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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services, was out of compliance.

A-0392- STANDARD: STAFFING AND DELIVERY OF CARE: The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on interviews and documents reviewed, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses to provide nursing care to all patients needed, in accordance with the facility's nurse staffing plan in three of three units reviewed (Behavioral Health Adult, Behavioral Health Geriatric Psychiatry, and Intensive Care Unit (ICU)).

A-0395 - (b)(3) - A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews, the facility failed to ensure patients in the intensive care unit (ICU) were continuously monitored by telemetry and pulse oximetry, as ordered by their provider to identify a change in a patient's condition in one of three ICU medical records reviewed (Patient #1).

Based on interviews and documents reviewed, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses to provide nursing care to all patients needed, in accordance with the facility's nurse staffing plan in three of three units reviewed (Behavioral Health Adult, Behavioral Health Geriatric Psychiatry, and Intensive Care Unit (ICU)).

Findings include:

Facility policy:

The Master Staffing Plan policy read, a nurse staffing plan shall be developed based on scope of care that meets the needs of the patient population, acuity, and frequency of care to be provided.

References:

According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, (1) The nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that: (c) Includes minimum staffing requirements for each inpatient unit and emergency department that are aligned with nationally recognized standards and guidelines.

The staffing plans, which were identified by staff as the facility's staffing grids, were provided by the facility. The staffing plans listed the name of each unit at the facility, the patient census for each unit, and the specified number of registered nurses (RNs) and technicians expected to be staffed and present on each unit according to the current patient census.

The daily assignment logs were provided by the facility and identified by the staff as the document used to track daily shift patient care assignments for staff on the units. The daily assignment logs listed the RNs and what patients were assigned to them for the shift.

1. The facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses (RNs) to provide nursing care to all patients as needed.

A. Document Review

i. The intensive care unit (ICU) daily staffing logs were reviewed for the day shift and night shift staffing from 12/25/23 through 1/31/24. According to the facility staffing plan for the ICU, the ratio of nurses to patients was one RN to every two patients. The review of the daily staffing logs revealed nurses had additional patients to care for beyond the expected ratio in the staffing grid for 63 of the 76 shifts reviewed.

ii. The behavioral health geriatric psychiatric unit daily staffing logs were reviewed on 1/30/24. The review included the day shift and night shift staffing from 12/31/23 through 1/29/24. According to the facility staffing plan for the behavioral health geriatric psychiatric unit, the ratio of nurses to patients was one RN to every seven patients on the day shift and one RN to every eight patients on the night shift. The review of the daily staffing logs revealed on the day shift of 12/31/23 the unit had a census of 32 patients. According to the facility staffing plan, this census called for five RNs and five behavioral health technicians (BHTs). The review revealed the unit was staffed with four RNs and four BHTs. The result was one RN had nine patients and two RNs had eight patients for the shift. This was beyond the expected ratio set forth by the facility staffing committee.

Similar instances of staff assigned an increased number of patients in contrast with the expected ratios in the staffing plan were found upon review of the day shift daily staffing logs for 1/2/24, 1/3/24, 1/6/24, 1/8/24, 1/10/24, 1/16/24, 1/17/24, 1/18/24, 1/23/24, 1/25/24, 1/27/24, and 1/29/24 and the night shift daily staffing logs for 1/1/24, 1/20/24, 1/21/24, 1/22/24, 1/25/24, and 1/28/24.

iii. The behavioral health adult psychiatric unit daily staffing logs were reviewed. The review included the day shift and night shift staffing from 1/1/24 through 1/29/24. According to the facility staffing plan for the behavioral health adult psychiatric unit, the ratio of nurses to patients was one RN to eight patients for the day shift and one RN to nine patients for the night shift. The review of the daily staffing logs for the day shift revealed RNs were staffed one RN to nine patients on 1/2/24, and 1/18/24. The review revealed the day shift ratios were one RN to 10 patients on 1/1/24, and 1/25/24 and the night shift ratios were one RN to 10 patients on 1/15/24. The review revealed the day shift ratios were one RN to 12 patients on 1/5/24 and 1/6/24. Furthermore, the review revealed the day shift ratios were one RN to 13 patients on 1/7/24 and 1/28/24. The night shift ratios were one RN to 13 patients on 1/20/24 and one RN to 14 patients on 1/21/24. This was beyond the expected ratio set forth by the facility staffing committee.

