call monitor tech to verify capture. Follow this process anytime the telemetry box is removed and reapplied. Verify assigned box, with patient ID and box number at least once per shift. Confirm telemetry box number and document in medical record ... When the monitor tech identifies that a patient is off the monitor and no prior notification has been received, the MT immediately calls the patient's nurse and/or Patient Care Tech. If no response from nurse or PCT the MT will contact the Charge Nurse. b. When the leads are reattached the team member calls the MT to confirm capture, including patient's name, room number and tele box number before leaving the room ...

B. Review of the policy, Admission of Patient From Emergency Department, last reviewed 5/2022, revealed: An emergency department nurse, emergency service technician, patient care technician/ patient service technician, or transporter (as determined by the primary nurse) accompanies the patient to the unit. The patient is transported with all necessary equipment. Reports are provided on all admitted patients following the facility's approved reporting process ...D. Emergency Center Patient Admission Orders ...4. All admit holds in the ED will have admission orders initiated within four hours.

C. Review of Patient #8 medical record showed that on 09/05/2022 Patient #8 was admitted to the hospital with a diagnosis of chest pain. Past medical history of cardiovascular stents(a tubular support placed temporarily inside a blood vessel, canal, or duct to aid healing or relieve an obstruction) placed times three, high blood pressure, and coronary artery disease. An interview on 1/10/2023 at 11:00 AM with the Regional Risk Manager revealed that on 09/06/2022 the transporter arrived at Patient #8's room to transport the patient to the cardiac catheterization lab for a heart catheterization. The RN (Registered Nurse) removed the telemetry box without physician orders for telemetry to be removed for transport. Patient #8 transported without cardiac monitoring. Further review of Patient #8 medical record revealed Ticket to Ride form (facility form to be filled out for patient to be transported to other areas of the hospital) with the destination as the cardiac catheterization (insertion of a narrow tube into the heart through an artery to examine how well the heart is functioning) lab and the telemetry area blank. Physician orders on 09/05/2022 at 7:47 PM showed telemetry and to maintain cardiac monitoring when patient is bathing.

D. A review of the medical record for Patient #12 showed he was admitted to the hospital from the emergency department on 9/9/22 with a diagnosis of acute compression fracture and a relevant medical history of hypertension.
Review of a physician's order in the medical record dated 9/9/22 9:22 AM reflected "place in observation." Telemetry: yes (telemetry is cardiac monitoring). Physician's orders dated 9/9/22 9:22 AM revealed an order for telemetry. The documentation reflected it had been acknowledged (signed) by an RN at 9:23 AM. A review of the History and Physical dated 9/9/22 9:57 AM reflected the following: Assessment/Plan Assessment: Hyponatremia (low sodium level), Primary hypertension, Plan: admit to inpatient observation, telemetry monitor. A review of the Emergency Department Ticket to Ride (communication tool) dated 9/9/22 reflected no indication the patient had an order for telemetry, or cardiac rate and rhythm communication. Upon review of the Admission database dated 9/9/22 11:40 AM, there was no indication the patient was on telemetry or any documentation reflecting a cardiac rate and rhythm. Review of the 9/9/22 shift assessment, 8:20 PM, revealed Patient #12 did not have his telemetry implemented. The box for cardiac monitor was checked "no." Review of the cardiac rhythm strip dated 9/10/22 5:10 AM, documentation on the strip reflected it was "relabeled to admit strip." Patient #12 was without cardiac monitoring for seventeen hours and 30 minutes; from the time the admission assessment was documented until the next morning.

E. On 09/17/2022 Patient #13's medical record revealed he was admitted to the hospital with diagnosis sickle cell pain. On 09/17/2022 physician orders for "telemetry may be off for tests and bathing". An interview on 01/10/2023 at 11:00 AM with the Regional Risk Manager revealed that Patient #13 refused to wear telemetry for day shift on 09/17/2022, CMU tech called the night shift charge nurse to find out who was the nurse for patient #13. The charge nurse informed CMU tech that the patient was transferred to another room during the day shift. The day shift nurse did not call to notify CMU of the transfer. Further review of Patient #13's medical record shows that the Ticket to Ride form for the destination of a room on another unit with no information on cardiac monitoring, and the Ticket to Ride form for the destination of another room on another unit with no information on telemetry. No evidence found that the Physician was notified of Patient #13's refusal to wear the cardiac monitor. The order for cardiac telemetry monitoring was still in place.

F. Review of Patient #1's medical record revealed on 12/01/2022 admitting diagnosis as shortness of breath, community acquired pneumonia right middle [lung] lobe, hypertensive urgency, and anemia. On 12/01/2022 at 10:53 PM physician orders for telemetry included, may be off for test, bathing/ showers. Further review of Patient #1 record shows that on 12/06/2022 at 2:13 AM the Central Monitor Unit (CMU) tech notified the RN for Patient #1 that the patients leads were off. The CMU tech called again on 12/06/2022 at 2:30 AM to notify the nurse that the patients leads were still off. On 12/06/2022 at 02:33 AM a Code Blue (cardiac arrest response) was called for Patient #1. The patient transferred to ICU and the brain MRI results were consistent with brain death, and ultimately Patient #1 expired.

