HospitalInspections.org

Based on hospital policy review, hospital document review, medical record review, and interview the hospital failed to ensure nursing services met all the needs of the patients by conducting ongoing assessments in order to meet those needs, and Registered Nurses (RNs) evaluated the care for each patient in accordance with hospital policies including the patient's health status and response to interventions for three (3) of three (3) (Patients #1, #2, and #3) sampled patients admitted with orders for cardiac monitoring.

The failure of the hospital to ensure nursing services followed hospital policies, followed physician's orders and implemented interventions to ensure optimal delivery of care to each cardiac patient placed all cardiac patients admitted at risk for IMMEDIATE JEOPARDY (a situation in which the facility's noncompliance with one or more requirements off participation has caused or is likely to cause injury, harm, impairment, or death to a patient.)

The findings included:

1. Nursing services failed to follow hospital policies and physicians orders for cardiac monitoring in order to evaluate the care needs of each patient and ensure interventions were initiated when patient's cardiac status had changed, and prior to finding the patients deceased.
Refer to A 0395.

Based on hospital policy review, hospital document review, medical record review, and interview nursing services failed to follow hospital policies and physicians orders for cardiac monitoring in order to evaluate the care needs of each patient and ensure interventions were initiated when patient's cardiac status had changed, and prior to finding the patients deceased for three (3) of three (3) (Patients #1, #2, and #3) sampled patients admitted with orders for cardiac monitoring.

The findings included:

1. Review of the facility's policy titled, "Cardiac Monitoring and Discontinuation/Telemetry" revealed, "Purpose: to identify potential life threatening arrhythmia's and notify the appropriate physician for treatment...Cardiac monitoring is initiated based on physician/LIP [Licensed Independent Practitioner] order...Notify monitor technician of patient transfers or temporary telemetry termination/interruptions...Nursing staff notifies the monitor technician when patients are off telemetry for bathing or tests/procedures. The standby mode is used. Monitor Technician's [Monitor Tech] Responsibilities...Notify the nurse directly of heart rate alarms, rhythm changes, or disruption of signal...The monitor technician will run a strip and save the strip for each event until status of event confirmed...After notifying the nurse of life threatening arrhythmia or disruption of signal and Rhythm has not resolved or Defibrillation has not been noted or Emery House has not been called by nursing staff. Then the monitor technician will call the nurse a second time and state "an Emery House will be called unless the nurse is in the patient's room...Shared Responsibilities...Checking for proper lead placement and that all leads are connected to the patient...Assure optimal signal reception...The monitor technician may provide upon request from the nurse or physician a comprehensive report (formerly known as a "full disclosure" report), consisting of the last 30 minutes prior to a life threatening event or Emory [Emery] House until either the patient is removed from the telemetry equipment or the event is concluded...Cardiac monitoring/telemetry is started and stopped by order of a physician...Prior to removing the monitor, the Monitor Technician is notified...that the patient is being discharged form telemetry. The monitor technician verifies the order for discontinuation...The monitor technician will document the date and time the patient is "Discontinued" from telemetry monitoring..."

2. Medical record review for Patient #1 revealed the patient was an 80 year old admitted to Hospital #3's cardiac step down unit after being evaluated in the hospital's Emergency Department (ED) on 12/16/2020. (A step down unit is a nursing unit designated to provide care for patients who are stable enough to be discharged from the intensive care unit but are not yet ready to be cared for on a medical-surgical unit.) Patient #1's admitting diagnoses included Acute on Chronic Congestive Heart Failure (CHF) (a weakness of the heart that leads to a build up of fluid in the lungs and surrounding body tissues), Acute Myocardial Infarction (heart attack- a life threatening condition that occurs when blood flow to the heart muscle is abruptly cut off causing tissue damage), Pneumonia (lung inflammation caused by bacterial or viral infection), and Acute Respiratory Failure. (Respiratory Failure occurs when the blood vessels surrounding the air sacs in the lungs can't properly exchange carbon dioxide for oxygen. With acute respiratory failure, the person experiences immediate symptoms from not having enough oxygen in the body.)

