HospitalInspections.org

Based on review of medical records (MR) and facility documentation, and staff interviews (EMP), it was determined that the facility failed to ensure the patient's right to receive care in a safe setting for one of 20 medical records (MR1).

Findings include:

1. Interview with EMP27, and review of facility documentation revealed, "... 4-16-12 On Easter Sunday, April 8th, when I went to 2NE to work, the monitor tech was sitting in front of the monitors, playing on some sort of game thing. ..."

2. Interview with EMP17, EMP1, and EMP24, and review of facility documentation revealed, "... received April 11 145 pm. ... At no time did I [EMP17] realize that the alarms for [the patient] had not been unsuspended. When the new tech [EMP15] was printing strips, he/she realized a flat line for [the patient] and went in the room to check him/her, this was around 1120 [PM]. ... 4-11-12 1130 AM ... [EMP17] failed to recognize that a pt [patient] was displaying changes in his/her heart rate and rhythm that were critical. ... April 9, 2012 Met with EMP17 at 3pm with EMP24. ... He/She admitted he/she had his/her ipad out for a short time. ..."

3. Review of MR1 revealed a Discharge Summary, dictated April 11, 2012, which revealed, "... Hospital Course: ... The patient was slated to have a coronary angiogram. However, the patient did develop a hypotensive episode at about midnight or early morning of 4/9/12 and sustained a cardiac arrest. The patient was resuscitated by the cardiac arrest team and blood pressure was brought back. The patient was transferred back to the Intensive Care Unit. EMP14 was contacted again who arranged for the patient to be transferred to [another facility] Intensive Care Unit for further management. ..."

4. At approximately 2:48 PM on April 16, 2012, when asked what EMP12 recalled about the events from April 8, 2012, relating to the patient, EMP12 stated, "... I was in the cath lab, express team was called. ... I ran from the cath lab to [the patient's] room, ... I asked what the precipitating events were, ... I was told by someone that he/she brady'd down. ..." When asked what the patient's condition was prior to transfer to another facility, EMP12 stated, "He/she still remained very serious. ..."

5. When asked, at approximately 8:40 AM on April 17, 2012, what EMP15 recalled of the events of April 8, 2012, EMP15 stated, "... EMP17 was giving me report, ... I noticed that [the patient] was off [the cardiac monitor] ... and it [cardiac monitor] was showing zero [heart rate], which was unusual. ... I went in to the room, saw that the patient was unresponsive, ... I told the [nurses], ... we need to get in there now. ... They called an express team. ..." When asked if there is an instance where it would be appropriate for a monitor technician to suspend a patient's cardiac monitor alarms, EMP15 stated, "No. ..."

6. Interview with EMP4 and EMP2, at approximately 10:35 AM on April 17, 2012, revealed that during other times EMP17 had been assigned as a monitor technician, EMP17 had not expressed concerns regarding lack of appropriate training or not having enough experience to feel comfortable performing the duties of monitor technician.