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Based on observations, policy review, medical record review, and staff interview; the facility failed to ensure nursing care was evaluated for each patient (A395).

Based on observation, policy review, medical record review, and staff interview, the facility failed to ensure nursing care was evaluated for one of 13 medical records reviewed (Patient #1). The census was 239.

Findings include:

Review of the policy titled, "Cardiac Monitoring Responsibilities," approved 06/15/22, revealed Critical Red Alarms are lethal dysrhythmias including ventricular fibrillation, ventricular tachycardia, asystole or artifact. Alarms may only be silenced at the nursing unit after nursing assesses the patient and telemetry status.

Review of the medical record for Patient #1 revealed an admission date of 05/26/23. A nursing shift assessment was documented at 8:13 PM on 05/28/23. Patient #1's vitals at 8:49 PM were temperature 97.5, pulse 65, blood pressure 115/59, and pulse oximetry was 90%. On 05/28/23 at 10:18 PM, a Code Blue was initiated. At 10:44 PM, Patient #1 was transferred emergently to the Medical Intensive Care Unit.

On 05/29/23 at 12:39 AM, the physician progress note stated cardiac arrest likely due to brady arrhythmia. The patient had anoxic encephalopathy, acute respiratory failure with hypoxia and hypercapnia due to cardiac arrest, and cardiogenic versus septic shock.

The medical record lacked documentation of any assessment or intervention on 05/28/23 from 8:13 PM to 10:18 PM when the Code Blue was initiated. The medical record lacked documentation as to who found the patient, the circumstances, and who called the Code Blue.

Review of the report of the telemetry alarms for Patient #1 revealed red alarms on 05/28/23 from 10:09 PM through 10:18 PM when the Code Blue was initiated. At 10:09:10 PM, the extreme Brady (bradycardia) alarm was generated for heart rate (HR) of 38. At 10:09:25 PM, the alarm was silenced from the desk. At 10:09:32 PM, the extreme Brady ended. At 10:09:57 PM, the extreme Brady alarm was generated for HR of 58. At 10:10:13 PM, the alarm was silenced from the desk. At 10:10:20 PM, the extreme Brady ended. At 10:11:41 PM, the extreme Brady alarm was generated for HR of 40. At 10:11:45 PM, the alarm was silenced from the desk. At 10:12:18 PM, the extreme Brady ended. At 10:12:19 PM, the alarm was silenced from the desk. At 10:12:47 PM, the Apnea (no respirations) alarm was generated. At 10:13:03 PM, the alarm was silenced from the desk. At 10:13:10 PM, the Apnea ended. At 10:13:20 PM, the Apnea alarm was generated. At 10:13:32 PM, the alarm was silenced from the desk. At 10:13:42 PM, the Apnea ended. At 10:14:09 PM, the alarm was silenced from the desk. At 10:14:34 PM, the extreme Brady alarm was generated for HR of 40. At 10:14:36 PM, the Apnea alarm was generated. At 10:14 PM, the alarm was silenced from the desk. At 10:15:08 PM, the extreme Brady ended. At 10:15:31 PM, the Apnea ended. At 10:15:47 PM, the extreme Brady alarm was generated for HR of 42. At 10:15:49 PM, the Apnea alarm was generated. At 10:15 PM, the alarm was silenced from the desk. At 10:16:14 PM, the Apnea alarm ended. At 10:16:32 PM, the Apnea alarm was generated. At 10:17:32 PM, the extreme Brady alarm ended. At 10:17:44 PM, the VTach (ventricular tachycardia) alarm was generated. At 10:18:05 PM, the Asystole alarm was generated for HR of 0.

On 06/06/23 at 1:15 PM, Staff F, the nurse assigned to Patient #1 at the time of the Code Blue, was interviewed by phone. Staff F stated that she had been told that Patient #1 was bradycardic all evening. His heart rate dropped to 29 and the charge nurse responded and called the code. Staff F stated she had given him medications an hour before and he was talking and fine at that time. Staff F saw the bradycardia on the telemetry and responded to the room.

On 06/07/23 at 8:20 AM, Staff G was interviewed by phone. Staff G stated she did not remember all of the details, but she heard the telemetry alarm and went to Patient #1's room. She was the first to the room. She did a sternal rub, there was no pulse, she pulled the code button and started compressions. Staff G was not aware of other alarms prior to entering the patient's room. Staff G stated it was not routine to silence alarms prior to getting to the room. Staff G stated she was in and out of rooms that night and not at the monitors. The details should be documented in the code narrator as part of the code documentation. Staff G could not speak to who would have silenced the alarms or if anyone else had entered Patient #1's room to check on him prior to her responding. They did not document every time they entered a patient's room. Any nurse should respond to alarms if the primary nurse was not around.

On 06/07/23 at 8:38 AM, Staff E was interviewed. Staff E verified that no additional documentation regarding Patient #1's condition immediately prior to the code was documented. Staff E stated she would need to see the patient's history of alarms to be able to speak to whether a rapid response should have been called as rapid responses were for changes in condition. It would also depend on what the physician was aware of and had discussed with the nurse.

On 06/07/23 from 8:55 AM to 9:10 AM, the Neuro Surgical Intermediate Care Unit was toured. Patient #1 had been in room 5N01. The closest desk where staff would sit to chart was observed to be between rooms 5N16 and 5N17 and across from room 5N02 and diagonal from room 5N01. The next desk, between rooms 5N14 and 5N15 and across from rooms 5N03 and 5N04, was where the surveillance monitor that silenced all the alarms prior to the Code Blue on 05/28/23 was located. Staff E verified this was the location where the alarm was silenced from. It was observed that the patient rooms did not have telemetry monitors; therefore, the alarms could not be silenced at the bedside. Patients on the floor just had portable telemetry boxes.

This deficiency represents non-compliance investigated under Substantial Allegation OH00143318.