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Based on review of facility policy, medical record review, and interviews, the facility failed to maintain an effective, ongoing Quality Assessment and Performance Improvement program focused on health outcomes related to cardiac monitoring orders in the Emergency Department (ED) for 1 patient (#5) of 5 patients reviewed.

The findings included:

Patient #5 was admitted to the outpatient dialysis unit on 1/20/2023 for dialysis where she complained of chest pain and shortness of breath. She was sent to the Emergency Department (ED) at 8:12 AM for evaluation of her chest pain. The patient was triaged and evaluated by the ED Nurse Practitioner (NP). The ED NP ordered diagnostic testing and cardiac monitoring. Her 12 lead EKG showed no acute findings. Labs were obtained but the telemetry monitor was not placed on the patient. Patient #5 was triaged back to the ED waiting room. The patient's laboratory diagnostic tests showed an elevated Potassium of 6.5 (normal 3.5-5.1) and an elevated B-Type Natriuretic Peptide (BNP-blood test to detect heart failure) of 9300 (normal 300-1799). At 11:24 AM she was brought back to the Results Waiting area (area in the triage area where diagnostic testing was performed) where additional labs were obtained, and an intravenous catheter was inserted. The ED NP consulted with the Hospitalist for admission. Patient #5 was sent back to the ED waiting room where she was waiting for transport to the dialysis unit. The patient went to the ED waiting room's restroom at 12:44 PM and an employee found the patient in the floor of the restroom. The patient was in cardiac arrest. Cardiopulmonary Resuscitation (CPR) was started, and Advanced Cardiac Life Support (ACLS) protocols were initiated for the patient. The patient was in a Pulseless Electrical Activity (PEA- rhythm on the monitor with no pulse) which progressed to Asystole (no cardiac activity or pulse) despite resuscitation efforts. The patient expired at 1:12 PM. The facility's leadership met and developed a plan of action to order additional telemetry monitors for the ED, however failed to ensure oversight and education to the ED staff was provided to ensure provider's orders for telemetry monitoring were implemented.

Refer to A-0286

Based on review of facility policy, medical record review, review of facility investigation, and interviews, the facility failed to ensure oversight of training and preventive actions related to cardiac telemetry monitoring for 1 Patient (#5) of 5 patients reviewed.

The findings included:

Review of facility policy "Cardiac-Pulse Oximetry Monitoring" last revised 1/14/2021 showed "...procedure [1] obtain order from provider...[2] obtain appropriate monitor as ordered...[B] apply monitor unit...ensure battery is charged and checked, and wires have proper connections and are intact...[D] verify monitoring...transmission...for areas with Central Monitoring Stations, ensure all necessary patient information had been communicated, including name, date of birth, room number, box number..."

Review of the facility's 2022-2023 Quality Plan showed "...purpose: to improve health outcomes and prevent/reduce medical errors across [named health system] through a systematic, effective, continual data-driven quality assurance and performance improvement...identify and regularly evaluate quality, patient safety, and harm indicators and results used to determine [named facility] success in pursuing top quality, patient safety, and harm reduction...Quality Assurance and Performance Improvement [QAPI] defines the method by which the facility selects, collects, monitors, and analyzes quality indicators and identifies priorities for improvement projects. Indicators are selected based on adverse events, processes of care, hospital service operations measures, contractual clinical indicators and others as deemed necessary by committee and approved Medical Staff Quality Committee as delegated by the governing board...QAPI's focus is to show improved health outcomes and the prevention and reduction of medical errors..."

Medial record review of a Dialysis Nurses Note dated 1/20/2023 at 8:12 AM showed the patient arrived at the unit for a scheduled dialysis appointment. The patient went to the bathroom and after coming out of the bathroom, she ambulated for 40 feet with her walker and became short of breath. The patient reported she had chest pain for 3 days with exertional shortness of breath. The Nephrologist (physician who specializes in care of the kidneys) was notified and informed the staff to send the patient to the Emergency Department (ED) for evaluation.

