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Based on staff interviews, policy and procedure reviews, medical record reviews, observations, and facility document reviews the hospital failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, including a complete analysis of an adverse event, development of an effective plan of correction, and measures in place to track performance and success, for a patient who was ordered cardiac telemetry monitoring in the Emergency Department (ED). Refer to A283.

Based on staff interviews, medical record reviews, policy and procedure reviews, and observations the Governing Body (GB) failed to implement Quality Assessment Performance Improvement (QAPI) efforts in response to the hospital's failure to ensure an ongoing patient safety plan for cardiac telemetry monitoring of patients located in the Emergency Department (ED). Refer to A309.

Based on staff interviews, policy and procedure reviews, medical record reviews, observations, and facility document reviews the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, a complete analysis of an adverse event was conducted, an effective plan of correction was developed and implemented, and failed to measure the success, track the performance, and ensure the actions taken were sustained for a patient who was ordered cardiac telemetry monitoring in the Emergency Department (ED), found unresponsive and became absent of vital signs for one (#1) of twelve sampled patients; the facility failed to ensure cardiac monitoring of patients in the ED was performed by qualified, dedicated and competent staff for five (#A, B, C, D, E) of five ED personnel files reviewed, which resulted in cardiopulmonary arrest for one (#1) of twelve sampled patients; and the facility's quality program failed to identify opportunities for improvement, and make changes to affect improvement in health outcomes, patient safety, and quality of care.

Findings included:

Review of the ED physician note for patient #1, dated 08/18/20 at 9:36 PM, revealed the patient presented with shortness of breath and a history of lung cancer. Following assessment of the patient the physician ordered admission to the Progressive Care Unit (PCU) with ongoing cardiac telemetry monitoring. Review of the orders, dated 08/18/20 at 11:57 PM, revealed the physician also ordered hourly vital signs (VS's), and notification for vital signs outside the parameters.

Review of the record revealed the patient remained in the ED until a bed became available in the PCU. Review of the record revealed the patient's VS were not assessed every hour and the VS that were assessed were outside of the parameters with no documentation of physician notification.

The facility policy, "Cardiac Monitoring", #NCL0100, was reviewed. The policy stated the purpose was to provide a continuous picture of the patient's cardiac electrical activity, record cardiac electrical activity for diagnostic or documentation purposes, and identify and treat various dysrhythmias. The policy further stated cardiac rhythm is interpreted, evaluated and documented every shift or more often if rhythm, rate changes and/or per unit standard by a telemetry skill validated licensed nurse; the interpretation of rhythm includes heart rate, PR, QRS, QT, QTC if indicated, identification of rhythm and initial of licensed nurse interpreting strip; and cardiac monitor strips will be reviewed by a telemetry skill validated licensed nurse at the following times: at the time of placement on telemetry, every shift or as designated by the unit, and when any change in rhythm is noted.

Review of a nursing note, dated 08/19/2020 at 9:30 AM, revealed the nurse walked by the room of patient #1 and noticed she was slumped over. The note stated the nurse went in to reposition the patient and observed the patient had no respirations and was in asystole on the bedside cardiac monitor. The note revealed immediate life saving measures were implemented.

Review of the facility's investigation revealed the patient VS became critical and remained critical for a total of 18 minutes without being acknowledged or treated. Review of the record and the facility's investigation revealed on 8/19/2020 at 9:10 am the patient's oxygen saturation decreased to 69% (critical level), at 9:19 am the heart rate was 19 bpm (beats per minutes) with no oxygen saturation detected, at 9:24 am the heart rate was 17 bpm with no oxygen saturation detected, and at 9:28 am the heart rate was 0 bpm with no oxygen saturation detected. Review of the record revealed no evidence the patient's change in cardiac rhythm was addressed immediately and per facility policy.

Review of the facility's corrective action plan revealed all monitors in the ED were tested for volume and adjusted to 55% for the bedside monitors and the central monitoring station in the ED. The facility educated the ED team on the alarm limits, the accountability for alarm action, and policy related to setting alarm limits related to patient condition. The facility would monitor the alarm volumes every 12 hours to ensure compliance.

Review of the facility's investigation and corrective action plan revealed the facility failed to ensure cardiac monitoring of patients in the ED was performed by qualified, dedicated and competent staff which resulted in patient #1's condition deteriorating to a critical level over approximately 18 minutes and resulted in cardiopulmonary arrest. The patient was resuscitated, transferred to a higher level of care, and expired on 8/21/2020.

