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Based on interview and record review the hospital failed to comply with the Condition of Participation for Nursing Services as evidenced by:

1. The facility failed to implement an effective system that provided oversight of staffing and maintenance of a safe environment for patients on continuous telemetry monitoring (A-0392).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the facility failed to provide a safe environment for one of 30 sampled patients (Patient 1) when telemetry monitor technicians (TT A and TT B) failed to follow facility policy and perform proper notifications to other staff when :

1. The facility was unable to provide evidence of notifications to the primary nurse or any other staff member when Patient 1 went from baseline to wide complex QRS (the bottom of the heart is contracting later than it should) with Left Bundle Branch Block ( a delay or blockage of electrical impulses to the left side of the heart making it difficult for the heart to pump blood efficiently).

2. The facility was unable to provide evidence of notifications to the primary nurse or any other staff member when Patient 1 went into ventricular tachycardia (VT; lower chambers of the heart beating too quickly).

3. The facility was unable to provide evidence of notifications to the primary nurse or any other staff member when Patient 1 experienced a high number of premature ventricular contractions (PVC; extra heartbeats that begin in one of the heart's two lower chambers).

These failures resulted in lost opportunities to intervene and provide appropriate timely treatment to Patient 1. Patient 1 expired on 7/1/2022.

Findings

Record review of Patient 1's history and physical, dated 6/30/ 2022, indicated Patient 1 was a 65-year-old man with coronary artery disease (CAD; damage or disease to the hearts major blood vessels), status post coronary artery bypass surgery (CABG; a surgical procedure to treat CAD) in 2019, and abdominal pain. He went to the emergency department with abdominal pain, nausea and vomiting, and chronic left sided chest pain. His troponins (a biomarker for measuring heart injury) were elevated. Surgery and cardiology were consulted regarding cholecystitis (inflamed gallbladder (A small, pouch-like organ in the upper right part of stomach. It stores bile, a fluid produced by the liver that helps break down fatty foods.) and elevated troponins.

Record review of Patient 1's physician orders, dated 6/30/2022, indicated Patient 1 was a full code (in the case his heart stopped beating and/or he stopped breathing, all resuscitation procedures will be provided to keep him alive).

Record review of Patient 1's physician orders, dated 6/30/2022, indicated Patient 1 to be placed on continuous telemetry monitoring (a portable device that continuously monitors the patient's heart while transmitting information to a central monitor) for arrhythmia (abnormal heart rhythm).

Record review of Patient 1's physician orders, dated 6/30/2022, indicated telemetry notification parameters to notify the physician for new onset of bundle branch block, any change in heart rhythm, and ventricular tachycardia.

Record review of Patient 1's cardiology consult note, dated 6/30/2022, indicated Patient 1 had " ...high sensitive troponin noted to be elevated to 2213 and 2011 and 2518."

Record review of the schedules for staffing in the telemetry monitoring station, on 7/1/2022, indicated two monitor technicians worked and were assigned estimated 77 patients. Each patient was assigned to either Telemetry Technician A (TT A) or to Telemetry Technician B (TT B) to monitor throughout their shift. The assignment sheet indicated Patient 1 was assigned to TT A.

Schedules for nursing staff on the medical telemetry unit, on 7/1/2022, were reviewed and the registered nurse C (RN C) was assigned to Patient 1 as his primary nurse.

Record review of Patient 1's telemetry strip sheets throughout his admission were reviewed and confirmed with the Medical Surgical Trauma Director (MSTD).

During an interview with the Manager of the Medical Surgical Telemetry (MMST) unit, on 3/3/2023 at 10:15 a.m., he indicated the telemetry technicians use I mobile phones to communicate with the nurses and with other caregivers as needed. He confirmed these phones were facility-provided.