Medical review of an ED Nurses Triage Note dated 1/20/2023 at 8:53 AM showed the patient presented to the ED and reported chest pain for days. She had been sent from the dialysis unit for evaluation prior to receiving her dialysis treatment. Her vital signs were as follows: Blood Pressure 203/65 (normal <120/80), Pulse 77 (normal 60-100), Respirations 20 (normal 16-20), and pulse oximetry of 100% (normal 95-100) on room air. Her pain score showed she was having chest pain with a score of a 7 out of 10 (0=no pain, 10=worst pain possible). She was triaged with an Emergency Severity Index (ESI) of a 2 indicating urgent needs.

Medical record review of an ED Physicians record dated 1/20/2023 at 8:50 AM showed the ED Nurse Practitioner (NP) evaluated the patient and, the patient reported intermittent chest pain over the past week with shortness of breath. The patient was on chronic dialysis and completed her last dialysis treatment on Wednesday (1/11/2023). The patient described pain to the substernal area as gradual and denied radiation. The following diagnostic testing was ordered: Electrocardiogram (EKG-test to measure electrical activity of the heart), Chest x-ray, Complete Blood Count (CBC), PT/INR (test to determine the thickness of the blood), B-Type Natriuretic Peptide (BNP-blood test to detect heart failure), Troponin (blood test to determine cardiac injury), and a Comprehensive Metabolic Panel (CMP). Cardiac monitoring to include telemetry was ordered. The patient's 12 lead EKG was reviewed by the ED Provider at 9:09 AM and did not show any acute findings.

Medical record review showed no documentation the cardiac monitor was applied. The labs were obtained in the triage area and the patient was sent back to the ED waiting room.

Medical record review of the Laboratory Diagnostic testing results dated 1/20/2023 showed the following:
9:42 AM: CBC: White Blood Count (WBC) 11.4 (normal 3.5-10.5); Hemoglobin 7.3 (normal 12.4-15.2); Hematocrit 23.3 (normal 36.0-46.0). The patient was a chronic dialysis patient.
9:54 AM: PT/INR, no acute findings.
10:09 AM: BNP; 9300 (normal 300-1799).
10:12 AM: Troponin; 0.02 (normal 0.00-0.03).
11:11 AM: CMP: potassium (electrolyte) 6.5 (normal 3.5-5.1); BUN (kidney function test) 57.5 (normal 7.0-17.0); Creatinine (kidney function test) 6.29 (normal 0.52-1.04). The patient was a chronic dialysis patient and had not been dialyzed since 1/11/2023.

Medical record review of an ED Provider Note dated 1/20/2023 (no time) showed "...patient initial cardiac workup is negative at this time. Patient noted to be in hyperkalemia, spoke with Nephrology who recommended no insulin or D50 (dextrose solution) at this time but to administer the calcium gluconate [calcium replacement]...patient will be taken for dialysis. Patient will be admitted to medical services for further evaluation and treatment for her chest pain..." Orders for D50, Calcium Gluconate 1 gram (gm), regular insulin 6 units, and Sodium Zirconium Cyclosilicate (medication to treat elevated potassium) were placed at 11:20 AM and cancelled at 11:21 AM after consultation with the Nephrologist.

Medical record review of the ED Patient Timeline dated 1/20/2023 at 11:46 AM showed Patient #5 was moved from the Results Waiting area to the PA1 (preadmit; area where treatment and provider evaluation was performed; this was not in the acute care unit of the ED).

Medical record review of an ED Nurses Note dated 1/20/2023 at 12:26 PM showed "...dialysis called to informed [inform] they are putting in a transport for the pt. [patient] Pt informed..." The patient was taken back to the ED waiting room to await transport to the dialysis department. The patient did not have a telemetry monitor on which was ordered by the ED provider during triage.

Medical record review of the ED Patient Timeline dated 1/20/2023 at 12:32 PM showed the Hospitalist placed orders for the patient to be admitted. There was an order for Telemetry Monitoring.