Review of five of five Unit Secretaries personnel files (#A, #B, #C, #D, #E), who are utilized to observe the cardiac telemetry monitors in the ED, revealed no formal education, training or competency for cardiac monitoring.

Review of the ED incident log for the past 12 months revealed a total of 510 incidents reported. Further review of the 510 incidents revealed 270 were related to the provision of patient care and 28 were related to a Delay/Lack of Response to Patient Condition.

On 11/17/20 at 10:00 AM, an interview, via telephone, was conducted with the facility Risk Manager (RM) which revealed the facility had failed to trend and analyze the reported incidents in the ED for quality of patient care, patient safety and outcomes. The RM confirmed the facility reports out on five categories of incidents under the corporate reporting structure. Review of the RM report provided to the Medical Executive Committee and Governing Board (MEC/GB) failed to show evidence of any trending or analysis of the ED incidents. Review of the RM report revealed tracking, trending, and analysis of the five corporate categories which included falls, medications, surgery, pressure ulcers, and labs. The RM was unable to provide evidence of trending and analysis of ED incidents.

Based on staff interviews, medical record reviews, policy and procedure reviews, and observations the Governing Body (GB) failed to implement Quality Assessment Performance Improvement (QAPI) efforts in response to the hospital's failure to ensure an ongoing patient safety plan for cardiac telemetry monitoring of patients located in the Emergency Department (ED); the facility failed to ensure patients with cardiac monitoring were treated timely which resulted in cardiac arrest, cardiopulmonary resuscitation, transfer to a higher level of care, and death for one (#1) of twelve sampled patients. The hospital's GB failed to ensure a quality improvement plan and patient safety plan was implemented to ensure patients located in all areas of the hospital, with cardiac monitoring, were monitored by qualified, dedicated and competent staff which resulted in cardiopulmonary arrest for one (#1) of twelve sampled patients.

Findings included:

Review of the medical record for patient #1 revealed the patient presented to the facility ED on 8/18/2020 with complaint of shortness of breath and a history of lung cancer. The ED physician evaluated the patient on 8/18/2020 at 9:36 pm and following evaluation the physician ordered admission to the Progressive Care Unit (PCU) with ongoing cardiac telemetry monitoring.

Review of the record revealed the patient remained in the ED until a bed became available in the PCU. Review of a nursing note, dated 08/19/2020 at 9:30 AM, revealed the nurse walked by the room of patient #1 and noticed she was slumped over. The note stated the nurse went in to reposition the patient and observed the patient had no respirations and was in asystole on the bedside cardiac monitor. The note revealed immediate life saving measures were implemented, the patient was transferred to a higher level of care and expired on 8/21/2020.

On 11/18/20 at 10:45 AM, an interview with the ED Director of Nursing revealed the patients on cardiac monitoring in the ED are monitored at a central location in the ED. The staff assigned to observe the cardiac monitors are the ED Unit Secretaries. The interview revealed the Unit Secretaries also perform other job duties at the same time they are charged with observing the cardiac monitors. The ED Director of Nursing confirmed once patients are transferred to an inpatient unit they are monitored by Central Cardiac Monitoring. The staff assigned to the Central Monitoring location are dedicated, trained and competent in recognition of cardiac arrhythmias. Their only job responsibility is to monitor the telemetry monitors and alert the bedside nurse to any changes in the patient's cardiac condition.

Review of five of five Unit Secretaries personnel files (#A, #B, #C, #D, #E), who are utilized to observe the cardiac telemetry monitors in the ED, revealed no formal education, training or competency for cardiac monitoring.

On 11/18/2020 at 10:30 am a tour of the facility ED was conducted. Two Unit Secretaries were observed and interviewed at the time of the tour. Interview with Unit Secretary "D" revealed the ED is split into 2 sections, Blue and Red. She stated she was assigned to the Blue side and her responsibilities included answering the phone, entering orders, and observing the cardiac telemetry monitors. She confirmed she did not have any formal training for the telemetry monitors but "learned it over the years." She confirmed if there are any alarms on the monitors, she would notify the patient's nurse.

At the time of the tour the second Unit Secretary "B", assigned to the Red side, was interviewed. She confirmed her responsibilities included answering the phone, entering orders, and observing the cardiac telemetry monitors. She stated she "keeps an eye on the monitors" and if it alarms, she notifies the nurse. She then documents on a log who was notified, the time notified and the outcome.

At the time of the tour an ED Physician was interviewed. He stated he would expect that the staff monitoring the telemetry were trained to recognize abnormalities.