Review of Physician #1's note dated 12/16/2020 at 7:33 PM revealed, "...will admit pt [Patient #1]...CHF exacerbation, Troponin I above reference range, Pneumonia..." (High Troponin levels may indicate a problem with the heart.)

Review of Physician #1's orders on 12/16/2020 at 11:14 PM through 11:16 AM revealed, "Initial Inpatient...Bed Type: Stepdown...Bed request...Stepdown...Telemetry Tech Monitor..."

Patient #1 remained in the hospital's ED until 12/17/2020 after a cardiac catheterization was performed. Following the procedure Patient #1 was moved to the hospital's stepdown unit. Patient #1 required the use of bilevel positive airway pressure (BiPAP) to keep his oxygen saturation levels (O2 sat) within a safe range. (BiPAP supplies pressurized air into the patient's airway with the use of a mask or nasal plugs that are connected to a ventilator. Oxygen saturation is a measurement of the amount of oxygen being carried by red blood cells. Normal oxygen saturation levels in human are 95-100 % and values under 90% are considered low).

Review of Patient #1's medical record dated 12/19/2020 through 12/20/2020 revealed the following:
12/19/2020 at 2:53 AM - Patient #1 was assessed by a respiratory therapist and given a breathing treatment. The patient was "cooperative" with the treatment and his O2 sat was recorded at 87% (low) with Face Mask Ventilation (FMV) in use.
12/19/2020 at 3:36 AM - Patient #1 was noted to be unresponsive and his respirations were labored and shallow with an O2 sat of 44% (low). The patient's cardiac monitor showed "Atrial/Ventricular Pacing". Patient #1's blood pressure was 112/80, heart rate was 94 beats per minute, and respiratory rate was 10 breaths per minute. The Medical Response Team (MRT) and Emery House code (an emergency response team) and Physician #2 responded to the patient's bedside. The patent's FMV was not connected to the machine; therefore the patient was not receiving oxygen. The FMV and tubing were reconnected and Patient #1 regained consciousness.
12/20/2020 at 8:00 PM - Patient #1 assessed by Registered Nurse (RN) #1. Blood pressure 98/58, Heart Rate 66 beats per minute, Respirations 20 breaths per minute, O2 sat 94% with high flow oxygen in use via nasal cannula. Cardiac monitor showed ventricular pacing (the heart rate is not beating normal).
12/20/2020 at 8:19 - 8:33 PM - Nursing Assistant (NA #1) gave Patient #1 a bath and placed the patient's cardiac monitor on standby mode. There was no documentation RN #1 was notified the patient's cardiac monitor was placed on standby mode.
There was no documentation after 8:33 PM of staff assessing or assisting Patient #1 until 11:05 PM.
12/20/2020 at 11:05 PM - RN #1 observed the cardiac monitor screen at the nurses station and noted Patient #1's monitor was on standby mode. RN #1 entered the Patient #1's room and found the patient unresponsive, not breathing, and pulseless. The RN turned the patient's cardiac monitor back on and the cardiac monitor showed the patient was in asystole. (Asystole is the most serious form of cardiac arrest and is usually irreversible. It is the state of total cessation of the heartbeat).
The MRT and Physician #3 responded to assist with cardiopulmonary resuscitation (CPR - is a procedure to revive a patient who has stopped breathing and whose heart has stopped beating ). The resuscitative efforts were unsuccessful and Patient #1 was pronounced dead at 11:24 PM.

The hospital was unable to locate the telemetry logs (cardiac monitoring logs) for the dates Patient #1 was in the hospital.