Medical record review of the ED Patient Timeline dated 1/20/2023 at 12:44 PM showed a Code BLUE (facility code for a cardiac arrest) was initiated for the patient. Cardiopulmonary Resuscitation (CPR) was started, and Advanced Cardiac Life Support (ALCS) protocols were initiated. At 1:12 PM the Code BLUE was stopped, and the patient expired.

Medical record review of an ED Nurses Note dated 1/20/2023 at 2:36 PM showed "...patient [pt.] to AC [acute care] 1 from WR [waiting room] after found down in bathroom unresponsive. Upon arrival to room, pt. receiving assisted respirations with BVM [bag valve mask], CPR in progress, ACLS protocol in progress. CPR continued and meds administered per ACLS protocol...efforts terminated after definitive airway established and medical futility reached...."

Medical record review of an ED Physicians Record dated 1/20/2023 at 5:03 PM showed "...above documentation per nurse practitioner...I evaluated the patient initially in triage. She was sent down for chest pain from dialysis. EKG, chest x-ray, Troponin are all reassuring she does have moderate pulmonary edema consistent with her history of dialysis volume overload on chest x-ray. At the time of my evaluation she is siting up comfortably in a wheelchair. She appears pale...Her ER [Emergency Room] workup is reassuring, vital signs are reassuring, plan was to send her back up to dialysis and admit to the hospital. Hospitalist had been consulted and admission orders placed. Unfortunately, just before transfer to dialysis the patient had an unexpected cardiac arrest and was found unresponsive in the waiting room bathroom. ACLS protocol was initiated with appropriate medications being given...There were no new EKG changes due to her hyperkalemia. During the cardiac arrest she was given medications including Calcium, Insulin, Bicarb, and Epinephrine. Airway was secured as above. She had a large amount of pulmonary hemorrhage of bright red blood which appeared to be coming from the airway. This was observed during video assisted intubation. We continued ACLS protocol for approximately 30 minutes. Initially the patient has PEA [pulseless electrical activity- rhythm on the monitor with no pulse] and was found subsequently to have asystole [no cardiac activity or pulse]. She did not have any cardiac motion whatsoever on bedside ultrasound performed twice during cardiac arrest ACLS. We were unable to obtain return of spontaneous circulation and patient was pronounced dead..."

Review of facility investigation showed Patient #5 had been sent to the ED from the dialysis unit on 1/20/2023 related to complaints of chest pain. The patient was evaluated at 8:50 AM, and diagnostic testing and cardiac monitoring was ordered. Diagnostic testing showed the patient had an elevated Potassium and BNP Levels. The facility's investigation confirmed the patient was not placed on the telemetry monitor as ordered.

During an interview on 2/16/2023 at 8:55 AM, Registered Nurse (RN) #1 stated the patient had come from the dialysis unit after she complained of chest pain for 3 days. The patient described the pain as a pressure type pain but did not complain of shortness of breath. The ED provider evaluated the patient and ordered labs and a chest x-ray. The labs were obtained in the triage area, and she was sent back to the ED waiting room for chest x-ray. The patient was pulled back to the Result Waiting area at 11:46 AM and additional labs were obtained. The ED provider spoke with the Nephrologist. The plan was to send the patient back to dialysis for treatment and the patient would be admitted. The patient was sent back to the waiting room and dialysis called for transport to take the patient to the dialysis unit. While the patient was in the waiting room, she went to the restroom and was found in the restroom in cardiac arrest. A Code Blue was initiated, and the patient expired. RN #1 stated at times there were not enough telemetry monitors for patients related to the increased ED census. She confirmed cardiac monitoring was ordered for the patient and the telemetry monitor was not applied.

During a telephone interview on 2/16/2023 at 10:15 AM, ED NP #1 stated he had evaluated the patient in the triage area after the patient presented to the ED with complaints of chest pain. The patient was scheduled for dialysis as an outpatient and stated she had been having intermittent chest pain for the past week with shortness of breath. The patient was hypertensive and was pain free in the triage room. A 12 lead EKG was performed which did not show any acute findings. A cardiac workup was initiated, and telemetry was ordered for the patient. The patient's laboratory diagnostic test showed an elevated potassium and he had ordered D10, Insulin, and calcium gluconate. He had spoken with the Nephrologist and the decision was made to not give the medications and to return the patient to the dialysis unit for dialysis which would assist in correcting the elevated potassium. ED NP #1 was notified by the ED staff the patient had suffered a cardiac arrest in the ED waiting room restroom. He responded to the restroom and assisted with the Code Blue for the patient. He stated he was not aware the patient was not on the telemetry monitor.

