HospitalInspections.org

Based on clinical record review, review of facility documentation, and staff interview it was determined the facility failed to develop and implement effective ongoing data specific / driven quality improvement program, that reflects problematic issues identified and known to managers regarding staff failure to follow protocols and procedures relating to the provision of nursing services. The facility failed to focus on specific indicators related to improvement required by nursing service personnel in order to prevent repeat occurrences of negative patient care outcomes.

The findings include:

On 06/21/2011 during the review of the clinical record for patient #1 it was disclosed the patient was admitted to the facility on 5/11/11 with a history of Cardiomyopathy, Automatic Internal Cardiac defibrillator (AICD)/Pacemaker, Coronary Artery Bypass Graft, Open Wounds (Pressure Ulcer, Vascular and Surgical Wounds) as well as various other medical conditions. The patient was placed on Telemetry monitoring (cardiac monitoring).

Clinical nurse's note by a Pulmonologist document, that on 05/12/2011 at 1012 hours the Pulmonologist responded to the Code Blue (call for resuscitation measures). The note specifies, the patient (#1) was seen only a few minutes before, and had no complaints. The patient was found unresponsive by Nursing; the patient was intubated and ventilation assisted with Ambu (Manual ventilation); the patient did not respond to Cardio Pulmonary Resuscitation (CPR).
The patient was pronounced dead at 1000 hours, according to the Code Blue Record. At the time of the survey the medical record lacked documentation of rhythm strips after 0400 hours on 5/12/11.
The surveyor made a request for the documentation of the rhythm strips on 6/21/11 and 6/22/11 at 1100, 1300 and 1520.

Review of the facility's Investigative Report (not dated) revealed under the title Findings: Staff including nurse, radiology technician, monitoring tech along with review of the medical record identified the following: 0800 routine vital signs were stable; 0830 radiology tech along with nurse assistance took a chest x-ray; 0840 nursing supervisor made rounds on the unit; 0905 nurse gave PO (by mouth) medications to patient; 0947 nurse entered the room and found the patient unresponsive and called a code blue.
It is documented on the report, under subtitle Human Factors: The Monitor Technician (MT) did not activate the proper protocol to ensure patient was on the Cardiac Monitor. The other factors that have directly influenced the outcome: The Monitor Technician did not have a list of each nurse ' s direct portable phone.


The surveyor requested from the risk manager and the chief executive officer to review the written causal analysis that had been performed and documented, in order to isolate the true / real indicators that caused and or contributed to the adverse incident described above. The managers provided a document titled "A Framework for a Root Cause Analysis and Action Plan in Response to a Sentinel Event". Review of this document revealed under the heading "Findings" notation of the patient's (#1) age, diagnoses and medical history ; on May 12, 2011 at 0947 the patient's nurse called a code blue. ACLS protocol; was followed and the patient was not revived and was pronounced expired. During postcode blue review and analysis it was noted that the patient was not on the monitor from 0844 until the code blue was called.


Surveyor inspection revealed, the last telemetry rhythm strip for patient #1, that was found and provided, is dated and timed 5/12/2011 at 0400 hours. This strip showed the patient's pacemaker was firing and capturing because he had a rhythm. Surveyor inspection revealed, based on Medication Administration Report, dated 05/12/11 at 0905, there was interaction with the patient at this time when medications were administered. The clinical record documents, a cardiac resuscitation code was called for patient #1 at 0947 and patient #1 was pronounced dead at 1000 hours.

