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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 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 document review, the facility failed to provide nursing services within recognized standards. Specifically, the facility failed to ensure continuous cardiac monitoring (telemetry) occurred as ordered in one of one telemetry patients medical records reviewed (Patient #4). In addition, the facility failed to have staff available who were able to access a medication emergently in one of three medical records reviewed (Patient #1).

Based on interviews and document review, the facility failed to provide nursing services within recognized standards. Specifically, the facility failed to ensure continuous cardiac monitoring (telemetry) occurred as ordered in one of one telemetry patients medical records reviewed (Patient #4). In addition, the facility failed to have staff available who were able to access a medication emergently in one of three medical records reviewed. (Patient #1)

Findings include:

Facility Policies:

The Continuous Cardiac Monitoring (Telemetry) policy read, the monitor technician notifies the patient's nurse if alarms sound, there is any change in patient rhythm, poor signal or loss of signal, or any change in monitoring lead.

The Nursing Staffing and Scheduling Guidelines Policy read, a registered nurse (RN) qualified by training, competencies as well as experience shall be designated as a House Supervisor for all inpatient units. If a House Supervisor was unavailable for a shift, a qualified registered nurse with competencies as well as experience shall be designated as the Charge Nurse. This nurse will assume the phone, additional pharmacy access, and will contact auxiliary personnel if any additional needs are necessary while on shift.

The Rapid Response Team Policy read, established guidelines for the Rapid Response Team (RRT): The RRT provides emergency care to patients based on the staff's request for assistance. Rapid Response may be called for any change in patient's condition outside the established parameters, early signs of clinical deterioration or anytime a caregiver has a "gut feeling" that all is not right with a patient. The RRT members include, but are not limited to: Nursing Supervisor, primary nurse of patient, ICU Nurse, Respiratory Supervisor, Respiratory Therapist of patient, Pharmacist as available, Pharmacy Technician, Nursing Assistant of patient and Physician as available.

1. The facility failed to ensure continuous cardiac (heart) monitoring occurred as ordered in a patient who experienced an unexpected death.

a. Medical record review revealed Patient #4 was admitted on 7/19/22 for treatment of respiratory failure with a history of aortic dissection repair (surgery to repair a tear in the ascending aorta), pneumonia, and cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping). On 7/20/22 at 6:01 a.m., a telephone order was received which read, "telemetry cardiac monitoring, continuous."

i. Further medical record review revealed Patient #4 had multiple incidences of irregular cardiac rhythms. For example:

On 7/23/22 at 6:18 p.m., Patient #4 had a 23 beat run of ventricular tachycardia (VT) (irregular heart rate caused by irregular electrical signals in the lower chambers of the heart).

On 7/24/22 at 8:00 a.m., Patient #4's cardiac rhythm was documented as atrial fibrillation (occurs when the upper chambers of the heart contract irregularly and get out of sync with the lower chambers of the heart).

On 7/24/22 at 4:00 p.m., Patient #4's cardiac rhythm was documented as atrial flutter with variable block (fast rate in the upper chambers of the heart with a fixed, or variable, rate in the lower chambers of the heart).

On 7/25/22 at 8:00 p.m., Patient #4's cardiac rhythm was documented as sinus tachycardia with frequent premature atrial contractions (PACs) (faster than normal heart rhythm with extra heartbeats that start in the upper chambers of the heart).

On 7/28/22, Patient #4 was documented as having supraventricular tachycardia (SVT) (an irregularly fast or erratic heartbeat that affects the heart's upper chambers).

The last documentation of Patient #4's cardiac rhythm occurred on 7/31/22 at 4:00 a.m., when he was documented as being in a normal sinus rhythm (a normal heart rhythm).

ii. On 7/31/22, documentation revealed Patient #4 was transferred from the medical observation unit (MOU) to a lower level of care, the Medical Surgical unit. The medical record revealed while in the Medical Surgical Unit, Patient #4 was sitting up and eating when he started to hold food in his mouth. The certified nursing assistant (CNA) left Patient #4 to get the respiratory therapist (RT), and when the RT had arrived, Patient #4 was pulseless and not breathing. He was pronounced dead on 7/31/22 at 5:22 p.m.

iii. Document and medical record review revealed no evidence that Patient #4 had been continuously monitored when he was transferred to the Medical Surgical Unit. Furthermore, review of a document titled Telemetry Call Log, dated 7/31/22, revealed there was no evidence of notification of a loss of signal from the MT to a nurse during the time Patient #4 had been switched from the MOU cardiac monitor to the telemetry box. This was in contrast to the CORE: Continuous Cardiac Monitoring policy which read, the monitor technician was expected to notify the patient's nurse if there was any change in patient rhythm, poor signal, loss of signal, or any change in monitoring lead.

b. On 8/11/22 at 12:08 p.m. and at 3:06 p.m., interviews occurred with registered nurse (RN) #5, who worked in the MOU. RN #5 stated in the MOU, patients had telemetry leads that connected to a monitor and transmitted to the central monitoring unit. RN #5 stated if the MOU telemetry leads came off of the patient, the monitor would show a flat line and it was expected that MTs would notify the nurse if the monitor showed a flat line so the nurse would know to check on the patient. RN #5 then stated it was important for a patient who had a cardiac history to be monitored with telemetry because it was a way to detect if something irregular was happening to their heart.

