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Based on interview and record review, the facility failed to ensure the facility's policy and procedure (P&P) was implemented within the facility when:

1. Patients 28 and 29 were not provided a Chlorhexidine Gluconate bath (CHG, bathing product that kills germs and reduces the spread of infection in hospitals).

2. For Patient 29, the facility did not report suspected neglect when Patient 29 was found with multiple wounds on admission including pressure injuries Stage three (full thickness tissue loss).

3. Patient 29 was not evaluated by a case manager and social services did not follow up.

4. For Patient 16, the facility did not administer a blood pressure medication when the patient met parameters.

5. For Patient 11, the facility did not report two critical blood pressures readings in a timely manner.

6. For Patients 1, 2, 4, 5, 9, 10, 24, and 31 the facility did not review, sign and/or place the telemetry strips in the physical chart on the unit.

7. For Patient 19, the facility did not scan the telemetry strips into the hard chart.

8. For Patient 11, the facility did not administer pain medication when Patient 11 was on comfort care with pain level of 6/10.

9. For Patient 5, the facility did not remove a home medication from Patient 5's bedside table.

10. For Patients 8 and 19, the facility did not report an adverse event when Patients 8 and 19 died.

These systemic failures could have resulted in a delay of care, infection and or death.

Findings:

1. The following records were reviewed with the Director of Education (DOE) on March 19, 2024, at 9:14 a.m.

a. Patient 28's face sheet and history and physical (H&P), indicated Patient 28 was admitted to the facility on October 17, 2023, for pneumonia (infection in lungs). There was no documented evidence Patient 28 was allergic to Chlorhexidine Gluconate (CHG).

A review of Patient 28's activity of daily (ADL) hygiene (Chlorhexidine Bath Care Completed) flow sheet, dated October 22, 2023, to October 28, 2023, indicated no documented evidence that Patient 28 was provided a CHG bath on October 22, 2023, October 23, 2023, October 24, 2023, October 25, 2023, October 26, 2023, October 27, 2023, and October 28, 2023.

A review of Patient 28's Body Systems Assessment II (two) Genitourinary flow sheet, dated October 22, 2023, at 12:48 p.m., indicated a foley catheter was placed with urine output of 60 ml (milliliters-unit of measurement).

An interview and record review were conducted with the Infection Prevention Coordinator (IPC) on March 19, 2024, at 11:37 a.m. The IPC stated the nurse should have done a CHG bath daily per facility policy.

An interview and record review were conducted with the DOE on March 19, 2024, at 11:39 a.m. The DOE stated for the above dates there were no documented evidence that the patient was given a CHG bath.

b. The following records for Patient 29 were reviewed with the Manager of Medical Surgical Telemetry (MMST) on March 21, 2024, at 2:50 p.m. Patient 29's face sheet and H&P, indicated Patient 29 was admitted to the facility on January 9, 2024, for slurred speech, rule out CVA (Cardiovascular Accident). There was no documented evidence Patient 29 was allergic to Chlorhexidine Gluconate.

A review of Patient 29's activity of daily (ADL) hygiene (Chlorhexidine Bath Care Completed) flow sheet, dated January 16, 2024, to January 18, 2024, indicated no documented evidence Patient 29 was provided a CHG bath on January 16, 2024, January 17, 2024, and January 18, 2024.

A review of Patient 29's Body Systems Assessment II (two) Genitourinary flow sheet, dated January 16, 2024, at 11:00 a.m., indicated a foley catheter was placed with urine output of 40 mls.

An interview and record review were conducted with the MMST on March 21, 2024, at 4:13 p.m. The MMST stated there is no documented evidence that Patient 29 received an CHG bath on the days listed above.

A review of the facility's (P&P) titled, "Infection Prevention and Control Plan," dated March 2023, indicated, "...Process Review: Prevalence studies to include line necessity, dressings, tubing, CHG dressing/device, scrub-the-hub and daily CHG bathing in non-critical care units, every shift CHG bathing for critical care units..."

2. The following records were reviewed with the MMST on March 21, 2024, at 3:14 p.m.
Patient 29's face sheet and H&P, indicated Patient 29 was admitted to the facility on January 9, 2024, for Slurred speech, rule out CVA, Severe Sepsis (life threatening emergency when your body's response to an infection), Bilateral (relating to two sides) lower extremity infected calciphylaxis (calcium accumulates in small blood vessels of the fat and skin tissues), Peripheral Artery Disease (a circulation condition), Non-ST elevation Myocardial Infarction (a type of heart attack that happens when your heart's need for oxygen can't be met), End Stage Renal Failure, peritoneal dialysis (filters waste for advanced kidney failure).

A facility document titled, "Abuse/Neglect Assessment," dated January 9, 2024, was reviewed. The document indicated, "...Abuse Neglect Assessment...Abuse and Neglect Types: None..."

The facility document titled, "Wound Care Note," dated January 12, 2024, at 4:39 p.m., was reviewed. The document indicated, "...Bilateral Lower Extremities Atypical Wounds: Bilateral lower extremities are noted with poorly defined, open wound beds exposing pink moist tissue with scattered white fibrous tissue and wet tan/brown/grey/black necrotic tissue extending from the calf to the ankle...Moderate green drainage with foul odor ...Right Posterior Upper Arm Atypical Wound: Suspected bulbous lesion...Bilateral Coccyx Pressure Injuries Stage 3 (POA) present on admission..."

An interview and record review were conducted with the Manager of Case Management (MCM), on March 21, 2024, at 4:46 p.m. The MCM stated, "looking at the pictures presented to me, yes this should have been reported to APS".

An interview and record review that included the wound photos were conducted with the Academy of Certified Social Worker (ACSW), on March 21, 2024, at 4:49 p.m. The ACSW stated if this patient came from home with these wounds this should have been reported.

An interview and record review were conducted with the Emergency Department Director (EDD) and the Emergency Department Manager (EDM), on March 21, 2024, at 5:24 p.m. The EDD stated the expectation would be for all staff to report an allegation of abuse or neglect. The EDD further stated this was not reported to APS.

There was no documented evidence that any mandated reporters including nurses, physicians, social workers, case managers, reported to the appropriate Chain of Command, hospital administration and APS immediately for possible abuse/neglect for Patient 29, who was a Dependent Adult.

The facility P&P titled, "Reporting Abuse Neglect Allegations policy 0648," dated March 2024, was reviewed. The document indicated, "...Neglect (A form of abuse): The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...Policy: It is the policy and the responsibility of (Name of the facility) to report all allegations of abuse/neglect appropriately. All employees of (Name of facility) shall adhere to the standards set forth in this policy directive. If an employee observes, abuse, mental abuse, or neglect has occurred; the employee shall escalate reporting of the allegations to the appropriate Chain of Command and to hospital administration immediately...If appropriate, provide notification to Social Services for follow-up, assessment, and potential APS/CPS reporting..."