A thorough review of the facility's documented analysis, revealed the facility did not document the core findings of staff action, lack of actions, or delay in taking action, found in their investigation to have contributed to the occurrence / outcome; causative factors and staff delay in providing necessary service are not identified and noted to have been analyzed.
The analysis report does not address the "cause or potential cause of the staff failure to act in accordance with established telemetry monitoring protocol and monitor technician job description (please refer to deficient practice cited in this report at A0267 and A0392 in this report). The facility's analysis merely list the occurrence as it happened
As a result the facility is unable to provide supportive evidence that substantiates their Quality Assurance and Improvement efforts and Risk Management Program efforts assures, in accordance with regulatory requirements at 482.21 for Quality Assurance & Improvement, the incorporation of quality indicator data that includes relevant patient care data identified as causing the provision of poor quality patient care, and that their program tracks adverse patient event indicators that reflects the actual cause of incidents. They are unable to provide supportive evidence to substantiate the actual cause of the incident involving patient #1 was analyzed appropriately, and that preventive measures implemented saturates the actual cause and will be successful in risk prevention and reoccurrence.

At the time of the survey the facility managers were unable to provide supportive evidence of the incorporation of the indicator of staff failure to follow protocols and policy in the Quality Improvement Program, nor are there measure designed and implemented that address identified behavior of staff, and speak to how the facility will include measures for staff and patient feedback and staff learning throughout the hospital. While education inservices were provided to staff, the facility does not have measures in place to collect data regarding staff feedback and learning. (Please refer to deficient practice cited in this report at A0267, and A0392 for additional details).
The facility measures implemented to prevent repeat occurrences does not establish risk prevention measures to prevent or manage staff failure to follow protocols. The Quality Assurance indicators for the facility measures remains, as they were prior to the identification of the issue of staff failing to respond to patient equipment alarms and policy, based on national safety goals assessing: Blood stream infections, restraints, pain management, ventilator related pneumonia, wounds and customer service described by the CEO as related to response to patient call Bells.

Based on clinical record review, facility document review, and staff interview it was determined nursing management / supervisory personnel failed to ensure nursing service personnel (telemetry monitoring technician) are performing their duties and responsibilities to the patient(s) when needed, and that these personnel can readily access a registered nurse. In addition, the facility failed to ensure nursing service personnel furnish the necessary patient service when required. This failure affected 1 of 10 sampled patients whose clinical records were reviewed (#1).

The findings include:

On 06/21/2011 during the review of the clinical record for patient #1 it was disclosed the patient was admitted to the facility on 5/11/11 with a history of Cardiomyopathy, Automatic Internal Cardiac defibrillator (AICD)/Pacemaker, Coronary Artery Bypass Graft, Open Wounds (Pressure Ulcer, Vascular and Surgical Wounds) as well as various other medical conditions. The patient was placed on Telemetry monitoring (cardiac monitoring).

On 05/12/2011 A Code Blue (call for resusicitation measures) was called to resuscitate patient #1.
A Pulmonologist, who responded to the Code Blue, documented a note on 5/12/11 at 1012 specifying, the patient was seen only a few minutes before, and had no complaints. The patient was found unresponsive by Nursing; the patient was intubated and ventilation assisted with Ambu (Manual ventilation); the patient did not respond to Cardio Pulmonary Resuscitation (CPR).

Continued record review revealed the patient was pronounced dead at 1000 hours, according to the Code Blue Record. At the time of the survey the medical record lacked documentation of rhythm strips after 0400 hours on 5/12/11.
The surveyor made a request for the documentation of the rhythm strips on 6/21/11 and 6/22/11 at 1100, 1300 and 1520.

The patient was pronounced dead at 1000 hours, according to the Code Blue Record.

Review of the facility's Investigative Report (not dated) revealed under the title Findings: Staff including nurse, radiology technician, monitoring tech along with review of the medical record identified the following: 0800 routine vital signs were stable; 0830 radiology tech along with nurse assistance took a chest x-ray; 0840 nursing supervisor made rounds on the unit; 0905 nurse gave PO (by mouth) medications to patient; 0947 nurse entered the room and found the patient unresponsive and called a code blue.
It was documented on the report, under subtitle Human Factors: The Monitor Technician (MT) did not activate the proper protocol to ensure patient was on the Cardiac Monitor. The other factors that have directly influenced the outcome: The Monitor Technician did not have a list of each nurse ' s direct portable phone.

