HospitalInspections.org

Based on interview and record review the facility failed to monitor and assess a cardiac patient and notify the physician after an episode of bradycardia for one (#1) of two patients reviewed for a cardiac arrest event out of a total sample of 10, resulting in the potential for missed treatment opportunities. Findings include:

On 7/29/20 at approximately 1300, Patient #1's clinical record was reviewed with the Certification Specialist Staff B and the Director of Patient Care Services Staff D who were also interviewed at that time. The following information was revealed:

Patient #1 was an 89 year old male who was admitted to the facility on 6/24/20 and expired in the facility on 6/30/20 after a cardiopulmonary arrest with a "Code Blue" (cardiopulmonary resuscitation event) on 6/27/20 at 0232.

Patient #1's Physician admission History and Physical assessment (H&P) documented that he was sent to the facility Emergency Department (ED) on 6/24/20 by his cardiologist for a diagnosis of worsening Ischemic Cardiomyopathy (heart muscle damage from lack of blood supply) and hypotension (low blood pressure) after cardiac testing which showed that his ejection fraction (amount of blood pumped out by the heart at each beat) was less than 30 percent (%) ( less than 35% is severe heart failure and high risk for sudden death).

Patient #1 's admission H&P also documented that he had multiple risk factors for heart problems which included Morbid Obesity, Coronary Artery Heart disease, Congestive Heart Failure, Hypertension (high blood pressure), Atrial Fibrillation (irregular heart beat), and a previous Coronary Artery Bypass Surgery (CABG) and Pulmonary Embolism (PE - blood clot in the lung).

Patient #1 did not have an Advanced Directive or Living Will, but his resuscitation choice was documented as "Full code" (all lifesaving measures possible) in the clinical record.

Patient #1's Nursing Care Plans dated 6/24/20 at 1913 included one for "Activity Intolerance" with interventions (instructions to the nursing staff) to "monitor for chest pain" and "cardiac monitoring".

Admission physician's orders included orders for Cardiac Monitoring per protocol. At this time a review of the facility policy entitled, "Telemetry Monitoring of Non-Critical Patients" dated 7/18 and an interview with Staff D at this time revealed that on the unit where Patient #1 was admitted vital signs (pulse and blood pressure) and a telemetry monitoring strip (electronic recording of heart electric rhythms, and heart rate) must be documented on the clinical record every four hours or for every significant change. Routine telemetry monitor alarm parameters (settings for alarms) were noted as a heart rate less than 50 or greater than 120 beats per minute. Per Staff D, heart rates outside of these parameters and/or dangerous arrhythmia (irregular heart rhythms) would cause the telemetry monitor to alarm at the nursing station and would trigger the system to print a monitoring strip which must be entered into the patient's clinical record.

Review of telemetry monitoring strips for Patient #1 revealed a strip recorded on 6/27/20 at 0128 which documented an episode of bradycardia (abnormally slow heart rate) with a heart rate of 42 beats per minute (bpm) (normal is 60 to 100 bpm). Review of Patient #1's clinical record at this time revealed there was no documentation that the Nurse assessed the patient after this episode of bradycardia until a Code Blue was called for Patient #1 one hour and four minutes later, at 0232. There was no documentation to indicate that a physician was notified of Patient #1's abnormal heart rate at 0128 or that any medications or treatments were given for this arrhythmia.

A telemetry monitoring strip dated 6/27/20 at 0228 for Patient #1 documented the monitor alarmed for arrhythmia which included premature ventricular contractions (PVC) and bradycardia (abnormal slowing heart electrical rhythms associated with heart beats).

A CPR (cardiopulmonary resuscitation) flow sheet for Patient #1 documented that cardiopulmonary resuscitation was started for Patient #1 on 6/27/20 at 0232 for cardiac arrest. The CPR flow sheet noted that Patient #1 's heart rhythm at the time of the Code Blue (6/27/20 at 0232) was pulseless electrical activity (PEA - electrical activity detected on the heart monitor without a corresponding pulse or heart beat). Patient #1 was intubated (placed on mechanical ventilation) and transferred to the intensive care unit (ICU). Patient # 1 remained unresponsive with poor prognosis and expired on 6/30/20.

