HospitalInspections.org

Based on hospital policy review, hospital document review, medical record review, and interview, nursing services failed to have an organized nursing service which ensured patients' needs were met regarding physician orders for cardiac monitoring for one (1) of three (3) (Patient #1) patients admitted with orders for cardiac monitoring and failed to followed hospital policy for transferring patients to a higher level of care for 1 of 1 (Patient #1) patients with transfer orders.

The findings included:

1. Review of the Hospital's "Cardiac Monitoring and Discontinuation/Telemetry" policy revealed, "...Purpose: to identify potential life-threatening arrhythmias for patients requiring cardiac monitoring and notifications of the authorized provider for treatment...Cardiac monitoring is initiated based on physician/LIP [Licensed Independent Practitioner] order..."

2. Review of the hospital's "Cardiac Monitoring/ Telemetry Management" training manual updated 8/2021 revealed, "...Note: The Registered Nurse [RN] must travel with the patient who is on telemetry..."

3. Review of the Hospital's "Transporting Patients within the Hospital" policy revealed, "...Patient's should be transported with the appropriate personnel and necessary equipment within the hospital. The appropriate transporter(s) should remain in attendance with the patient until the appropriate personnel in the receiving area or unit is present or aware of the patient...The following patients require escorting...Cardiac and oximetry monitoring will be continued...The appropriate associates RT [Respiratory Therapist], RN, MD [Doctor of Medicine] will remain with the patient until the patient is returned to the unit..."

4. Medical record review for Patient (Pt) #1 revealed Pt #1 arrived via Emergency Medical Services (EMS) to the Emergency Department (ED) on 8/21/2021 with complaint of weakness for three (3) days, Fever, Abdomen Distended, and Tremors. Pt #1 was Covid 19 positive.

Past medical history included Sepsis, Non-ST Elevation Myocardial Infarction (NSTEMI, a type of heart attack), Liver Cirrhosis, Chronic Kidney Disease, Metabolic Acidosis, Hypertension, Congestive Heart Failure, History of (H/O) ventricular tachycardia, Implantable cardioverter-defibrillator (ICD), H/O Colon Cancer, and H/O renal cell cancer.

5. Review of the physician order for Patient #1 dated 8/21/2021 at 10:12 PM, revealed orders for the patient to be on medical /surgical unit with telemetry.

On 8/23/2021 at 9:30 AM, the physician orders revealed, "...Telemetry 48 hours...Medical Necessity: Acute Coronary Syndrome (ACS), May NOT go on Standby..." The order was signed by RN #1 as being reviewed on 8/23/2021 at 11:04 AM. (Acute coronary syndrome is a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart. One such condition is a heart attack (myocardial infarction) when cell death results in damaged or destroyed heart tissue. Even when acute coronary syndrome causes no cell death, the reduced blood flow changes how your heart works and is a sign of a high risk of heart attack).

On 8/23/2021 Pt. #1 was transferred from ED to telemetry/medical floor.

On 8/24/2021 at 12:00 PM, the physician orders revealed an order for Computed Tomography (CT) of the thorax. The patient refused to go to CT on 8/24/2021. There was no documentation why the patient refused.

On 8/24/2021 at 12:02 PM, the physician orders revealed an order to place Pt. #1 on Vapotherm 40 liters 100 percent (%) FIO2 due to Pt. #1's increasing oxygen demands. (Vapotherm is a high velocity therapy which provides mask-free, non-invasive ventilatory support. As an advanced form of high flow nasal cannula, it can be used to provide high flow oxygenation).

On 8/25/2021 at 7:50 AM, physician orders for Pt. #1 revealed, "...Telemetry 48 hours...Medical Necessity: Acute Coronary Syndrome (ACS), May NOT go on Standby...!!!!!Patient has a previous telemetry order, check to see if patient is actively being monitored..." The orders were signed by RN #1 as being reviewed on 8/25/2021 at 8:37 AM.

6. Patient #1 was placed on Vapotherm (high flow oxygen) 40 liters at 100 % FIO2 (Fraction of Inspired Oxygen) on 8/24/2021 at 1:50 PM. Pt. #1's oxygen saturation (O2 sat) was documented as follows:
On 8/24/2021 at 1:50 PM O2 sat was 90 %,
On 8/24/2021 at 111:59 PM, O2 sat was 87 %, low
On 8/24/2021 at 11:42 PM, O2 sat was 89 %, low
On 8/25/2021 at 7:50 AM, O2 sat was 95 %,
On 8/25/2021 at 10:20 AM, O2 sat was 92 %.
FiO2 is defined as the concentration of oxygen that a person inhales.