On 11/18/20 at 11:10 AM the ED Medical Director was interviewed. The ED Medical Director stated he understood the Unit Secretaries were trained and were required to pass a test for the monitoring of telemetry patients. He confirmed overseeing the Unit Secretaries was not his responsibility.

The facility policy, "Cardiac Monitoring", #NCL0100, was reviewed. The policy stated the purpose was to provide a continuous picture of the patient's cardiac electrical activity, record cardiac electrical activity for diagnostic or documentation purposes, and identify and treat various dysrhythmias. The policy further stated cardiac rhythm is interpreted, evaluated and documented every shift or more often if rhythm, rate changes and/or per unit standard by a telemetry skill validated licensed nurse; the interpretation of rhythm includes heart rate, PR, QRS, QT, QTC if indicated, identification of rhythm and initial of licensed nurse interpreting strip; and cardiac monitor strips will be reviewed by a telemetry skill validated licensed nurse at the following times: at the time of placement on telemetry, every shift or as designated by the unit, and when any change in rhythm is noted.

Review of the facility's investigation revealed the patient Vital Signs (VS) became critical and remained critical for a total of 18 minutes without being acknowledged or treated. Review of the record and the facility's investigation revealed on 8/19/2020 at 9:10 am the patient's oxygen saturation decreased to 69% (critical level), at 9:19 am the heart rate was 19 bpm (beats per minutes) with no oxygen saturation detected, at 9:24 am the heart rate was 17 bpm with no oxygen saturation detected, and at 9:28 am the heart rate was 0 bpm with no oxygen saturation detected. Review of the record revealed no evidence the patient's change in cardiac rhythm was addressed immediately and per facility policy.

Review of the facility's corrective action plan revealed all monitors in the ED were tested for volume and adjusted to 55% for the bedside monitors and the central monitoring station in the ED. The facility educated the ED team on the alarm limits, the accountability for alarm action, and policy related to setting alarm limits related to patient condition. The facility would monitor the alarm volumes every 12 hours to ensure compliance.

Review of the facility's investigation and corrective action plan revealed the facility failed to ensure cardiac monitoring of patient's in the ED was performed by qualified, dedicated and competent staff which resulted in patient #1's condition deteriorating to a critical level over approximately 18 minutes and resulted in cardiopulmonary arrest. The patient was resuscitated, transferred to a higher level of care, and expired on 8/21/2020.

Review of the ED incident log for the past 12 months revealed a total of 510 incidents reported. Further review of the 510 incidents revealed 270 were related to the provision of patient care and 28 were related to a Delay/Lack of Response to Patient Condition.

On 11/17/20 at 10:00 AM, an interview, via telephone, was conducted with the facility Risk Manager (RM) which revealed the facility had failed to trend and analyze the reported incidents in the ED for quality of patient care, patient safety and outcomes. The RM confirmed the facility reports out on five categories of incidents under the corporate reporting structure. Review of the RM report provided to the Medical Executive Committee and Governing Board (MEC/GB) failed to show evidence of any trending or analysis of the ED incidents. Review of the RM report revealed tracking, trending, and analysis of the five corporate categories which included falls, medications, surgery, pressure ulcers, and labs. The RM was unable to provide evidence of trending and analysis of ED incidents.


On 11/19/2020 at 3:40 p.m. the facility provided an action plan to address the deficiencies. The facility implemented staff monitoring of the ED cardiac telemetry monitors with 24/7 dedicated, trained and competency tested personnel to ensure the same standard of care for all patients in the facility. The facility updated the policy "Cardiac Monitoring" to ensure ED patients received the same standard of care related to cardiac monitoring. The facility installed printers in the ED cardiac monitoring area to ensure staff had the ability to print cardiac activity strips to align with the cardiac monitoring policy and procedure.

Based on staff interviews, policy and procedure reviews, observations and medical record reviews, the medical staff failed to ensure policies governing medical care provided in the Emergency Department (ED) were established and followed for cardiac telemetry monitoring and the provision of services, equipment, personnel and resources to ED patients was provided timely to protect the health and safety of all patients located in the hospital's ED. Refer to A1104.

Based on medical record reviews, personnel file reviews and staff interview, it was determined the facility failed to ensure Emergency Department (ED) staff performing cardiac telemetry monitoring were qualified and competent for the provision of patients cardiac activity for five (#A, B, C, D, E) of five personnel file reviews. Refer to A1112.

