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Based on a review of medical records, Bylaws, meeting minutes, facility policy and procedures and staff interviews, it was determined that the Governing Body failed to ensure that adequate numbers of staff continuously monitored and changes in condition were immediately conveyed to nursing staff when one (P#1) of five (5) (P#1, P#2, P#3, P#4, P #5) patients sampled experienced bradycardia (low heart rate) on 12/1/25 beginning at 6:38 a.m. P#1 was found unresponsive and pulseless by staff on 12/01/25 at 6:57 a.m. Resuscitation efforts were unsuccessful, and P#1 was pronounced deceased on 12/01/25 at 7:30 a.m.

Findings included:
A review of the facility ' s " Amended and Restated Bylaws " revealed that the purposes of the corporation included:
a) Establishing and maintaining inpatient beds and clinical programs/services to provide diagnosis and treatment for patients, and associated healthcare facilities, programs, and services for inpatients and outpatients;
b) Undertaking educational activities related to the provision of health care services;
c) Promoting and conducting scientific research related to the provision of health care services; and
d) Participating in other activities designed and undertaken to promote the health status and well-being of the community.

The Board of Directors obligations and responsibilities was subject to the facility ' s Bylaws, the corporation policies and the corporation governance protocols. The Corporation Board directs and oversees the affairs of the Corporation. The obligation of the Corporation Board was to ensure that the resources and capacities of the Corporation were deployed in a manner that promoted community benefit and health status. In order to meet this obligation, the Corporation Board fulfilled two responsibilities:
1. Providing general strategic, managerial, operational, financial, and clinical oversight of the Corporation; and
2. Credentialing (appointing, reappointing, and determining clinical privileges of) members of the corporation ' s medical staff. Such credentialing decisions of the Corporation Board were final and did not require approval of the facility ' s Board.

Quality of Care: The Corporation Board shall, in discharging its ultimate responsibility for the quality of care, assign to the medical staff reasonable authority for ensuring appropriate professional and community standards in the care of patients.

Review of the Medical Executive Committee (MEC) meeting minutes from June 2025 through December 2025 indicated the committee met monthly to discuss medical and clinical affairs of the facility per Bylaws regulations. A further review of the MEC meeting minutes dated 12/11/2025 failed to give evidence that the committee discussed the death of P #1 that took place on 12/01/2025.

Review of the Telemetry and Nursing staffing at the time P #1 was admitted revealed Telemetry was operating with one Tech. There were no concerns about nursing staffing.

Cross refer to A0385 as it relates to the facility's failure to ensure that nursing staff wre notified of a patient's change in condition while on continuous telemetry monitoring.

Based on a review of medical records, facility policy and procedures and staff interviews, it was determined that the facility failed to ensure that patients on cardiac telemetry were continuously monitored and changes in condition were immediately conveyed to nursing staff when one (P#1) of five (5) (P#1, P#2, P#3, P#4, P #5) patients sampled experienced bradycardia (low heart rate) on 12/1/25 beginning at 6:38 a.m. P#1 was found unresponsive and pulseless by staff on 12/01/25 at 6:57 a.m. Resuscitation efforts were unsuccessful and P#1 was pronounced deceased on 12/01/25 at 7:30 a.m.


Findings Included:

Cross refer to A0144 as it pertains to the facility's failure to ensure that patients are cared for in a safe environment.

Based on a review of medical records, facility policy and procedures and staff interviews, it was determined that the facility failed to ensure that patients were cared for in a safe environment while on cardiac telemetry when one (P#1) of five (5) (P#1, P#2, P#3, P#4, P #5) patients sampled experienced bradycardia (low heart rate) on 12/1/25 beginning at 6:38 a.m. and nursing staff were not notified. P#1 was found unresponsive and pulseless by nursing staff on 12/01/25 at 6:57 a.m. Resuscitation efforts were unsuccessful and P#1 was pronounced deceased on 12/01/25 at 7:30 a.m.