7. Review of a bed request order dated 8/25/2021 at 8:53 AM revealed orders for Pt. #1 to be transferred to Stepdown (a Stepdown unit is a nursing unit that provides a higher level of care than medical unit).

8. Review of RN #1's addendum note dated 8/25/2021 revealed RN #1 documented orders were placed for CT chest for Pt. #1. Pt. #1 was on Vapotherm 40 liters at 100% FIO2 and was currently saturating 92%. Pt. #1 had a bed request for stepdown for closer monitoring. RN #1 called Respiratory to the room to detach the Vapotherm and place Pt. #1 on a non-rebreather mask at 15 liters and hooked to portable oxygen tank. (Non-rebreather masks are used to deliver oxygen therapy to people who require high-concentration oxygen but aren't in need of breathing assistance. They're considered low-flow oxygen delivery systems).The Transporter and RN were present in the room when therapist arrived. RN #1 documented Pt. #1 was lying in bed presenting no distress. Pt. #1's incontinence pad was changed and the patient was placed on the transporter stretcher. The Respiratory therapists removed patient's Vapotherm and placed Pt. #1 on a non-rebreather mask at 15 liters of oxygen. Pt. #1 was then repositioned by the RN and transporter. The head of the bed was raised to 30 degrees and patient was transported to elevator in route to radiology by the transporter.

There was no documentation a RN went with Pt. #1 to CT, no documentation the RN had removed remote telemetry monitor or placed the monitor in standby mode, and no documentation a RN had assisted with Pt. #1's transport to a higher level of care unit.

Review of the 8/25/2021 patient census and staffing on the med/surg overflow unit (COVID) floor was 12 patients. The RN to patient ratio was 1 nurse to 5 patients.

9. Review of the Emory House Record (code record) revealed a code was called to the Radiology Department on 8/25/2021 at 11:08 AM. Pt #1 was not on a cardiac monitor at this time. At 11:13 AM, Pt. #1 was placed on a cardiac monitor which indicated the patient was in Pulseless Electrical Activity (PEA, no pulse). At 11:16 AM, the cardiac monitor indicated Ventricular Fibrillation (abnormal heart rhythm). At 11:22 AM, Pt. #1 the cardiac monitor indicated Pt. #1 was back in PEA and resuscitation efforts were terminated after 4 rounds of Cardio-Pulmonary Resuscitation (CPR). The resuscitative efforts were unsuccessful and Pt. #1 expired on 8/25/2021 at 11:22 AM. (CPR - a procedure to revive a person who has stopped breathing and whose heart has stopped beating).

10. Review of Pulmonary/Critical Care physician progress note dated 8/25/2021 at 11:45 AM revealed the physician documented, "...responded to a code blue in 4 Shorb (name of unit) CT scan area around 10:45 AM. On my arrival ACLS (Advanced Cardiac Life Support) was ongoing with chest compressions. The patient had a non-rebreather mask on and was not being bagged with a bag valve mask [BVM] (Bag-valve-mask ventilation is the standard method for rapidly providing rescue ventilation to patients with apnea or severe ventilatory failure). We placed pads on the patient, Epi (epinephrine) was given, compressions were ongoing. Respiratory therapy did arrive with a BVM and a filter (patient was Covid positive). Patient was being bagged and ACLS ongoing. There was one V Tach (ventricular tachycardia, abnormal heart rhythm) rhythm and Amiodarone was given after a Defibrillation at 300 J (joules, amount of electrical shock given). After several rounds of ACLS, the code was called and the patient pronounced dead at 11:22 AM.

After the code I had a debrief with respiratory therapist, nurse and CT scan techs (technicians).

Apparently patient was on Vapotherm high flow oxygen and was supposed to be transfer from 7 Shorb (telemetry) to 6 Shorb (stepdown). On transport patient was placed on a non-rebreather at 15 L (liters). He was taken by transport services without telemetry and/or continuous pulse oximetry. In route to 6 Shorb, patient was taken to 4 Shorb into the CT scanner. On arrival to CT he remained on the NRB hooked up to an oxygen portable tank. The transporter left. After the CT scan was completed the patient was placed in the travel stretcher and transport services were called.