Patient #1's cardiac monitor was in standby mode from 8:33 PM until 11:05 PM; a total of 2 hours and 32 minutes. There were five additional Registered Nurses (RNs), one NA, and two patient care assistants (PCAs) on this nursing unit caring for a total of 24 patients at the time of Patient #1's death. None of the nursing staff members notified RN #1 the patient's monitor was on standby mode, even though a cardiac monitor screen was visible at the nurses station on the unit.

Review of the Discharge Summary written by Physician #4 on 12/21/2020 revealed Patient #1 died in the hospital on 12/20/2020 at 11:34 PM due to "Respiratory Arrest."

In an interview on 1/20/2021 at 2:58 PM, RN #2 verified RN #1 was unaware NA #1 had put the patient's cardiac monitor on standby when she gave the patient a bath earlier that evening. RN #2 then stated RN #1 went into the patient's room a little after 11:00 PM and found that the patient didn't have a pulse and the patient's oxygen and heart monitor had been pulled off.

In a telephone interview on 12/22/2021 at 8:40 AM, NA #1 verified she put the Patient #1's cardiac monitor on standby mode when she gave the patient a bath and had forgotten to turn the cardiac monitor back on. NA #1 verified she didn't let anyone know the patient's monitor was on standby. NA #1 was asked what time she last saw Patient #1. The NA stated, "Close to 9:00 PM."

In a telephone interview on 1/22/2021 at 8:35 AM, RN #3 informed this surveyor she responded to Patient #1's room after RN #1 called for help. RN #3 stated the patient's monitor was not connected when she first entered the room and the Patient #1's eyes were "rolled back in his head."

In a telephone interview on 1/22/2021 at 9:20 AM, RN #1 verified Patient #1 was assigned to her on the evening of 12/20/2020 and she had assessed the patient around 8:00 PM that evening. RN #1 stated around 11:00 PM she was at the nurses station and looked at the cardiac monitors and noticed Patient #1's cardiac monitor was on standby mode.
The RN stated neither NA #1 or the nurse assigned to the cardiac monitors screen at the nurses station, had informed her that Patient #1's cardiac monitor was on standby mode. RN #1 stated she then went to Patient #1's room and found the patient "lifeless"
RN #1 stated, "I knew [Patient #1] had been gone for awhile, it hadn't happened in the last 10 or 15 minutes...We didn't get him back at all [CPR did not work]."

Review of the hospital's investigation of Patient #1's death dated 12/20/2020 revealed Patient #1 was noted to be on standby on the cardiac monitor at the nurses station at about 11:05 PM. The nurse went into the Patient #1's room and found the patient off the cardiac monitor and the patient's high flow oxygen was off. The patient was unresponsive and not breathing. A CPR team was called and CPR was started at 11:08 PM. The CPR was unsuccessful and Patient #1 was pronounced dead at 11:24 PM.
The hospital determined there was a breakdown in communication among nursing staff regarding placing a patient in standby mode as well as who should remove and or place the monitors on standby. The hospital also determined there were gaps in communication between nursing staff and monitor techs when patients were off the monitor or on standby.
There was no documentation new interventions were immediately put in place to prevent future occurrences.

3. Medical record review for Patient #2 revealed the patient was a 69 year old admitted to Hospital #3 for observation on the telemetry unit (cardiac monitoring) after being evaluated in the hospital's Emergency Department (ED) on 12/28/2020. Patient #2's admitting diagnoses included Altered Mental Status, and Congestive Heart Failure exacerbation.

Review of the History and Physical Exam dated 12/28/2020 revealed Patient #2 had a past medical history of Coronary Artery Disease (a heart disease that involves the reduction of blood flow to the heart muscle), Peripheral Vascular Disease (a slow and progressive circulation disorder that may affect any blood vessel outside of the heart), Diabetes (a disease that results in too much sugar in the blood), and Cardiomyopathy. (Cardiomyopathy is a disease that causes the heart muscle to become enlarged, thick, or rigid.)

