HospitalInspections.org

Based on record review, interview, and observation, the facility failed to ensure the patient received care in a safe setting for one patient (#1) out of three patients reviewed for telemetry/cardiac monitoring.

Findings:
On 2/8/22 Patient #1 experienced seven unreported Red (potentially lethal arrhythmia (problem with the rate or rhythm of heartbeat)) Alarms while on telemetry monitoring. A code was started at 7:15 PM and resuscitative efforts were initiated. After 39 minutes, the resuscitative efforts were unsuccessful and return of spontaneous circulation was not achieved. Time of death was pronounced at 7:50 p.m.

Review of Staff M, Monitor Support Technician's (MST), website browsing history on 2/8/22 revealed Google searches were conducted, and YouTube was accessed to watch music from 4:22 PM through 7:00 PM.

Review of Staff A, RN, Nursing Manager's, 2021-2022 Employee Dashboard-Data for January 1, 2022 - March 2, 2022, revealed Staff A, observed Staff M, MST, Staff J, MST, and Staff L, MST, engaging in non-work-related activities while on telemetry monitoring.

An observation 01/01/22 revealed Staff M, was observed using Facebook on a personal cell phone on 1/1/22 and was observed watching videos on the computer with the door to the telemetry monitoring room closed twice on 1/20/22, and that on 1/20/22 expectations were shared with Staff M by Staff A regarding use of FaceTime, watching videos, and engaging in other non-work-related activities.

Further observations on various days revealed Staff J was observed watching videos on a personal cell phone on 2/1/22 and was informed by Staff A of the need to pay attention and the expectation not to watch videos on the phone. It was revealed that Staff L was observed reading a book on 3/1/22 and was reminded by Staff A to avoid distractions such as reading, music, videos, social media while performing job duties.

During an interview conducted on 2/28/22 at 2:57 PM, Staff A, RN, Unit Manager, stated that on 2/8/22 a follow up call was not made in response to an alarm going off. She stated that [Staff M's name] silenced the alarm each time it went off.

During an interview conducted on 3/1/22 at 10:52 AM, Staff E, RN, Charge Nurse, stated, " ... The little readout on the telemetry box is useful to get a baseline. If the patient complains of symptoms, has chest pain, you can't rely on what you see on the box, you need the monitors in the telemetry room or the strips. You can use the boxes basically to see rhythm, and can see if it appears to be sinus [normal heart rhythm] or sinus tach [sinus tachycardia: a faster than normal heartbeat] ..."

During an interview conducted on 03/01/2022 at 2:10 PM, Staff G, RN, Unit 64, stated, "On 2/8/22, I stopped getting calls from the monitor tech [Staff M] after 12:00 PM or so ...At 7:05 PM, during shift hand-off, I got a call from a monitor tech [Staff J] stating that Patient#1 was showing asystole on the monitor. I saw a tech nearby, so I asked them to check on the patient. The tech came out of the room stating Patient#1 was unresponsive, so we all went into the room and called a code ...I have no confidence in the staff that watches the telemetry monitors here."

During an interview conducted on 3/1/22 at 4:59 PM, Staff L, MST, stated that on 2/8/21 upon clocking in to work, she approached Staff M. She stated, "I approached [Staff M's name] for shift hand-off and noticed music playing very loudly and an alarm flashing on the monitor. I asked her what was going on with the alarm. She said that it was not a real alarm, and it was going off all day. I took a closer look at the monitor and saw a rhythm that looked like asystole with pacer spikes ... I went back and looked at the rhythm history on the monitor and noticed that about twenty minutes before I confronted [Staff M's name] about the alarm, the patient's rhythm changed from normal sinus rhythm to asystole with pacer spikes. I have gone to my manager [Staff A's name] twice to express my concerns about [Staff M's name]. Just last month, I reported to her that I found [Staff M's name] asleep while she was supposed to be watching the monitors. I have also seen [Staff M's name] FaceTimeing people on her cell phone and playing loud music while she was supposed to be working.

Observation revealed telemetry monitors are not available on the unit, and the telemetry boxes attached to each patient only provide a small display of the patient's heart rhythm that is difficult to see.

During an interview conducted on 2/28/22 at 3:38 PM, Staff A stated about Staff M, "This particular tech challenged the test, she did not take the [6.5 hour in person ECG] class. She was scheduled to take it, however, has since resigned."

Review of Staff M's personnel file revealed staff M failed the Initial MST ECG Interpretation examination, passing with remediation and verbal retesting. The file revealed Staff M was to attend telemetry class in January 2022, however had not attended this class.

Review of Policy S-031: Staff Response to Bedside Cardiac, Telemetry and Pulse Oximetry Alarms Policy, last reviewed November 2021, read: "Purpose: To identify the requirements for staff to respond to cardiac, telemetry, and pulse oximetry alarms. Policy Statements: ... XII. If RED alarm sounds, (potentially lethal alarm) a triple high-volume level tone sounds, and all available staff must respond immediately to the alarm. The RN must immediately verify patient status at the bedside. A. In the ICU/IMCs, the RN responds directly to the alarms. B. In adult and pediatric non-ICU/IMC areas, the MST/ST announces the RED alarm and overhead pages "RED ALARM" or "tele emergency" and notifies the RN immediately. C. In the Adult ED the MST immediately notifies any available RN to respond to the alarm"