He (Pt. #1) was on the stretcher awaiting transport and the CT tech went to check on him and he was unresponsive. The oxygen tank it was hooked up to was empty and not providing oxygen. He was not a wall oxygen supply. A code was called at that time and I arrived soon after that in response to the code.

After this debriefing I spoke with named CEO [Chief Medical Officer] and the patient's attending named hospitalist.

11. Review of the hospital's "Root Cause Analysis" form revealed, on 8/25/2021, RN #1 notified the Respiratory Therapist (RT) of Pt #1 being transferred to a higher level of care. The RT transitioned Pt #1 to a non-rebreather at 15 liters per minute attached to a portable oxygen tank. The portable oxygen tank was half full. RN #1 disconnected Pt. #1's remote cardiac monitor. The RT learned that Pt. #1 was going to see CT before going to the stepdown unit, but thought it was OK because CT would hook Pt. #1 to wall oxygen. Pt. #1 was transported to CT by the hospital transporter. Pt. #1's was not placed on the wall oxygen but was left on the portable O2 tank. After the CT was completed Pt. #1 was placed back on a stretcher. A CT tech who was watching the patient through a window left the patient. A few minutes later another CT tech looked through the CT window and noticed the patients Non-Rebreather mask was deflated. The CT Tech went into the room and found the patient unresponsive. Emory House was called and the CT tech started CPR.

12. On 8/25/2021 at 12:10 PM, Risk Management was notified by the physician that Pt #1 had orders for telemetry and was on a Non-Rebreather with oxygen Pt #1 was transported to CT without an RN to monitor and the PT #1 had been taken off telemetry. The portable oxygen tank had been taken back to Pt #1's room with the body. Risk Management staff immediately obtained the oxygen tank. The tank was empty. RN #1 stated to the Risk manager she did not know that a patient on telemetry had to be transported by the RN.

13. In an interview in the conference room on 9/15/2021 at 1:24 PM, RN #1 informed this surveyor she was the nurse assigned to Pt. #1 on 8/25/2021. RN #1 stated a CT had been ordered for the patient. RN #1 stated, "...I called Respiratory, the patient was on Vapotherm. The RT and transporter came. The RT took him [Pt. #1] off Vapotherm and put him on 15 liters nonrebreather. His vital signs were stable and he was alert and oriented. Then the transport took him to CT. He was on a monitor until we put him on the stretcher, I don't remember seeing an order for the cardiac monitor..." RN #1 was asked if she was aware of the hospital policy for the nurse to remain with patient during transfer. RN #1 stated if the patient is unstable or if the patient is going to a higher level of care the nurse has to be present. RN #1 stated the physician wanted the CT done first before the patient went to step down. RN #1 stated the transport provided the O2 tank. RN #1 stated, "...we nurses don't typically hook the patient up to oxygen, RT or transport does..." RN #1 verified she had called telemetry to inform them the monitor was off.

14. In an interview in the conference room on 9/15/2021 at 1:42 PM, Respiratory Therapist (RT) #1 stated she was called to Pt. #1's room because the patient was going to transfer to six (6) Shorb. The patient was on a high flow binasal (Vapotherm). The nurse was getting him ready. She [RN #1] told me the patient was going to CT first. When he was ready to go I put him on a NRB at 15 L per portable O2 tank. RT #1 stated the portable oxygen tank was half full. The RT did not assist with the transport. The RT stated he responded to an Emery House and upon arrival the patients mask [Pt. #1] was connected to the portable tank and he was not on telemetry or a SPO2 (oxygen saturation level) monitor.

An estimation of duration of e-cylider oxygen tank when half full and running at 15 liter/minute revealed the patient was at risk for running out of oxygen at 18-22 minutes.

15. In an interview in the conference room on 9/15/2021 at 1:50 PM, Computed Tomography Technician (CT) tech #1 stated she was the biopsy tech that day. CT tech #1 stated CT tech #3 was in the CT room with Pt. #1 and asked me to watch the patient while she went to the bathroom. Pt #1 was on the bedpan. CT tech #1 stated transport had been called by CT tech #3 to come and get the patient. CT tech #1 stated she left the room to find a radiologist stating when she came back to the room, she told CT tech #2 and CT tech #3 she was going to eat. CT tech #1 stated Pt. #1 was still in the CT room, but she didn't know that. CT tech #1 stated the last time she saw the patient he was pulling the covers up. She stated she did not have any contact with the patient other than observing him through the window in the CT area. CT tech #1 stated the policy was Covid patients have to stay in the room until picked up by transport and cannot go in the holding area. She stated the nurses used to come with the patients, but they don't anymore unless the patient is on a monitor.