Findings Included:

Review of P#1's medical record revealed she was admitted as an inpatient on 11/30/25 at 8:45 a.m. with a diagnosis of congestive heart failure. Physician orders included telemetry monitoring, heart failure protocol and a cardiology consultation.

A review of P #1's flowsheet revealed that on 12/1/25 at 4:26 a.m., P#1's heart rate (HR) was 95 beats per minute (bpm) (normal was 60-100 bpm)


A review of P#1's telemetry strips dated 12/1/25 revealed the following:
6:37:05 HR: 105
6:38:09 HR :46
6:39:03 HR: 49
6:42:19 HR: 40
6:43:00 HR:44
6:45:03 HR: 38
6:46:02 HR: 31
6:47:02 HR: 34
6:48:02 HR: 36
6:49:02 HR: 39
6:51:01 HR: 41
6:52:03 HR: 41
6:53:02 HR: 39
6:54:03 HR: 38
6:55:52 HR: 166
6:57:28 HR: 47


A review of 'Nursing Notes' revealed that on 12/1/25 at 6:55 a.m., RN LL found P#1 unresponsive with no pulse, CPR was started and a code was called. A review of 'Code Documentation' revealed that PA CC responded to a Code Blue for P#1. Continued review revealed that resuscitation efforts following protocol continued for approximately 30 minutes and time of death was called at 7:30 a.m.

A review of the 'Telemetry Surveillance Call Log' for 11/30/25 beginning at 10:00 p.m. failed to reveal an entry that pertained to P#1.

A review of the facility's policy number 17502401 titled "Scope of Care: Piedmont Newton - House Telemetry," lasted revised 3/17/25, revealed that the telemetry operated 24 hours a day, seven days a week. The house telemetry unit was equipped to monitor up to 64 patients on telemetry and 12 patients on intermediate intensive care unit (IMCU) at one time and 10 patients in the intensive care unit (ICU). Skill mix included managers, monitor technicians, registered nurses (RN), licensed practical nurses (LPN), and paramedics. Patient assessment consisted of assist nursing staff who provided care by observation of patient rhythms on telemetry and remote bedside monitoring. It also included observing and reporting changes in rhythm per policy and procedure.

A review of the facility's policy titled, "Nursing Procedure - Telemetry Non-ICU Nursing Areas", no number, effective 9/20/24 revealed the purpose of the procedure was to provide guidelines for telemetry in non-ICU nursing areas. Upon placement of a telemetry order, a requisition was to be printed to notify the monitor tech of a new order. The telemetry box was placed on the patient and the nurse called the monitor tech and verified transmission of the signal, as well as verified and documented the rate, rhythm, and box number in the electronic health record (EHR).

The role and responsibility of the Primary Nurse was to check the electrodes and wires once per shift for stability and firm adherence of the electrodes to the skin and to check the batteries daily and as needed. Every shift on cohorted cardiac units the nurse verified and documented rhythm in the EHR upon admission and then every four hours. For rhythm or rate changes, the primary nurse assessed the patient and documented pertinent findings and notified the physician of the change and any pertinent assessment findings. The primary nurse notified the monitor technician of the patient's transfer to another room, code status changes, removal of telemetry, patient complaints chest discomfort, shortness of breath, palpitations, dizziness, etc., or when the telemetry transmitter dropped on the floor, submerged in water, or was soiled with biohazardous materials.

The role and responsibility of the Monitor Technician (MT) was to cross check the list of patients with telemetry orders with the patients being monitored at the beginning of each shift. Ensured that proper alarm limits were set and always audible. Alarm rate limits were to be set to alarm if heart rate was less than 50 or greater than 120 beats per minute. When pulse oximetry was in place, the low limit was 88%. To reduce false alarms, parameters may be individualized and set based on the clinical presentation of the patient. Before customizing any parameters, verification of clinical condition was made with the primary nurse. The monitor tech analyzed telemetry strips upon initiation of telemetry, once per shift and with rhythm changes. Measurements included heart rate, time intervals, and rhythm interpretation. The MT notified the primary nurse of change in the patient's rhythm, significant change in rate (an increase or decrease of 10% or outside of standard parameters), oxygen saturation less than 90%, or any finding outside of patient-specific alarm settings. The MT notified the primary nurse and STAT Rapid Response Team for lethal and life-threatening arrhythmia. The MT documented each time a nurse was notified. MT logs were reviewed by entity-based process improvement groups on a regular basis. MTs immediately notified the primary nurse or other appropriate staff members of any patient who was unexpectedly not monitored. If the patient remained unmonitored after a maximum of ten minutes the MT notified the nursing supervisor or the unit manager that the patient was not monitored.