On 06/21/2011 at 1420 hours during a telephone interview with the Monitoring Technician (MT#2), who was involved in the 5/12/11 incident , the Technician stated she noticed the leads were off because she got a straight line on the monitor. She looked for the nurse from the door of the monitoring room. She did not see the nurse. Upon inquiry the MT stated she is unsure of the exact time that elapsed, but stated a few minutes later she saw the nurse at the desk. She went over to the nurse and informed her that the patient ' s leads were off. The MT stated, I think the nurse told me I am going into the room. The MT further stated that she (the monitor tech) was not worried and did not consider the straight line (flat line on the scope) as a rhythm change.

The interview revealed the technician who saw a straight line on the monitor; in order to look for the nurse from the door of the Monitoring Room, she would have to leave the Telemetry scope monitoring other patients (# ). This was done rather than using the phone to call the nurse as per policy and protocol.
The desk at which the monitor technician saw the nurse is outside the monitoring room and cannot be seen from inside the monitoring room, vision of the nurse's desk requires leaving the telemetry monitoring scope. When the monitoring technician specifies, she "went over to the nurse and informed her that the patient's leads were off", this indicates leaving the monitoring room and the patients telemetry monitors unattended.

I asked the monitor technician how could she be sure it was not Asystole (absence of cardiac rhythm /without cardiac conductivity) versus the leads being off, the MT replied because the monitor screen was showing " Leads Off " and it would say asystole. The MT stated she did not follow the Algorithm titled Notification/Communication of Lethal Rhythm Changes, (see details of the Algorithm protocol above). It is verified, the MT did not notify any staff member as required. The MT stated she did not follow the policy.

During an interview with the RM and the CEO on 6/22/11 at 1330 they stated, the MT failed to follow the procedure. The RM stated the MT was told action was pending, and that the MT was informed "we are awaiting guidance from Human Resources (HR)". The CEO stated we notified our regional office of the incident. We formed a sanction subcommittee under the guidance of our Quality Council and notified Legal on 5/12/11. The RM stated we filed an Adverse Incident, 15 Day Report with the State on 5/24/11.

Review of the facility's protocol titled Notification/ Communication of Lethal Rhythm Changes, which is posted on the wall of the monitoring room, disclosed the following as a responsibility of the Monitor Technician:
Place a call immediately to the patient ' s nurse.
The patients nurse receives the phone call and responds.
The rhythm change is communicated appropriately. The action is documented by the MT.
If the nurse does not respond the nursing supervisor is called.
The nursing supervisor receives the call and responds.
The rhythm change is communicated appropriately. The action is documented by the MT.
If the nursing supervisor does not respond the MT calls a " Code Blue " to the patient ' s room overhead.

Supportive evidence for the conduct of the above process was not found or provided by Kindred Hospital personnel during the survey.

A review of the Job Description for the monitoring technician contained in her personnel record disclosed, the position reports to the Clinical Nurse Manager of the Nursing Department. Review of the Job Summary of responsibilities reveals the following: Monitors rhythm pattern of patients to detect abnormal pattern variances, using telemetry equipment: Reviews patient information to determine normal heart rhythm pattern, current pattern and prior variances. Observes screen of cardiac monitor and listens for alarm to identify abnormal variation in heart rhythm. The job specific responsibilities and duties include the following:
Monitors telemetry of patients by observing telemetry monitors for changes in cardiac rhythms. Maintains accurate records of telemetry patients.
Immediately notifies R.N. or Supervisors of rhythm changes.

The review of the Job Description revealed the Job Description fails to inform the monitoring technician of what are their responsibilities and accountabilities, upon viewing abnormal cardiac pattern / variances.

Please refer to the deficient practices cited in this report at A0392 for additional detailed information.