G. Patient #14's medical record review showed on 01/03/2023 at 3:52 PM Patient #14 was admitted to a hospital room for syncope episode (fainting or passing out) and bradycardia (low heart rate). An interview on 01/10/2023 at 11:00 AM with the Regional Risk Manager revealed that the nurse placed the telemetry unit on the patient but did not call CMU to complete the process (verifying capture of the heart rhythm in the CMU). This was not caught during the telemetry rounding process at 10:00 PM where all telemetry units are verified. Further review of the patient medical record reveals that the admission cardiac strip was captured on 01/04/2023 at 11:13 AM. Patient #14 physician orders revealed that on 01/03/2023 at 3:52 PM telemetry, may be off for bathing and test. The patient was not monitored for 19 hours and 21 minutes.

H. During a tour of the CMU observed Patient #7 off (showing leads off/ asystole(a condition in which the heart stops beating)) the cardiac monitor screen on 01/09/2023 at 10:43 AM in the CMU. The CMU tech called the nurse for patient #7 to notify that patient was off telemetry monitoring, and again at 10:50 AM the patient was still off telemetry monitoring, CMU tech called to inform the nurse that Patient #7 was still not on cardiac monitoring. Cardiac monitoring resumed on 01/09/2023 at 10:56 AM, according to confirmation with CMU tech.

I. A tour was conducted on 01/09/2023 at 10:20 AM on the Central Monitoring Unit. Upon entering the secured room, surveyor observed 3 monitor towers (towers 2, 3, & 4) with cardiac rhythms displayed and no staff were in front of the cardiac telemetry screens.

J. On 1/10/23 at 11:00 AM an interview was conducted with the regional Risk Manager. She disclosed that when Patient #12 was admitted to the nursing unit on September 9, 2022, nursing did not call to put the telemetry on as per protocol. The CMU tech called the charge nurse to verify that the patient was supposed to be on cardiac monitoring and was informed that the patient was supposed to be on telemetry. The primary RN called the CMU tech and informed them that the patient had been in the room since the beginning of their shift at 7:00 PM without a cardiac monitor on and will go put the cardiac monitor on now. Cardiac monitoring did not begin until 5:08 AM on 9/10/22.

K. On 1/11/23 at 2:15 PM a tour of the emergency department (ED) was conducted. At 2:16 PM an interview was conducted with Staff K, RN traveler(contract nurse). Staff K said if there is a situation in which it's an abdominal pain with telemetry ordered, then "I don't know if they have to be on a monitor for transport." If the patient is going to a telemetry floor and we don't have a monitor, then we can put them on a Zoll (defibrillator with monitor) or a life pack. Otherwise, they will stay here until a monitor is available. "If I am bringing them to the floors, I bring them in the room and wait until I see the nurse, verify they are on a monitor and have a rhythm transmitting."

L. On 1/11/23 at 2:23 PM an interview was conducted with Staff L, RN traveler. She said transport takes the patients to the floors. If they are not on a cardiac drip, then a nurse doesn't have to go. The transporter takes the patient and the Ticket to Ride to the floor. The nurse on the floor can see the admission orders, and that's how she knows if they are on a cardiac monitor.

M. On 1/11/23 at 2:30 PM an interview was conducted with Staff M, RN. Staff M said if they're [patients] not on a drip, transport or techs can take them. "We call the nurse on the floor to tell them what's going on with the patient."

N. On 1/11/23 at 2:33 PM an interview was conducted with Staff N, RN. Staff N said the nurse goes with the patient if they are on a cardiac drip. "It depends on the circumstances. If you feel like it's necessary. The orders have telemetry monitoring and we do call report periodically. If they're going to telemetry, then they know they will need a monitor."

O. A tour was conducted on the telemetry unit, Swann 5 on 1/11/23 at 2:30 PM. During the tour, an interview was conducted with Staff O, RN at 2:35 PM. Staff O said the nurses receive a page [pager call] when a patient is coming, with their name, diagnosis, age, and assigned telemetry box. Nurses call CMU (central monitoring unit) and tell them the room number and name of the patient, and when the telemetry box is placed, the nurse calls CMU and verifies the rhythm, name, room number, and box number. Transporters bring them up. Patients don't come to the floor on a monitor unless they are open heart [surgery patients].

P. At 2:54 PM on 1/11/23 an interview was conducted with Staff P, RN. Staff P said nurses get a text notification that they are receiving a patient from the emergency room. They tell us the name and room number. They notify us when the patient is here. It's either an ER (emergency room) tech or a transporter who bring the patients up. They don't come up on a monitor. The monitor is placed in the room and put on the patient when they arrive. Then we notify the monitor techs. The rate and rhythm are documented on the assessment with the box number.

Q. At 3:05 PM on 1/11/23 an interview was conducted with the manager of Imaging Services. He disclosed that he is responsible for overseeing transportation of patients. Central transport takes patients to their destination. It depends on who is available to transport them. Primarily, it's transport. There is a list of things we can't transport like [patients receiving] cardiac drips. They have to have a nurse or qualified person for that. They call CMU if they are transporting a patient on a monitor.

R. On 1/12/23 at 10:10 AM an interview was conducted with the Director of Quality. The Director of Quality said they have four hours to implement admission orders. Telemetry is initiated on the floor unless they are in ED (emergency department) hold on telemetry. Then monitoring is continued from there. "We have been really looking at our policies and how to interpret them, and then how that gets communicated to the leadership out there. We are looking at the reconciliation of admission orders. Right now, orders are reconciled every twelve hours, but we don't have a process for reconciling admission orders. The cardiac policy says that if they have an order that says they can be off tele (telemetry) for bathing or tests then that includes for transport. It does not say that in the order, so we are looking at that."