During a telephone interview on 2/16/2023 at 11:24 AM, ED Physician #1 stated she had reviewed the 12 lead EKG and found no acute findings suggestive of an acute myocardial infarction. She confirmed she was not aware the patient was not on telemetry monitoring. The patient had been sent back to the ED waiting room for transport back to the dialysis unit. The patient suffered a cardiac arrest in the ED waiting room restroom. The etiology of the cardiac arrest was undetermined.

During an interview on 2/16/2023 at 2:00 PM, the Director of Risk Management, stated on 1/20/2023 a meeting was conducted with the Director of Risk Management, the ER Director, the ED Nurse Manager, the Chief Nursing Officer (CNO), and the Chief Executive Officer (CEO). The patient's case was reviewed, and it was determined the incident would be reviewed as a Sentinel Event. Patient #5 had cardiac monitoring ordered in triage and the telemetry monitor was not applied as ordered. On 1/26/2023 a meeting was held and included the Director of Risk Management, the ER Director, the ED Nurse Manager, the CNO, the CEO, and the Corporate Market CEO and a plan of action was developed which included adding additional telemetry monitors to the ED. On 2/2/2023, a quote for 10 additional telemetry monitors was requested from the vendor. On 2/6/2023 the quote was received from the vendor and sent to the Market CNO for expedited approval. On 2/8/2023 a final meeting was conducted. Continued interview with the Director of Risk Management confirmed the facility did not implement immediate education or oversight of the ED staff to ensure patients ordered telemetry monitoring received the monitoring as ordered by the providers. She confirmed the patient had an order for telemetry and the ED staff failed to place the telemetry monitor on the patient, the facility failed to ensure telemetry monitoring for the patient, and the patient suffered an unwitnessed cardiac arrest in the ED waiting room restroom.

Based on review of facility policy, medical record review, review of facility investigation, and interviews, the facility failed to follow an ED Provider order for telemetry in the Emergency Department (ED) for a patient who presented with chest pain for 1 patient (#5) of 5 ED patients reviewed.

The findings included:

Patient #5 presented to the outpatient dialysis unit on 1/20/2023 for dialysis and upon arrival complained of chest pain and shortness of breath. She was sent to the ED at 8:12 AM for evaluation of her chest pain. The patient was triaged and evaluated by the ED Nurse Practitioner (NP) and diagnostic testing was ordered. In the triage area, an electronic order was placed for cardiac monitoring. The labs were obtained but the telemetry monitor was not completed for the patient and the patient was triaged back to the ED Waiting Room. The patient's laboratory diagnostic test showed an elevated Potassium of 6.5 (normal 3.5-5.1) and an elevated B-Type Natriuretic Peptide (BNP-blood test to detect heart failure) of 9300 (normal 300-1799). Her 12 lead EKG (electrocardiogram-test to measure and evaluate electrical activity of the heart) showed no acute findings. At 11:24 AM Patient #5 was brought back to the Results Waiting area (area in the triage area where diagnostic testing was performed) where additional labs were obtained and an intravenous catheter was inserted. Orders for D50 (dextrose solution), Calcium Gluconate (calcium replacement and used to treat elevated Potassium levels) 1 gram, regular insulin (medication used to treat high blood glucose levels) 6 units, and Sodium Zirconium Cyclosilicate (medication to treat elevated potassium) were placed at 11:20 AM. The ED NP had spoken with the Nephrologist (physician who specializes in kidney disease) who stated not to give the medications and to send the patient back to the dialysis unit for dialysis. The orders were cancelled at 11:21 AM. The ED NP consulted with the Hospitalist for admission to the facility after dialysis. The patient was sent back to the ED Waiting Room where she was waiting for transport to the dialysis unit. The telemetry monitor was not placed on the patient. At 12:44 PM the patient went into the ED Waiting Room's restroom. An employee went by the restroom and found Patient #5 in the floor of the restroom. The patient was in cardiac arrest. Cardiopulmonary Resuscitation (CPR) was started and Advanced Cardiac Life Support (ACLS) protocols were initiated for the patient. The patient was in Pulseless Electrical Activity (PEA- rhythm on the monitor with no pulse) which progressed to Asystole (no cardiac activity or pulse) despite resuscitation efforts. The patient expired at 1:12 PM.