The P&P titled, "Recognizing and Reporting Elder Abuse Neglect 1525," dated March 2020, was reviewed. The document indicated, "...The law specifies that all mandated reporters including nurses, physicians, non-medical practitioners, psychiatrists, psychologists, social workers, marriage and family therapists (MFT's), residents, interns, and any other person currently licensed under the Business and Professional capacity or within the scope of his or her employment...Elder abuse should be reported if an observation is made that an elder or dependent adult has sustained physical injuries, which appear to have been inflicted upon him/her by other than accidental means by any person. Additional forms of Elder Abuse can include abandonment, abduction, deprivation, financial abuse, isolation, neglect/self-neglect..."

3. The following records were reviewed with the MMST on March 21, 2024, at 4:20 p.m.

The facility document titled, "Discharge Planning Assessment," dated January 10, 2024, at 3:54 p.m., was reviewed. The document was authored by social worker (SW), the document indicated, "...Pt confirmed residing in a mobile home which has both stairs and a ramp for entry, w/ [with] his wife, [name of wife and phone number], who pt [patient] stated is having increased difficulty managing his care needs at home. He is w/chair [wheelchair] dependent and needs assistance transferring in and out of w/chair to the toilet and recliner...Will try to reach pt's [patients] wife for more details and inquire re: [regarding] community resource needs..."

The facility document titled, "Consult to Case Management," dated January 11, 2024, at 7:59 a.m. was reviewed.

An interview and record review were conducted with MMST, on March 21, 2024, at 4:28 p.m. The MMST stated I cannot find a case management evaluation.

An interview and record review were conducted with the MCM, on March 21, 2024, at 4:50 p.m. The MCM stated, "I do not see a case management evaluation, this should be done 24 hours to 48 hours of admission, then a reassessment should have been done every five days".

There was no documented evidence that a Case Manager evaluated Patient 29 per medical doctor (MD) order during his hospitalization.

There was no documented evidence that the SW followed up with Patient 29 within five days per policy.

The P&P titled, "Discharge Planning and Social Services Needs- D01," dated November 2023, was reviewed. The documented indicated, "...All patients admitted to inpatient services will be evaluated by Case Management within one working day of admission to determine continuum of care needs and availability of community resources ...patient will be evaluated for Social Service interventions...Reporting to various abuse agencies...Adult Protective Services...All inpatient are screened for discharge needs and social issues by case managers or the social worker within one working day. High risk patients are interviewed and must have a documented discharge plan or social service notes in the medical record prior to discharge...Patient are reassessed every five days for appropriateness of the discharge plan, further social service needs, after being transferred to another unit, or when there is a change in condition..."

4. On March 19, 2024, at 9:30 a.m., a concurrent interview and record review were conducted with the Director of Medical Surgical/Telemetry (DMST) for Patient 16. Patient 16 was admitted on March 12, 2024, for atrial fibrillation with rapid ventricular response (a type of arrythmia, or abnormal heartbeat caused by rapid contractions of the atria [a chamber in the heart] that causes the heart to beat quickly).

A review of Patient 16's vital signs dated March 16, 2024, indicated Patient 16's blood pressure at 6 a.m. was 172/68. The document further indicated Patient 16's blood pressure at 5 p.m. was 188/83. There was no documented evidence Patient 16 was given a PRN (as needed) blood pressure medication per physician orders. The DMST stated the Registered Nurse (RN) should have given the PRN medication as ordered by the physician.

The facility document titled, "ORDER SHEET," dated March 14, 2024, at 00:38 (12:38 a.m.) was reviewed. The documented indicated, "...Hydralazine 20 mg/ML vial...10 mg 0.5 ml [milliliter-unit of measurement], IV [intravenous] Push, q4h [every four hours] PRN...Comment FOR SBP [systolic blood pressure] GREATER THAN 160 mmHg [unit of measurement]."

A review of the P&P titled, "Medication Administration and Monitoring Policy," dated August 2023, was conducted. The P&P indicated, "...To provide guidelines so that medications will be administered in a safe, accurate and consistent manner...Patients will be monitored based on parameters specified in the medication order...Medication will be administered on the established scheduled times or based on patient need..."

5. On March 21, 2024, at 3:20 p.m., a concurrent interview and record review were conducted with MST and CNM. Patient 11 was admitted on February 1, 2024, for gastrointestinal hemorrhage and hypertension (elevated blood pressure).

A review of Patient 11's vital signs flow sheet, dated February 4, 2024, at 7:30 a.m., indicated, "...a blood pressure of 187/94..." The high blood pressure was reported to the physician at 9:47 a.m.

A concurrent interview was conducted with MST at 4:25 p.m. The MST stated the nurse reported the lab values but reported it late. The RN should have reported the high blood pressure to the physician within 30 minutes.

A review of Patient 11's vitals sign flow sheet, dated February 5, 2024, at 4:39 a.m. indicated, "...blood pressure of 189/92..." There was no documented evidence the RN reported the elevated blood pressure to the physician.

A concurrent interview was conducted with the MST at 4:27 p.m. The MST stated the RN did not report the high blood pressure to the physician. She further stated the RN should have reported the high blood pressure within 30 minutes.

A review of the untitled document dated February 1, 2024, at 5:48 a.m., indicated "...hydrALAZINE...10 mg, 0.5 mL...Dose 10 mg...0.5 mL...IV push...Frequency q4 [every 4 hours] ...PRN [as needed] ...Reason...Blood Pressure...Comment FOR SBP GREATER THAN 160 mmHg [unit of measurement] ..."

A review of the P&P titled, "Critical Values and Abnormal Signs Reporting...," dated December 2022, was conducted. The P&P indicated "...Notification to the physician will be done within 30 minutes of receiving the critical result..."

6. For Patients 1, 2, 4, 5, 9, 10, 24, and 31, the facility did not review, sign, and/or place the telemetry strips in the physical chart on the unit.

The following records were reviewed:

For Patient 1, a record review was conducted on March 19, 2024, at 10:10 a.m., with the MMST and Clinical Nutrition Manager (CNM). Patient 1's face sheet, history and physical (H&P), indicated Patient 1 was admitted to the facility on March 17, 2024, for Non-ST elevated myocardial infarction (heart attack).

A review of Patient 1's hard chart on the unit was conducted, the telemetry strips dated March 17, 2024, at 8 a.m., and March 18, 2024, at 4 a.m. were in the chart, not signed.

An interview was conducted with the Nurse Manager (NM) on March 18, 2024, at 10:06 a.m. The NM stated the primary nurse did not sign the telemetry strips as per policy. She stated the primary nurse is responsible for reviewing and signing the telemetry strips every 4 hours per the facility's policy.

For Patient 2, a record review was conducted on March 19, 2024, at 10:10 a.m., with MMST and CNM. Patient 2's face sheet and H&P indicated Patient 2 was admitted to the facility on March 13, 2024, for Urinary Tract Infections (infection in the urinary tract) and Severe Sepsis.

A review of Patient 2's hard chart on the unit was conducted, the telemetry strips dated, March 17, 2024, at 8:00 p.m., March 18, 2024, at 12:00 a.m., and March 18, 2024, at 4:00 a.m. were in the chart not signed.