This was in contrast to the facility's Master Staffing Plan policy which read, a nurse staffing plan must have been developed based on scope of care that met the needs of the patient population, acuity, and frequency of care to be provided.

Furthermore, this was in contrast to the regulations followed by the facility, Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan which read, the nurse staffing committee would develop and oversee a master nurse staffing plan which included minimum staffing requirements for each inpatient unit.

B. Medical Record Review

i. Medical record review revealed Patient #1 was admitted to the intensive care unit (ICU) on 11/1/23 after a right upper lobectomy (removal of a part of the lung). On 11/1/23 at 10:40 a.m., a provider order was placed for telemetry and pulse oximetry (oxygen) monitoring. The provider order also indicated the oxygen level was to be kept above 90%.

Medical record review also revealed Patient #1 developed complications after surgery that included atrial fibrillation (an irregular, rapid heartbeat), pulmonary embolisms (blood clots in the lung), and a stroke. Furthermore, the Admission/Shift Assessment documented on 11/11/23 at 4:00 p.m. revealed Patient #1 was on a heated high-flow oxygen nasal cannula that delivered oxygen at 65 liters per minute (lpm) and 85% fraction of inspired oxygen (FIO2) (the concentration of oxygen in the gas mixture).

Provider documentation revealed on 11/11/23 at 4:28 p.m., Patient #1's oxygen saturation was 83%. After this oxygen saturation, the pulse oximeter stopped reading Patient #1's oxygen levels.

Review of nursing documentation revealed on 11/11/23 at 4:31 p.m., Patient #1 was off the pulse oximeter. Patient #1's heart rate was 103 bpm and respiratory rate was 27 breaths per minute.

Nursing documentation also revealed at 4:35 p.m., Patient #1's heart rate was 38 bpm and respirations were 32 breaths per minute. Patient #1 remained off the pulse oximeter and a code blue (cardiac arrest) was called. There was no evidence that Patient #1's abnormal heart and respiration rate or being off the pulse oximeter were addressed by a registered nurse until the code blue was called, despite the high-priority alarm that was set to alarm when Patient #1's oxygen was not monitored and their heart rate dropped below 50 bpm.

Further review of nursing documentation on 11/11/23 at 8:50 p.m. revealed the primary nurse was in an isolation room and responded when the staff assistance alarm and code blue alarm alerted.

Review of the ICU staffing log for 11/11/23 revealed the RN assigned to care for Patient #1 had three ICU patients assigned to them (Patients #1, #7, and #8). Review of the medical records of Patients #1, #7, and #8 revealed provider orders which indicated the patients required ICU level of care and were not a low level acuity. This was in contrast to the ratios set forth in the ICU matrix by the facility staffing committee which directed staffing at one RN to two patients.

ii. Medical record review revealed Patient #9 was admitted to the behavioral health adult psychiatric unit on 1/5/24 for treatment of a psychotic (a mental disorder characterized by a disconnection from reality) episode. Nursing documentation on 1/6/24 at 7:18 p.m. revealed Patient #9 was found on the floor of the bathroom on 1/6/24 at 5:00 p.m. Nursing documentation revealed Patient #9 stated their legs were numb after they stood up from the toilet and lost their balance and fell. Nursing documentation further revealed Patient #9 had fallen and had pain in his head and neck. The patient was transported to the emergency room for evaluation. Nursing documentation on 1/7/24 at 6:04 p.m. revealed Patient #9 also had a splint placed on their left wrist at the emergency room.

Staffing logs for the behavioral health adult psychiatric unit were reviewed for the day shift staffing and revealed Patient #9's nurse had 12 patients on 1/6/24. This was an additional four patients beyond the expected ratio in the staffing plan set forth by the facility staffing committee.