Based on clinical record review, facility document review, and staff interview it was determined nursing management / supervisory personnel failed to ensure nursing service personnel (telemetry monitoring technician) are performing their duties and responsibilities to the patient(s) when needed and that such personnel can readily access a registered nurse. This failure affected 1 of 10 sampled patients (#1) whose clinical records were reviewed.

The findings include:

On 06/21/2011 during the review of the clinical record for patient #1 it was disclosed the patient was admitted to the facility on 5/11/11 with a history of Cardiomyopathy, Automatic Internal Cardiac defibrillator (AICD)/Pacemaker, Coronary Artery Bypass Graft, Open Wounds (Pressure Ulcer, Vascular and Surgical Wounds) as well as various other medical conditions. The patient was placed on Telemetry monitoring (cardiac monitoring).

Clinical nurse's note substantiate the performance of a nursing assessment by a RN at 0800. The patient is described as alert and oriented times three; respirations unlabored; on Oxygen via a Nasal Cannula. The nurse documents, the patient ' s cardiac rhythm "was paced", there are no cardiac strip to support this statement. Facility policy requires the performance of rhythm strips every 4 hours and as necessary. The nurse documents that she administered the patient his medications at 0905, left and returned to the patient's room at approximately 0947, and found the patient unresponsive. A Code Blue (call for resuscitation measures) was called.

The Pulmonologist who responded to the Code Blue, documented a note on 5/12/11 at 1012, specifying the patient was seen only a few minutes before, and had no complaints. The patient was found unresponsive by Nursing; the patient was intubated and ventilation assisted with Ambu (Manual ventilation); the patient did not respond to Cardio Pulmonary Resuscitation (CPR).

The patient was pronounced dead at 1000 hours, according to the Code Blue Record. At the time of the survey the medical record lacked documentation of rhythm strips after 0400 hours on 5/12/11.
The surveyor made a request for the documentation of the rhythm strips on 6/21/11 and 6/22/11 at 1100, 1300 and 1520.


Review of the facility's Investigative Report (not dated) revealed under the title Findings: Staff including nurse, radiology technician, monitoring tech along with review of the medical record identified the following: 0800 routine vital signs were stable; 0830 radiology tech along with nurse assistance took a chest x-ray; 0840 nursing supervisor made rounds on the unit; 0905 nurse gave PO (by mouth) medications to patient; 0947 nurse entered the room and found the patient unresponsive and called a code blue.
No evidence was found or provided during the course of the survey to substantiate the nurse supervisor saw patient #1 at 0840 during her tour. The relevance of this statement on the Investigative Report is unknown, and remains unexplained by the facility.

It is documented on the report, under subtitle Human Factors: The Monitor Technician (MT) did not activate the proper protocol to ensure patient was on the Cardiac Monitor. The other factors that have directly influenced the outcome: The Monitor Technician did not have a list of each nurse ' s direct portable phone.

During an interview conducted on 06/21/2011 at 1100, the nurse manager stated following a complaint investigation on 3/12/11 a process was initiated: The complaint related to a delayed response to a ventilator alarm.
The MT will document the escalating call in a log titled Nurse Notification of Significant Change, she further stated the only time a monitor can be removed from a patient is with a physician ' s order; the supervisor provides the MT with a list of each nurse ' s direct phone; the nurses and the Respiratory Therapist (RT) were issued Spectra - Link phones in March; during the shift the nursing supervisor will call each phone to ensure the phone is working and the nurse or the RT is answering the calls. The receptionist randomly places calls to staff as an addition check.

Supportive evidence for the conduct of the above process was not found or provided by Kindred Hospital personnel during the survey.

