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Based on record review, interview and policy review, the facility failed to ensure a patient on a telemetry unit was assessed timely when his heart rate slowed. The patient ultimately expired. The facility census was 380.

See A395

Based on record review, interview and policy review, the facility failed to ensure failed to ensure a patient on a telemetry unit was assessed timely when his heart rate slowed. The patient ultimately expired. This affected one (Patient #8) of ten patients reviewed and had the potential to affect all patients on cardiac telemetry monitoring. The facility census was 380.

Findings include:

Record review revealed Patient #8 was transported to the Emergency Department (ED) on 12/18/24 at 1:20 PM for evaluation of visual hallucinations, confusion, and disorientation. The patient was alert and oriented and able to provide history. The history was augmented by a family member who was at the bedside. According to the patient, he was admitted to the facility a few weeks prior for abdominal pain and diagnosed with an acute appendicitis that was managed non-operatively. The patient was discharged home on a 10 day course of antibiotics. He was instructed to return to the hospital for fevers greater than 101.5 degrees Fahrenheit (F), inability to tolerate a diet, or unexpected pain. The patient's family member also revealed that the patient had recently been diagnosed with an oropharyngeal tumor for which he planned to follow up with oncology at another hospital later that week. Patient #8 patient denied any headache, fever, chest pain, cough, flu-like symptoms, abdominal pain, change in appetite, vomiting, syncope, fall or injury. A physician's history and physical stated the patient reported he felt "reasonably well today" all things considered.

The patient's vital signs on admission were blood pressure 133/60, pulse 89, temperature 99.8 degrees F, respirations 20, and oxygen saturation of 100 percent. Review of the laboratory values revealed an elevated white count of 46.8 (reference range 3.6-10.5 thousands per microliter). The WBC was up from 20.1 about two weeks prior. Prior to any further laboratory testing, the patient was medicated with one liter of normal saline and Zosyn, an antibiotic. Patient #8 was admitted to a telemetry unit at 11:20 PM.

Admission orders included telemetry monitoring using a portable device that continuously monitors patient/electrocardiogram, respiratory rate, and/or oxygen saturations while automatically transmitting information to a central monitor.

Review of the telemetry monitoring revealed at 11:56 PM, the cardiac rhythm was a normal sinus rhythm with a heart rate of 95 beats per minute. At 2:24 AM, Patient #8's heart rate dropped to 27 beats per minute. At 2:26 AM, the patient's heart rate was 17 beats per minute. At 2:36 AM, Staff I, the monitor technician, sent a message to Staff J, the acute care technician, through the Voalte hospital communication system stating that the patient's leads were off and asked Staff J if she could fix them. Staff J immediately responded yes, she would. The medical record revealed Staff J entered the patient's room to fix the leads at approximately 2:50 AM. The patient was unresponsive and, at 2:56 AM, a code blue button on the wall was pressed. There was no documentation the Registered Nurse, Staff H, was notified Patient #8's heart rate had dropped.

Review of the code blue sheet revealed medications were given and cardiopulmonary resuscitation (CPR) was started. At 3:08 AM, Patient #8 was in asystole, no heart beat. At 3:11 AM, Patient #8 regained a heart beat and CPR was paused. At 3:12 AM, Patient #8's blood pressure was 159/68 at 3:12:43 AM. The patient was transported to the facility's Intensive Care Unit at 3:17 AM.

A physician's significant event progress note stated after return of spontaneous circulation was achieved, she reviewed the telemetry monitor at the nurse's station and noted there was a bradycardic episode at 2:23 AM that evolved into asystole at 2:26 AM. The note stated at 2:36 AM, Staff I requested that Staff J change the leads on the patient and Staff J went to the room at approximately 2:50 AM and found the patient unresponsive.

A critical care physician's progress note on 12/19/24 at 3:38 PM stated he met with the patient's family and explained that if the patient had another event of cardiac arrest, CPR may be futile. The family chose to transition care to a Do Not Resuscitate Comfort Care Arrest (DNR CCA). Palliative care was consulted. The patient never regained consciousness and died on 12/20/24 at 6:51 PM.

During an interview on 01/02/25 at 1:30 PM Staff A, Regulatory Compliance Staff and Staff B,the Director of Nursing stated the medical record lacked documentation the primary RN was notified of the change in the patient's electrocardiogram or the need to have the leads changed. The change in the patient's electrocardiogram was not escalated to the Charge Nurse, the Administrative Supervisor, the Assistant Nurse Manager, the Nurse Manager, or the Director. It was confirmed that from 2:23 AM - 2:50 AM, 27 minutes, the Staff I did not notify the primary RN, Staff H, nor escalate the patient's monitor issues. Staff B stated that Staff I was terminated due to her failure to follow the policy for escalation of ELECTROCARDIOGRAM changes.

During an interview on 01/02/25 at 11:00 AM, Staff H stated he went to lunch at approximately 2:15 AM. He notified Staff I that he was going to lunch. He returned from lunch after 30 minutes and went into another patient's room that needed to go to the bathroom. Staff H stated he never received a call regarding Patient #8 until the code blue was called.

During an interview on 01/02/25 at 11:30 AM, Staff K, an acute care technician, stated Staff J was floated to the unit and it was her first time working on the unit. Staff K stated that Staff J asked her to help with her patients as she was unsure how things worked on the unit. Staff J asked her to show her how to change the leads on Patient #8 and when they went in the room, the patient appeared to be sleeping. Staff J lightly touched the patient while she called his name. Staff J called his name a little louder and the patient still did not answer. Staff K stated she she pressed the code blue button on the wall.

During an interview on 01/02/25 at 12:30 PM, Staff J stated that she had only been a float pool acute care technician since 10/01/24. Although she has worked as an ACT on different units, this was the first time she had worked on this unit. She also had never placed leads before and thought she needed help. Staff J stated she asked another staff to help her. When she received the message to change the leads, she didn't realize there was any urgency. Staff J stated since this incident, a nurse showed her how to place leads and she has placed them twice.

The facility policy titled "Telemetry Escalation Protocol" stated when a Unit Clerk Monitor Watcher (UCMW) calls a primary RN with monitor issues such as a patient being off the monitor, a change of rhythm, or batteries or leads needing replacing, and there is no answer, he/she must escalate the unresolved issue to the charge nurse. If the issue remains unresolved after three minutes, the issue must be escalated to the Administrative Supervisor. If the issue remains unresolved after three minutes, the UCMW must escalate the issue to the Assistant Nurse Manager and then escalate to the Nurse Manager and then escalate to the Director. The protocol lists the Voalte extensions for the Charge Nurse, Administrative Supervisor, Assistant Nurse Manager, Nurse Manager, and Director and further instructs UCMW's to escalate up the chain command every three minutes until the issue is resolved.