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Based on document review and staff interview, it was determined for 1 of 1 (Pt #1) patient, the Hospital failed to ensure magnetic resonance imaging (MRI) was conducted in a manner to protect the health and safety of the patient and failed to ensure the Radiology staff activated the RRT (rapid response team) for an MRI patient who had an acute change in condition during an MRI. Therefore, the Condition of Participation, 42 CFR 482.26, Radiologic Services, was NOT met, as evidenced by:

Findings include:

1. The Hospital failed to ensure MRI was conducted in a manner to protect the health and safety of ED patients who require cardiac monitoring. See 535-A.

2. The Hospital failed to ensure the Radiology staff activated the RRT for an MRI patient who had an acute change in condition during an MRI. See 535-B.

Two Immediate Jeopardies (IJ) were identified at 42 CFR 482.26, Radiologic Services. The IJs began on 06/29/2021 due to the Hospital's failure to MRI was conducted in a manner to protect the health and safety of the patient and its failure to ensure the Radiology staff activated the RRT for an MRI patient who had an acute change in condition during an MRI. The IJs were identified on 07/01/2021 and were announced on 07/06/2021 at 3:55 PM, during a meeting with the Illinois Chief Nursing Officer (E#1), Regulatory Compliance Specialist (E# 12), Director of Quality (E#13), and Nursing Leader (E#14). The IJs were not removed by the survey exit date of 07/06/2021.

A. Based on document review and interview, it was determined for 1 of 1 Emergency Department patient (Pt #1), the Hospital failed to ensure magnetic resonance imaging (MRI) was conducted in a manner to protect the health and safety of emergency department (ED) patients who require cardiac monitoring. This has the potential to affect all future ED patients who require cardiac monitoring during an MRI.

Findings include:

1. Pt #1's medical record was reviewed throughout the survey (07/01/2021 through 07/06/2021). Pt #1 presented to the ED by ambulance on 06/28/2021 at 10:59 PM with a chief complaint of diaphoresis/near syncopal event (excessive sweating/feeling like you are going to pass out) at 10:30 PM. "Pt sts (states) he suddenly felt sweaty and got tunnel vision like he was going to pass out. Upon arrival pt complaint resolved." Pt history of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure and Supraventricular Tachycardia. "Assessment revealed a pt in no acute distress, A & O (alert and oriented), PWD (pink, warm, and dry), and ambulatory." Vital signs were noted: blood pressure 147/96, heart rate 87, respiratory rate 20, oxygen saturation 94%.
Provider was at bedside at 11:07 PM." Laboratory, cardiac monitoring, nasal cannula oxygen, pulse oximetry, peripheral intravenous (IV), portable chest x-ray, CT (computed tomography) head without contrast, CT of chest, and ECG (electrocardiogram/ EKG) were ordered. Troponin (Cardiac test) was within normal limits. On 6/30/21 at 2:29 AM, "Decision to admit pt for observation with diagnosis of near syncopal." At 3:11 AM, additional orders were placed by the Hospitalist including a MRI brain with and without contrast. Pt was in MRI at 7:50 AM with the exam starting at 7:52 AM. At 8:10 AM a ED nursing note stated, "Writer attempted to contact MRI for estimated remaining time of MRI completion so tech could transport pt straight up to IMC (Intermediate Care Unit) after imaging with no response." At 8:40 AM an ED nursing note stated, "Pt brought back from MRI, MRI tech states ""Pt had an EPISODE down in MRI."" Pt unresponsive, no palpable pulses, CPR began in room (ED room) ...." Pt #1 was resuscitated, placed on a ventilator, and admitted to the Intensive Care Unit. Pt #1's status improved, ventilator was discontinued, and was discharged home on 07/01/2021 at 5:22 PM. Pt was discharged with a Holter monitor (cardiac monitor) and was to follow up with cardiologist on 07/02/2021.

2. An interview was conducted an MRI technician (E #4) on 07/01/2021 at approximately 1:30 PM. E #4 stated, "The patient (Pt #1) was on the cardiac monitor in ER. I removed him off of the monitor and took him to MRI. I did not place him on my monitor (MRI compatible) in MRI. A nurse must accompany the patient if they are to be on the monitor." There was no physician order that Pt #1 could be removed from cardiac monitoring during the MRI.

3. An interview was conducted with ED RN (E #5) on 07/01/2021 at approximately 2:30 PM. E #5 stated, "The pt was on cardiac monitoring in the ED. A few minutes after my assessment, MRI came and got the pt and took the pt to MRI. I was unaware of when they actually got the pt. The patient was not being monitored (no cardiac monitor in the MRI)." E #5 also stated, "I have never went with a pt to MRI nor has any other nurse that I'm aware of (unless the patient is intubated). We are able to see monitoring if using ED monitors (during CT or X-ray) as they are centrally monitored. I'm unsure if the ED monitor is MRI compatible. I'm unaware how the patient would be monitored if not on the ED monitor."