An interview with Monitor Technician (MT) DD took place on 12/22/25 at 11:30 a.m. in the telemetry room. MT DD explained his role was to keep his eyes on the monitor at all times. MT DD said there were two Techs in the room monitoring the entire facility, ICU, IMCU, and Med-surg. MT DD said he was to call the patient's primary nurse as soon as something was abnormal with the heart rate. MT DD said he was to call the Charge Nurse within five minutes if the primary nurse did not answer the phone. MT DD explained if the arrythmias was severe enough he was instructed to call a rapid response.

An interview with Charge Nurse JJ took place on 12/22/25 at 1:13 p.m. in the Board Room. RN JJ said she was aware of the case with P#1. RN JJ explained that providers entered orders to have patients placed on telemetry; then the nurse was to place the box on the patient to start the monitoring. RN JJ said once the box was in place, the nurse called telemetry and advised them of the patients information. Charge Nurse JJ explained that the monitor technician's responsibility was to watch everything about the patient's heart rhythms and always monitor the screens. Charge Nurse JJ explained that if the monitor tech noticed something abnormal, the tech was to call the patient's primary nurse to report what they had observed. Charge Nurse JJ said the protocol was for the monitor tech to escalate their observations to the Charge Nurse if they could not get in touch with the primary nurse. If the charge nurse could not be contacted, the monitor tech was to notify the house supervisor and rapid response. Charge Nurse JJ explained that rounds were to be done hourly either by the nurse or a patient care tech.
Charge Nurse JJ said that the telemetry machine alarm went off every time the heart rate went down or up, if the battery was low, and if the leads came off.

An interview with Telemetry Manager HH took place on 12/22/25 at 3:00 p.m. in the Board Room. Manager HH explained that monitor techs monitored all patients that were on telemetry. Manager HH said that techs were to call the patient's nurse, the Charge Nurse, and if necessary, the House Supervisor if the patient was off telemetry for five minutes. Manager HH said that monitor tech could also call a rapid response. Manager HH explained that she had spoken with MT BB regarding P#1.

A phone interview with Monitor Technician (MT) BB took place on 12/23/25 at 12:19 p.m. MT BB said she was the telemetry tech on duty the night P #1 became bradycardiac(low heart rate). MT BB explained that she had been working alone the night of the incident and she was monitoring more than 60 patients that night. . MT BB recalled that were two patients with low heart rate that night, but she said the heart rate was about 50 beats/minute.MT BB said it was towards the end of the shift that P #1's heart rate started to drop. MT BB said when the morning relief (MT DD) came, she asked him to keep an eye on these two patients because their heart rate was low. MT BB said she called RN LL about P#1's heart rate but the nurse did not answer the call.

A phone interview with Registered Nurse (RN) LL took place on 12/23/25 at 5:01 p.m. RN LL said he was assigned as the primary nurse to P #1 on the morning the patient developed the drop in heart rate. RN LL said there was nothing wrong with the patient during the overnight hours. RN LL said he saw and talked to P #1 around 6:10 a.m.- 6:15 a.m. RN LL recalled that he and the oncoming nurse went into P#1's room around 6:45 a.m. to 6:50 a.m. for report/shift change. RN LL said he called the patient a couple of times, but she did not respond. RN LL said when he realized P #1 was unresponsive, he called a code, and the response team arrived. RN LL said he did not receive any call from telemetry during the night about P#1. RN LL explained that all nurses carried a hospital issued cell phone with them when they started shift. RN LL said the monitor techs had all the nurses' numbers and what patients were assigned to a particular nurse.