C. Interviews

i. An interview was conducted on 2/5/24 at 11:00 a.m. with ICU RN #11. RN #11 stated the ICU nurse to patient ratio was one RN to two patients unless there was a need to take a third patient. RN #11 stated they took a third patient at times when the patient was a lower acuity level patient if the unit was short-staffed.

ii. An interview was conducted on 1/31/24 at 1:40 p.m. with the ICU clinical nurse coordinator (CNC) #1. CNC #1 stated they had never seen the written matrix for the unit, but knew from being trained that the nurse to patient ratio was one RN to two patients. CNC #1 stated when there was a need to give more patients to a nurse due to a staffing shortage, it was accepted practice to add a third lower acuity level patient to the RNs assignment, which gave the RN three patients.

iii. An interview was conducted on 1/29/24 at 12:15 p.m. with the ICU clinical nurse coordinator (CNC) #2. CNC #2 stated they were unsure of how the matrix was developed but the ICU was staffed one RN to two patients and one RN to three patients if one of the patients had a lower acuity. CNC #2 stated if there were four or five patients with a low acuity level, it was considered acceptable for one RN to care for all four patients. CNC #2 stated there was no place in the written unit matrix that directed staffing for one RN to three patients. CNC #2 stated it was important to follow the matrix of one RN to two patients so nothing was missed in the care of the patient. CNC #2 stated there was a risk of patient harm if the RN had more than two high acuity level patients to care for.

iv. An interview was conducted with the ICU nurse manager (Manager) #4 on 1/31/24 at 3:01 p.m. Manger #4 stated there was nothing in the ICU matrix that supported RNs being assigned more than two patients. Manager #4 stated if there were multiple lower acuity level patients, the patients were moved to an area where there was one RN and one patient care technician (PCT). Manager #4 stated patient safety was the reason a matrix was followed when assignments were made. Manager #4 stated the risks of the matrix not being followed were mistakes or omissions in patient care and included the risk of death to the patient.

v. An interview was conducted with the behavioral health geriatric psychiatric unit registered nurse (RN) #7 on 1/29/24 at 2:50 p.m. RN #7 stated they did not know how the matrix was developed but was informed by the clinical nurse coordinator the ratio was one RN to seven patients for the day shift. RN #7 stated took seven patients and at times took eight patients if the unit was short-staffed. RN #7 stated the reason the matrix was followed was in order to ensure patients received safe care and the patient's needs were met. RN #7 stated when RNs had more than seven patients, there was an increased risk of patient falls or mistakes in patient care. RN #7 stated patients did not get the care or attention they needed when RNs had more than seven patients.

vi. An interview was conducted with the behavioral health geriatric psychiatric unit clinical nurse coordinator (CNC) #3 on 1/29/24 at 2:25 p.m. CNC #3 stated the ratio for day shift was one RN to six to seven patients. CNC #3 stated there were times when the unit was short staffed and RNs took more patients but the matrix did not support these ratios. CNC #3 stated the patient was a priority and was the basis for assignments made by the nursing matrix standard. CNC #3 stated mistakes were made when RNs were overwhelmed with too many patients and that led to patient harm. CNC #3 stated when RNs had more than seven patients, there were medication errors, the quality of patient care was less, patients' needs were not met, and patients' mental health needs were not supported.

vii. An interview was conducted with behavioral health adult psychiatric unit RN #8 on 1/29/24 at 3:05 p.m. RN #8 stated they did not know how the matrix was created and had recently learned the nurse to patient ratio for the unit was one nurse to eight patients. RN #8 stated they worked frequently with up to 12 patients. RN #8 stated there was a risk of injury to staff or other patients when the matrix was not followed. RN #8 stated there was also a risk of errors and patients did not get their physical or mental health needs met when nurses had more than eight patients.

viii. An interview was conducted with behavioral health adult psychiatric unit RN #9 on 1/29/24 at 3:55 p.m. RN #9 stated they did not know how the matrix was created but the nurse to patient ratio was one RN to eight patients. RN #9 stated they were frequently assigned up to 12 patients during shifts when they were short-staffed. RN #9 stated patient and staff injury was a risk when they took more patients than what was given in the matrix. RN #9 stated staff did not take meal breaks and stayed past the end of the shift so work was finished and patients were safe.