Refer to A-0395

Based on review of faclity policy, medical record review, review of facility investigation, and interviews, the facility failed to ensure cardiac monitoring was implemented for a patient with chest pain for 1 patient (#5) of 5 patients reviewed.

The findings included:

Review of facility policy "Cardiac-Pulse Oximetry Monitoring" last revised 1/14/2021 showed "...procedure [1] obtain order from provider...[2] obtain appropriate monitor as ordered...[B] apply monitor unit...ensure battery is charged and checked, and wires have proper connections and are intact...[D] verify monitoring...transmission...for areas with Central Monitoring Stations, ensure all necessary patient information had been communicated, including name, date of birth, room number, box number..."

Medical review of an ED Nurses Triage Note dated 1/20/2023 at 8:53 AM showed the patient presented with chest pain for days. She had been sent from dialysis and had not received treatment. Her vital signs were as follows: Blood Pressure 203/65, Pulse 77, Respirations 20, and pulse oximetry of 100% on room air. Her pain score showed she was having chest pain with a score of a 7/10 indicating the patient was having pain. She was triaged with an Emergency Severity Index (ESI) of a 2 indicating urgent needs.

Medical record review of an ED Physicians record dated 1/20/2023 at 8:50 AM showed the ED Nurse Practitioner had evaluated the patient who presented from dialysis related to chest pain. The patient had intermittent chest pain over the past week with shortness of breath. The patient was on chronic dialysis. She complained of cough, congestion, and shortness of breath. The following diagnostic testing was ordered: Electrocardiogram (EKG), Chest x-ray, Complete Blood Count (CBC), PT/INR (test to determine the thickness of the blood), B-Type Natriuretic Peptide (BNP-blood test to detect heart failure), Troponin (blood test to determine cardiac injury), and a Comprehensive Metabolic Panel (CMP). Additional orders for cardiac monitoring and continuous pulse oximetry were ordered.

Medical record review showed no documentation the cardiac monitor and pulse oximeter was applied on 1/20/2023 during the patient's ED admission. The labs were obtained in the triage area and the patient was sent back to the ED waiting room.

Medical record review of the Laboratory Diagnostic testing results dated 1/20/2023 showed the patient's Potassium (electrolyte) was 6.5 (normal 3.5-5.1); BUN (kidney function test) 57.5 (normal 7.0-17.0); Creatinine (kidney function test) 6.29 (normal 0.52-1.04). Her B-Type Natriuretic Peptide (BNP-blood test to detect heart failure), was 9300 (normal 300-1799).

Medical record review of an ED Provider Note dated 1/202/2023 (no time) showed "...patient initial cardiac workup is negative at this time. Patient noted to be hyperkalemia, spoke with Nephrology who recommended no insulin or D50 at this time but to administer the calcium gluconate (calcium replacement)...patient will be taken for dialysis. Patient will be admitted to medical services for further evaluation and treatment for her chest pain..." Orders for D50, Calcium Gluconate (calcium replacement and used to treat elevated Potassium levels) 1 gram, regular insulin 6 units, and Sodium Zirconium Cyclosilicate (medication to treat elevated potassium) were placed at 11:20 AM and cancelled at 11:21 AM.

Medical record review of the ED Patient Timeline dated 1/20/2023 at 11:46 AM showed the patient was moved from the Results Waiting area to the PA1 (preadmit; area where treatment and provider evaluation was performed, this was not in the acute care unit of the ED).

