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Based on review of facility documents, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure telemetry alarms were working correctly for one of five telemetry medical records reviewed (MR1).


Findings include:


Review on June 5, 2024, at approximatley 2:00 PM, of the facility's "Patient Rights and Responsibilities POL-6602082" dated July 6, 2023, revealed, "... AHN is committed to honoring patient's rights ... Care Deliver: You have the right to: ... Receive kind, respectful, safe, quality care delivered by skilled staff. ... Receive efficient and quality care with high professional standards that are continually maintained and reviewed. ...".



Review on June 5, 2024, at 1:45 PM, of the facility's "RN Registered Nurse" job description revealed, "The Registered Nurse assesses human responses and plans, Implements and evaluates nursing care for individuals or families for whom the nurse is responsible. The Registered Nurse is fully responsible for all actions as a licensed nurse and is accountable to patients for the quality of care. ... Essential Responsiblities: Considers maintenance of a safe environment, patient condition, complexity of the intervention and predictability of the outcome. ..."'.


Review on May 31, 2024, at approximately 1:00 PM, revealed, "November 14, 2019... GE Healthcare safety notice: Telemetry alarms may not sound ... GE Healthcare ... released six potential safety issues with its Apex Pro Telemetry system under certain conditions. ... is out of wireless range, its battery has been depleted or a communication failure between the server and transmitter has taken place, a 'no telem' condition occurs. This condition, along with 'ECG leads fail,' system time changes and system restarts, is related to the potential safety issues, according to the safety notice. ... Patients can experience ECG arrhythmias before and after a 'no telem' condition and may not re-activate after the condition is resolved. Third could result in delayed treatment for the potentially life-threatening ECG arrhythmia event. ...".



Review on May 31, 2024, of a facility document dated May 9, 2024, revealed, " ... Telemetry system completely failed. Staff were unaware that [MR1] was not on the monitor as it was not alarming at the of the event. There was no rhythm appearing on the telemetry monitor. New electrodes and batteries had just been placed in the telemetry pack. Telemetry pack was pulled out of use. Biomed came and took pack and said it was a 'Synthesizer Error.' Biomed to repair Telepak. ... Only this telemetry box and patient were effected by the outage. The patient had come back onto the monitor after the RN Troubleshot the box, batteries were replaced and new electrodes were placed. Staff did not become aware of the new outage when the patient was found unresponsive on the floor. ... 5/7: Telemetry pack was repaired and brought back into services after synthesizer error was cleared. ...".




Review of MR1 on June 4, 2024, at approximatley 12:00 PM, of an "H&P date of service 5/7/2024 12:26 PM" revealed that the patient was admitted to the Emergency department on May 7, 2024 at 11:42, for increased shortness of breath and found to be hypoxic. The patient was unresponsive on May 8, 2024, and a "Code" was started at 03:44:21, compressions and epinephrine was administered, and the patient's cardiac rhythm returned to "Sinus tachycardia". The code ended at 04:09:14. The patient was transferred to the intensive care unit. After the code the family placed the patient on comfort care and MR1 ceased to breath on May 9, 2024, at 14:09.



Review on June 4, 2024, at approximatley 2:00 PM, of a nursing note for MR1, dated May 8, 2024, 4:26 AM, revealed, "... RN was doing hourly rounding around 0310. Pt was in bed, bed alarm on, leads and batteries were changed due to heart monitor saying no telemetry, ... Around 0335, ... pt was found unresponsive in the bathroom with oxygen off. .. Pt was taken to bed, CPR was started and code was called. ...".



The above findings were confirmed by EMP1 on May 31, 2024, between 12:00 and 12:30 PM.

Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined the facility failed to document rhythm strips of monitored patient per facility policy for one of three medical records reviewed (MR7), and failed to document telemetry battery changes of telemetry patients two of three medical records reviewed (MR7 and MR9).


Findings include:


Review on June 5, 2024, at 2:00 PM, revealed a policy, "Bedside Monitoring System Policy #60.3.3.07 POL-5423719", which indicated, "... 1. General Monitoring information. ... Batteries will be changed every 24 hours. ... Documentation of the rhythm strips will be done every 4 hours in critical care units and every 8 hours in other areas. ... An alarm history review is completed by the nurse at the end of every shift. ... For monitored patients, documentation of cardiac rhythm includes strip, patient name, room number, date, time, lead, heart rate, ... QRS duration QT interval ... Quarterly monitoring will be done by Clinical Engineering Department and results will be reported to the Patient Safety Committee. ...".

Review of MR7 on June 7, 2024, at approximatley 11:00 AM, revealed that the patient was admitted to the hospital on May 25, 2024, at 0100. Further reviewed revealed that he patient was transferred to 5 west from the emergency department at 1218, and required stenting to the left anterior descending artery. Continued review revealed that MR7 was placed on the cardiac monitor on May 24, 2024, at 23:00, and that nursing staff failed to document the QT and QRS waves on May 26, 2024, at 7:00 PM, on May 27, at 7:00 PM, and on May 28, 2024, at 2:00 PM.

Review of MR7 on June 5, 2024, at approximately 11:00 AM, revealed no documentation that the telemetry batteries were changed every 24 hours, as per facility policy.

Review of MR9 on June 5, 2024, at approximately 11:30 AM, revealed that the patient was admitted to the hospital on May 28, 2024, at 2:50 PM with a chief complaint of confusion. The patient was admitted and was placed on a telemetry monitor. Further review of MR9 revealed no documentation that the telemetry batteries were changed every 24 hours as per facility policy.

During an interview on June 7, 2024, at 11:45 AM, EMP1 confirmed the above findings. .