HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to ensure operational direction and compliance with all Conditions of Participation resulting in one condition-level deficiency (Nursing Services) not being met.

The hospital failed to ensure the emergency communication system was accessible and available to alert staff about the emergency medical condition, which resulted in the staffs' failure to respond to one of 58 patients who had a lethal heart rhythm, asystole (flat line, no electrical activity) and delay in emergency treatment. Subsequently, the patient needed resuscitation and transfer to ICU (intensive care unit) and was pronounced dead within hours.

Findings:

1. Failure to ensure that nursing services are provided to meet the needs of the patients. (Refer to A-0392)

2. Failure to respond to emergency treatment in a timely manner.

These failures had a cumulative effect and created this systemic deficit which resulted in the hospital's inability to ensure patient safety and quality healthcare.

Based on observation, interview, and record review, the hospital failed to ensure the emergency cardiac (heart) communication system was accessible and available to alert nursing staff of a medical emergency and respond immediately for one (Patient 30) of 58 patients on cardiac monitors.

This failure resulted in the delayed emergency medical response for Patient 30 having an unstable arrhythmia (irregular heartbeat) and cardiac arrest (loss of heart activity and breathing stops). Patient 30 subsequently died.

Findings:

Definition: Telemetry Unit - a unit organized, operated, and maintained to provide care for and continuous cardiac monitoring of patients in a stable condition, having or suspected of having a cardiac condition or a disease requiring the electronic monitoring, recording, retrieval, and display of cardiac electrical signals.

A review of Patient 30's admission record indicated Patient 30 was admitted to the hospital on 4/1/23 for stroke (blood supply to part of the brain is interrupted or reduced, preventing oxygen to the brain tissue) and seizures. On 4/2/23, Patient 30 was admitted to the hospital's telemetry unit and was a full code (all resuscitative efforts to be implemented).

A review of Patient 30's physician's order, dated 4/2/23 at 2:34 a.m., indicated for nurses to, "Initiate Cardiac Monitoring" for Patient 30's tachycardia (fast heartbeat).

During an observation and interview on 4/21/23, at 10:15 a.m., with Assistant Nurse Manager (ANM 1), ANM 1 stated nursing staff monitor patients for arrhythmia on telemetry monitors mounted outside of the patient rooms and the telemetry monitoring room had technicians to monitor patients and call nurses for alerts and arrhythmias through a system called, "Vocera" (directs alerts and calls to the nurses' Vocera phone).

During a concurrent observation and interview, on 4/18/23 at 1:20 p.m., with the Monitoring Technician 1 (MT 1), MT 1 stated she calls the assigned primary nurse first if a patient alarm triggers. When the primary nurse is not answering, the break relief nurse and ANM are called in that order.

During an interview on 4/20/23, at 8:05 a.m., with the primary nurse, Registered Nurse 1 (RN 1) assigned to Patient 30 on 4/3/23, RN 1 stated she could not log into the Vocera system because she did not have a Vocera phone for the entire shift on 4/3/23. RN 1 further stated she last saw Patient 30 in bed at 6:30 a.m. At 7:15 a.m., when RN 1 exited another patient's room, RN 1 stated she did not hear or was informed of any alarms when she happened to see asystole (flat line, no electrical activity) on the wall monitor and ran into Patient 30's room to assess. Patient 30 was unresponsive. RN 1 stated she initiated a Code Blue alert (specialty trained team that responds to a medical emergency and provides resuscitative care).

A review of the hospital's "Emergency Code Log," indicated on 4/3/23, at 7:29 a.m., Patient 30 had an "Adult Code Blue" announced overhead.

A review of Patient 30's progress note, "Code Blue Note and Timekeeping," dated 4/3/23, indicated at 7:30 a.m., "Code Blue called," and compressions (cardiopulmonary resuscitation or CPR-chest compressions to get blood flowing) started at 7:31 a.m. Patient 30 was resuscitated.

During an interview on 4/21/23, at 8:15 a.m., with Physician (P1), P1 stated delays as little as a few minutes in CPR lowers the probability of survival.