An interview was conducted with the NM on March 18, 2024, at 10:06 a.m. The NM stated the primary nurse did not sign the telemetry strips per policy. She stated the primary nurse is responsible for reviewing and signing the telemetry strips every four hours per the facility's policy.

For Patient 4, a record review was conducted on March 19, 2024, at 10:35 a.m., with the MMST and CNM. Patient 4's face sheet and H&P indicated Patient 4 was admitted to the facility March 17, 2024, for acute urinary tract infection.

A review of Patient 4's hard chart on the unit was conducted, the telemetry strip for admission on March 17, 2024, at 12:00 a.m., and March 18, 2024, at 4:00 a.m., was not in the chart.

An interview was conducted on March 19, 2024, at 2:20 p.m., with the MMST. The MMST stated when the patient was admitted to the unit on telemetry the nurse should have completed an admission telemetry strip, reviewed, signed, and placed in the hard chart. She further stated the registered nurse did put the 4 a.m., telemetry strip in the chart and it was not signed.

For Patient 5, a record review was conducted on March 19, 2024, at 2:20 p.m., with the MMST and CNM. Patient 5's face sheet and H&P indicated Patient 5 was admitted to the facility on March 13, 2024, for respiratory failure and diabetes (a disorder in which the body cannot control sugar levels).

A review of Patients 5's records were conducted. The telemetry strips for March 13, 2024, at 11:44 p.m., and March 14, 2024, at 3:45 a.m. were dated but not signed by the nurse. The telemetry strips for March 18, 2024, 8:00 a.m., and March 18, 2024, 12:00 p.m., were missing from the patients' chart.

An interview was conducted on March 19, 2024, at 3:05 p.m. with the MMST. The MMST stated the strips for March 18, 2024, 8:00 a.m., and 12:00 p.m., were missing from the patient's chart and the telemetry strips for March 14, 2024, at 3:45 a.m., and March 13, 2024, at 11:44 p.m., were dated but not signed by the nurse. She stated the nurse did not follow the facility's policy for telemetry monitoring, signing telemetry strips and placing the strips in the patient's chart.

For Patient 9, a record review was conducted on March 18, 2024, at 9:59 a.m., with the MMST and CNM. Patient 9's face sheet and H&P indicated Patient 9 was admitted to the facility March 13, 2024, for acute hypoxic respiratory failure (low levels of oxygen in the blood).

A review of Patient 9's hard chart on the unit was conducted. The telemetry strips for March 18, 2024, 12 a.m., and March 18, 2024, 4 a.m., were not placed in the patient's chart.

An interview was conducted with the NM on March 18, 2024, at 10:06 a.m. The NM stated the primary nurse did not sign the telemetry strips as per policy. She stated the primary nurse is responsible for reviewing and signing the telemetry strips every four hours per the facility's policy.

For Patient 10, a recorded review was conducted on March 18, 2024, at 9:59 a.m., with the MMST and CNM. Patient 10's face sheet and H&P indicated Patient 10 was admitted to the facility on March 8, 2024, for wide ventricular depolarization (an irregular heart rhythm).

A review of Patient 10's hard chart on the unit was conducted. The telemetry strips for March 17, 2024, at 4 a.m., and March 18, 2024, at 12 a.m., were in the chart but not signed.

An interview was conducted with the NM on March 18, 2024, at 10:06 a.m. The NM stated the primary nurse did not sign the telemetry strips as per policy. She stated the primary nurse is responsible for reviewing and signing the telemetry strips every four hours per the facility's policy.

For Patient 24, a record review was conducted on March 19, 2024, at 1:37 p.m., with the IPC and the DOE. Patient 24's face sheet and H&P indicated Patient 24 was admitted to the facility March 12, 2024, for congestive heart failure (heart unable to pump blood as well as it should) to the telemetry unit.

A review of Patient 24's hard chart on the unit was conducted. The telemetry strip for March 14, 2024, at 8 a.m., was in the chart but not signed.

An interview and record review were conducted with the DOE on March 20, 2024, at 9:55 a.m. The DOE stated the expectation for the RN would be to review and sign the telemetry strip. The DOE further stated the telemetry strip for March 14, 2024, at 8 a.m., should have been signed by the RN, the strip was not signed.

For Patient 31, a record review was conducted on March 19, 2024, at 10:35 a.m., with the MMST and CNM. Patient 31's face sheet and H&P indicated Patient 31 was admitted to the facility March 10, 2024, for incarcerated ventral hernia (blood supply to the intestine is blocked).

A review of patients 31's hard chart on the unit was conducted. The telemetry strips for March 17, 2024, at 8 p.m., and March 18, 2024, at 12 a.m., were in the chart but not signed.

An interview was conducted with the MMST on March 18, 2024, at 10:35 a.m. The NM stated the nurse did not sign the telemetry strips and placed them in the patient's chart. The NM stated the nurse should have signed each strip and then put them in the chart.

A review of the facility's (P&P) titled, "Telemetry Monitoring Remote", Dated May 2022, was reviewed. The document indicated "...Each Monitor Technician will monitor 30 to 60 monitors and will analyze, run, and input the rhythm...as applicable, into the medical record for every patient, excluding ICU... step down and telemetry level of care, monitor technicians will run the strips and interpret them with initials. Monitor Technicians or Registered Nurses document the rhythm...as applicable, in the electronic medical record the 0800/2000, 1200/0000, and 1600/0400 strips. The strips should be documented and placed in the medical record within 90 minutes of due time. An admission and discharge strip shall be run, interpreted with initials, and documented in electronic medical record. Registered Nurses must sign off strips that are analyzed..."

7. On March 19, 2024, at 9:30 a.m., an interview and concurrent record review of Patient 19 was conducted with the DMST. The "History and Physical," dated February 25, 2024, indicated Patient 19 was admitted to the facility on February 23, 2024, with diagnoses of hypertension, CKD (chronic kidney disease), lower extremity edema (swelling of legs), shortness of breath on exertion and abdominal distention.

On March 19, 2024, at 10:24 a.m., Patient 19's telemetry strips for February 24, 2024, at 12 a.m. to February 25, 2024, at 01:29:10 a.m. were reviewed with the DMST. The DMST stated telemetry strips were printed, reviewed, signed, and placed in the patient's chart by the registered nurse at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.). The following strips were not found in Patient 19's electronic health record:
-February 24, 2024, at 1600 (4 p.m.);
-February 24, 2024, at 2000 (8 p.m.); and
-February 25, 2024, at 0000 (12 a.m.).

On March 21, 2024, at 9 a.m., an interview was conducted with Telemetry Technician (TT) 1. The TT 1 stated telemetry strips are delivered to the unit every four hours, at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.). The TT 1 further stated the RN will review, sign, and place the strips in the patient's chart.

On March 21, 2024, at 9:45 a.m., an interview was conducted with the Charge Nurse (CN) 2. CN 2 stated the registered nurses are expected to review the telemetry strips every four hours that are brought up by the telemetry technicians.

