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Based on medical records, policy and procedures, telemetry logs and interviews it was determined that the facility failed to supervise and evaluate the nursing care for each patient with a telemetry monitor in two (#2, #4) of four patients sampled.

Findings include:

1. Review of Patient #2's medical record reveals that on 01/02/2021 at 3:36 AM, A Charge Nurse was doing rounds and went in to take a closer look at Patient #2. A code blue (cardiac arrest) was called. Advanced cardiac life support (ACLS) started; Patient #2 expired at 3:49 AM. Upon further review of Patient #2's medical record, there was no evidence that the telemetry technician notified the nurse of the rhythm change from Atrial fibrillation (Afib) with bundle branch block (BBB) to a life-threatening rhythm requiring immediate notification of change.

2. Review of Patient #4's medical record reveals that on 03/30/2021 at 4:00 AM, a nursing note (late entry) documented a change in patient cardiac rhythm from sinus rhythm (SR)/sinus tachycardia (ST) to Atrial fibrillation (Afib) with Rapid ventricular response (RVR). Further review of the medical record reveals Patient #4 was on a telemetry monitor. Patient heart rate was 130-150 beats per minute (bpm). Patient #4 was transferred to a higher level of care. Extensive review of medical records shows no evidence that the tele technician notified the nurse of a life-threatening change in heart rhythm.

Review of Policy and Procedure title, "Cardiac Telemetry Monitoring"
Revised Date 01/27/2020
...Interpretation of cardiac monitoring is the responsibility of the register nurse. They may delegate this task to personnel who have competed an approved basic arrhythmia interpretation class and have demonstrated competency. However, this does not relinquish the RN responsibility ...Monitoring technicians will be responsible for monitoring cardiac tele, running documentation strips, and communicating to the nurse changes in patient rhythm and when patient are off monitor ...If patient rhythm is not transmitting to the central station the monitor personnel will call for immediate resolution by calling a "Telemetry Alert" to the patient room and bed ...If the patient rhythm is transmitting but a suspected life threatening rhythm is detected the monitoring personnel will immediately call a "code Blue" ... the following arrhythmia alarm MUST be activated at all times: asystole, ventricular tachycardia, ventricular fibrillation, severe bradycardia (HR less than 50), severe tachycardia (HR 150 or greater) ... Monitor technician will immediately call "code blue" of suspected life-threatening arrhythmias. The monitor technician will run continuous strips and record on the event log and await further instruction by the RN .... A change in rhythm or rate ...the monitor tech notify the RN of change in patient's rhythm and print a strip of changed rhythm ...The monitor technician will maintain a daily telemetry event log to record tele event, calls placed to the care team and alerts or codes initiated from the monitoring station ...

Review of the telemetry logs shows no evidence documented of Patient #2 and Patient #4, changes in cardiac rhythm, nor notification of the Registered Nurse. The Telemetry technician failed to immediately notify the Nursing staff of a life-threatening rhythm.

Interview with Risk Manager/Director of Patient Safety confirm the above findings.