ix. An interview was conducted with behavioral health adult psychiatric unit RN #10 on 1/29/24 at 4:05 p.m. RN #10 stated the nurse to patient ratio was one RN to eight patients, but did not understand how that ratio developed. RN #10 stated they frequently had more than eight patients for a shift assignment and at times it went up to 12 patients. RN #10 stated it was difficult to care for patients' needs when there was more than eight patients assigned. RN #10 stated the milieu was difficult to manage when staffing was inadequate and safety was at risk for patient or staff harm.

x. On 2/1/24 at 2:17 p.m. an interview was conducted with the behavioral health director of nursing (DON) #12. DON #12 stated some behavioral health staff attended the quarterly staffing committee meetings. DON #12 stated the new matrix was presented to staff in December of 2023 and the staff had access to it on the behavioral health units. DON #12 stated this matrix included nursing ratios of one RN to seven patients (day shift) and one RN to eight patients (night shift) for the behavioral health geriatric psychiatric unit. DON #12 stated the nursing ratios for the behavioral health adult psychiatric unit was one RN to eight patients (day shift) and one RN to nine patients (night shift).

DON #12 stated patients were transferred to an overflow unit or admissions were stopped when there was not enough staff to care for the patients. DON #12 stated this kept RNs within the matrix nursing to patient ratios. DON #12 also stated unit managers came in and took care of patients when the units were short-staffed.

The facility was unable to provide evidence of patients transferred to overflow units when the staffing assignments exceeded the staffing matrix. This was in contrast to the document review of the daily assignment logs for the behavioral health adult and geriatric psychiatric units which showed staff were assigned patients outside the matrix ratios on multiple occasions. This was also in contrast to interviews conducted which revealed staff were assigned patients outside the matrix ratios on multiple occasions.

Based on document review and interviews, the facility failed to ensure patients in the intensive care unit (ICU) were continuously monitored by telemetry and pulse oximetry, as ordered by their provider to identify a change in a patient's condition in one of three ICU medical records reviewed (Patient #1).

Findings include:

Facility policies:

The Pulse Oximetry policy read, the purpose for pulse oximetry was to determine the need for oxygen therapy and the amount of oxygen needed to maintain a satisfactory oxygen saturation. Additionally, indications for pulse oximetry included monitoring of critical patients.

The Cardiac Telemetry Monitoring policy read, rhythm changes and/or life-threatening arrhythmias must be assessed and responded to immediately to assure the safety of the patient and ensure prompt treatment of a problem. Prompt notification of cardiac arrhythmias and/or rhythm changes is essential for patient safety.

References:

The Carescape Modular Monitors Carescape One clinical reference guide for the telemetry and pulse oximetry monitor read, high-priority alarms (red) require an immediate response; medium priority alarms (yellow) require a prompt response.

Pictures of the facility alarm settings for the telemetry and pulse oximetry monitors provided by ICU nurse manager (Manager #4) revealed the parameters for heart rates alarmed as a high-priority (red) alarm when the heart rate fell below 50 beats per minute (bpm) or went above 120 bpm. The parameter for the oxygen saturation alarmed as a high-priority (red) alarm when the oxygen saturation fell below 89%.

1. The facility failed to ensure patients had continuous cardiac and oxygen monitoring to detect any changes in condition.

A. Medical Record Review

i. Medical record review revealed Patient #1 was admitted to the intensive care unit (ICU) on 11/1/23 after a right upper lobectomy (removal of a part of the lung). On 11/1/23 at 10:40 a.m., a provider order was placed for telemetry and pulse oximetry (oxygen) monitoring. The provider order also indicated the oxygen level was to be kept above 90%.

Medical record review also revealed Patient #1 developed complications after surgery that included atrial fibrillation (an irregular, rapid heartbeat), pulmonary embolisms (blood clots in the lung), and a stroke. Furthermore, the Admission/Shift Assessment documented on 11/11/23 at 4:00 p.m. revealed Patient #1 was on a heated high-flow oxygen nasal cannula (HHFNC) that delivered oxygen at 65 liters per minute (lpm) and 85% fraction of inspired oxygen (FIO2) (the concentration of oxygen in the gas mixture).