Review of Physician #5's note dated 12/28/2020 at 12:15 PM revealed Patient # 2 would require observation in the hospital's telemetry unit due to "Altered Mental Status and CHF exacerbation."

Review of the physician's orders written by Physician #5 on 12/28/2020 revealed, "Observation Services, Bed Type: Telemetry [cardiac monitoring]..."

Review of Patient #2's medical record dated 12/28/2020 through 12/30/2020 revealed the following:
12/28/2020 at 8:56 PM - Patient #2's cardiac monitor was initiated.
12/28/2020 at 11:52 PM - Patient #2's cardiac monitor revealed sinus rhythm with a first degree Atrioventricular (AV) block. (An AV block occurs when conduction through the AV node of the heart is slowed.) The monitor also indicated Patient #2 was experiencing premature ventricular contractions (PVCs). (PVC extra heart beats that disrupt the regular rhythm of the heart.) Patient #2's monitor also showed the patient had a bundle branch block. (A bundle branch block is either a complete or a partial interruption of the electrical pathways inside the wall of the heart between the two lower chambers (ventricles).
There was no documentation Patient #2's cardiac monitor was in use after 12/28/2020 at 11:52 PM.
There was no documentation a physician was notified the cardiac monitor was not in use and no documentation of an order to discontinue the cardiac monitor.
12/29/2020 at 12:13 AM - Advanced Practice Nurse (APN) #1 ordered 4 point soft restraints because the patient was "pulling at medical devices."
12/29/2020 at 12:45 AM - Patient #2 was placed in 4 point restraints for behaviors of pulling out his intravenous catheter (IV) line, pulling out his catheter, and "disrupting" his dressing.
12/29/2020 at 6:11 AM - Patient #2 was "agitated and confused through the shift," the physician was notified and orders were obtained to sedate the patient and put in restraints.
12/29/2020 at 1:40 PM - Physician #6 ordered 1 milligram (mg) of Haldol IV push every 6 hours as needed for "Agitation." (Haldol is an antipsychotic medication that decreases excitement in the brain.)
12/29/2020 at 7:05 PM - revealed Patient #2's vital signs were a blood pressure of 126/76, his heart rate was 126 beats per minute, his respiratory rate was 20 breaths per minute, and his O2 sat was 98%.
12/29/2020 at 7:58 PM - Patient #2 was assessed by RN #4. The patient appeared to be confused, respirations were regular and unlabored, and heart sounds were regular.
12/30/2020 at 2:04 AM - RN #4 administered Haldol 1 mg IV push to Patient #2 (Based on the Federal Drug Administration's (FDA).gov "...Haldol Injection is not approved for Intravenous Administration. If Haldol is administered intravenously, the ECG (cardiac monitor) should be monitored for QT prolongation and Arrhythmias...").
There was no documentation Patient #4's vital signs, cardiac status, respiratory status, or behavioral status were assessed after the Haldol was administered.
There was no documentation of any staff interaction with Patient #2 until 1 (one) hour and 6 minutes later at 3:10 AM.
12/30/2020 at 3:10 AM - RN #4 entered Patient's #2's room and found the patient unresponsive and not breathing. CPR was initiated, the restraints were removed, the MRT team and Physician #7 responded to the patient's bedside. The CPR was unsuccessful. Patient #2 was pronounced dead at 3:37 AM.

The hospital was unable to locate the telemetry logs (cardiac monitoring logs) for Patient #2.

There were six RNs, and three NAs on the nursing unit caring for a total of 40 patients at the time of Patient #2's death.

Review of the Discharge Summary written by Physician #6 on 12/30/2020 revealed Patient #2 died in the hospital on 12/30/2020 at 3:27 AM due to "Sudden cardiac death."

In an interview on 1/20/2021 at 3:15 PM, RN #6 stated Patient #2 had been very confused and combative and staff were unable to keep the cardiac monitor on the patient even after applying soft restraints. RN #6 did not know if the Patient #2's physician had been informed the patient was off the cardiac monitor.