Medical record review of an ED Nurses Note dated 1/20/2023 at 12:26 PM showed "...dialysis called to informed they are putting in a transport for the pt. Pt informed..." The patient was taken back to the ED Waiting Room for transport to the dialysis department.

Medical record review of the ED Patient Timeline dated 1/20/2023 at 12:44 PM showed a Code BLUE (facility code for a cardiac arrest) was initiated for the patient. Cardiopulmonary Resuscitation (CPR) was started and Advanced Cardiac Life Support (ALCS) protocols were initiated. At 1:12 PM the Code BLUE was stopped, and the patient expired.

Medical record review of an ED Nurses Note dated 1/20/2023 at 2:36 PM showed "...patient [pt.] to AC [acute care] 1 from WR [waiting room] after found down in bathroom unresponsive. Upon arrival to room, pt. receiving assisted respirations with BVM [bag valve mask], CPR in progress, ACLS protocol in progress. CPR continued and meds administered per ACLS protocol [see Code Blue record for details]. Efforts terminated after definitive airway established and medical futility reached...."

Medical record review of an ED Physicians Record dated 1/20/2023 at 5:03 PM showed "...above documentation per nurse practitioner in the need. I evaluated the patient. I evaluated the patient initially in triage. She was sent down for chest pain from dialysis. EKG, chest x-ray, Troponin are all reassuring she does have moderate pulmonary edema consistent with her history of dialysis volume overload on chest x-ray. At the time of my evaluation she is siting up comfortably in a wheelchair. She appears pale. She is Spanish speaking. Her ER [Emergency Room] workup is reassuring, vital signs are reassuring, plan was to send her back up to dialysis and admit to the hospital. Hospitalist had been consulted and admission orders placed. Unfortunately just before transfer to dialysis the patient had an unexpected cardiac arrest and was found unresponsive in the waiting room bathroom. ACLS protocol was initiated with appropriate medications being given. She had already been given Calcium Gluconate for her mild hyperkalemia. There were no new EKG changes due to her hyperkalemia. During the cardiac arrest she was given medications including Calcium, Insulin, Bicarb, and Epinephrine. Airway was secured as above. She had a large amount of pulmonary hemorrhage of bright red blood which appeared to be coming from the airway. This was observed during video assisted intubation. We continued ACLS protocol for approximately 30 minutes. Initially the patient has PEA [pulseless electrical activity- rhythm on the monitor with no pulse] and was found subsequently to have asystole [no cardiac activity or pulse]. She did not have any cardiac motion whatsoever on bedside ultrasound performed twice during cardiac arrest ACLS. We were unable to obtain return of spontaneous circulation and patient was pronounced dead..."

Review of facility investigation showed Patient #5 had been sent to the ED on 1/20/2023 related to complaints of chest pain from the dialysis unit. At 8:50 AM she was evaluated in the ED where diagnostic testing and cardiac monitoring was ordered. Diagnostic testing showed the patient had an elevated Potassium and BNP Levels. The patient was evaluated where the ED Provider had discussed the diagnostic findings with the Nephrologist who agreed the patient could return to dialysis for treatment. While in the ED Waiting room, waiting on transport to the dialysis unit, the patient went to the restroom and suffered a cardiac arrest. It was discovered the registration staff did not have a process for prompt notification to the ED nursing staff in the event of an emergency. The facility's investigation confirmed the patient was not placed on the telemetry monitor.

During an interview on 2/16/2023 at 8:55 AM, Registered Nurse (RN) #1 stated the patient had come from the dialysis unit after she complained of chest pain for 3 days. The patient described the pain as a pressure type pain but did not complain of shortness of breath. The ED provider evaluated the patient and ordered labs, a chest x-ray, and cardiac monitoring. The labs were obtained in the triage area and she was sent back to the ED Waiting room for the chest x-ray. The patient had been pulled back to the Result Waiting area at 11:46 AM and additional labs were obtained and attempts to start an intravenous line. The ED provider had spoken with the Nephrologist. The plan was to send the patient back to dialysis for treatment and the patient would be admitted. The patient was sent back to the waiting room and dialysis had called for transport to take the patient to the dialysis unit. While the patient was in the waiting room, she went to the restroom and was found in the restroom in cardiac arrest. A Code Blue was initiated, and the patient expired. She stated at times there were not enough telemetry monitors for the patients related to the increased ED census. She confirmed cardiac monitoring was ordered for the patient and the telemetry monitor was not applied.