16. In an interview in the conference room on 9/15/2021 at 2:40 PM, the Patient Transporter stated she transported Pt #1 to CT and let them (CT tech) know she was there with Pt. #1. The transporter stated, "... I handed the patient off to them. The tech asked me if I was going to be taking the patient back and I told her no, they had to put in another request for transport. We don't wait on patients. He (Pt. #1 seemed alert when we left the room. He had on the oxygen mask and the oxygen was going pretty fast ..."

17. In an interview in the conference room on 9/15/2021 at 3:14 PM, CT tech #2 stated she assisted placing Pt. #1 on the bedpan after scan was completed stating, "...I looked in the room to see if he had been picked up by transport. I didn't see anyone outside the door. He wasn't moving. I went in and did a sternal rub and told my coworker he was not breathing. I started chest compressions. The NRB O2 bag was on but was deflated. He did not have a cardiac monitor on. There should be someone observing patients at all times..."

18. In an interview in the conference room on 9/16/2021 at 8:45 AM, CT tech #3 stated, "...when the patient arrived, I asked transport if they were going to wait. The transporter said she wasn't allowed to wait for him. The transported said the holding nurse was putting in a request for transport. I got him on the table, went out in the hall did the scan and put him back on the stretcher. I checked on the transporter and it had not been assigned. I called them (transport) and told them I needed someone to come and get the patient. I told named CT tech #1 I needed to go to the bathroom and she told me to go ahead to lunch. I told her she needed to watch him. I went to lunch. While I was eating lunch, CT tech #1 told me she was going to eat lunch, then the code went off. I never would have went to lunch or left the room if I knew CT tech #1 was not going to be in the room. I would have never left. I had talked to his Nurse (RN #1) and she said he was fine to come down. He was on a NRB, and I left it on the tank (Portable tank). CT's are so quick we don't usually hook the patient to the wall O2. I should have put him on the wall O2. Covid patients have to stay in the CT room until transport or nurse comes and get them. The nurses have always had to bring patient. When COVID started I don't know why it changed. We are at the mindset that all COVID patients need a nurse with them. CT techs cannot leave a patient unattended..."

19. In a telephone interview on 9/16/2021 at 1:30 PM, Physician #1 verified the CT needed to be completed on Pt. #1. The physician stated, "...this patient was initially on oxygen and within 24-48 hours his oxygen needs went up, so really needed the CT to determine if developing a clot, or pneumonia not worsening. He was very sick..."

20. RN #1 reviewed a physician order on 8/23/2021 at 9:30 AM and on 8/25/2021 at 8:37 AM stating that Pt. #1 could not go on cardiac monitoring standby. On 8/25/2021, after the order was reviewed by RN #1, Pt. #1 was taken off the monitor by RN #1 and Pt #1 was sent to CT without being monitored. RN #1 did not follow physician orders for cardiac monitoring and did not follow hospital policy for cardiac monitoring.

21. Pt. #1 had orders to be transferred to a high level of care. The hospital policy states that if a patient is changing level of care the nurse needs to travel with the patient. The RN did not remain with Pt. #1 during transport to CT and then on to the stepdown (a higher level of care unit).

22. Review of the hospital's corrective action plan revealed the following:
The hospital's President called for mandatory department leaders to attend 8/26/21 9:05 AM Safety Huddle In-Person. He discussed the need to push the pause button and reflect on our High Reliability Safety Tools. These tools are proven to decrease safety events by 80%. In our current environment we need to calm our associates and articulate use of these tools. All leaders were asked to go back to their units and hold discussions with frontline associates regarding our Safety Tools - 9/26/21, President/Associate Chief Nursing Officer & Director of Risk.

"Associates held accountable based on our Just Culture Algorithm - 9/17/21, Nursing, CD, Director of Respiratory Therapy, and Director of Radiology.

All Contracted Registered Nurses will complete the Cardiac Monitoring 2021 Cornerstone education - 10/1/21, Associate Chief Nursing Officer.

Duration of E-cylinder (Oxygen tank/cylinder) signs posted above each tank storage area as a reference - 9/17/21, Director of Respiratory Therapy.