There was ongoing failure to follow physicians' orders for cardiac telemetry monitoring to ensure patients in the ED, with the possibility of suffering a cardiac arrhythmia, could result in delay of treatment and possibly death.

Based on policy review, medical record review and staff interview, it was determined the medical staff failed to ensure policies governing medical care provided in the Emergency Department (ED) were followed for cardiac telemetry monitoring and the provision of services, equipment, personnel and resources to ED patients was provided timely to protect the health and safety of all patients located in the hospital's Emergency Department for one (#1) of twelve sampled patients.

Findings included:

Review of the facility "Cardiac Monitoring" policy #NCL0100, revised 02/19, revealed, " ...PURPOSE ...to provide a continuous picture of the patient's cardiac electrical activity, record cardiac electrical activity for diagnostic or documentation purposes, and identify and treat various dysrhythmias ...POLICY ...cardiac rhythm is interpreted, evaluated and documented every shift or more often if rhythm, rate changes and/or per unit standard by a telemetry skill validated licensed nurse ...interpretation of rhythm includes heart rate, PR, QRS, QT, QTC if indicated, identification of rhythm and initial of licensed nurse interpreting strip ...PROCEDURE ...monitor strips will be reviewed by a telemetry skill validated licensed nurse at the following times: (1) at the time of placement on telemetry; (2) every shift or as designated by the unit; and (3) when any change in rhythm of note."

Review of the facility "Assessment/Reassessment" policy # BC-NCL0132, revised 05/2020, revealed, "POLICY...skill validated individuals, as designated by department/discipline policy, scope of practice for the discipline, licensure, rules/regulations and/or certification requirements, perform assessments ...the scope of assessments and reassessment are based on the patient's diagnosis, the care setting...and the response to and effectiveness of care and interventions...the patient's status is reassessed at regular intervals ...reassessment is triggered by changes in the patient's condition or needs ...or physician and to determine the response to effectiveness of care and interventions. Reassessment is completed per department policy and as follows: (a) Significant changes in condition/diagnosis; (b) Change in level of care; (c) Patient at risk for adverse outcome; (d) Response to treatment; (e) Physician order; (f) As specified by clinical standards."

Review of the medical record for patient #1 revealed the patient presented to the facility ED on 8/18/2020 with complaint of shortness of breath and a history of lung cancer. The ED physician evaluated the patient on 8/18/2020 at 9:36 pm and following evaluation the physician ordered admission to the Progressive Care Unit (PCU) with ongoing cardiac telemetry monitoring at 11:57 pm, hourly vital signs (VS), and for the nurse to call for VS outside parameters.

Review of the patient's VS from 08/18/20 at 9:36 pm until 08/19/20 at 8:15 am revealed the patient's VS (Heart Rate (HR), Respiratory Rate (RR), and Blood Pressure (BP)) were outside of normal parameters with no documentation of physician notification.

Review of the patient VS record revealed from 08/19/20 at 1:46 am until 7:27 am, a total of 5 hours and 41 minutes, the patient's VS were not assessed by the nurse.

Review of the Respiratory Therapist BiPap check on 8/19/2020 at 7:46 am revealed a HR of 84, oxygen saturation 92% and labored breathing. At 8:15 am a focused assessment by the RN (Registered Nurse) revealed a cardiac rhythm of normal sinus rhythm, BP 127/77, HR 90%, and decreased oxygen saturation of 90%.

Review of the record revealed the patient remained in the ED until a bed became available in the PCU. Review of a nursing note, dated 08/19/2020 at 9:30 am, revealed the nurse walked by the room of patient #1 and noticed she was slumped over. The note stated the nurse went in to reposition the patient and observed the patient had no respirations and was in asystole on the bedside cardiac monitor. The note revealed immediate life saving measures were implemented, the patient was transferred to a higher level of care and expired on 8/21/2020.

On 11/18/20 at 10:45 am, an interview with the ED Director of Nursing was conducted. She confirmed following the patient event the cardiac monitor for patient #1 was sequestered and the following information was obtained: at 9:10 am oxygen saturation was 69% (critical level); at 9:19 am HR 19 bpm (beats per minute), no oxygen saturation detected; at 9:24 am HR 17 bpm, no oxygen saturation detected; and at 9:28 am HR 0 bpm, no oxygen saturation detected.