Review of the facility's protocol titled Notification/ Communication of Lethal Rhythm Changes, which is posted on the wall of the monitoring room, disclosed the following as a responsibility of the Monitor Technician:
Place a call immediately to the patient ' s nurse.
The patients nurse receives the phone call and responds.
The rhythm change is communicated appropriately. The action is documented by the MT.
If the nurse does not respond the nursing supervisor is called.
The nursing supervisor receives the call and responds.
The rhythm change is communicated appropriately. The action is documented by the MT.
If the nursing supervisor does not respond the MT calls a " Code Blue " to the patient ' s room overhead.

On 06/21/2011 at 1420 hours during a telephone interview with the Monitoring Technician (MT#2), who was involved in the 5/12/11 incident , the Technician stated she noticed the leads were off because she got a straight line on the monitor. She looked for the nurse from the door of the monitoring room. She did not see the nurse. Upon inquiry the MT stated she is unsure of the exact time that elapsed, but stated a few minutes later she saw the nurse at the desk. She went over to the nurse and informed her that the patient ' s leads were off. The MT stated, I think the nurse told me I am going into the room. The MT further stated that she (the monitor tech) was not worried and did not consider the straight line (flat line on the scope) as a rhythm change.

The interview revealed the technician who saw a straight line on the monitor; in order to look for the nurse from the door of the Monitoring Room, she would have to leave the Telemetry scope monitoring other patients (# ). This was done rather than using the phone to call the nurse as per policy and protocol.
The desk at which the monitor technician saw the nurse is outside the monitoring room and cannot be seen from inside the monitoring room, vision of the nurse's desk requires leaving the telemetry monitoring scope. When the monitoring technician specifies, she "went over to the nurse and informed her that the patient's leads were off", this indicates leaving the monitoring room and the patients telemetry monitors unattended.

I asked the monitor technician how could she be sure it was not Asystole (absence of cardiac rhythm /without cardiac conductivity) versus the leads being off, the MT replied because the monitor screen was showing " Leads Off " and it would say asystole. The MT stated she did not follow the Algorithm titled Notification/Communication of Lethal Rhythm Changes, (see details of the Algorithm protocol above). It is verified, the MT did not notify any staff member as required. The MT stated she did not follow the policy.

During an interview with the RM and the CEO on 6/22/11 at 1330 they stated, the MT failed to follow the procedure. The RM stated the MT was told action was pending, and that the MT was informed "we are awaiting guidance from Human Resources (HR)". The CEO stated we notified our regional office of the incident. We formed a sanction subcommittee under the guidance of our Quality Council and notified Legal on 5/12/11. The RM stated we filed an Adverse Incident, 15 Day Report with the State on 5/24/11.


A review of the Job Description for the monitoring technician contained in her personnel record disclosed, the position reports to the Clinical Nurse Manager of the Nursing Department. Review of the Job Summary of responsibilities reveals the following: Monitors rhythm pattern of patients to detect abnormal pattern variances, using telemetry equipment: Reviews patient information to determine normal heart rhythm pattern, current pattern and prior variances. Observes screen of cardiac monitor and listens for alarm to identify abnormal variation in heart rhythm. The job specific responsibilities and duties include the following:
Monitors telemetry of patients by observing telemetry monitors for changes in cardiac rhythms. Maintains accurate records of telemetry patients.
Immediately notifies R.N. or Supervisors of rhythm changes.

The review of the Job Description revealed the Job Description fails to inform the monitoring technician of what are their responsibilities and accountabilities, upon viewing abnormal cardiac pattern / variances.

Based on clinical record review, facility record review, staff interviews and observation it was determined the facility failed to perform appropriate causal analysis, data collection of indicators relevant to the identified causative factor, and established relevant risk prevention strategies aimed at preventing recurrent adverse incident relating to responsibilities of personnel performing telemetry monitoring.

The findings include:

On 06/21/2011 during the review of the clinical record for patient #1 it was disclosed the patient was admitted to the facility on 5/11/11 with a history of Cardiomyopathy, Automatic Internal Cardiac defibrillator (AICD)/Pacemaker, Coronary Artery Bypass Graft, Open Wounds (Pressure Ulcer, Vascular and Surgical Wounds) as well as various other medical conditions. The patient was placed on Telemetry monitoring (cardiac monitoring).