Provider documentation revealed on 11/11/23 at 4:28 p.m., Patient #1's oxygen saturation was 83%. After this oxygen saturation, the pulse oximeter stopped reading Patient #1's oxygen levels. Review of nursing documentation revealed on 11/11/23 at 4:31 p.m., Patient #1 was off the pulse oximeter. There was no documentation indicating why the patient was off of the pulse oximeter. Patient #1's heart rate was documented at 103 bpm and respiratory rate was documented at 27 breaths per minute at this time.

Nursing documentation also revealed at 4:35 p.m., Patient #1's heart rate was 38 bpm and respirations were 32 breaths per minute. Patient #1 remained off the pulse oximeter and a code blue (cardiac arrest) was called. According to the provider's documentation, after one round of chest compressions, one milligram (mg) of epinephrine (a medication given to increase blood pressure) and one ampoule of sodium bicarbonate (a medication given to help with acid buildup in the blood caused by cardiac arrest), the patient had a return of spontaneous circulation. The provider documented concern for hypoxic arrest (loss of oxygen to the body) secondary to the patient removing the HHFNC and that a pulmonary embolism (PE, sudden blockage of blood flow to the lungs) was not ruled out.

There was no evidence that Patient #1's abnormal heart and respiration rate or being off the pulse oximeter were addressed by a registered nurse until the code blue was called, despite the high-priority alarm that was set to alarm when Patient #1's oxygen was not monitored and their heart rate dropped below 50 bpm.

Further review of nursing documentation on 11/11/23 at 8:50 p.m. revealed the primary nurse was in an isolation room and responded when the staff assistance alarm and code blue alarm alerted.

This was in contrast to the facility policy, Cardiac Telemetry Monitoring which read, rhythm changes must have been assessed and responded to immediately to assure the safety of the patient and ensure prompt treatment of a problem.
Furthermore, this was in contrast to the Carescape Modular Monitors Carescape One clinical reference guide which read high-priority alarms required an immediate response.

B. Document Review

i. The ICU Unit Activity Report for call lights document revealed the call light activity from the ICU pod F room #58 was reviewed for 11/11/23. The review revealed Patient #1's call light was activated on 11/11/23 at 4:29 p.m. and was routed to the RN's phone but was not answered. The review also revealed the system rang the RN's phone again after 30 seconds and rang to the nurses' station in another minute. Further review revealed the staff assist call was made at 4:33 p.m.

C. Interviews

i. On 2/1/24 at 8:42 a.m. an interview was conducted with ICU patient care technician (PCT) #6. PCT #6 stated Patient #1 was in ICU pod F (an ICU patient care area made up of 12 patient rooms and separated by a long hallway from the main ICU area). PCT #6 stated they were working both sides of the ICU (the main area and pod F) on 11/11/23. PCT #6 stated the two RNs in pod F were in rooms with patients when PCT #6 stepped away from the desk for a reason they were unable to remember. PCT #6 stated this left no staff member at the desk where the telemetry and pulse oximetry monitors were. PCT #6 stated they anticipated the time away to be short, so there was no communication provided to the RNs about their leaving the unit.

PCT #6 stated Patient #1's daughter had activated the patient call light prior to them returning to the unit and Patient #1's daughter met PCT #6 in the hall and alerted them that Patient #1 was in distress. PCT #6 stated they found the patient unresponsive and without oxygen or the pulse oximetry probe on their finger and activated the staff assist alarm for help.

PCT #6 stated communication was important so patients were monitored and others were aware of the activities in the unit for patient safety. PCT #6 stated call lights and alarms were answered immediately because there might have been something seriously wrong with the patient. PCT #6 stated the sooner the call lights and alarms were responded to, the better chance the patient had of a good outcome.