A review of Patient 30's "Death Note," dated 4/4/23 at 11:37 a.m., indicated Patient 30 was pronounced dead, on "4/3/23 at 10:11 a.m.,"..."Immediate Cause of Death: Acute hypoxic (severe, low oxygen level) respiratory failure" due to "aspiration pneumonitis (inhaled substance into the lungs), "asystole cardiac arrest," and "encephalopathy (altered brain function or structure)."

During an interview on 4/20/23, at 8:45 a.m., with oncoming shift manager, ANM 1 stated on 4/3/23, after receiving report at 7 a.m. to 7:15 a.m. from ANM 2, ANM 1 initiated a staff meeting and later heard the Code Blue announcement. ANM 1 stated he may have logged into the Vocera system after the Code Blue.

During an interview on 4/20/23, at 10:15 a.m., with the Nursing Manager (NM), NM stated he knew RN 1 could not log into Vocera since orientation and was not aware of their policy that Vocera phones were required to be used by nurses caring for telemetry patients.

During an interview on 4/20/23, at 10:45 a.m., with off-going ANM 2, ANM 2 stated, on 4/3/23 around 7:00 a.m., she gave report to ANM 1 and did not receive any alerts or calls about Patient 30 and logged out her Vocera phone at 7:05 a.m. ANM 2 further stated she knew RN 1 could not be alerted or called through Vocera, so the plan was for ANM 2 and RN 4 to receive Patient 30's Vocera alerts and calls. (RN 4 was unavailable for an interview).

A review of Patient 30's telemetry monitor alarm log indicated as follows on 4/3/23:

-At 7:21 a.m., an alarm for "HR 49< 50" (heart rate less than 50 beats per minute or bpm. Normal heart rate is 60-100 bpm) was triggered.

-At 7:22 a.m., an alarm for "Brady (bradycardia) 34<40" (slow heart rate less than 40 bpm) was triggered.

-At 7:24 a.m., an alarm for "Asystole" was triggered.

-At 7:31 a.m., an alarm for, "Vent fib/tach" (ventricular fibrillation- extremely dangerous abnormal rhythm and can lead to sudden cardiac death. ventricular tachycardia -when the lower chamber of the heart beats too fast to pump well and the body does not receive enough oxygenated blood).

During an interview on 4/20/23, at 3:15 p.m., MT 1 stated on 4/3/23 at about 7:20 a.m., Patient 30 had a low, heart rate alarm. MT 1 immediately called RN 1, the break relief nurse, and then ANM 1 but was unable to reach them. MT 1 stated a second attempt to call all three nurses were unsuccessful.

A review of Patient 30's, "Vocera Login and Logout" assignments, dated 4/2/23 at 11:00 p.m. to 4/3/23 at 8:45 a.m., indicated between 7:03 a.m. and 7:47 a.m., only the break relief nurse RN 4, was assigned to receive Patient 30's telemetry alerts and calls through Vocera. The log indicated off-going ANM 2 was logged out at 7:03 a.m., RN 1 was not logged in because she didn't have a phone. RN 4 logged out at 7:47 a.m. The log did not indicate oncoming ANM 1 was logged into Patient 30's assignment to receive alerts. No staff had responded to the alert alarms.

A review of the Vocera alert log titled, "Search Results for Clinical Alerts," indicated on 4/3/23, alert alarms were sent to RN 4 as follows: On 4/3/23 at 7:22 a.m.,"Extreme Brady (brady 34<40)," At 7:24 a.m., an alert alarm for "Asystole." At 7:30 a.m., an alert alarm for"V fib/tach." RN 4 had not responded.

A review of the hospital's policy and procedure (P&P) titled, "Clinical Alarm Notification Systems (CANS) NCAL (northern California) Regional Policy," dated 7/2021, indicated Vocera phones were assigned to nurses and those nurses were assigned patients at the beginning of the shift. The P&P further indicates RN will ensure that phone is correctly programmed with assigned patients, and all required alarms are audible ... RNs carry assigned phone at all times except when on breaks or meals ... and during shift change the off-going shift must keep their Vocera phone until the end of shift and the oncoming shift is available.