Clinical nurse's note by a Pulmonologist document, that on 05/12/2011 at 1012 hours the Pulmonologist responded to the Code Blue (call for resuscitation measures). The note specifies, the patient (#1) was seen only a few minutes before, and had no complaints. The patient was found unresponsive by Nursing; the patient was intubated and ventilation assisted with Ambu (Manual ventilation); the patient did not respond to Cardio Pulmonary Resuscitation (CPR).
The patient was pronounced dead at 1000 hours, according to the Code Blue Record. At the time of the survey the medical record lacked documentation of rhythm strips after 0400 hours on 5/12/11.
The surveyor made a request for the documentation of the rhythm strips on 6/21/11 and 6/22/11 at 1100, 1300 and 1520.

Review of the facility's Investigative Report (not dated) revealed under the title Findings: Staff including nurse, radiology technician, monitoring tech along with review of the medical record identified the following: 0800 routine vital signs were stable; 0830 radiology tech along with nurse assistance took a chest x-ray; 0840 nursing supervisor made rounds on the unit; 0905 nurse gave PO (by mouth) medications to patient; 0947 nurse entered the room and found the patient unresponsive and called a code blue.
No evidence was found or provided during the course of the survey to substantiate the nurse supervisor saw patient #1 at 0840 during her tour. The relevance of this statement on the Investigative Report is unknown, and remains unexplained by the facility.

It is documented on the report, under subtitle Human Factors: The Monitor Technician (MT) did not activate the proper protocol to ensure patient was on the Cardiac Monitor. The other factors that have directly influenced the outcome: The Monitor Technician did not have a list of each nurse ' s direct portable phone.

Corrective actions to be taken are: (1) immediate re-education with monitor tech on duty to review process for escalating issues in real time; (2) provide current list of nurses portable phone numbers to the monitor tech; (3) implement audits to ensure current list of phone numbers for nurses's portable phone is available in the monitor tech station; (4) mandatory re-education for all monitor technicians on process to escalate telemetry issues in real time; (5) Audit patients on telemetry to ensure they have a physicians order for telemetry monitoring.

The surveyor requested from the risk manager and the chief executive officer to review the written causal analysis that had been performed and documented, in order to isolate the true / real indicators that caused and or contributed to the adverse incident described above. The managers provided a document titled "A Framework for a Root Cause Analysis and Action Plan in Response to a Sentinel Event". Review of this document revealed under the heading "Findings" notation of the patient's (#1) age, diagnoses and medical history ; on May 12, 2011 at 0947 the patient's nurse called a code blue. ACLS protocol; was followed and the patient was not revived and was pronounced expired. During postcode blue review and analysis it was noted that the patient was not on the monitor from 0844 until the code blue was called.

Surveyor inspection revealed, the last telemetry rhythm strip for patient #1, that was found and provided, is dated and timed 5/12/2011 at 0400 hours. This strip showed the patient's pacemaker was firing and capturing because he had a rhythm. Surveyor inspection revealed, based on Medication Administration Report, dated 05/12/11 at 0905, there was interaction with the patient at this time when medications were administered. The clinical record documents, a cardiac resuscitation code was called for patient #1 at 0947 and patient #1 was pronounced dead at 1000 hours.