In telephone interview on 1/22/2021 at 8:50 AM, RN #4 verified she was the nurse assigned to care for Patient #2 on the date of his death. RN #4 stated Patient #2 had been very confused and combative, was in restraints, and they were unable to keep the patient's cardiac monitor in place.
RN #4 was asked if anyone informed the physician they were unable to keep the patient's monitor on the patient and RN #4 stated, "I'm not sure if anyone did; I did not."
RN #4 stated she had given Patient #2 Haldol around 2:00 AM, then left the room to care for another patient. RN #4 stated a few minutes later, closer to 3:00 AM, she realized she didn't hear Patient #2 moving about anymore so she went into the patient's room and discovered the patient wasn't breathing.

In a telephone interview on 1/22/2021 at 9:44 AM, RN #5 stated RN #4 called for help from Patient #2's room and the CPR team was called. The RN stated CPR had already begun as she was taking the crash cart into the patient's room. (A crash cart is a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest.)
RN #5 stated, "[Patient #2] was still in restraints, so I took the restraints off, [Patient #2] didn't make it [died]."
RN #5 verified Patient #2's cardiac monitor was not in use and was unsure if the patient's physician had been notified.

Review of the hospital's investigation of the death of Patient #2 revealed the patient had pulled off the cardiac monitor on 12/28/2020 at 11:43 PM and the monitor was never put back on the patient. The patient was placed in 4 point soft restraints on 12/29/2020 at 12:20 AM. Patient #2 was given an injection of Haldol by RN #4 on 12/30/2020 at 2:04 AM. According to the hospital's badge tracking system, a NA had entered Patient #2's room for 28 seconds on 12/30/2020 at 2:22 AM. There was no documentation what the NA did in the Patient's room during those 28 seconds. Patient #2 was found unresponsive on 12/30/2020 at 3:10 AM.
The hospital determined the root cause of the patient's death was the patient was off the cardiac monitor and there was no communication with the patient's physicians informing them the patient would not keep the cardiac monitor on. The hospital also determined there were gaps in communication between nursing staff and monitor techs when patients were off the monitor or on standby mode.
There was no documentation new interventions were immediately put in place to prevent future occurrences.

4. Medical record review for Patient #3 revealed the patient was an 88 year old admitted to Hospital #1's telemetry unit (cardiac monitoring) after being evaluated in Hospital #1's ED on 12/24/2020. Patient #3's admitting diagnoses included Acute Metabolic Encephalopathy, Pneumonia, Hyponatremia (low sodium level), Hypokalemia (low potassium level), Hypertension (high blood pressure) and Elevated troponin level. Patient #3 had a past medical history of breast and colon cancer.

Review of a physician's note written by Physician #8 on 12/24/2020 at 2:44 PM, revealed, "...Admit to Inpatient Telemetry Unit..."

Review of the physician's orders written by Physician #8 on 12/24/2020 at 3:04 PM, revealed, "...Inpatient...Bed Type: Telemetry..."