During an interview on 2/16/2023 at 9:45 AM, ED Technician (tech) #1 stated she had observed the patient in the ED Waiting room. She had received a 'vocera call' (hands-free communication to connect healthcare workers) stating someone was stuck in the bathroom. She was not aware the patient was not on the telemetry monitor. The ED charge nurse called the 'vocera' and stated someone had fallen in the ED Waiting room bathroom which was reported by the registration tech. When she got to the restroom, she found the patient in the floor with no pulse and not breathing. She had called for help and CPR was started.

During a telephone interview on 2/16/2023 at 10:15 AM, ED Nurse Practitioner (NP) #1 stated he had evaluated the patient in the triage area after the patient presented to the ED with complaints of chest pain. The patient was scheduled for dialysis as an outpatient and had stated she had been having intermittent chest pain for the past week with shortness of breath. The patient was hypertensive and was pain free in the triage room. A 12 lead EKG was performed which did not show any acute findings. A cardiac workup was initiated and telemetry was ordered for the patient. The patient's laboratory diagnostic test showed an elevated potassium and he had ordered D10, Insulin, and calcium gluconate. He had spoken with the Nephrologist and the decision was to not give the medications and to return the patient to the dialysis unit for dialysis which would assist in correcting the elevated potassium. He had contacted the hospitalist for admission once the dialysis was completed. He was notified by the ED staff the patient had suffered a cardiac arrest in the ED Waiting Room restroom. He responded to the restroom and assisted with the Code Blue for the patient. He stated he was not aware the patient was not on the telemetry monitor.

During a telephone interview on 2/16/2023 at 11:24 AM, ED Physician #1 stated she had reviewed the 12 lead EKG and found no acute findings suggestive of an acute myocardial infarction. She was not aware the patient was not on telemetry. The patient had been sent back to the ED Waiting Room for transport back to the dialysis unit. The patient suffered a cardiac arrest in the ED Waiting Room restroom. The etiology of the cardiac arrest was undetermined. The patient was found in PEA and ACLS protocols were initiated. She was treated with D10, Insulin, Sodium Bicarbonate, and Epinephrine. The patient progressed into asystole and despite all efforts, the patient expired.

During an interview on 2/16/2023 at 2:00 PM, the Director of Risk Management, stated on 1/20/2023 a meeting was conducted. The patient's case was reviewed and it was decided the incident would be reviewed as a Sentinel Event. The patient had cardiac monitoring ordered in triage and the telemetry monitor was not applied as ordered. On 1/26/2023 a meeting including the staff described above and the Corporate Market CEO was conducted to discuss the plan of action which included adding additional telemetry monitors were moved to the ED triage area and to the Results Waiting area; the ED staff will place a telemetry monitor on all chest pain patients who present to the ED triage area unless the patient required a room in the acute care area or a bedside cardiac monitor; additional 'Vocera' badges were ordered from the manufacturer with a tentative dated of arrival 2/28/2023; establishing an easy way to identify patients who were on a telemetry monitor using large visible pink armbands; and placing emergency pull cord in ED waiting room restrooms. On 2/2/2023, a quote for 10 additional telemetry monitors was requested from the vendor. On 2/6/2023 the quote was received from the vendor and sent to the market CNO for expedited approval. On 2/8/2023 a final meeting was conducted. She confirmed the patient had an order for telemetry and the ED staff failed to place the telemetry monitor on the patient; the facility failed to ensure monitoring for the patient and the patient suffered an unwitnessed cardiac arrest in the ED Waiting Room restroom. She confirmed the facility had not provided immediate training for the staff regarding telemetry monitoring.