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Based on interview and record review, the provider failed to make reasonable efforts to offer and ensure a chosen family member or representative was notified of the patient's admission for 1 of 1 patient (Patient #6) at that patient's discretion.

The findings included:

Upon inquiry to Staff "C" in "Patient Access" on 02/09/22 at 11:39 AM for the process of notification of admission to patients' primary family or representative, Staff "C" reported she asks patients being admitted for an emergency contact/NOK (next of kin) or their next person to notify on case of emergency. Staff "C" showed documentation of this for Patient #6 who she reported was being admitted that day; however, denied offering to notify that person for Patient #6.

During interview on 02/09/22 at 11:52 AM, the Director of Patient Access explained that Patient Access asks patients for their next of kin or representative information but does not do notification calls, and that nursing might do this.

After further inquiry regarding notifications of admissions, the Vice-President of Quality reported during interview on 02/10/22 at 4:27 PM that they did a quick audit for the last 2 weeks and found that 240 out of 717 patients were asked if want a family member or other person notified of their admission; of those 240 patients, 184 responded "yes"; and that staff called and made notifications for 97 of the 184 who desired them to do so.

Based on observation, interview and record review, the provider failed to ensure staff monitoring telemetry followed Policies and Procedures to identify and timely notify the patients' Primary Nurse of life-threatening arrhythmias and interruptions in telemetry monitoring for 4 of 4 patients reviewed for telemetry.

The findings included:

The hospital's Policy and Procedure "Cardiac Telemetry Monitoring," effective date 07/21/16, last revision 05/15/21, documents under Policy, "Rhythm changes, life-threatening arrhythmias, and/or loss of signal will be responded to in an immediate manner. Loss of signal interrupts monitoring, placing the telemetry patient at risk. Rhythm changes and/or life-threatening arrhythmias must be assessed and responded to immediately to assure the safety of the patient and ensure prompt treatment of a problem. Prompt notification of cardiac arrhythmias and/or rhythm changes is essential for patient safety; a defined escalation pathway is used to
ensure timely notification and treatment as indicated" and "Patients requiring telemetry will have their cardiac rhythm continuously monitored and documented at pre-determined intervals per facility protocols..."

This same Policy and Procedure documents under Procedure, "In the event that a patient's cardiac rhythm is not transmitting to the central monitoring station the Telemetry Technician will contact the Primary RN for immediate resolution. 1. If the situation is not responded to/resolved within 2 minutes, the Telemetry Technician will escalate the notification to the unit's Charge RN. 2. If immediate response/resolution is not reached following notification to the unit Charge RN, the Telemetry Technician will initiate an overhead/electronic "Telemetry Alert" to the patient bedside. Department staff will immediately respond to the patient room and the patient will be evaluated and/or address the transmission issue. a) Upon assessment, the care team staff will immediately activate any necessary facility-specific rapid response or resuscitation process as indicated based on patient condition..."

1) Review of Patient #1's record revealed Patient #1 presented to the Emergency Department (ED) on 01/07/22 at 3:51 AM with respiratory failure, tested positive for "COVID," was placed on bipap (a device that helps with breathing), and her clinical "impressions" included pneumonia and "non-ST elevated myocardial infarction" (type of heart attack). Patient #1 had orders for admission to the Progressive Care (Cardiac Step Down) Unit but remained in the ED waiting for a bed. Nursing notes by the day shift (7 AM to 7 PM) nurse on 01/08/22 documented that at 7:00 PM Patient #1 was lying in bed with the head of the bed elevated, was easily aroused, and had the bipap in place; shift report was given to the oncoming nurse at 7:15 PM; and Patient #1 was seen unresponsive at 7:38 PM, whereupon CPR (cardiopulmonary resuscitation) was started and "Code Blue" called, and the Code Blue team arrived at 7:40 PM, as well as the oncoming nurse and Emergency Department doctor.

Patient #1's "Code Blue Record" dated 01/08/22 documents at 7:40 PM the patient was in asystole, that the nurse had entered the room and found her unresponsive and in asystole, she was intubated at 7:42 PM, still in asystole at 7:45 PM and death was declared at 7:46 PM.

During interview with the Patient Safety Director on 02/10/22 beginning at 10:15 AM, the Patient Safety Director denied having any printed telemetry strips for Patient #1 from this event. During continued interview and concurrent review of facility documentation regarding Patient #1's telemetry alarms, the Patient Safety Director reported the following from 01/06/22: an asystole (no heart rhythm) alarm was activated with high priority at 7:13:25 PM (hours:minutes:seconds), then a bradycardia (low heart rate) alarm with medium priority at 7:16:00 PM, a V (ventricular) fib (fibrillation)/V tach (tachycardia) alarm with high priority at 7:16:24 PM to 7:16:41 PM, then asystole alarms from 7:16:41 PM to 7:23:01 PM and asystole again at 7:23:21 PM.