A thorough review of the facility's documented analysis, revealed the facility did not document the core findings of staff action, lack of actions, or delay in taking action, found in their investigation to have contributed to the occurrence / outcome; causative factors and staff delay in providing necessary service are not identified and noted to have been analyzed.
The analysis report does not address the "cause or potential cause of the staff failure to act in accordance with established telemetry monitoring protocol and monitor technician job description (please refer to deficient practice cited in this report at A0385 and A0392 in this report). The analysis merely list the occurrence as it happened
As a result the facility is unable to provide supportive evidence that substantiates their Quality Assurance and Improvement efforts and Risk Management Program efforts assures, in accordance with regulatory requirements at 482.21, the incorporation of quality indicator data that includes relevant patient care data identified as causing the provision of poor quality patient care, and that their program tracks adverse patient event indicators that reflects the actual cause of incidents. They are unable to provide supportive evidence to substantiate the actual cause of the incident involving patient #1 was analyzed appropriately, and that preventive measures implemented saturates the actual cause and will be successful in risk prevention and reoccurrence.

During an interview with the nurse manager on 06/21/2011 at 1100 the nurse manager stated, a process was initiated following a complaint investigation on 3/12/11. The complaint related to a delayed response to a ventilator alarm. The process implemented in March 2011 specifies:
The Monitor Technician will document the escalating call in a log titled Nurse Notification of Significant Change. The only time a monitor can be removed from a patient is with a physician ' s order.

The problem identified in the example offered by the nurse manager indicates staff delayed in their response to a ventilator alarm. The preventive measures to stop the reoccurrence of staff delay in response to an alarm is documenting escalating call in a log and when to remove a monitor from a patient. These measures do not saturate the problem identified. This is supportive evidence that the facility fails to implement appropriate preventive measures aimed at impacting actual cause of poor and unacceptable staff behavior (delay in response to patient care alarms).

On 06/21/2011 at 1420 hours during a telephone interview with the Monitoring Technician (MT#2), who was involved in the 5/12/11 incident , the Technician stated she noticed the leads were off because she got a straight line on the monitor. She looked for the nurse from the door of the monitoring room. She did not see the nurse. Upon inquiry the MT stated she is unsure of the exact time that elapsed, but stated a few minutes later she saw the nurse at the desk. She went over to the nurse and informed her that the patient ' s leads were off. The MT stated, I think the nurse told me I am going into the room. The MT further stated that she (the monitor tech) was not worried and did not consider the straight line (flat line on the scope) as a rhythm change.

The interview revealed the technician who saw a straight line on the monitor; in order to look for the nurse from the door of the Monitoring Room, she would have to leave the Telemetry scope monitoring other patients (# ). This was done rather than using the phone to call the nurse as per policy and protocol.
The desk at which the monitor technician saw the nurse is outside the monitoring room and cannot be seen from inside the monitoring room, vision of the nurse's desk requires leaving the telemetry monitoring scope. When the monitoring technician specifies, she "went over to the nurse and informed her that the patient's leads were off", this indicates leaving the monitoring room and the patients telemetry monitors unattended.

I asked the monitor technician how could she be sure it was not Asystole (absence of cardiac rhythm /without cardiac conductivity) versus the leads being off, the MT replied because the monitor screen was showing " Leads Off " and it would say asystole. The MT stated she did not follow the Algorithm titled Notification/Communication of Lethal Rhythm Changes, (see details of the Algorithm protocol above). It is verified, the MT did not notify any staff member as required. The MT stated she did not follow the policy.
In this situation staff unacceptable behavior is failure to follow policy.

At the time of the survey the facility managers were unable to provide supportive evidence of the incorporation of the indicator of staff failure to follow protocols and policy in the Quality Improvement Program, nor are there measure designed and implemented that address the identified staff failures and speaks to how the facility will include measures for staff and patient feedback and staff learning throughout the hospital. While education inservices were provided to staff, the facility does not have measures in place to collect data regarding staff feedback and learning.
The facility measures implemented to prevent repeat occurrences does not establish risk prevention measures to prevent or manage staff failure to follow protocols. The Quality Assurance indicators for the facility measures remains, as they were prior to the identification of the issue of staff failing to respond to patient equipment alarms and policy, based on national safety goals assessing: Blood stream infections, restraints, pain management, ventilator related pneumonia, wounds and customer service described by the CEO as related to response to patient call Bells.