On March 21, 2024, at 10:59 a.m., an interview was conducted with the Charge Nurse (CN) 1. CN 1 stated the telemetry technicians print the patient's telemetry strips every four hours at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.) then deliver the strips to the unit for the registered nurse to review, sign and place in the patient chart.

A review of the policy and procedure (P&P) titled, "Telemetry Monitoring Remote," dated November 2023, was conducted. The P&P indicated, "...To ensure patient safety and to provide a clear process for monitoring of patients on telemetry...The Monitor Technician will alert the patient's nurse of any dysrhythmias. Rhythm strips will be entered in the patients' medical record...Each Monitor Technician will monitor 30-60 monitors and will analyze, run and input the rhythm...as applicable into the medical record for every patient...Rhythm Strips & Documentation - For step down and telemetry level of care, monitor technicians will run the strips and interpret them...Monitor Technicians or Registered Nurses documents the rhythm...in the electronic medical record the 0800/2000, 1200/0000, and 1600/0400..."

8. On March 21, 2024, at 3:20 p.m., a concurrent interview and record review were conducted with MST and CNM. Patient 11 was admitted on February 1, 2024, for gastrointestinal hemorrhage and hypertension (elevated blood pressure).

A review of Patient 11's pain assessment was conducted with the MST and CNM. The document indicated "...February 2, 0224...9 a.m... Pain 6/10..." There was no documented evidence Patient 11 was given pain medication.

A review of the facility untitled document dated February 1, 2024, indicated "...acetaminophen (Tylenol) 650 mg, 2 tabs...oral...q4 hours...pain 1-3/fever..."

A review of the facility untitled document dated February 1, 2024, indicated "...morphine 2 mg, 1 mL...injection IV push...frequency q4...pain 7-10 (severe)..."

On March 21, 2024, at 4:30 p.m., an interview with the MST was conducted. The MST stated Patient 11 should have been given pain medication per the pain scale. She further stated the registered nurse should have followed the medication order.

On March 21, 2024, at 5:25 p.m., an interview with the Director of Pharmacy (DOF) was conducted. The DOF stated by the nurse not giving the medication the doctor ordered would be considered a medication error.

A review of the P&P titled, "Medication Administration and Monitoring Policy," dated August 2023, was conducted. The P&P indicated, "...Medications will be administered on established times or based on patient needs as specified by the ordering LIP (Licensed Independent Practitioner) ..."

9. On March 18, 2024, at 10:53 a.m., an observation and concurrent interview was conducted with MMST. Patient 5 was admitted on February 13, 2024, for respiratory failure with acute hypoxia. One medication was observed on the bedside table. The medication was Albuterol 90 mcg (unit of measurement). A concurrent interview with Patient 5 was conducted. Patient 5 stated he liked to keep it at bedside so he could use it when he felt short of breath. He further stated he used it a few hours ago and the nurses knew he had it at bedside.

On March 18, 2024, at 11 a.m. an interview with the MMST was conducted. The MMST stated the policy of the hospital is that no outside medications are allowed at the bedside. She further stated Patient 5 should not have had the medication at the bedside.

A review of the P&P titled, "Medication Administration and Monitoring Policy," dated August 2023, indicated "...Medications may not be left at the patient's bedside for self-administration...Patient self-administration is not allowed..."

10. On March 19, 2024, at 9:30 a.m., an interview and concurrent record review of Patient 19 was conducted with the DMST. The "History and Physical," dated February 25, 2024, indicated Patient 19 was admitted to the facility on February 23, 2024, with diagnoses of hypertension, CKD, lower extremity edema, shortness of breath on exertion and abdominal distention.

The facility document titled, "Modified Early Warning Score," dated February 24, 2024, at 23:02 (11:02 p.m.) was reviewed. The documented indicated, "...4 (HI)... (score of 3-4 requires extra attention)" The DMST stated a score of 4 was high and indicated the patient met a higher risk to deteriorate.

The facility document titled, "Progress Note-Nurse," dated February 25, 2024, at 00:00 (12 a.m.) was reviewed. The documented indicated, "...Rounded on patient around 0000 d/t elevated MEWs score...Rapid response and code blue was called approximately 1 hour after d/t patient being found unresponsive..."

The facility document titled, "CARDIOPULMONARY RECORD," dated February 25, 2024, was reviewed with the DMST. The document indicated, "...Time of Arrest Noted: 0104 (1:04 a.m.) ...Time of first assisted ventilation: 0105 (1:05 a.m.) ...compressions 0106 (01:06 a.m.) ...Rhythm...0129 (1:29 a.m.) ...code ended...pea (pulseless electrical activity) ..."

The facility document titled, "Progress Note-Nurse," dated February 25, 2024, at 2:57 was reviewed with the DMST. The document indicated, "...0104 (1:04 a.m.) ...Call received from monitor tech patient heart rate dropping to 30's. Was attending to another patient charge Nurse Mary went to the room and found patient not breathing and initiated CPR (cardiopulmonary resuscitation) ...0105 am (1:05 a.m.): Code Blue (patient requiring resuscitation [reviving someone from apparent death]) called and team at bedside..." The DMST stated the telemetry strips were printed when cardiac events or change of rhythm occurred. The telemetry strips for February 25, 2024, prior to code blue were reviewed. There were three pages of strips printed prior to Patient 19 coding. Page 2/3 (2 of 3) documented February 24, 2024, from 01:04:10 (1:04 & 10 seconds) to February 24, 2024, at 01:05:00 (1:05 a.m.), page 3/3 (3 of 3) documented February 24, 2024, at 01:05:10 (1:05 & 10 seconds) to February 24, 2024, at 01:05:40 (1:05 & 40 seconds a.m.). There was no documented evidence of Patient 19's cardiac rate decline prior to 1:04 and 10 seconds a.m. Page 1/3 (1 of 3) was not scanned into Patient 19's medical record. The DMST stated pages 1/3 were not scanned and could not be recovered.

On March 20, 2024, at 3:03 p.m., an interview was conducted with the DMST. The DMST stated the telemetry monitor technician logs for February 24, 2024, through February 25, 2024, have not been found. The DMST stated any time a patient is not a DNR (do not resuscitate) the death would be considered unexpected. The DMST further stated any death not expected would be reviewed by the unit director. The DMST further stated a root cause analysis (RCA) was not completed for Patient 19.

On March 21, 2024, at 12:05 p.m., an interview was conducted with the Director of Quality (DOQ) and the Chief Nursing Officer (CNO). The DOQ stated there was no root cause analysis completed for Patient 19. The DOQ stated no telemetry log was available because they were discarded after a few days. She further stated the logs that were in place prior to March 2024, only had information of when the patient was off telemetry or when the patient was moved to another room or went off the floor. The CNO stated an event review would have been beneficial, but it was not done. She further stated it should have been done after Patient 19 died to see if there was a trend that was missed.