4. An interview was conducted on 07/06/2021 at approximately 12:00 PM with the Regulatory and Compliance Specialist (E #12). E #12 stated, "There is no formal education we can find for the MRI use compatible cardiac monitor." The monitor was put into service on 12/29/2020.

B. Based on document review and interview, it was determined for 1 of 1 (Pt #1) MRI (magnetic resonance imaging) patient, who did not have nursing present, the Hospital failed ensure the Radiology staff activated the RRT (rapid response team) for an MRI patient who had an acute change in condition during an MRI. Pt #1 became unresponsive and pulseless, requiring cardiopulmonary resuscitation, mechanical ventilation, and admission to the Intensive Care Unit. This failure has the potential to affect all patients who have an acute change in condition during an MRI.

Findings include:

1. Pt #1 presented to the Emergency Department (ED) on 6/28/2021 at 10:59 PM with the chief complaint of diaphoresis/near syncopal (excessive sweating and feeling like going to pass out) event. Triage nursing documentation indicated, "patient states he suddenly got sweaty and had tunnel vision like he was going to pass out. States this morning did a lot of work in the sun and did not feel good since. Upon arrival to ED patient complaint resolved. Pt reports a past medical history of COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure) and SVT (Supraventricular Tachycardia). Assessment revealed a pt in no acute distress, A & O (alert and oriented), PWD (pink, warm, and dry), and ambulatory." Vital signs were noted: blood pressure 147/96, heart rate 87, respiratory rate 20, oxygen saturation 94%. Provider was at bedside at 11:07 PM." Laboratory, cardiac monitoring, nasal cannula oxygen, pulse oximetry, peripheral intravenous (IV), portable chest x-ray, CT (computed tomography) head without contrast, CT of chest, and ECG (electrocardiogram/ EKG) were ordered. Troponin (Cardiac test) was within normal limits. On 6/30/21 at 2:29 AM, "Decision to admit pt for observation with diagnosis of near syncopal." At 3:11 AM additional orders were placed by Hospitalist (E #9) to include a MRI of the brain with and without contrast. Pt was in MRI at 7:50 AM with the exam starting at 7:52 AM. At 8:40 AM, an ED nursing note stated, "Pt brought back from MRI, MRI tech stating patient had an EPISODE down in MRI. Pt unresponsive, no palpable pulses, CPR began in ED room. Pt in PEA (pulseless electrical activity). Pt being bagged. ED MD (E #10) at bedside ...at 8:54 AM patient regained pulses. Patient was placed on a ventilator at 9:00 AM ...at 9:50 AM patient taken to ICU (intensive care unit).

2. On 7/2/2021 at approximately 10:00 AM the policy "SMD Code Yellow-RRT" was reviewed (no revision date). The policy noted, "To assist in the rapid evaluation of patients' life threatening change in condition utilizing evidence-based guidelines for Rapid Response Team (RRT) ... A. Criteria Indicating a Potential Need to Notify the Rapid Response Team ... include acute changes in patient's status that result in staff/family concern about the patients ... 7. Altered mental status or changes in LOC (level of consciousness) ... 10. Seizure (new, repeated, or prolonged"

3. An interview was conducted with MRI technician (E #4) on 7/1/21 at approximately 1:30 PM. E #4 stated, "patient started to draw his legs up and appeared to be retching. I took him out of the scanner, and he vomited a little ... I thought he was losing consciousness and started seizing (having seizures). I laid him down and called CT (computerized tomography) techs for assistance and the four of us rushed him back to the ED. I did not call a Code Yellow and should have".

4. An interview was conducted with MRI technician (E #6) on 7/1/21 at approximately 3:30 PM. E #6 stated, "He started moving his legs, we stopped the scan. The other MRI tech went in to check on the patient. We slid him out and the patient was gagging ...patient vomited ...patient got stiff, clutched my hand real tight and we laid him back. I asked the other tech to get help to move him back onto the cart. Two CT techs came over and we moved him onto the cart, and we took him back to the ED. We did not call a Code Yellow and agree we should have."

5. The Code Yellow - RRT training, imbedded in the safety module training, was reviewed on 7/2/21.
a. MRI technician (E#4) completed training on 7/15//20.
b. CT tech/MRI tech in training (E#6) completed training on 3/24/21.
c. CT technician (E#7) completed training on 8/27/2020.
d. CT technician (E#11) completed training on 5/3/2021.