During interview and record review with the MSTD, on 3/6/2023 at 1:06 p.m., she confirmed the telemetry strip "is like a screenshot of what is going on at that time in the patient's heart." The MSTD reviewed the strips and confirmed, on 7/1/2023:

1. At 3:30 p.m., Patient 1 was at his baseline heart rhythm.
2. At 3:46 p.m. Patient 1's telemetry strips indicated a change from baseline heart rhythm and went into left bundle branch block with a wide QRS. At 3:46 p.m., Patient 1's telemetry strip indicated in the span of one minute he experienced 17 PVC .
3. At 3:47 p.m., Patient 1's telemetry strip indicated in the span of one minute he experienced 27 PVC.
4. At 3:49 p.m. Patient 1's telemetry strips indicated he had a MI.
5. At 3:50 p.m. Patient 1's telemetry strips indicated VT. At 3:50 p.m., Patient 1's telemetry strip indicated in one minute he experienced 24 PVC.
6. At 3:51 p.m. the leads on Patient 1's chest then came off and there was no telemetry monitoring.
7. At 4:15 p.m., Patient 1's nurse, RN C, was rounding and checked on Patient 1. RN C discovered the leads which were used for telemetry monitoring were off Patient 1 and the Patient 1 was non responsive. RN C reapplied the leads to Patient 1, which indicated Patient 1 was in VT. She called a Code Blue (an emergency code used to describe the critical status of a patient in a medical emergency) and the team attempted to resuscitate (the process of reviving someone with medical care) Patient 1.
8. Time of death was pronounced at 4:38 p.m.

During an interview with the MSTD, on 3/6/2023 at 1:06 p.m., the MSTD indicated TT A should have notified the nurse and should have escalated to the charge nurse and called a Code Blue when Patient 1 had a change from baseline heart rhythm, on 7/1/2022 at 3:46 p.m., to left bundle branch block and wide QRS. She indicated this was a potential lethal heart rhythm and a big change for Patient 1. She confirmed there was no notification to the primary nurse or any other care providers to Patient 1 by TT A or TT B.

During an interview with the MST D, on 3/6/2023 at 1:06 p.m., the MSTD confirmed there was no notification to the primary nurse by TT A or TT B, on 7/1/2022 at 3:49 p.m., when Patient 1's telemetry monitoring indicated acute change. As part of the investigation she reviewed camera footage, and discovered TT A had left the building on an unscheduled break. The MSTD indicated in the course of her investigation she was able to confirm with video footage TT A was not in the monitoring station and was observed to have exited the building. She confirmed TT A was not monitoring Patient 1 or any other patient assigned to her. This left TT B with estimated 77 patients to monitor at that time. The MSTD indicated breaks should be covered by other staff and that it was too difficult for one person to watch monitor of all the patients. She stated having so many patients for one telemetry technician to monitor was not safe for the patients being monitored. The MSTD confirmed there should have been notification to RN C and a Code Blue should have been called.

During an interview with the MSTD, on 3/6/2023 at 1:06 p.m., the MSTD confirmed there was no notification to the primary nurse by TT A or TT B, on 7/1/2022 at 3:50 p.m., when Patient 1's telemetry monitoring indicated Patient 1 was experiencing VT. The MSTD confirmed there should have been notification to RN C.

During an interview with the MSTD, on 3/6/2023 at 1:06 p.m., the MSTD confirmed, on 7/1/2022 at 3:46 p.m., Patient 1's telemetry strip indicated in one minute he experienced 17 PVC. The MSTD confirmed on 7/1/2022 at 3:47 p.m., Patient 1's telemetry strip indicated in one minute he experienced 27 PVC. The MST D confirmed on at 3:50 p.m., Patient 1's telemetry strip indicated in one minute he experienced 24 PVC. The MST D indicated these were a high number of PVC and should have prompted notification to RN C.

During an interview with the interim Manager of the Transitional Care Unit (MTCU), on 3/6/2023 at 2:12 p.m., The MTCU stated "PVC less than 10 a minute is less concerning." He confirmed Patient 1 had 27 in one minute and that "is a lot" and the Telemetry Technician should have notified Patient 1's nurse. The MTCU also confirmed there should have been notifications with the changes from baseline, the MI, and VT. He also confirmed anytime a patient "is off telemetry monitoring, the nurse should be notified." The MTCU confirmed the policy would be for escalation of Code Blue being called.

During an interview with the MSTD, on 3/6/2023 at 1:06 p.m., the MSTD confirmed there was no notification to the primary nurse by TT A or TT B when Patient 1 was off continuous monitoring from 3:50 p.m. to 4:15 p.m. The MST D stated "it is unknown what happened between 3:50 p.m. to 4:15 p.m. on 7/1/2022" and confirmed the nurse should have been notified and the order for continuous telemetry monitoring should have been followed.

Record review of nursing notes, dated 7/1/2022, indicated Patient 1's primary nurse went into Patient 1's room "to connect leads back up and patient was unresponsive, code blue was called ....patient was pronounced ...at 4:38 p.m."