On March 20, 2024, at 1 p.m., a record review and concurrent interview of Patient 8's medical record was conducted with MST and CNM. The "History and Physical," dated February 17, 2024, indicated Patient 8 was admitted to the facility February 17, 2024, with diagnoses of newly placed pacemaker, hypertension, and abdomen pain.

On March 21, 2024, at 10:24 a.m., Patient 8's telemetry strips for February 20, 2024, at 12:56 p.m. to February 20, 2024, at 13:41 (1:41 p.m.) were reviewed with the MST. The strips indicated Patient 8 was off telemetry from 12:56 a.m. to 1:10 pm. Strips indicated on February 20, 2024, at 12:56 pm PT OFF TELE and on February 20, 2024, at 13:10 (1:10 pm) note on strip "PT PUT BACK ON TELE" and on February 20, 2024, at 13:41 (1:41 pm) HR 0.

The Facility Document titled "CARDIOPULMONARY RECORD" dated February 20, 2024, was reviewed with MST. The document indicated, "...Time Arrest Noted 1310...Breathing Assisted...Time of first assisted ventilation 1318 ...Intubation time 1318 ...1311 ...Breathing Assisted ...Pulse ...Compressions ...Rhythm ...Asystole ...Epinephrine ...1314 ...VTACH ... 1317 ...PEA ...1329 ...Breathing ...Assisted ...Blood Pressure 136/75 ...Rhythm ST ...1334 ...Rhythm Asystole ...1335 ...Rhythm Asystole ..."

The Facility Document titled "[Facility Name] Expiration Record" dated February 20, 2024, was reviewed with the MST. The document indicated, "...Notification of Death...Date/Time Death 0220/24 13:55 ...Pronounced By... [Name of Physician] ...Autopsy...No..."

The facility Document titled "Progress Note-Nurse" dated February 20, 2024, at 1830 (6:30 p.m.) was reviewed with the MST. The document indicated, "...@1240 primary RN left the room...patient was complaining about left neck pain and LLE [left Lowe extremity] pain...@1256...tele monitor record, the monitor was off from the patient ...RN or charge nurse did not receive phone call or notification from telemetry...@1305...w

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented for two of 31 sampled patients (Patients 8 and 19), when:

1. Patient 8 was not continuously monitored on the telemetry and not recognizing and reporting cardiac changes.

This failure resulted in a delay of treatment for Patient 8 and could have contributed to Patient 8's death.

2. Patient 19 had multiple episodes of low heart rate which were not addressed.

This failure resulted in the delay of treatment for Patient 19 and could have contributed to patient 19's death.

Findings:

1. On March 20, 2024, at 1 p.m., a record review and concurrent interview was conducted with the Medical/Surgical/Telemetry Registered Nurse (MST) and the Charge Nurse Manager (CNM). The facility document titled, "History and Physical," dated February 17, 2024, indicated Patient 8 was admitted to the facility February 17, 2024, with diagnoses of newly placed pacemaker (regulate heart rate and rhythm), hypertension (high blood pressure) and abdomen pain.

On March 21, 2024, at 10:24 a.m., Patient 8's telemetry strips for February 20, 2024, at 12:56 p.m. to February 20, 2024, at 13:41 (1:41 p.m.) were reviewed with the MST. The strips indicated Patient 8 was from telemetry from 12:56 a.m. to 1:10 pm. Strips indicated on February 20, 2024, at 12:56 pm, "PT [patient] OFF TELE" and on February 20, 2024, at 13:10 (1:10 pm) note on strip, "PT [patient] PUT BACK ON TELE" and on February 20, 2024, at 13:41 (1:41 pm) HR (heart rate) 0.

The facility Document titled "CARDIOPULMONARY RECORD," dated February 20, 2024, was reviewed with the MST. The document indicated, "...Time Arrest [heart stopped pumping] Noted 1310 ...Breathing Assisted ...Time of first assisted ventilation [breathing] 1318 ...Intubation [tube for breathing] time 1318 ...1311 ...Breathing Assisted ...Pulse ...Compressions ...Rhythm ...Asystole [heart stopped pumping] ...Epinephrine ...1314 ...VTACH [irregular heart beat] ... 1317 ...PEA[pulseless electrical activity] ...1329 ...Breathing ...Assisted ...Blood Pressure 136/75 ...Rhythm ST ...1334 ...Rhythm Asystole ...1335 ...Rhythm Asystole ..."

The facility Document titled "[Facility Name] Expiration Record" dated February 20, 2024, was reviewed with the MST. The document indicated, "...Notification of Death...Date/Time Death 0220/24 13:55...Pronounced By... [Medical Physician Name] ...Autopsy...No..."

The facility Document titled "Progress Note-Nurse," dated February 20, 2024, at 1830 (6:30 p.m.) was reviewed with the MST. The document indicated, "...1240 primary RN [Registered Nurse] left the room...patient was complaining about left neck pain and LLE [left lower extremity] pain...@1256...tele monitor record, the monitor was off from the patient...RN or charge nurse did not receive phone call or notification from telemetry...1305 [1:05 p.m.]...went in to room because family noticed something was wrong...patient was barely responding...1308 [1:08 p.m.] Called code rapid...1310 [1:10 p.m.] called code blue...1335 [1:35 p.m.] daughter asked to stop chest compressions...declared of patient's decease..."

On March 20, 2024, at 2:19 p.m., an interview was conducted with the Telemetry Technician (TT) 2. TT 2 stated they are responsible for watching 60 or more patients at a time. The TT 2 stated she just finished printing the 12 p.m. strips and was documenting the information in the computer. The TT 2 stated it can take an hour to an hour and a half to print and put in the computer. The TT 2 stated she was distracted while doing the strips and probably did not notice Patient 8 was off when she glanced over at the monitors. The TT 2 stated while putting the information in the computer she glances over at the screens every few minutes to make sure no one is off. The TT 2 stated she did not call the nurse or call a rapid for Patient 8.

On March 21, 2024, at 9:30 a.m., an interview was conducted with the Manager of Med/Surg/Tele (MOMST). The MOMST stated the nurse was at the bed side and Patient 8 was restless and wanting to be turned. The MOMST stated Patient 8's leads were off as noted on the strip.

2. On March 19, 2024, at 9:30 a.m., an interview and concurrent record review of Patient 19 was conducted with the Director of Med/Surge/Tele (DMST). The "History and Physical," dated February 25, 2024, indicated Patient 19 was admitted to the facility on February 23, 2024, with diagnoses of hypertension, CKD (chronic kidney disease), lower extremity edema (swelling of legs), shortness of breath on exertion and abdominal distention.

The facility document titled, "Modified Early Warning Score ([MEWS] -parameters to identify patients at an increased risk of catastrophic deterioration)," dated February 24, 2024, at 23:02 (11:02 p.m.), was reviewed. The documented indicated, "...4 (HI)... (score of 3-4 requires extra attention)" The DMST stated a score of four was high and indicated the patient met a higher risk of deterioration.