Based on document review, observation and staff interview, it was determined for 1 of 1 (Pt #1) Emergency Department (ED) patient required cardiac monitoring and an MRI (magnetic resonance imaging), the Hospital failed to ensure cardiac monitoring was completed during the provision of MRI services requiring cardiac monitoring. Therefore, the Condition of Participation, 42 CFR 482.55, Emergency Services, was NOT met, as evidenced by:

Findings include:

1. The Hospital failed to ensure cardiac monitoring was completed during the provision of MRI services required cardiac monitoring. See A 1103.

One Immediate Jeopardy was identified at 42 CFR 482.55, Emergency Services on 06/29/2-21, due to the Hospital's failure to ensure cardiac monitoring was completed during the provision of MRI services requiring cardiac monitoring. Subsequently, Pt #1 became unresponsive and pulseless, requiring cardiopulmonary resuscitation, mechanical ventilation, and admission to the Intensive Care Unit. The IJs were identified on 07/01/2021, and were announced on 07/06/2021 at 3:55 PM, during a meeting with the Illinois Chief Nursing Officer (E#1), Regulatory Compliance Specialist (E# 12), Director of Quality (E#13), and Musing Leader (E#14). The IJ was not removed by the survey exit date of 07/06/2021.

Based on document review and interview, it was determined for 1 of 1 (Pt #1) ED (emergency department) patient who required cardiac monitoring, the Hospital failed to ensure cardiac monitoring was completed during the provision of Magnetic Resonance Imaging (MRI) services required cardiac monitoring. This was evident in Pt #1 who became unresponsive, pulseless, required cardiopulmonary resuscitation and mechanical ventilation and was then admitted to the Intensive Care Unit. This failure represents a threat to the health and safety of all ED patients who require cardiac monitoring and MRI services.

Findings include:

1. Pt #1's record was reviewed throughout the survey. Pt #1 was brought to the Emergency Department (ED) by ambulance on 06/28/2021 at 10:59 PM with a chief complaint of diaphoresis/near syncopal event. The triage nurse note stated: "Pt present to ED via (ambulance service) from home with complaints of near syncope PTA (prior to arrival) at 10:30 PM. Pt sts (states) he suddenly felt sweaty and got tunnel vision like he was going to pass out. States this morning did a lot of work in the sun and did not feel good since. Upon arrival pt complaint resolved. Pt reports a past medical history of COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure) and SVT (Supraventricular Tachycardia). Assessment revealed a pt in no acute distress, A & O (alert and oriented), PWD (pink, warm, and dry), and ambulatory" Vital signs were noted: blood pressure 147/96, heart rate 87, respiratory rate 20, oxygen saturation 94%. The ED MD (E #8) was at bedside at 11:07 PM. Orders were placed at 11:12 PM for labs, x-ray, CT scan and cardiac monitoring. An order for MRI (magnetic resonance imaging) brain with and without contrast was ordered at 3:11 AM by the hospitalist (E #9). Pt was in MRI at 7:50 AM with the exam starting at 7:52 AM. Nursing note stated, "0840: Pt brought back from MRI, MRI tech stating patient had an EPISODE down in MRI. Pt unresponsive, no palpable pulses, CPR began in ED room. Pt in PEA (pulseless electrical activity). Pt being bagged. ED MD (E #10) at bedside ... at 8:54 AM patient regained pulses. Patient was placed on a ventilator at 9:00 AM ... at 9:50 AM patient was taken to ICU (intensive care unit).

2. The policy titled "SMD Transportation of Patients on Telemetry (undated) was reviewed on 07/02/20201 at approximately 10:30 AM. The policy stated "B. Emergency Department... Unless otherwise ordered by a provider, all ED patients on telemetry will be placed on remote telemetry or a transport monitor while being transported outside of the ED."

3. An interview was conducted with a MRI technician (E #4) on 07/01/2021 at approximately 1:30 PM. E #4 stated "The patient was on the cardiac monitor in ER. I removed him off of the monitor and took him to MRI. I did not place him on my monitor in MRI. A nurse must accompany the patient if they are to be on the monitor."

4. An interview was conducted with ED RN (E #5) on 07/01/2021 at approximately 2:30 PM. E #5 stated, "The pt was on cardiac monitoring in the ED. A few minutes after my assessment, MRI came and got the pt and took the pt to MRI. I was unaware of when they actually got the pt. The patient was not being monitored (cardiac monitored - while in the MRI)." E #5 also stated "I have never went with a pt to MRI nor has any other nurse that I'm aware of (unless the patient is intubated). We are able to see monitoring if using ED monitors as they are centrally monitored (CT and X-rays). I'm unsure if the ED monitor is MRI compatible. I'm unaware how the patient would be monitored if not on the ED monitor."

5. An interview was conducted with the Director of Quality and Safety (E#12) on 7/6/21 at approximately 12:00 PM. E#12 stated, "There has been no formal education that we could find (for the MRI compatible monitor). It's been in service since 12/29/2020.