Review of Patient 1's "Post code note," dated 7/1/2023 at 4:44 p.m., indicate the patient was found unresponsive by the nursing staff, on 7/1/2023 at 4:15 p.m., and life saving measures were initiated. The patient expired at 4:38 p.m. The note further indicated " ...the patient was having intermittent episodes of wide complex tachycardia between 3:30 p.m. and 3:50 p.m. At that point, leads were disconnected until 4:15 p.m. when the nurse went to check on patient and found him unresponsive."

During an interview with the MSTD, on 3/6/2023 at 1:06 p.m., the MSTD indicated she conducted the investigation of the events on 7/1/2022 regarding Patient 1 and the care of Patient 1. She indicated the paper log in which the telemetry technicians track contact with nursing indicated TT B contacted Patient 1's primary nurse. The MSTD confirmed the phone logs did not corroborate this claim because there was no call in I mobile phone logs which detail staff communications. She stated, during the facility investigation, she was able to pull these logs and verify all communications. The MSTD indicated only one call was verified for Patient 1, on 7/1/2022, in the I mobile phone logs and it was to the unit coordinator during Patient 1's Code Blue. The MSTD indicated this was " ...too late." The MSTD stated there was " ...no credibility" in the accounts TT A or TT B provided.

During an interview with the MSTD, on 3/6/2023 at 1:06 p.m., the MSTD stated there were complaints by TT A and TT B regarding the monitor screen. The MSTD indicated screen issues were ruled out as being faulty in the investigation the facility conducted.

During an interview with the MSTD, on 3/6/2023 at 1:06 p.m., the MSTD stated both TT A and TT B indicated in staff interviews they individually notified the nurse using their facility supplied I mobile. The MSTD stated they were unable to verify this in the I mobile phone logs. And finally, the MSTD stated the primary nurse only became aware of Patient 1's condition when she rounded. The MSTD stated her investigation determined there was "...a lack of accountability by the monitor technicians that day" (TT A and TT B). The MST D stated "...the staff did not do everything they should have, and it could have been a different outcome for Patient 1."

During an interview with the Manager of the Medical Surgical Telemetry (MMST) unit, on 3/3/2023 at 10:15 a.m., he indicated the telemetry technicians on average monitor a total of 90 to 95 patients. He indicated per practice the expectation "is to have three telemetry technicians who monitor 30 patients each." He also confirmed no monitor problems "have been reported during this time or any other time by any staff who do monitoring."

Record review of the county's medical examiner note, dated 10/27/2022, indicated Patient 1 died on 7/1/2022 at 4:38 p.m. The note indicated the cause of death was hypertensive (high blood pressure) and arteriosclerotic cardiovascular disease (narrowed arteries close to the heart) and ruled the death to be accidental.

During an interview with the MSTD, on 3/6/2023 at 1:06 p.m., the MSTD indicated she completed the investigation and determined there was no credible evidence the primary nurse or any other staff were notified of the changes in Patient 1's condition. She said as a result the telemetry technician, TT A, who assigned to monitor Patient 1 was terminated by the facility. The MSTD indicated RN C was on contract through an agency, and the facility terminated her contract. The MSTD indicated TT B was a long term employee and allowed for her to resign or be terminated, so she chose to voluntarily resign.

Record review of the job description for a Telemetry Monitor Tech, undated, indicated the monitor tech responds to alarms, interprets rhythms, alerts nurse when indicated, maintains a safe working environment, adheres to hospital policy, and reports problems or concerns.

Review of facility policy, "Cardiac Telemetry Monitoring," dated 2/2021, indicated "patients on continuous telemetry monitoring will be continuously monitored at the telemetry monitoring centralized station with prompt notification by the Telemetry Technician to the Registered Nurse of any rhythm changes or life-threatening arrhythmias." The Policy indicated this was essential for patient safety so the patient could be assessed and treated immediately. Per policy, a change in rhythm included going from a regular rhythm to an irregular one, an increase in premature complexes, change to a life-threatening arrhythmia, new onset tachycardia, and groupings or runs of premature complexes. The Policy further indicated, in the event of a suspected life-threatening rhythm, the Telemetry Technician would immediately activate a "Code Blue," notify the primary nurse or charge nurse, document the event and notification, and finally print copies of the telemetry strips and have them sent to the unit.