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Based on interview, medical record review, and facility policy review, the hospital failed to ensure the effective delivery of nursing services to provide safe and quality care to one of 20 sampled patients (Patient 1) when:

A. The hospital failed to ensure a policy for telemetry (tracing of electrical activity of the heart rate and rhythm) monitoring was implemented for one of 20 sampled patients (Patient 1) when:

1. Monitor Tech (MT) 1 contacted Registered Nurse (RN) 1 to check on Patient 1 but did not tell RN 1 that Patient 1 was in ventricular fibrillation (VFIB, a type of arrhythmia [irregular heart rhythm] that is life-threatening. When the heart is in VFIB, the definitive treatment is to perform electrical defibrillation, which is the act administering an electrical current across the chest to help the heart return to a normal rhythm).

2. RN 1 assessed the wrong patient (Patient 2) and told MT 1 that the patient was sitting up and eating.

3. MT 1 asked RN 1 to check the telemetry leads (part of telemetry monitor attached to patient's skin, used to detect heart activity) on Patient 1, to which RN 1 replied that she would in a few minutes.

4. MT 1 failed to follow up with RN 1, and 12 minutes later RN 2 discovered Patient 1 unresponsive and without a pulse. (Refer to A0398).

These failures resulted in a delay in care and treatment decisions, which potentially contributed to Patient 1's death.

The cumulative effect of these failures resulted in the hospital's inability to provide effective, safe and quality nursing services in accordance with the statutorily-mandated Conditions of Participation Nursing Services.

Based on interview, clinical record review, and facility policy and procedure review, the hospital failed to ensure a policy for telemetry (tracing of electrical activity of the heart rate and rhythm) monitoring was implemented for one of 20 sampled patients (Patient 1) when:

1. Monitor Tech (MT) 1 contacted Registered Nurse (RN) 1 to check on Patient 1 but did not tell RN 1 that Patient 1 was in ventricular fibrillation (VFIB, a type of arrhythmia [irregular heart rhythm] that is life-threatening. When the heart is in VFIB, the definitive treatment is to perform electrical defibrillation, which is the act administering an electrical current across the chest to help the heart return to a normal rhythm);
2. RN 1 assessed the wrong patient (Patient 2) and told MT 1 that the patient was sitting up and eating;
3. MT 1 asked RN 1 to check the telemetry leads (part of telemetry monitor attached to patient's skin, used to detect heart activity) on Patient 1, to which RN 1 replied that she would in a few minutes; and
4. MT 1 failed to follow up with RN 1, and 12 minutes later RN 2 discovered Patient 1 unresponsive and without a pulse.

These failures resulted in a delay in care and treatment decisions, which potentially contributed to Patient 1's death.

Findings:

Review of Patient 1's clinical record titled, "History and Physical", dated 7/21/2024, indicated Patient 1 was admitted to the hospital due to an exacerbation of Patient 1's heart and lung diseases.

Review of Patient 1's clinical record titled, "Orders", dated 7/21/2024, indicated a physician order for Patient 1 to be placed on telemetry.

Review of Patient 1's clinical record titled "Monitor Rhythm Strips", dated 7/25/2024, from 8:49 a.m. to 9:03 a.m., indicated the following:

At 8:49 a.m. the monitor rhythm strip indicated a system alarm, including pause and VFIB/VTAC (ventricular tachycardia, a type of arrhythmia). The strip indicated the heartrate was 84 followed by 0 (zero). The strip included a notation, which indicated, "Per RN [RN 1] PT [patient] eating and sitting up ...RN will check later."

At 9:01 a.m. the monitor rhythm strip indicated a manual recording and asystole (when the heart's electrical system fails entirely causing the heart to stop pumping).

At 9:03 a.m. the monitor rhythm strip indicated a system alarm, including VFIB/VTAC. The strip indicated the heart rate was zero and a notation, which indicated "code blue [a hospital-wide alert system used to indicate that a patient requires emergency medical attention, most often as the result of a respiratory or cardiac arrest]. ...RN called Pt pulseless informing me no one called ..."

Review of Patient 1's clinical record titled, "Physician Orders: Code Blue Form", dated 7/25/2024 at 9 a.m., indicated that Patient 1 was pulseless (no heart beat), her lips were blue, initial heart rhythm was VFIB, and chest compressions were started. The record further indicated that resuscitation (emergency procedure for when someone's breathing or heartbeat stops) ended at 9:11 a.m.