Medical record review for Patient #3 dated 12/28/2020 through 1/2/2021 revealed the following:
12/28/2020 at 3:21 AM - Monitor Technician #1 notified RN #8 that Patient #3's cardiac monitor showed the patient's heart rate and rhythm had changed to sinus tachycardia at a rate of 150 beats per minute. (Sinus tachycardia refers to an increased heart rate that exceeds 100 beats per minute.) There was no documentation of nursing assessments at this time.
12/28/2020 at 4:00 AM - Patient #3's vital signs were assessed by a NA. The patient's blood pressure was 160/87, heart rate was 97 beats per minute, respiratory rate was 18 breaths per minute, and O2 sat was 95%. There was no documentation Patient #3 was assessed by an RN.
12/28/2020 at 6:59 AM - RN #8 documented she received a cardiac rhythm strip from the Unit Coordinator showing Patient #3's heart rate had increased to 155 beats per minute. RN #8 documented the patient denied any new complaints or symptoms and she had notified the Family Nurse Practitioner (FNP).
12/28/2020 at 7:30 AM - RN #9 assessed Patient #3. The patient's cardiovascular assessment status was documented as "Heart rhythm regular" and "Heart tones audible." There was no documentation what the patient's heart rate was. There was no documentation of the patient's cardiac monitor rhythm. The patient's respiratory assessment status was documented as "Respirations Unlabored..."
12/28/2020 at 7:44 AM - RN #8 completed an Electrocardiogram (ECG or EKG) on Patient #3 (An EKG is a test that monitors the heart and measures the electrical activity of the heartbeat.) The EKG showed Patient #3 was in sinus tachycardia with occasional PVCs and an inferior infarction (heart attack) could not be ruled due to the abnormality of the EKG. The EKG was compared to Patient #3's EKG that was done on 12/24/2020. The patient was no longer in sinus rhythm.
1/1/2021 at 2:45 AM - Cardiac monitor Tech #1 notified RN #10 that the patient's cardiac monitor showed the patient was in Atrial Flutter at a rate of 150 beats per minute. (Atrial flutter is a condition in which the heart's upper chambers beat too quickly.)
1/1/2021 at 3:00 AM - RN #10 documented "Telemetry [Cardiac monitor Tech] called hr [heart rate] increased and rhythm changed. Lab is drawing blood on pt." There was no documentation the RN assessed Patient #3 at this time.
1/1/2021 at 4:00 AM - Patient #3's vital signs were assessed by a NA. The patient's blood pressure was 122/68, heart rate was 96 beats per minute, respiratory rate was 20 breaths per minute. There was no documentation Patient #3 was assessed by an RN at this time.
1/1/2021 at 7:21 AM - Patient #3's vital signs were assessed by a NA. The patient's blood pressure was 123/71, heart rate was 86 beats per minute, and O2 sat was 91 %. The patient's respiratory rate was not documented. There was no documentation Patient #3 was assessed by an RN at this time.
1/1/2021 at 12:23 PM - RN # 11 assessed Patient #3. The patient's cardiovascular assessment status was documented as "Meets Guidelines." There was no documentation of the patient's cardiac rhythm or rate. The patient's respiratory assessment was documented as "Respirations Labored..." There were no interventions documented for the patient's labored breathing.
1/1/2021 at 12:30 PM - Patient #3's vital signs were assessed by a NA. The patient's blood pressure was 115/76, heart rate was 116 beats per minute, and O2 sat was 91 %. The patient's respiratory rate was not documented.
1/1/2021 at 6:55 PM - Patient #3's vital signs were assessed by a NA. The patient's blood pressure was 117/79 heart rate was 77 beats per minute, and O2 sat was 88 %. The patient's respiratory rate was not documented.
1/1/2021 at 8:00 PM - RN #7 assessed Patient #3. The patient's cardiovascular assessment status was documented as "Heart rhythm regular" and "Heart tones audible." There was no documentation of the patient's cardiac rhythm or rate. The patient's respiratory assessment was documented as "Respiratory pattern Tachypnea" and Respirations Labored..." (Tachypnea is abnormally rapid breathing.) There was no documentation of interventions for the patient's labored breathing.
1/1/2021 at 9:00 PM, 11:00 PM - Patient #3 was repositioned by a member of the nursing staff.
1/2/2021 at 1:00 AM, and 3:00 AM - Patient #3 was repositioned by a member of the nursing staff.
1/2/2021 at 4:00 AM - Patient #3 was assessed by RN #7. The patient's blood pressure was 98/65, respiratory rate was 22 breaths per minute and his O2 sat was 92%. The patient's heart rate and cardiac rhythm was not documented. There was no documentation Patient #3 was assessed by nursing staff again until 6:30 AM.
1/2/2021 at 5:26 AM - the cardiac monitor strip report showed Patient #3 was no longer on the cardiac monitor. There was no documentation why the patient was not on the monitor.
1/2/2021 at 6:30 AM - RN #7 found Patient #3 unresponsive, not breathing, and pulseless. CPR was initiated, and the MRT team and Physician #5 responded to the patient's bedside. CPR was unsuccessful.
Patient #3 was pronounced dead at 6:48 AM.