During telephonic interview on 02/10/22 at 1:47 PM with Patient #1's day shift nurse from 01/08/22, Staff "A" reported her patients that day were at the back of the ED and she was told at the start of her shift that telemetry is monitored from the front of the ED and they do not print rhythm strips in the ED; that although there were additional monitors at the back of the ED, she was unable to see those monitors and be near her patients at the same time; and that from any patient's room she could only view that patient's telemetry on the room monitor. During this interview Staff "A" reported she gave the oncoming nurse report before entering Patient #1's room to give her a late medication; that when she entered the room Patient #1 was unresponsive and in asystole, so she called a Code Blue, other staff came to help, and they started CPR. Staff "A" denied anyone telling her of any abnormal rhythms for Patient #1 before she entered the room (at 7:38 PM, noted above) to find her unresponsive.

2) During observation of telemetry monitoring in the Emergency Department (ED) on 02/08/22, Patient #2's telemetry displayed no rhythm but the words "leads fail" at 3:34 PM. During rechecks of the telemetry display monitors on 02/08/22 at 3:43 PM, at 3:49 PM, at 3:58 PM, and continuous observation from 4:03 PM through 4:11 PM, Patient #2's telemetry continued to display the words "leads fail" and showed no cardiac waveform.

Patient #2's "Emergency Provider Report" documents she presented to the ED on 02/08/22 with complaints of headache and vomiting for 2 days, hypertension and chest pain and her Clinical Impressions were "hypertensive urgency" and "chest pain, headache, and pneumonia." Patient #2's order dated 02/08/22 at 9:53 PM documents "telemetry monitoring."

3) During observation of telemetry monitoring in the ED on 02/08/22, Patient #3's telemetry displayed no rhythm but the words "leads fail" at 3:34 PM. During rechecks of the telemetry display monitors on 02/08/22 at 3:43 PM, at 3:49 PM, at 3:58 PM, and continuous observation from 4:03 PM through 4:11 PM, Patient #3's telemetry continued to display the words "leads fail" and showed no cardiac waveform.

Patient #3's "Emergency Provider Report" documents she presented to the ED on 02/07/22 with complaint of abdominal pain. Patient #3's order dated 02/07/22 at 10:54 PM documents "telemetry monitoring" and the continuous indication "arrhythmia-suspect/known."

4) During observation of telemetry monitoring in the ED on 02/08/22, Patient #4's telemetry displayed no rhythm but the words "leads fail" at 3:34 PM. Immediate observation of Patient #4's room revealed the patient to be in bed with no staff present. During rechecks of the telemetry display monitors on 02/08/22 at 3:58 PM, and continuous observation from 4:03 PM through 4:11 PM, Patient #4's telemetry continued to display the words "leads fail" and showed no cardiac waveform.

Patient #4's "face sheet" documents she presented to the ED on 02/07/22 for right side of neck/face pain/seizure versus TIA/CVA (mini-stroke or stroke). Patient #4's order dated 02/07/22 at 11:26 PM documents telemetry monitoring for "arrhythmia-suspect/known."

During interview on 02/08/22 between 3:34 PM and 3:43 PM, the Director of Emergency Services reported Patient #2 was waiting to be admitted and Patients# 3 and 4 had been "admitted" but were waiting for beds to become available in their intended units. During concurrent electronic record review on 02/08/22 from 3:51 PM to 3:53 PM, the Director of Emergency Services showed and confirmed active telemetry orders remained in place for Patients# 2, 3, and 4 and provided no explanation for why they were not being actively monitored.

During further interview on 02/08/22 at 3:58 PM, the Director of Emergency Services reported ED Charge Nurses watch telemetry monitors in addition to their "Charge Nurse" duties, including communicating with Fire Rescue units, coordinating ED beds, assignments and needs for incoming patients, and calling transport to come get patients being admitted as they are assigned to beds in other areas. During this interview and observation until 4:11 PM, the Charge Nurse, Staff "B" was observed to use the "Fire Rescue" communication phone multiple times as well as answering and addressing multiple calls on a desk phone but was not heard to speak about telemetry or problems with patient leads, or to direct any staff to check on patients with no readings on the monitors.

During interview on 02/08/22 at 4:12 PM, Charge Nurse, Staff "B" explained that this was her day off, but she came in for a meeting and stayed because they were very busy; that the ED has a dedicated "Monitor Tech" during the day shift for about 3 or 4 days a week but otherwise Charge Nurses stay at and watch the monitors in addition to their regular duties.

During interview on 02/08/22 at 4:18 PM, the Patient Safety Director reported plans for ED telemetry to be monitored remotely from another floor but was unable to explain how this might improve ED staff responsiveness to telemetry problems.