RN #5 stated she had transferred Patient #4 from the MOU to the Medical Surgical Unit at approximately 12:00 p.m. on 7/31/22. RN #5 stated she had removed the patient from the MOU's cardiac monitor and placed the telemetry box on Patient #4 prior to transferring him to the Medical Surgical unit. RN #5 stated the portable telemetry box could show a patient's cardiac rhythm, but it would not show if the rhythm was transmitted to the central monitoring unit. In addition, RN #5 stated she did not notify the MT of the change between monitors, but she mentioned to the receiving nurse in the Medical Surgical unit to check with the MT to make sure the telemetry box was transmitting.

e. On 8/11/22 at 4:09 p.m., an interview was conducted with the chief clinical officer (CCO) #4. CCO #4 stated she reviewed the event regarding Patient #4 and identified a gap in the central telemetry monitoring process. CCO #4 stated if the telemetry monitor showed a patient had been disconnected, the monitor technician was expected to call the nurse to alert them that the patient was not being monitored. Upon request, CCO #4 was unable to provide evidence of reeducation, inservices, or meetings regarding the expectations of MTs to notify the nurse when patients were suddenly not being monitored.

f. On 8/11/22 at 3:24 p.m., an interview was conducted with monitor technician (MT) #7. MT #7 stated that she had not received any additional training in the last two weeks.


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2. The facility failed to ensure supervisory staff had access to medications in an emergency event which caused a delay in care.

a. A review of Patient #1's medical record revealed Patient #1 was admitted on 7/26/22 for respiratory failure and history of seizures. On 7/28/22 at 8:34 p.m., a change in condition note was entered by the RN. The note documented Patient #1 was found unresponsive during a seizure activity which lasted 30 seconds and a Rapid Response (an emergency code which alerts additional staff to assist with patient care) was initiated. Documentation further revealed the medical doctor (MD) #1 was notified and Lorazepam (medication for the treatment of anxiety and seizures) was ordered to start as soon as possible (ASAP) to treat active seizure.

On 7/28/22 at 8:29 p.m., a provider's order was entered. The order read, Lorazepam 1 mg, start ASAP. On 7/28/22 at 8:40 p.m., eleven minutes after the order was entered, a Lorazepam medication administration documentation was entered by the RN.

b. On 8/4/22 at 10:41 a.m., an interview with medical doctor (MD) #1 was conducted. MD #1 stated Patient #1 presented with myoclonic seizures (seizures with muscle twitches); however, on 7/28/22 the primary RN felt Patient #1's seizure was different and a Rapid Response was called. MD #1 stated there was a delay in care when Lorazepam was ordered. She stated she recalled nursing staff was unable to remove the anti-seizure medication from the automatic dispensing machine (ADM). MD #1 stated the nursing staff was able to remove medication from ADM only after the pharmacist on-call was called and the Lorazepam medication was approved on the patient's medication list.

c. On 8/3/22 at 1:19 p.m., an interview with RN #2 was conducted. RN #2 stated if a patient had a seizure and required emergency medications such as Lorazepam, staff would need special access to override the ADM to obtain the medication. RN #2 stated house supervisors had privileges to override medications (obtain medications without an order) in the ADM.

RN #2 stated a staff RN could assume house supervisor responsibility if a house supervisor was not available for a shift. RN #2 stated the outgoing house supervisor would verify with the chief clinical officer (CCO) and pharmacist on-call if competencies were met in order to grant the covering nurse access to override medication in the ADM.

d. On 8/4/22 at 11:31 a.m., an interview with the nursing educator (Educator) #3 was conducted. Educator #3 stated he was responsible for the completion of staff competencies. Educator #3 stated staff competencies varied depending on the staff job title. Educator #3 stated the facility did not have a formalized process regarding competencies for the house supervisor role if coverage from a staff nurse was needed. He stated he was not involved in the selection process of the house supervisor and there were no competency checklists completed by the facility.

e. On 8/4/22 at 11:45 a.m., an interview with the chief clinical officer (CCO) #4 was conducted. CCO #4 stated whenever a house supervisor was not available for a shift, a verbalized process was done to choose a staff member to assume the responsibilities of house supervisor. CCO #4 stated a discussion between the CCO and outgoing House Supervisor was conducted to select a nurse to cover for the next shift, which was based on the staff member's experience and tenure with the facility. CCO #4 further explained the CCO and House Supervisor would select a staff member among the scheduled staff to be the charge nurse for the shift. CCO #4 stated the charge nurse would use the House Supervisor's phone to act as a liaison between the staff and the provider on-call, administrator on-call and pharmacist on-call. CCO #4 stated there were no competency checklists for the charge nurse role.

CCO #4 stated she was made aware of Patient #1's delayed medication administration due to the charge nurse's unauthorized ADM override access. CCO #4 stated the staff members on duty during the delayed Lorazepam administration incident did not have access to override medications because staff was deemed not competent from the pharmacy standpoint and was not granted authority to override medications for the shift. CCO #4 stated she reviewed the event with staff involved. CCO #4 further stated chart audits were done on patients with seizure diagnosis to ensure they had PRN (as needed) anti-seizure medication orders.

Upon request, the facility was unable to provide evidence of chart audits or a current process to ensure a charge nurse would have access to override emergency medication from the ADM.