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Based on record review and staff interviews it was determined the hospital failed to develop and implement measurable, data driven quality indicators to ensure the immediate availability of trained registered nurses for patient cardiac events. Findings include:

Review of the closed record for Patient #1 and interviews with the Chief Nursing Officer and Quality/Risk Manager on on 05/25/10 at 10:15 AM revealed this patient suffered life threatening cardiac arrhythmias on 03/21/10. Although these arrhythmias were first noted by a monitor technician at approximately 11:18 PM, this information was not communicated to the registered nurse. The nurse discovered the patient to be in asystole at approximately 11:40 PM and emergency procedures were initiated. The patient subsequently expired approximately at 12:06 AM, on 03/22/10. The hospital had recognized this adverse patient event and implemented a revised policy to prevent recurrence. This revised policy included the intervention that a Rapid Action Personnel (RAP) team was contacted immediately by the monitor technicians in the event a life threatening arrhythmia was detected. (Refer to A 392)

An interview with the Quality/Risk Manager on 05/25/10 at 2:15 PM revealed the hospital had not developed or implemented quality indicators to monitor the effectiveness and ongoing compliance of this revised policy. The Quality/Risk Manager stated the hospital planned to conduct mock drills with the monitor technicians to ensure the revised procedures were followed. However, the hospital had not developed a system to detect misses or near misses of actual patients who experienced cardiac events.

Based on record review, staff interviews and direct observations, it was determined the hospital failed to implement effective training on revised policies to ensure the immediate availability of trained nursing staff in the event of a patient cardiac emergency. A review of one (Patient #1) of nine closed medical records for patients who received care in the critical care unit (CCU) revealed the patient's primary nurse was not immediately notified when this person suffered lethal cardiac arrhythmias. Findings include:

A review of the closed medical record for Patient #1 revealed this person was admitted to the hospital on 03/20/10 with complaints of left upper extremity weakness and difficulty walking. The patient was admitted to the CCU's telemetry wing and placed on a cardiac monitor. An interview with the monitor technician (Monitor Technician #1), on 05/26/10 at 1:04 PM and further record review revealed at approximately 10:06 PM on 03/21/10, the patient was noted to be experiencing atrial fibrillation. The nurse contacted the attending physician and consulting cardiologist and received orders for medication and laboratory studies in the morning. At at approximately 11:18 PM, the monitor technician noted that the patient was experiencing ventricular tachycardia, a cardiac condition designated in the hospital policies as being potentially lethal. The monitor technician stated she attempted to contact the primary nurse by way of the unit secretary. Normally, the technician would have contacted the nurse directly by way of a hospital issued wireless telephone that was distributed to licensed nursing staff, when first reporting for duty. However, on this particular day the nursing staff telephone numbers had not been given to the monitor technician because of confusion created by an emergency situation that had occurred during shift change. At approximately 11:30 PM, the monitor technician noted Patient #1 was in asystole (cardiac arrest). The technician again attempted to inform the nurse by way of the unit secretary. A few moments later, the technician heard an emergency code announced for the patient's room over the hospital public address system.

An interview with Patient #1's primary nurse on 05/25/10 at 11:25 AM revealed she never received the information about Patient #1 experiencing ventricular tachycardia or asystole. After initially providing care to Patient #1 the nurse stated she provided care for about 20 minutes to another patient. Upon leaving the patient's room, she heard a cardiac monitor alarm sounding at the nursing station. She observed that Patient #1's monitor showed the patient was in asystole. She immediately entered the patient's room and noted that the unit secretary was in the room and the patient was not breathing. An emergency code was called and lifesaving measures were attempted, but were unsuccessful. The nurse stated if she had been made aware the patient had experienced ventricular tachycardia or asystole she would have immediately taken action to correct the arrhythmias.

An interview with the unit secretary on 05/26/10 at 11:27 AM, revealed she informed the primary nurse of the monitor technician's message that the patient was experiencing atrial fibrillation. The nurse contacted the patient's physician and treatment was provided. When the technician called and stated the patient was experiencing ventricular tachycardia, she informed the technician the nurse was aware of the arrhythmia. The unit secretary stated she informed the nurse of this information. (A claim that was disputed by the nurse.) A few minutes later, the technician called and informed her the patient's monitor leads had become dislodged. She entered the patient's room to replace the leads and noted the patient to be cool and unresponsive. Before she could seek assistance, the primary nurse entered the room and called an emergency code.

Hospital policies were reviewed and interviews with the chief nursing officer (CNO) and risk manager were conducted on 05/25/10 at 10:15 AM. These interviews revealed the hospital had conducted an investigation involving this incident and determined the staff failed to follow hospital policies regarding notification of the nursing staff in the event of a potentially life threatening arrhythmia. The previous policy stated the monitor technician was to immediately telephone the nursing staff in the event of ventricular tachycardia, ventricular fibrillation or asystole. The nursing staff was to immediately respond and assess the patient and notify the monitor technician of the patient's status. If the monitor technician had not been contacted by the nursing staff within two minutes, the rapid action personnel (RAP) team was to be paged to the patient's room. The RAP team consisted of a critical care unit nurse, a respiratory therapist and the house nursing supervisor. Several areas had broken down in this system. The monitor technician had not obtained the wireless telephone numbers for the licensed nursing staff who were on duty, therefore, nursing staff had not been notified directly of the patient's condition. The unit secretary had assumed the primary nurse was aware of the patient's lethal arrhythmia.

Direct observations on 05/25/10 at 1:40 PM, revealed patients' cardiac status was monitored by a monitor technician located in a small room away from the immediate patient area. Cardiac monitoring for the critical care unit, including the telemetry section, was performed in this area.

In order to prevent recurrence of this incident and ensure the immediate availability of a registered nurse, the hospital had revised it's policy and procedures. At the direction of the medical executive committee, the policy was revised so that monitor technician was to immediately contact the RAP team to respond to all life threatening arrhythmias. If the RAP team had not updated the technician with the patient's status within two minutes, the technician was to call a "code blue" (full medical emergency code). The facility provided evidence of staff training on this new policy to five monitor technicians (Monitor Technicians #1, #2, #3, #4 and #5) within the past week. However, interviews with Monitor Technician #1 on 05/26/10 at 1:04 PM, Monitor Technician #2 on 05/25/10 at 1:40 PM, Monitor Technician #4 on 5/26/10 at 1:36 PM and Monitor Technician #5 on 05/26/10 at 1:40 PM revealed these individuals were not knowledgeable about the hospital's revised procedures. Each stated in the event of a life threatening arrhythmia the unit nurse would be contacted exclusively or prior to RAP team notification.