Review of Patient 1's clinical record titled "Discharge Summary," dated 7/25/24 at 5:12 p.m., indicated, "Patient passed away on 7/25/24 at 09:11 [a.m.]."

During an interview with the Manager of Medical Acute Unit (MMAU) on 8/1/2024 at 11:30 a.m., MMAU stated she was the recorder during the code blue for Patient 1 on 7/25/2024. MMAU stated she interviewed RN 1 and RN 2 following the event. MMAU stated RN 1 told her that MT 1 called her to check on Patient 1, and RN 1 told MT 1 that Patient 1 was sitting up and eating. MMAU stated that RN 1 stated that she thought she was checking on Patient 1 when she was actually looking at Patient 2. MMAU stated Patient 1 was in the adjoining room. When asked about RN 1's availability for interview, MMAU stated RN 1 was currently on a leave of absence.

During an interview with Interim Patient Quality Safety Manager (IPQSM) on 8/1/2024 at 1:25 p.m., IPQSM stated that she conducted interviews with MT 1, RN 1, and RN 2. IPQSM stated that MT 1 stated he called RN 1 on 7/25/2024 at 8:49 a.m. to check the telemetry leads on Patient 1 and RN 1 replied to MT 1 that she would in a few minutes.

During an interview with RN 2 on 8/2/2024 at 10:57 a.m., RN 2 stated that when she entered Patient 1's room on 7/25/2024 at 9:02 a.m. she found Patient 1 unresponsive, and her lips were blue. RN 2 stated she started cardiopulmonary resuscitation (CPR, an emergency procedure done when someone's breathing or heartbeat has stopped) and told RN 1 to call a code blue. RN 2 stated she asked RN 1 if MT 1 had called her about Patient 1. RN 2 stated RN 1 replied that she thought MT 1 had called for a patient in the adjoining room (Patient 2). RN 2 stated Patient 1's room was next to Patient 2's room and the rooms were separated by a curtain.

During a concurrent interview and record review with MT 1 on 8/2/2024 at 11:40 a.m., MT 1 reviewed Patient 1's monitor rhythm strips dated 7/25/2024, and stated, at 8:49 a.m. the telemetry monitor interpreted the heart rhythm as VFIB. MT 1 stated "I called the nurse to know if the patient is safe. She confirmed that the patient is sitting up and eating. I asked her if she could fix the leads for me. She said I will in a few minutes. I did not write VFIB on the strip as she confirmed that the patient was sitting up and was okay." When asked to describe the procedure for when a patient had a lethal heart rhythm, like VFIB, MT 1 stated the monitor techs would call the primary nurse first, and if not able to reach the primary nurse, they would call the charge nurse. MT 1 stated that if the monitor tech was unable to reach the charge nurse, they would activate a code blue. MT 1 stated this was according to policy.

Review of the facility's job description titled, "MONITOR TECH-R," dated 8/25/2022, indicated, "Recognizes emergency situations (including life threatening arrhythmias) and responds effectively and appropriately. Notifies the RN with rhythm changes in a proactive approach ...Anticipates patient/unit needs during emergency/code situations without requiring direction ...performs legible, timely, concise and accurate documentation according to policies and procedures."

Review of the facility's administrative policy titled, "Continuous Cardiac Monitoring via Telemetry (Telemetry Monitoring)," dated 8/8/2023, indicated, "Continuous cardiac monitoring is used to: a. Immediately recognize sudden cardiac arrest to improve time to defibrillation. b. Recognize deteriorating conditions that may lead to a life-threatening arrhythmia. c. Facilitate management of arrhythmias ... Any communications regarding patient care concerns are to be timely, complete and accurate and follow the Chain of Command for escalation, if necessary, to achieve resolution ..."

Review of the facility's administrative procedure titled, "Continuous Cardiac Monitoring via Telemetry (Telemetry Monitoring)," dated 8/8/2023, indicated, "E. Documentation ...2. The Monitor Tech or other qualified personnel: a. Will report any significant rhythm changes immediately to the patient's primary nurse ...3. Will call a CODE BLUE automatically for any lethal arrhythmias: a. Sustained ventricular tachycardia b. Ventricular fibrillation c. Asystole ...5. Nursing staff are required to respond immediately to any STAT [immediately] calls or response requests from the Monitor Tech ..."