Educate Radiology Techs to immediately transition patients from portable oxygen to wall oxygen until they are leaving the department - 10/1/21, Director of Radiology VERIFICATION OF CONTROL: Monitor weekly compliance rate of education - 10/4/21, ACNO, Director of Quality, and Director of Radiology".

This surveyor was able to verify the implementation of the above action plans by observations and interview.

Based on medical record review, and interview, the Radiologic Services failed to ensure patient safety for patients receiving radiologic services for one (1) of one (1)) (Patient #1) patients reviewed that received a Computed Tomography scan (CT scan).

The findings included:

1. Medical record review for Patient (Pt) #1 revealed Pt #1 arrived via Emergency Medical Services (EMS) to the Emergency Department (ED) on 8/21/2021 with complaint of weakness for three (3) days, Fever, Abdomen Distended, and Tremors. Pt #1 was found to be Covid 19 positive. Pt. #1 remained in the ED as an inpatient until a Covid bed was available.

On 8/23/2021 Pt. #1 was transferred from ED to telemetry/medical floor.

2. On 8/24/2021 at 12:00 PM, the physician orders revealed an order for Computed Tomography (CT) of the thorax. The patient refused to go to CT on 8/24/2021. There was no documentation why the patient refused.

3. The CT was completed on 8/25/2021 at 10:28 PM and the patient was left in the CT room for transport to pick up and transport him to a stepdown unit with a higher level of care.

4. Review of the Emory House Record (code record) revealed a code was called to the Radiology Department on 8/25/2021 at 11:08 AM. Pt #1 was not on a cardiac monitor at this time. At 11:13 AM, Pt. #1 was placed on a cardiac monitor which indicated the patient was in Pulseless Electrical Activity (PEA, no pulse). At 11:16 AM, the cardiac monitor indicated Ventricular Fibrillation (abnormal heart rhythm). At 11:22 AM, Pt. #1 the cardiac monitor indicated Pt. #1 was back in PEA and resuscitation efforts were terminated after 4 rounds of Cardio-Pulmonary Resuscitation (CPR). The resuscitative efforts were unsuccessful and Pt. #1 expired on 8/25/2021 at 11:22 AM. (CPR - a procedure to revive a person who has stopped breathing and whose heart has stopped beating).

5. Review of the hospital's "Root Cause Analysis" form revealed, on 8/25/2021, RN #1 notified the Respiratory Therapist (RT) of Pt #1 being transferred to a higher level of care. The RT transitioned Pt #1 to a non-rebreather at 15 liters per minute attached to a portable oxygen tank. The portable oxygen tank was half full. RN #1 disconnected Pt. #1's remote cardiac monitor. The RT learned that Pt. #1 was going to see CT before going to the stepdown unit, but thought it was OK because CT would hook the Pt. #1 to wall oxygen. Pt. #1 was transported to CT by the hospital transport. Pt. #1's was not placed on the wall oxygen but was left on the portable O2 tank. After the CT was completed Pt. #1 was placed back on a stretcher. A CT tech who was watching the patient through a window left the patient. A few minutes later another CT tech looked through the CT window and noticed the patients Non-Rebreather mask was deflated. The CT Tech went into the room and found the patient unresponsive. Emory House was called and the CT tech started CPR. On 8/25/2021 at 12:10 PM, Risk Management was notified by the physician that Pt #1 had orders for telemetry and was on a Non-Rebreather with oxygen Pt #1 was transported to CT without an RN to monitor and the PT #1 had been taken off telemetry. The portable oxygen tank had been taken back to Pt #1's room with the body. Risk Management staff immediately obtained the oxygen tank. The tank was empty. RN #1 stated to the Risk manager she did not know that a patient on telemetry had to be transported by the RN.

6. In an interview in the conference room on 9/15/2021 at 1:24 PM, RN #1 informed this surveyor she was the nurse assigned to Pt. #1 on 8/25/2021. RN #1 stated a CT had been ordered for the patient. RN #1 stated, " ...I called Respiratory, the patient was on Vapotherm. The RT and transporter came. The RT took him [Pt. #1] off Vapotherm and put him on 15 liters nonrebreather mask (NRB). His vital signs were stable and he was alert and oriented. Then the transport took him to CT. RN #1 stated he was on a monitor until we put him on the stretcher, I don't remember seeing an order for the cardiac monitor. RN #1 was asked if she was aware of the hospital policy for the nurse to remain with patient during transfer. RN #1 stated if the patient is unstable or if the patient is going to a higher level of care the nurse has to be present. RN #1 stated the physician wanted the CT done first before the patient went to step down. RN #1 stated the transport provided the O2 tank. RN #1 stated we nurses don't typically hook the patient up to oxygen, RT or transport does. RN #1 stated she had called telemetry to inform them the monitor was off. (Non-rebreather masks are used to deliver oxygen therapy to people who require high-concentration oxygen but aren't in need of breathing assistance).