The facility document titled, "Progress Note-Nurse," dated February 25, 2024, at 00:00 (12 a.m.), was reviewed. The documented indicated, "...Rounded on patient around 0000 [12 a.m.] d/t [due to] elevated MEWs score...Rapid response and code blue (patient requiring resuscitation [reviving someone from apparent death]) was called approximately 1 [one] hour after d/t patient being found unresponsive..."

On March 19, 2024, at 10:24 a.m., Patient 19's telemetry strips for February 24, 2024, at 12 a.m. to February 25, 2024, at 01:29:10 a.m., were reviewed with the DMST. The DMST stated telemetry strips were printed, reviewed, signed, and placed in the patient's chart by the registered nurse at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.). The following strips were not found in Patient 19's electronic health record:
-February 24, 2024, at 1600 (4 p.m.),
-February 24, 2024, at 2000 (8 p.m.),
-February 25, 2024, at 0000 (12 a.m.).

The facility document titled, "CARDIOPULMONARY RECORD," dated February 25, 2024, was reviewed with the DMST. The document indicated, "...Time of Arrest Noted: 0104 (1:04 a.m.) ...Time of first assisted ventilation(breathing): 0105 (1:05 a.m.) ...compressions 0106 (01:06 a.m.) ...Rhythm...0129 (1:29 a.m.) ...code ended...pea (pulseless electrical activity) ..."

The facility document titled, "Progress Note-Nurse," dated February 25, 2024, at 2:57 a.m., was reviewed with the DMST. The document indicated, "...0104 [1:04 a.m.] ...Call received from monitor tech patient [Patient 19] heart rate dropping to 30's. Was attending to another patient [Charge Nurse Name] went to the room and found patient not breathing and initiated CPR [cardiopulmonary resuscitation] ...0105 am [1:05 a.m.] ...Code Blue [patient requiring resuscitation-reviving someone from apparent death] called and team at bedside..." The DMST stated the telemetry strips were printed when cardiac events or change of rhythm occurred. The telemetry strips for February 25, 2024, prior to code blue were reviewed. There were three pages of strips printed prior to Patient 19 coding. Page 2/3 documented February 24, 2024, from 01:04:10 [1:04 & 10 seconds] to February 24, 2024, at 01:05:00 [1:05 a.m.], page 3/3 documented February 24, 2024, at 01:05:10 [1:05 & 10 seconds] to February 24, 2024, at 01:05:40 [1:05 & 40 seconds a.m.]. There was no documented evidence of Patient 19's cardiac rate decline prior to 1:04 and 10 seconds a.m. Page 1/3 was not scanned into Patient 19's medical record. The DMST stated pages 1/3 were not scanned and could not be recovered.

On March 20, 2024, at 3:03 p.m., an interview was conducted with the DMST. The DMST stated the telemetry monitor technician logs for February 24, 2024, through February 25, 2024, have not been found. The DMST stated any time a patient is not a DNR (do not resuscitate) the death would be considered unexpected. The DMST further stated any death not expected would be reviewed by the unit director. The DMST further stated a root cause analysis (RCA) was not completed for Patient 19.

On March 21, 2024, at 9 a.m., an interview was conducted with Telemetry Technician (TT) 1. TT 1 stated one telemetry technician can be responsible for monitoring up to 60 patients at one time. The TT 1 stated the telemetry monitors are set to show bradycardia (slow heart rate) at 50 beats per minute (BPM) or less. The TT 1 stated the registered nurse is alerted of any sudden changes. The TT 1 stated if a patient's heart rate went from 101 to 30 there was something wrong, there is a gap, the strip page 1/3 should have been printed and placed in the chart. The TT 1 stated the old log was simple, and the TT 1 only logged when the patient was off telemetry and not when cardiac changes were identified. The TT 1 further stated if a patient's rhythm was Atrial Fibrillation (A Fib [irregular heartbeat]) then changed to bradycardia, the RN would be called and if they did not answer the TT would call a rapid response because this event is not normal.

On March 21, 2024, at 9:45 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she received a call but was in an isolation room and did not answer it. She further stated after the phone call she heard the rapid response called overhead for Patient 19. She stated Charge Nurse (CN) 2 responded to the rapid response then called a code blue.

On March 21, 2024, at 10:59 a.m., an interview was conducted with Charge Nurse (CN) 1. CN 1 stated telemetry technician (tele tech) logs prior to March 2024 were vague and only identified when the patient was off telemetry, batteries were low, or when the patient was moved from one room to another. She further stated the log did not identify any patient cardiac changes. CN 1 stated the tele tech logs were discarded after a few days.

On March 21, 2024, at 12:05 p.m., an interview was conducted with the Director of Quality (DOQ) and the Chief Nursing Officer (CNO). The DOQ stated there was no root cause analysis completed for Patient 19. The DOQ stated no telemetry log was available because they were discarded after a few days. She further stated the logs that were in place prior to March 2024, only had information of when the patient was off telemetry or when the patient was moved to another room or went off the floor. The CNO stated an event review would have been beneficial, but it was not done. She further stated it should have been done after Patient 19 died to see if there was a trend that was missed.

A review of the policy and procedure (P&P) titled, "Management of Telemetry Alarms - 1293," dated November 2023, was conducted. The P&P indicated, "...The telemetry monitor technician will monitor and respond to the telemetry monitor alarms for all cardiac monitored inpatient areas...All alarms are considered high risk and the telemetry monitor technician will immediately notify the registered nurse, who must respond immediately...Life-threatening rhythms...the monitor tech will initiate a Code Blue...then document the rhythm and notification on the telemetry band...Non-life-threatening rhythms:...telemetry tech will follow the Tele-escalation process...and document rhythm and notification on the telemetry band..."

A review of the policy and procedure (P&P) titled, "Telemetry Monitoring Remote," dated November 2023, was conducted. The P&P indicated, "...To ensure patient safety and to provide a clear process for monitoring of patients on telemetry...The Monitor Technician will alert the patient's nurse of any dysrhythmias. Rhythm strips will be entered in the patients medical record...Each Monitor Technician will monitor 30-60 monitors and will analyze, run and input the rhythm and HR and PRI, QRS, and QT measurements, as applicable into the medical record for every patient...Rhythm Strips & Documentation - For step down and telemetry level of care, monitor technicians will run the strips and interpret them...Monitor Technicians or Registered Nurses documents the rhythm...in the electronic medical record the 0800/2000, 1200/0000, and 1600/0400 strips...Monitor Technicians will monitor response time of staff in responding to telemetry alarms every shift utilizing the Response Time to Telemetry Alarm Audit Tool...The telemetry technician will follow the Telemetry Escalation Process anytime a patient...a lethal rhythm is identified, and/or alarms warrant notification of the RN..."






Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented for two of 31 sampled patients (Patients 8 and 19), when:

1. Patient 8 was not continuously monitored on the telemetry and not recognizing and reporting cardiac changes.

This failure resulted in a delay of treatment for Patient 8 and could have contributed to Patient 8's death.