Review of the Telemetry Log (cardiac monitor logs) provided by Hospital #1 dated 1/2/2021 revealed the following:
1/2/2021 at 5:30 AM - Monitor Tech #1 notified Unit Coordinator #1 that Patient #3 was off the cardiac monitor and the unit coordinator's response was "ok they in there."
1/2/2021 at 6:15 AM - Monitor Tech #1 called Unit Coordinator #1 again and informed the Coordinator that Patient #3 was still of the cardiac monitor. Monitor Tech #1 asked if the staff were still in the patient's room. The Unit Coordinator's response was "Yes."
1/2/2021 at 6:49 AM - Monitor Tech #1 called Unit Coordinator #1 and documented, "status of Pt [patient] unknown."
1/2/2021 at 7:20 AM - RN #7 called and informed the day shift monitor tech (Monitor Tech #2) Patient #3 died at 6:48 AM.

Patient #3 was off the cardiac monitor from 5:26 AM until 6:30 AM, a total of 1 (one) hour and 4 minutes. The Unit Coordinator was notified the patient was off the monitor at 5:30 AM and again at 6:15 AM. There was no documentation Patient #3 was assessed by any hospital personnel until 6:30 AM, when the patient was found unresponsive, not breathing and pulseless by RN #7. There were five RNs, and two NAs on the unit caring for a total of 28 patients at the time of Patient #3's death.

Review of the Discharge Summary written by Physician #9 on 1/5/2021 revealed Patient #3 died in the hospital on 1/2/2021 at 6:48 AM.

Review of the hospital's investigation of the death of Patient #3 revealed Unit Coordinator #1 had been informed by Monitor Tech #1 that Patient #3 was off the cardiac monitor at 5:30 AM. The Unit Coordinator informed RN #7, but RN #7 was providing care to another patient in a different room until "at least 6:15 AM." When RN #7 went into Patient #3's room the patient was in full cardio-pulmonary arrest. The Monitor Tech called the Unit Coordinator two additional times. The Unit Coordinator did not notify any other nurses or hospital staff informing them Patient #3 was off the cardiac monitor, and no one went into the patient's room to check on the patient until RN #7 completed his task in another patient's room. The hospital was unable to determine the exact time Patient #3 went into cardiac arrest. Patient #3 was pronounced dead at 6:48 AM on 1/2/2021.
There was no documentation new interventions were immediately put in place to prevent future occurrences.

In a telephone interview on 1/21/2021 at 3:27 PM, Physician #5 reported hospital staff had called the code (Emery House) at 6:39 AM. The physician was informed Patient #3 had not been on the monitor and was found unresponsive at 6:25 AM. Physician #5 continued and informed this surveyor Patient #3 was in asystole and CPR was already in progress when he entered the room at 6:40 AM. Physician #1 was unaware how long the patient had been off the cardiac monitor.

In a telephone interview on 1/22/2021 at 8:08 AM, Unit Coordinator #1 verified she had been notified by Monitor Tech #1 "two or three" times saying Patient #3 was off the monitor. The Unit Coordinator stated RN #7 was informed and that the RN had stated he would check on Patient #3 as soon as he had finished with the other patient he was working with.
Unit Coordinator #1 was asked if she had informed any other nurses or hospital staff that Patient #3 was off the cardiac monitor since RN #7 was unavailable at the time and the Unit Coordinator stated, "The only person I notified was the nurse [RN #7]..."
The Unit Coordinator was then asked if she used the call system to call into Patient #3's room to ask if the patient was alright and the Unit Coordinator #1 stated, "No...I let the nurse know..."