7. In an interview in the conference room on 9/15/2021 at 1:42 PM, Respiratory Therapist (RT) #1 stated she was called to Pt. #1's room because the patient was going to transfer to six (6) Shorb. The patient was on a high flow binasal (Vapotherm). The nurse was getting him ready. She [RN #1] told me the patient was going to CT first. When he was ready to go I put him on a NRB at 15 L per portable O2 tank. RT #1 stated the portable oxygen tank was half full. The RT did not assist with the transport. The RT stated he responded to an Emery House and upon arrival the patients mask [Pt. #1] was connected to the portable tank and he was not on telemetry or a SPO2 (oxygen saturation level) monitor.

An estimation of duration of e-cylider oxygen tank when half full and running at 15 liter/minute revealed the patient was at risk for running out of oxygen at 18-22 minutes.

8. In an interview in the conference room on 9/15/2021 at 1:50 PM, Computed Tomography Technician (CT) tech #1 stated she was the biopsy tech that day. CT tech #1 stated, CT tech #3 was in the CT room with Pt. #1 and asked me to watch the patient while she went to the bathroom. Pt #1 was on the bedpan. CT tech #1 stated transport had been called by CT tech #3 to come and get the patient. CT tech #1 stated she left the room to find radiologist stating when she came back to the room, she told CT tech #2 and CT tech #3 she was going to eat. CT tech #1 stated Pt. #1 was still in the CT room, but she didn't know that. CT tech #1 stated the last time she saw the patient he was pulling the covers up. She stated she did not have any contact with the patient other than observing him through the window in the CT area. CT tech #1 stated the policy was Covid patients have to stay in the room until picked up by transport and cannot go in the holding area. She stated the nurses used to come with the patients, but they don't anymore unless the patient is on a monitor.

9. In an interview in the conference room on 9/15/2021 at 2:40 PM, the Patient Transporter stated she transported Pt #1 to CT and let them (CT tech) know she was there with Pt. #1. The transporter stated, "... I handed the patient off to them. The tech asked me if I was going to be taking the patient back and I told her no, they had to put in another request for transport. We don't wait on patients. He (Pt. #1 seemed alert when we left the room. He had on the oxygen mask and the oxygen was going pretty fast ..."

10. In an interview in the conference room on 9/15/2021 at 3:14 PM, CT tech #2 stated she assisted placing Pt. #1 on the bedpan after scan was completed stating, "...I looked in the room to see if he had been picked up by transport. I didn't see anyone outside the door. He wasn't moving. I went in and did a sternal rub and told my coworker he was not breathing. I started chest compressions. The NRB O2 bag was on but was deflated. He did not have a cardiac monitor on. There should be someone observing patients at all times..."

11. In an interview in the conference room on 9/16/2021 at 8:45 AM, CT tech #3 stated, "...when the patient arrived, I asked transport if they were going to wait. The transporter said she wasn't allowed to wait for him. The transported said the holding nurse was putting in a request for transport. I got him on the table, went out in the hall did the scan and put him back on the stretcher. I checked on the transporter and it had not been assigned. I called them (transport) and told them I needed someone to come and get the patient. I told named CT tech #1 I need to go to the bathroom and she told me to go ahead to lunch. I told her she needed to watch him. I went to lunch. While I was eating lunch, CT tech #1 told me she was going to eat lunch, then the code went off. I never would have went to lunch or left the room if I knew CT tech #1 was not going to be in the room. I would have never left. I had talked to his Nurse (RN #1) and she said he was fine to come down. He was on a NRB, and I left it on the tank (Portable tank). CT's are so quick we don't usually hook the patient to the wall O2. I should have put him on the wall O2. Covid patients have to stay in the CT room until transport or nurse comes and get them. The nurses have always had to bring patient. When COVID started I don't know why it changed. We are at the mindset that all COVID patients need a nurse with them. CT techs cannot leave a patient unattended..."

The CT techs failed to observe and monitor Pt #1 while he was in the CT area waiting for transport.