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Based on observation, interview and record review, the facility failed to follow its Clinical Alarms Management policy to ensure patient safety during a hospital admission in the Intensive Care Unit (ICU).

This failure resulted in a delayed response to a patient's (Patient 1) potentially life-threatening situation, and potentially contribute to his death.

FINDINGS:

During a review of Patient 1's Electronic Medical Record (EMR), dated 8/25/25, the EMR indicated the patient was admitted to the Intensive Care Unit (ICU) from the Emergency Department (ED) on 8/25/25 at 9:20 p.m., with a diagnosis of significant bradycardia [an abnormally slow resting heart rate less than 60 beats per minute]. EMR indicated medical orders for cardiac monitoring.

During a concurrent interview and record review on 10/14/24 25 at 2:15 p.m., with the ICU Critical Care Manager (CCM), the Philips Cardiac Monitoring Audit Report for Patient 1, dated 8/26/25, was reviewed. The Audit indicated a "Yellow Alarm" for missed heart beats was silenced on 8/26/25 at 1:07:14 a.m. and at 01:32:14 a.m., a "Red Alarm" for low oxygen saturation levels was silenced by a staff nurse at 01:32:43 a.m. CCM stated "Yellow Alarms" indicate a non-life-threatening situation requiring attention as soon as possible and "Red Alarm" indicate potentially life-threatening situations immediate response.

In the same interview with CCM, CCM explained her investigation of the incident. CCM stated she reviewed a video recording of the nursing station during the time of the event. CCM stated the recording showed the Break Nurse silenced a cardiac monitor "Yellow Alarm" for Patient 1 from the nurses' station and remained seated at the nurses' station for 15 minutes. CCM stated the recording showed the "Red Alarm" was silenced by another ICU nurse at the other nurse's station. CCM stated the recording showed this nurse did not leave the nurses' station to visually check the patient.

CCM stated she interviewed the Break Nurse who had silenced the "Yellow Alarm" who said she left the nurses' station to help bathe another patient in a room adjacent to Patient 1's room, remaining there for 30 minutes. CCM stated the Break Nurse acknowledged she did not visually check on the Patient 1 after the "Yellow Alarm" nor did she use the cardiac monitor function to view Patient 1's cardiac data while in the other patient's room. CCM stated she expected the staff nurses to use the cardiac monitor function to view their assigned patient's cardiac data if they are detained in another patients' room.

CCM stated she interviewed the ICU Nurse who had silenced the "Red Alarm". CCM stated he said he had noted the message on the Central Monitor indicated Patient 1's "Leads off," and had assumed the patient was being bathed. CCM this nurse did not respond to the red alarm according to policy by visually checking on the patient after silencing this red alarm.

During the same interview with CCM, the ICU staff nurse break schedule for the 8/25/25 night shift was reviewed. The schedule indicated the Break Nurse was responsible to monitor Patient 1 from 1 a.m. until Primary Nurse returned from her break. CCM stated the Break Nurse did not conduct a visual check of Patient 1 while providing break coverage for Patient 1's Primary Nurse. CCM stated ICU staff discovered Patient 1 had no pulse at 1:55 a.m. and that the alarm for the cardiac monitor was silenced.

During a review of the facility's policy and procedure (P&P) titled, "Clinical Alarms Management", dated 4/3/2025, P&P indicated "Clinician and licensed/unlicensed staff responsibilities include: Providing a timely response to clinical alarms based on alarm priority level; Any employee who hears an alarm will investigate the source of the alarm ... Priority level for Cardiac Monitoring indicates a Red alarm is High priority and response time is immediate with goal of visual check of patient < 2 minutes. A Yellow alarm is moderate priority and response time is rapid with a goal of visual check of patient within 2-5 minutes."