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Based on observation, interview and record review, the hospital failed to provide nursing services that were organized and provided for the supervison of patient care when five of 30 sampled patients (Patients 15, 16, 17, 18 and 30) who had need of continuous monitoring of their vital signs, had telemetry monitoring alarms (a device worn to continuously monitor for arrhythmias, abnormal electrical heart rhythms which can result in the heart stopping) silenced for a three to 16-day period without a physician's order or nursing staff's awareness.

An Immediate Jeopardy (IJ) situation was identified and the hospital's administrator was notified on 6/12/23 at 5:02 p.m. The hospital submitted an acceptable Plan of Action on 6/13/23 at 2:00 p.m. and the IJ situation was removed.

This systemic failure resulted in the hospitals inability to ensure safe health care was being provided as required by the Nursing Service Condition Of Participation (refer to A-0395).


















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Based on observation, interview and record review, the hospital failed to supervise and evaluate the nursing care of five of 30 sampled patients (Patients 15, 16, 17, 18 and 30) who had need of continuous monitoring of their vital signs, had telemetry monitoring alarms (a device worn to continuously monitor for arrhythmias, abnormal electrical heart rhythms which can result in the heart stopping) silenced for a three to 16-day period without a physician's order or nursing staff's awareness.

This failure had the potential to result in delayed recognition of abnormal heart rhythms resulting in death or disability.

An Immediate Jeopardy (IJ) situation was identified and the hospital's administrator was notified on 6/12/23, at 5:02 p.m. The hospital submitted an acceptable Plan of Action on 6/13/23, at 2:00 p.m. and the IJ situation was removed.


Findings:

During a review of Patient 15's History and Physical assessment (H&P), dated 6/9/23, indicated Patient 15 was admitted to the hospital's medical/surgical unit with a diagnosis of atrial fibrillation with rapid ventricular response (a-fib/RVR, abnormal heart rhythm that causes a high heart rate).

Review of Patient 15's physician's order indicated an order for "Cardiac Monitoring (order for telemetry)," dated 6/9/23. Further review of the physician's order showed there were no instructions to disable Patient 15's telemetry alarm.

During a review of Patient 16's H&P, dated 6/4/23, indicated Patient 16 was admitted to the hospital's medical/surgical unit with a diagnosis of congestive heart failure (reduced heart output due to congestion in the vascular system).

Review of Patient 16's physician's orders indicated an order for "Cardiac Monitoring," dated 6/5/23. Further review of the physician's order showed there were no instructions to disable Patient 16's telemetry alarm.

During a review of Patient 17's H&P, dated 6/6/23, indicated Patient 17 was admitted to the hospital's medical/surgical unit, on 6/6/23, for post-surgical telemetry monitoring. Continued review of Patient 17's H&P indicated Patient 17 had surgery on 6/6/23 and "PVC and ventricular tachycardia (PVC, premature ventricular contraction, abnormal heartbeat; ventricular tachycardia, life threatening high heart rate)" was observed during the surgery.
Review of Patient 17's physician's orders dated on 6/6/23 indicated an order for "Cardiac Monitoring". Further review of the physician's order showed there were no instructions to disable Patient 17's telemetry alarm.

During a review of Patient 18's H&P, dated 5/16/23, indicated Patient 1, had a diagnosis of "Upper GI Bleed (bleeding in the stomach)," and was admitted to the Intensive Care Unit (ICU) on 5/16/23 due to blood loss.

Review of Patient 18's physician's orders indicated an order for "Cardiac Monitoring," dated 5/16/23. Further review of Patient 18's physician's order showed there were no instructions to disable Patient 18's telemetry alarm.

During a review of Patient 30's H&P, dated 5/22/23, indicated Patient 30 was admitted to the Intensive Care Unit (ICU) for a Pontine hemorrhage (bleeding in the brain).

Review of Patient 30's physician's orders indicated an order for "Cardiac Monitoring," dated 5/22/23. Further review of the physician's order showed there were no instructions to disable Patient 30's telemetry alarm

By observation on 6/12/23 at 11:30 a.m., Monitoring Technician 1 (MT-1), MT-1 was in the "Central Monitoring Room" monitoring patient telemetry for the hospital. The central monitoring room had two telemetry patient monitoring stations and two monitoring technicians were present. By continued observation, there were five patients observed to have their Electrocardiogram (ECG) alarms off on the monitoring screen.

In an interview on 6/12/23 at 11:30 a.m., MT-1 stated "Some ECG alarms are off" indicating certain arrhythmia alarms were turned off for Patients 15, 16, 17, 18 and 30. MT-1 stated, the "multi-form PVC" alarms were turned off for Patients 16, 17, 18 and 30 while the "a-fib/RVR" alarm was disabled for Patient 15. MT-1 continued by stating when alarms were disabled, there would be no visual or audio indication of those arrhythmias for telemetry monitoring stations in the monitoring room and at the nurses' station. MT-1 further stated the alarms were disabled according to nursing instruction, and the monitoring technician had not checked for a physician's order before the alarms were disabled.

During an interview on 6/12/23 at 11:45 a.m. with Registered Nurse 1 (RN 1), RN 1 stated she was not aware of disabled telemetry alarms for and did not instruct monitoring technicians to turn off the alarms for the shift.

During a review of facility's telemetry monitoring report, titled, "Patient Rooms identified with Multi.Form.PVC Alarms disabled", dated 6/15/23, showed the following:

1. Patient 18 had a "multi-form PVC" alarm disabled on 5/27/23 and the alarm had been disabled for 16 days.
2. Patient 30 had a "multi-form PVC" alarm disabled on 5/27/23 and the alarm had been disabled for 16 days.
3. Patient 16's "multi-form PVC" alarm was disabled on 6/6/23, and remained disabled for five days.
4. Patient 17's "multi-form PVC" alarm was disabled on 6/9/23, and was disabled for three days.

In an interview on 6/12/23 at 11:35 a.m., with ICU Manager (UM), UM stated the hospital nurses were expected to obtain a physician's order to modify all telemetry settings before instructing monitoring technicians to initiate the changes.

Review of hospital's policy and procedure (P&P), titled "Remote Monitoring of Patients," dated 4/21/21, indicated "Cardiac Telemetry monitoring is used to alert nursing to serious arrhythmias that require immediate assessment and intervention." The P&P further indicated the, "alarm limits will be set according to notification parameters written in physician orders" and the "RN is expected to communicate notification parameters to the Monitor Technician".

Review of the hospital's P&P, titled, "Clinical Alarm Management Policy," dated 3/16/23, indicated the "RN and licensed clinicians will assess the patient and alarmed equipment at the start of each shift to ensure appropriate parameters and alarm levels are in place based on ...medical orders."