This was in contrast to interviews and document review which revealed Patient #1's call light and monitor alarms were not answered immediately.

ii. An interview conducted with ICU clinical nurse coordinator (CNC) #1 on 1/31/24 at 1:40 p.m., revealed all ICU patients were to have continuous telemetry and pulse oximetry monitoring. RN #1 stated the patient bedside monitors were able to show the vital signs of two patients at once. RN #1 stated the best way to continuously monitor patients was to have the information of two patients on one monitor in the patient room. RN #1 stated while this was the best way to continuously monitor patients, it was not done consistently by RNs and the decision was left to their discretion. RN #1 stated when an ICU nurse had a third patient, they relied on other staff to help monitor the third patient because the monitors only showed two patients at a time. RN #1 stated it was difficult to continuously monitor patients when the two patients were not on the monitor, especially when there were only two RNs in the ICU pod (the area of patient rooms). RN #1 stated it was important to monitor patients continuously because medications and treatments were based on the vital signs that were monitored and patients experienced harm when not monitored. RN #1 stated patients risked serious consequences such as stroke or death if they were not monitored continuously.

iii. An interview conducted with ICU CNC #2 on 1/31/24 at 10:48 a.m., revealed staff were to respond to all telemetry and pulse oximetry alarms as soon as the alarms sounded. CNC #2 stated telemetry and pulse oximetry alarms were audible in the nurses' stations and patient rooms as long as the patient room door remained open. CNC #2 stated patients in isolation had closed doors and alarms could not be heard. CNC #2 stated the best way to continuously monitor patients was to ensure two patients' information from the telemetry monitor was pulled up on the monitor used by the nurse. CNC #2 stated this was not done by all nurses, was not required to monitor patients continuously, and was at the discretion of the nurse. CNC #2 stated it was important to pull up two patients on one monitor so the patient's abnormal vital signs could be seen and treated immediately to prevent harm to the patient. CNC #2 stated when nurses did not continuously watch the monitors they could miss a change in the patient's condition that would result in patient harm.

CNC #2, who was the charge nurse during Patient #1's event on 11/11/23, stated Patient #1 was not monitored while the primary nurse was behind a closed patient room door and there was no staff at the nurses' station to monitor patients. CNC #2 stated patient care technician (PCT) #6 had returned to the unit and was summoned by Patient #1's daughter to assist with the patient's deteriorated condition.

iv. An interview conducted with the ICU nurse manager (Manager) #4 on 1/31/24 at 3:01 p.m. revealed staff were expected to monitor staff continuously. Manager #4 stated it was the responsibility of all unit staff to listen for telemetry and pulse oximetry alarms and respond. Manager #4 stated those who sat at the nurses' station to document in medical records responded to alarms when the primary nurse was unable to respond. Manager #4 stated if there was no one at the nurses' station, the alarms were heard around the unit and were responded to by other staff members. Manager #4 stated they defined continuous monitoring as continuously monitoring respirations, heart rate, pulse oximetry, and arterial lines.

Manager #4 stated continuous monitoring did not mean the nurse watched the patient or the monitor continuously. Manager #4 stated nurses were able to print out strips of vital sign information if they were unable to monitor the patient in real-time. This was in contrast with the Cardiac Telemetry Monitoring policy read, rhythm changes and/or life-threatening arrhythmias were expected to be responded to immediately to assure the safety of the patient and ensure prompt treatment of a problem.

Manager #4 stated the bedside patient monitors used to monitor two patients' information were optimal, but not required. Manager #4 stated this practice was beneficial if the nurse was in a patient room for an extended period of time or if other staff members were not available to help attend to the telemetry and pulse oximetry alarms. Manager #4 stated it was important to continuously monitor patients to detect early changes that might have led to a patient's demise. Manager #4 stated if nurses did not continuously monitor patients, they would miss an important change in the heart rate or other vital signs that could be fatal for the patient.

v. An interview conducted with medical doctor (MD) #5 on 1/31/24 at 11:41 a.m. revealed all patients in the ICU had orders for continuous telemetry and pulse oximetry. MD #5 stated the expectation was that patients were hooked up to the monitors with the correct parameters for the vital signs and that patients were continuously monitored for changes in condition. MD #5 stated it was important to continuously monitor patients because ICU patients were significantly more sick than other patients and had the potential to decompensate quicker than other patients. MD #5 stated when patients were monitored continuously, it allowed staff to identify a change in the patient's condition and treat the problem to prevent harm to the patient. MD #5 stated they expected a response to telemetry and pulse oximetry alarms within two to three minutes. MD #5 stated the patient risked decompensation or death when staff did not respond immediately to alarms to treat the patient's change in condition.