During interview with the ED Director of Nursing on 11/18/2020 at 10:45 am she confirmed nursing staff failed to notify the physician of patient #1's VS which were outside of parameters and failed to obtain hourly VS per physician orders. She confirmed the patient's cardiac activity was not monitored continuously per physician order. The ED Director confirmed telemetry monitoring of patients located in the ED are not provided the same standard of care as patients located in other areas of the hospital. Additionally, the ED Director stated that the ED telemetry monitoring equipment was not set up to print telemetry monitoring strips for placement in the medical record.

Based on medical record reviews, personnel file reviews and staff interview, it was determined the facility failed to ensure Emergency Department (ED) staff performing cardiac telemetry monitoring were qualified and competent for the provision of patients cardiac activity for five (#A, B, C, D, E) of five personnel file reviews for one (#1) of twelve sampled patients.

Findings included:

Review of the medical record for patient #1 revealed the patient presented to the facility ED on 8/18/2020 with complaint of shortness of breath and a history of lung cancer. The ED physician evaluated the patient on 8/18/2020 at 9:36 pm and following evaluation and testing the physician ordered admission to the Progressive Care Unit (PCU) with ongoing cardiac telemetry monitoring at 11:57 pm.

Review of a nursing note, dated 08/19/2020 at 9:30 am, revealed the nurse walked by the room and noticed the patient was slumped over. The nurse attempted to reposition the patient and noticed the patient was not breathing and was in asystole (total cessation of electrical activity from the heart). The ED staff monitoring the cardiac telemetry monitors failed to timely identify and notify appropriate clinical staff of a critical change in the patient's cardiac condition. Upon observation of the unresponsive patient the nurse-initiated resuscitation measures, the patient was transferred to a higher level of care and expired.

Review of the facility's investigation for the event that occurred in the ED on 8/19/2020 revealed the patient's VS became critical and remained critical for a total of approximately 20 minutes without being acknowledged or treated. Review of the record revealed no evidence the patient's change in cardiac rhythm was addressed immediately. Review of the facility's analysis of the event revealed identification of monitor alarm volumes not being audible by nursing staff or staff monitoring the telemetry monitors at the ED nursing station as the apparent cause of the event.

Review of the facility's corrective action plan revealed all monitors in the ED were tested for volume and adjusted to 55% for the bedside monitors and the ED monitoring station. The facility educated the ED team on the alarm limits, the accountability for alarm action, and policy related to setting alarm limits related to patient condition.

Review of the facility's investigation and corrective action plan revealed the facility failed to ensure the cardiac monitoring of patient's in the ED monitoring station was performed by qualified, dedicated and competent staff which resulted in patient #1's condition deteriorating to a critical level over approximately 20 minutes and resulted in cardiopulmonary arrest and ultimately death.

On 11/18/2020 at 10:30 am a tour of the facility ED was conducted. Two Unit Secretaries were observed and interviewed at the time of the tour. Interview with Unit Secretary "D" revealed the ED is split into 2 sections, Blue and Red. The Unit Secretary stated she was assigned to the Blue side and her responsibilities included answering the phone, entering orders, and observing the cardiac telemetry monitors. She confirmed she did not have any formal training for the telemetry monitors but "learned it over the years." She confirmed if there are any alarms on the monitors, she would notify the patient's nurse.

At the time of the tour the second Unit Secretary "B", assigned to the Red side, was interviewed. She confirmed her responsibilities included answering the phone, entering orders, and observing the cardiac telemetry monitors. She stated she "keeps an eye on the monitors" and if it alarms, she notifies the nurse. She then documents on a log who was notified, the time notified and the outcome.
At the time of the tour an ED Physician was interviewed. He stated he would expect that the staff monitoring the telemetry were trained to recognize cardiac abnormalities.

On 11/18/20 at 10:45 AM, an interview with the ED Director of Nursing was conducted. The interview revealed the ED staff responsible for monitoring the cardiac telemetry monitors located at the ED monitoring station, at the time of the event on 8/19/2020 and currently, were the Unit Secretaries. She confirmed the Unit Secretaries observe the cardiac monitors for alarms which are triggered by cardiac arrythmias. Once an alarm is triggered the Unit Secretary would alert the nurse.

Review of five of five Unit Secretaries personnel files (#A, #B, #C, #D, #E), who are utilized to observe the cardiac telemetry monitors in the ED, revealed no formal education, training or competency for cardiac monitoring.

On 11/18/20 at 11:10 AM the ED Medical Director was interviewed. The ED Medical Director stated he understood the Unit Secretaries were trained and were required to pass a test for the monitoring of telemetry patients. He confirmed overseeing the Unit Secretaries was not his responsibility.