2. Patient 19 had multiple episodes of low heart rate which were not addressed.

This failure resulted in the delay of treatment for Patient 19 and could have contributed to patient 19's death.

1. On March 20, 2024, at 1 p.m. a record review and concurrent interview was conducted with the MST and CNM. The facility document titled, "History and Physical," dated February 17, 2024, indicated Patient 8 was admitted to the facility February 17, 2024, with diagnoses of newly placed pacemaker (regulate heart rate and rhythm), hypertension (high blood pressure) and abdomen pain.

On March 21, 2024, at 10:24 a.m., Patient 8's telemetry strips for February 20, 2024, at 12:56 p.m. to February 20, 2024, at 13:41 (1:41 p.m.) were reviewed with the MST. The strips indicated Patient 8 was off of telemetry from 12:56 a.m. to 1:10 pm. Strips indicated on February 20, 2024, at 12:56 pm, "PT [patient] OFF TELE" and on February 20, 2024, at 13:10 (1:10 pm) note on strip, "PT [patient] PUT BACK ON TELE" and on February 20, 2024, at 13:41 (1:41 pm) HR (heart rate) 0.

The Facility Document titled "CARDIOPULMONARY RECORD" dated February 20, 2024, was reviewed with the MST. The document indicated, "...Time Arrest [heart stopped pumping] Noted 1310 ...Breathing Assisted ...Time of first assisted ventilation [breathing] 1318 ...Intubation [tube for breathing] time 1318 ...1311 ...Breathing Assisted ...Pulse ...Compressions ...Rhythm ...Asystole [heart stopped pumping] ...Epinephrine ...1314 ...VTACH [irregular heart beat] ... 1317 ...PEA[pulseless electrical activity] ...1329 ...Breathing ...Assisted ...Blood Pressure 136/75 ...Rhythm ST ...1334 ...Rhythm Asystole ...1335 ...Rhythm Asystole ..."

The Facility Document titled "[Facility Name] Expiration Record" dated February 20, 2024, was reviewed with the MST. The document indicated, "...Notification of Death...Date/Time Death 0220/24 13:55...Pronounced By...[Medical Physician Name]...Autopsy...No..."

The facility Document titled "Progress Note-Nurse" dated February 20, 2024, at 1830 (6:30 p.m.) was reviewed with the MST. The document indicated, "...1240 primary RN left the room...patient was complaining about left neck pain and LLE [left lower extremity] pain...@1256...tele monitor record, the monitor was off from the patient...RN or charge nurse did not receive phone call or notification from telemetry...1305 [1:05 p.m.]...went in to room because family noticed something was wrong...patient was barely responding...1308 [1:08 p.m.] Called code rapid...1310 [1:10 p.m.] called code blue...1335 [1:35 p.m.] daughter asked to stop chest compressions...declared of patient's decease..."

On March 20, 2024, at 2:19 p.m., an interview was conducted with the Telemetry Technician (TT) 2. TT 2 stated they are responsible for watching 60 or more patients at a time. The TT 2 stated she just finished printing the 12 p.m. strips and was documenting the information in the computer. The TT 2 stated it can take an hour to an hour and a half to print and put in the computer. The TT 2 stated she was distracted while doing the strips and probably did not notice Patient 8 was off when she glanced over at the monitors. The TT 2 stated while putting the information in the computer she glances over at the screens every few minutes to make sure no one is off. The TT 2 stated she did not call the nurse or call a rapid for Patient 8.

On March 21, 2024, at 9:30 a.m., an interview was conducted with the Manager of Med/Surg/Tele (MOMST). The MOMST stated the nurse was at the bed side and Patient 8 was restless and wanting to be turned. The MOMST stated Patient 8's leads were off as noted on the strip.

2. On March 19, 2024, at 9:30 a.m., an interview and concurrent record review of Patient 19 was conducted with the Director of Med/Surge/Tele (DMST). The "History and Physical," dated February 25, 2024, indicated Patient 19 was admitted to the facility on February 23, 2024, with diagnoses of hypertension, CKD (chronic kidney disease), lower extremity edema (swelling of legs), shortness of breath on exertion and abdominal distention.

The facility document titled, "Modified Early Warning Score ([MEWS] -parameters to identify patients at an increased risk of catastrophic deterioration)," dated February 24, 2024, at 23:02 (11:02 p.m.), was reviewed. The documented indicated, "...4 (HI)...(score of 3-4 requires extra attention)" The DMST stated a score of four was high and indicated the patient met a higher risk of deterioration.

The facility document titled, "Progress Note-Nurse," dated February 25, 2024, at 00:00 (12 a.m.), was reviewed. The documented indicated, "...Rounded on patient around 0000 [12 a.m.] d/t [due to] elevated MEWs score...Rapid response and code blue (patient requiring resuscitation [reviving someone from apparent death]) was called approximately 1 [one] hour after d/t patient being found unresponsive..."

On March 19, 2024, at 10:24 a.m., Patient 19's telemetry strips for February 24, 2024, at 12 a.m. to February 25, 2024, at 01:29:10 a.m. were reviewed with the DMST. The DMST stated telemetry strips were printed, reviewed, signed, and placed in the patient's chart by the registered nurse at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.). The following strips were not found in Patient 19's electronic health record:
-February 24, 2024, at 1600 (4 p.m.),
-February 24, 2024, at 2000 (8 p.m.),
-February 25, 2024, at 0000 (12 a.m.).

The facility document titled, "CARDIOPULMONARY RECORD," dated February 25, 2024, was reviewed with the DMST. The document indicated, "...Time of Arrest Noted: 0104 (1:04 a.m.)...Time of first assisted ventilation(breathing): 0105 (1:05 a.m.)...compressions 0106 (01:06 a.m.)...Rhythm...0129 (1:29 a.m.)...code ended...pea (pulseless electrical activity)..."

The facility document titled, "Progress Note-Nurse," dated February 25, 2024, at 2:57 a.m., was reviewed with the DMST. The document indicated, "...0104 [1:04 a.m.]...Call received from monitor tech patient [Patient 19] heart rate dropping to 30's. Was attending to another patient [Charge Nurse Name] went to the room and found patient not breathing and initiated CPR [cardiopulmonary resuscitation]...0105 am [1:05 a.m.]...Code Blue [patient requiring resuscitation-reviving someone from apparent death] called and team at bedside..." The DMST stated the telemetry strips were printed when cardiac events or change of rhythm occurred. The telemetry strips for February 25, 2024, prior to code blue were reviewed. There were three pages of strips printed prior to Patient 19 coding. Page 2/3 documented February 24, 2024, from 01:04:10 [1:04 & 10 seconds] to February 24, 2024, at 01:05:00 [1:05 a.m.], page 3/3 documented February 24, 2024, at 01:05:10 [1:05 & 10 seconds] to February 24, 2024, at 01:05:40 [1:05 & 40 seconds a.m.]. There was no documented evidence of Patient 19's cardiac rate decline prior to 1:04 and 10 seconds a.m. Page 1/3 was not scanned into Patient 19's medical record. The DMST stated pages 1/3 were not scanned and could not be recovered.