A Responding Physician's Code Blue summary for Patient #21 dated 6/27/20 at 0356 documented the following initial findings, "Physician called to floor to find patient unresponsive, pulseless and apneic (not breathing). Nurse states that patient had been undergoing diuresis however felt somewhat strange about an hour prior to being found unresponsive, blue and apneic (not breathing) by nurse."

There was no documentation to indicate that a physician was notified of Patient #1's abnormal heart rate at 0128 or that the nurse assessed Patient #1 or took a manual blood pressure or heart rate at that time. There was no nursing documentation of patient complaints or patient assessment or manual vital signs taken when the patient reportedly (per the code blue physician's summary note) "felt somewhat strange about an hour prior to being found unresponsive, blue and apneic" at 0232 on 6/27/20.

A "late entry" Nursing Note by Patient #1's assigned nurse Staff W was dated 6/27/27 at 0410 (70 minutes after the Code Blue form was signed as finished) and noted the following, " patient began to brady down (slowing heart rate), heart rate dropped to late 30's, RN (Registered Nurse) found patient in bed, nasal cannula (oxygen tubing) off, blood in mouth, skin cyanotic (blue), breathing was irregular. RN began sternal rub and attempted to arouse patient. RN called for help and Code Blue." There was no documentation in this late entry to indicate what at time this event occurred. This was the only Nursing Progress Note documented for Patient #1 on the shift that his cardiac arrest occurred (1900 on 6/26/20 to 0700 on 6/27/20).

On 7/29/20 at approximately 1540, Staff W was interviewed by telephone. Staff W said that she did not notify the physician of Patient #1's low heart rate on 6/27/20 at 0128 or document that she assessed or monitored Patient #1 more closely after this episode because she was told in report (nurse to nurse summary of patient status at each change of shift) that it was normal for Patient #1's heart rate to drop to the 50's. There was no documentation of this in the clinical record. Staff W said that at one point (she was unable to state what time this happened) Patient #1 told her that he didn't feel well. Staff W said that she documented this and took another set of vitals. This was not documented in the clinical record.

On 7/29/20 at approximately 1545, Staff W was asked about Patient #1's Code Blue. Staff W said, "He started to brady down to the 30's and I came in to check on him. Don't know what time. He had his oxygen off and was almost agonal breathing (gasps which are not true breathing, but a brainstem reflex during cardiac arrest). He had some blood in his mouth. I tried to clean it out. I didn't like how he looked so I called a code."

On 7/29/20 at approximately 1600 Staff Y the House Supervisor was interviewed by telephone. Staff Y said that she was at the nursing station for a couple of minutes on 06/27/20 when Staff W went into Patient #1's room to check on him because the monitors showed a cardiac rhythm with a rate in the 30's. Staff Y said that Staff W called for help. Staff Y said that she immediately went into the room to check Patient #1 and noticed that the telemetry monitor showed a recorded rhythm, but the patient had no pulse (pulseless electrical activity) and was blue and not breathing.

On 7/29/20 at approximately 1615 Staff D was interviewed regarding nursing expectations for patient assessment and monitoring after an episode of bradycardia. Staff D stated that it was facility policy and a standard of practice for a nurse to perform an assessment of the patient and notify the physician for a heart rate in the 40's. Staff D said that nurses should check manually for a pulse and heart rate if a patient was blue and unresponsive and should start CPR immediately if there was no heart beat, even if the telemetry monitor showed an electrical rhythm in the heart. Staff D stated that after the event she and Staff Y had discussed providing training and education to telemetry Nursing staff on recognizing Pulseless Electrical Activity.

On 7/29/20 at approximately 1800 review of the facility policy entitled, "Telemetry Monitoring of Non-Critical Patients" dated 7/2018 revealed the following statement, "Arrhythmia that are new, symptomatic, reflect a change from baseline, and/or require immediate intervention will promptly be reported to the physician."

On 7/29/20 at approximately 1805 review of the facility policy entitled, "Vital Signs.." dated 6/20 revealed the following statement, "Abnormal findings will be rechecked whenever there is a significant change above or below the normal mean of each individual patient. All significant changes are to be promptly reported to the physician."

On 7/29/20 at approximately 1810 review of the facility policy entitled, "Nursing Assessment Process and Documentation" dated 6/20 revealed the following statement, "Any significant change in a patient's condition will be assessed and documented. Additionally, physician and family notification will occur in a timely manner.