In an telephone interview on 1/22/2021 at 8:19 AM, RN #7 informed this surveyor he had made rounds and checked on Patient #3 at approximately 5:30 AM, then went to care for another patient who required a blood transfusion. RN #7 stated after he finished taking care of the other patient, he had been informed Patient #3 was off the cardiac monitor and went right in the room and found Patient #3 wasn't breathing and didn't have a pulse.
RN #7 was asked how many times the Unit Coordinator had told him the patient was off the monitor and the RN stated he couldn't remember.

In a telephone interview on 1/22/2021 at 9:49 AM, Monitor Tech #1 stated she had called the Unit Coordinator and informed them Patient #3 was off the cardiac monitor. The Monitor Tech stated she didn't know if she was told to hold on, or that staff would check, but "I do know she [Patient #3] didn't come back on the monitor so I called them back."
Monitor Tech #1 stated, "I was told they [hospital staff] were in the room." The Monitor Tech stated she called the Unit Coordinator a third time because Patient #3 was still not put back on the cardiac monitor.
Monitor Tech #1 was asked if she ever spoke to RN #7 informing the RN that Patient #3 the patient was off the monitor and the Monitor Tech stated, "No...I was told the nurse was in the patient's room."

5. In an interview on 1/20/2021 at 10:00 AM, Hospital #1's Clinical Risk Management Director (CRMD) was asked what interventions the hospital had implemented to prevent future occurrences and the CRMD stated the hospital's Chief Nursing Officer, Interim Clinical Director, Administrative Director of Nursing, Clinical Educator for the Telemetry Unit, and herself met on 1/19/2020 to finalize a plan. The CRMD stated Hospital #1 had started educating nursing staff (RNs, NAs, and Unit Coordinators) and Monitor Techs how to properly report and respond when a patient's cardiac monitor was off or put on standby and when nursing staff received a call from monitor techs, the person taking the call will use the call system and call into the patient's room and if they are alright. If the patient doesn't respond, a member of the nursing staff will have to go into the patient's room and check on them.
Hospital #1's CRMD was asked if Hospital #3 had participated in developing the plan the CRMD stated, "No the system is addressing this at some level, but each issue is different".
There was no documentation any of the staff training had been completed.

In an interview on 1/20/2021 at 2:58 PM, the Clinical Director of Hospital #3's stepdown unit (RN #2), was asked what interventions had been put into place to prevent future occurrences and RN #2 stated, she had sent out an email saying when a NA wanted to put a patient's monitor on standby, they needed to notify the nurse so they would know too. RN #2 stated the information had also been posted on the communication board on the unit and the Patient Care Coordinators were also discussing it with the staff during the shift huddles. RN #2 provided this surveyor a copy of the email that was sent to the nursing staff on 1/11/2021 at 2:56 PM. The email included the following:
NAs must check with the nurse before putting a patient on standby for any reason.
The nurse needs to follow up to make sure the patient is placed back on the monitor after the appropriate time frame. (There were no time frames listed on the email)
If a patient refuses to wear a monitor, the nurse needs to call the physician and notify them, then document it in the medical record
Monitor techs need to be notified when patients placed are placed on standby and why they are on standby.
RN #2 provide this surveyor a copy of the information that was placed on the communication board on the Stepdown unit on 1/12/2021. The posting showed a nurse must be asked prior to placing any patient on stand-by.

Interviews were conducted with staff members at both Hospital #1 and Hospital #3; ten (10) were registered nurses, three (3) were nursing assistants, three (3) were Unit Coordinators, and three (3) were Monitor Techs. All staff members were asked what interventions the hospital (s) had put in place to prevent future occurrences. The responses varied widely and were inconsistent indicating the Hospitals had not implemented an effective plan to prevent future occurrences.