On March 20, 2024, at 3:03 p.m., an interview was conducted with the DMST. The DMST stated the telemetry monitor technician logs for February 24, 2024, through February 25, 2024, have not been found. The DMST stated any time a patient is not a DNR (do not resuscitate) the death would be considered unexpected. The DMST further stated any death not expected would be reviewed by the unit director. The DMST further stated a root cause analysis (RCA) was not completed for Patient 19.

On March 21, 2024, at 9 a.m., an interview was conducted with Telemetry Technician (TT) 1. TT 1 stated one telemetry technician can be responsible for monitoring up to 60 patients at one time. The TT 1 stated the telemetry monitors are set to show bradycardia (slow heart rate) at 50 beats per minute (BPM) or less. The TT 1 stated the registered nurse is alerted of any sudden changes. The TT 1 stated if a patient's heart rate went from 101 to 30 there was something wrong, there is a gap, the strip page 1/3 should have been printed and placed in the chart. The TT 1 stated the old log was simple, and the TT 1 only logged when the patient was off telemetry and not when cardiac changes were identified. The TT 1 further stated if a patient's rhythm was Atrial Fibrillation (AFib [irregular heart beat]) then changed to bradycardia, the RN would be called and if they did not answer the TT would call a rapid response because this event is not normal.

On March 21, 2024, at 9:45 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she received a call but was in an isolation room and didn't answer it. She further stated after the phone call she heard the rapid response called overhead for Patient 19. She stated Charge Nurse (CN) 2 responded to the rapid response then called a code blue.

On March 21, 2024, at 10:59 a.m., an interview was conducted with Charge Nurse (CN) 1. CN 1 stated telemetry technician (tele tech) logs prior to March 2024 were vague and only identified when the patient was off telemetry, batteries were low, or when the patient was moved from one room to another. She further stated the log did not identify any patient cardiac changes. CN 1 stated the tele tech logs were discarded after a few days.

On March 21, 2024, at 12:05 p.m., an interview was conducted with the Director of Quality (DOQ) and the Chief Nursing Officer (CNO). The DOQ stated there was no root cause analysis completed for Patient 19. The DOQ stated no telemetry log was available because they were discarded after a few days. She further stated the logs that were in place prior to March 2024, only had information of when the patient was off telemetry or when the patient was moved to another room or went off the floor. The CNO stated an event review would have been beneficial, but it was not done. She further stated it should have been done after Patient 19 died to see if there was a trend that was missed.

A review of the policy and procedure (P&P) titled, "Management of Telemetry Alarms - 1293," dated November 2023, was conducted. The P&P indicated, "...The telemetry monitor technician will monitor and respond to the telemetry monitor alarms for all cardiac monitored inpatient areas...All alarms are considered high risk and the telemetry monitor technician will immediately notify the registered nurse, who must respond immediately...Life-threatening rhythms...the monitor tech will initiate a Code Blue...then document the rhythm and notification on the telemetry band...Non-life-threatening rhythms:...telemetry tech will follow the Tele-escalation process...and document rhythm and notification on the telemetry band..."

A review of the policy and procedure (P&P) titled, "Telemetry Monitoring Remote," dated November 2023, was conducted. The P&P indicated, "...To ensure patient safety and to provide a clear process for monitoring of patients on telemetry...The Monitor Technician will alert the patient's nurse of any dysrhythmias. Rhythm strips will be entered in the patients medical record...Each Monitor Technician will monitor 30-60 monitors and will analyze, run and input the rhythm and HR and PRI, QRS, and QT measurements, as applicable into the medical record for every patient...Rhythm Strips & Documentation - For step down and telemetry level of care, monitor technicians will run the strips and interpret them...Monitor Technicians or Registered Nurses documents the rhythm...in the electronic medical record the 0800/2000, 1200/0000, and 1600/0400 strips...Monitor Technicians will monitor response time of staff in responding to telemetry alarms every shift utilizing the Response Time to Telemetry Alarm Audit Tool...The telemetry technician will follow the Telemetry Escalation Process anytime a patient...a lethal rhythm is identified, and/or alarms warrant notification of the RN..."

Based on observation and interview the hospital failed to ensure supplies and equipment were unexpired, clean and ready for use when:

1. Expired supplies were found in a cart in the Operating Room (O.R.) area;

This failure has the potential to result in complications causing patient harm.

2. Unit 2's drain in the nutrition room was found with debris and black/grey build-up.

This failure has the potential for the drain to become a breeding ground for bacteria and germs leading to foul odor and/or health hazards.

Findings:

1. During a tour of the O.R. conducted on March 18, 2024, at 1:22 p.m., with the Director of Surgery (DOS), a supply cart which contained a box of da Vinci Xi (EndoWrist Stapler 45 Reload, count six- stapler used for surgery with smart technology) was observed with an expiration date of September 30, 2023.

An interview was conducted on March 18, 2024, at 1:59 p.m., with the DOS. The DOS verified the expiration date was September 30, 2023 and stated the expired staplers should not have been in the cart, and should have been discarded.

An interview was conducted on March 20, 2024, at 9:00 a.m., with the Director of Supply Chain (DOSC). The DOSC stated the robot cart [da Vinci Xi, EndoWrist Stapler 45 Reload, six count] expired on September 30, 2023. The DOSC further stated the Operating Room Material Coordinator (ORMC) is supposed to check for expiration dates weekly. The ORMC stated if an expired product is found, it is removed, and all expired non-refundable products are discarded. The DOSC stated there is no policy/procedure (P&P) or log for this process at this time.

2. A tour of Unit 2 was conducted on March 18, 2024, at 11:15 a.m., with the Manager Medical Surgical/Telemetry (MMST). The floor drain in the Nutrition Room (T2013) was observed to have dark gray/black colored thick grime and debris in the drain.

An interview was conducted on March 18, 2024, at 11:20 a.m., with the MMST. The MMST stated the drain was dirty and should have been cleaned.

An interview was conducted on March 18, 2024, at 11:20 a.m., with the Director of Plan Operations (DPO). The DPO stated, "I can say that looks pretty bad. Yes, that is pretty dirty." The DPO also stated his department was not responsible for cleaning the drain, they are responsible for snaking the drain when it is plugged. The DPO stated there was no policy for his department to clean the drain.

An interview was conducted on March 18, 2024, at 2:45 p.m., with the Director of Quality (DOQ). The DOQ stated engineering should be the one to clean the drains in the nourishment room. The DOQ further stated that Environmental Services (EVS) should have cleaned the drain as well.

An interview was conducted on March 20, 2024, at 9:11 a.m., with the Director of Environmental Services (DEVS). The DEVS stated he saw the drain with the DPO and it was dirty. The DEVS stated that he was not sure when the drain was last cleaned, but to his knowledge the drain had not been cleaned since he has been at the facility for the last six months. The DEVS stated there was no policy for the drains to be reviewed or cleaned.