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Based on interview and record review, the hospital failed to ensure an organized nursing service that provided safe patient care for one of 20 sampled patients (Patient 1) when:

A. Staff failed to follow a policy and procedure for the continuous maintenance and monitoring of audible clinical alarms when the continuous pulse oximetry (SPO2T, a method of detecting and monitoring oxygenation, used to detect sudden changes in a patients clinical status and is useful for early detection low oxygen levels) audible alarm was turned off (silenced) for Patient 1, and staff did not respond to Patient 1's drop in oxygen level for 43 minutes. Refer to A0398.

This failure resulted in a delay in care and treatment, which subsequently resulted in Patient 1's death.

The cumulative effects of this problem resulted in the inability of the hospital to comply with the statutorily mandated Condition of Participation for Nursing Services.

Based on interview, record review, and facility policy and procedure review, the hospital failed to ensure staff followed a policy and procedure for the continous maintenance and monitoring of clinical alarms when the continuous pulse oximetry (SPO2T, a method of detecting and monitoring oxygenation, used to detect sudden changes in a patients clinical status and is useful for early detection low oxygen levels) audible alarm was turned off (silenced) for one of 20 sampled patients (Patient 1), and staff did not respond to Patient 1's drop in oxygen level for 43 minutes.

This failure resulted in a delay in care and treatment, which subsequently resulted in Patient 1's death.

Findings:

During a review of Patient 1's clinical record titled, "History and Physical" (H&P), dated 10/5/2024, the H&P indicated Patient 1 was admitted to the hospital due to shock (critical condition brought on by the sudden drop in blood flow), chronic respiratory failure (history of breathing difficulty), pneumonia (an infection in the lungs), and encephalopathy (disturbance in brain function).

During a review of Patient 1's clinical record titled, "Orders", dated 10/07/2024, at 11:05 a.m., the physician order indicated, "MEASURE CONTINUOUS PULSE OXIMETRY [SPO2T]."

During a review of Patient 1's pulse oximetry clinical log, dated 10/10/2024, at 9:35 p.m. and 10 seconds, the clinical log indicated, "Patient transferred from 2108," which meant Patient 1 was transferred from the Intensive Care Unit to the 4 South Medical Telemetry Unit.

During a review of Patient 1's pulse oximetry clinical log, dated 10/10/2024, at 9:35 p.m. and 13 seconds, the clinical log indicated, "SpO2T - [audible] Alarms ON."

During a review of Patient 1's pulse oximetry clinical log, dated 10/10/2024, at 9:44 p.m. and 51 seconds, the clinical log indicated, "SpO2T - Alarms from On to Off [silenced]."

During a review of Patient 1's "Strip Report," dated 10/10/2024, the Strip Report indicated a continuous recording of Patient 1's heart rate, heart rhythm, and oxygen level (SPO2T). The first recording of Patient 1's SpO2T was at 10:26 p.m. and 8 seconds and indicated 100% (normal oxygen saturation range from 92% to 100%) and the heart rate (HR) was 86 beats per minute (normal heart rate range from 60 to 100 beats per minute). On 10/11/2024 at 2:36 a.m. and 6 seconds, the SpO2T was recorded at 84% and the HR at 90 beats per minute. At 2:54 a.m. and 55 seconds, the SpO2T was recorded at 20% and the HR at 93 beats per minute. At 3:18 a.m. and 45 seconds, the SpO2T was recorded at 24%, the HR at 63 beats per minute, and a note indicating "...RN notified." At 3:19 a.m. and 19 seconds, the SpO2T was recorded at 18% and the HR at 22 beats per minute, which was 43 minutes from the initial recording of Patient 1's drop in SpO2T at 2:36 a.m. and 6 seconds.

During a review of Patient 1's clinical record titled, "IP [inpatient] Nursing," dated 10/11/2024, at 4:02 a.m., Registered Nurse (RN) 1 indicated, "Late entry or 0319 [3:19 a.m.] ...monitor tech [Name], called me to check on this patient for low HR. Upon entering room, patient was unresponsive and high flow O2 (oxygen) in patients hand ...attempts to stimulate patient were ineffective. Patient had a very weak heart rate and overhead [paged] RRT [rapid response team, a team that responds to situations in a hospital when patients need immediate care]...heart rate was 37 at 0322 [3:22 a.m.]."

During a review of Patient 1's clinical record titled, "Rapid Response Team Activation," dated 10/11/2024, at 4:47 a.m., the clinical record indicated, "Responded to overhead. Patient unresponsive, on High Flow Nasal Cannula [oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 60 liters per minute], No respirations, No pulse. Asystole [no heart beat] on monitor. Partial code status [medical directive that indicates what resuscitation procedures can be performed for a patient]. Medical Doctor [name] arrived to bedside. Will pronounce patient [legal time of death] at time of Rapid Response Team call".

During a review of Patient 1's clinical record titled, "Death Summary," dated 10/11/2024, at 12:26 p.m., the clinical record indicated, "[Patient 1] had acute desats [decrease in blood oxygen levels] and bradycardia [decrease in heart rate] resulting in cardiac arrest [heart suddenly stops beating]. She had elected against chest compressions [the act of pushing down on the center of a person's chest with your hands to help blood flow and restore breathing], or shocks [the delivery of electrical current to the heart to restore electrical activity]. Her time of death 3:27 a.m."

During a phone interview on 12/3/2024, at 12 p.m., with Monitor Tech (MT) 1, MT 1 stated she was assigned to the centralized monitor station for all patients on cardiac and pulse oximetry monitors. MT 1 confirmed Patient 1 was on continuous pulse oximetry as well as cardiac monitoring. MT 1 stated she did not see or hear any changes in Patient 1's pleth (a visual indicator on a monitor of a patient's blood flow and pulse, which may be used to measure oxygen saturation). MT 1 stated, "[On 10/11/24] Around 3:20 [a.m.], [Patient 1's] heart rate started dropping and the alarm sounded ...[Name of nurse] was nearby ...asked him to check the patient." MT 1 further stated, "If I don't see or hear alarms ...I can't escalate". MT 1 stated, "All alarms were default to always be on ...we don't turn off or change alarms."

During a phone interview on 12/3/2024, at 2:10 p.m., with RN 2, RN 2 stated, on 10/11/2024, during the incident with Patient 1, she was assigned as charge nurse on 4 South. RN 2 stated she was in the hallway and glanced up at one of the monitor screens and observed Patient 1's heart rate in the 30's and dropping. RN 2 stated she responded by going to Patient's 1 room, and found staff present, medical treatment was provided according to physician orders and facility policy. RN 2 stated Patient 1 was pronounced dead by the MD. RN 2 stated, "After the incident, I wanted to look at [Patient 1] monitor history and noticed the [pulse oximetry] alarm was turned off." RN 2 stated the facility policy was to never turn off alarms.

During an interview on 12/4/2024, at 9:18 a.m., with Nurse Manager (NM) 1, NM 1 stated she was the manager for the monitor technicians. NM 1 stated staff should not turn off clinical alarms, and Patient 1's pulse oximetry monitor alarm should not have been turned off.

During an interview on 12/4/2024, at 1:38 p.m., with NM 2, the facility policy and procedure (P&P) titled, "Clinical Alarms," dated 5/2/2023 was reviewed. NM 2 stated, "The expectation was for staff to follow facility policy, [Patient 1's] pulse oximetry monitor alarm should not have been turned off."

Review of the facility P&P titled, "Clinical Alarms," dated 5/2/2023, indicated, "Pulse Oximeter Alarm: 5.7.3 Staff shall not "turn off" these alarms".