HospitalInspections.org

Based on policy review, observations, medical record review, CMU (Central Monitoring Unit) documentation, hospital document reviews and staff and provider interviews, the hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to receive care in a safe environment; failed to have an organized nursing service to meet patient care and safety needs and failed to meet the emergency needs of patients.

The findings included:

1. Hospital staff failed to provide a safe environment for 3 of 32 patients reviewed by failing to ensure systems were in place and functioning for continuous pulse oximetry monitoring of a patient during transport (Patient #10), to provide timely response and patient evaluation to telemetry monitor alarms (Patient #14) and to provide accurate patient identification during initial quick registration and promptly correct the electronic misidentification and mitigate the associated risks (Patient #24).

Cross refer to §482.13 Patient Rights' Standard: Tag A 0144.

2. The hospital failed to ensure adequate staff was available to assess and respond to a monitored telemetry patient with leads off and the patient subsequently expired for 1 of 32 patients reviewed (Patient #14).

Cross refer to 482.23 Nursing Standard: Tag A 0392.

3. Nursing staff failed to supervise and monitor care by failing to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport (Pt #10) and failing to prevent and control infections. Nursing staff failed to identify and communicate accurate and timely COVID precautions on an inpatient unit creating an unsafe environment for patient care (Pt #34).

Cross refer to 482.23 Nursing Standard: Tag A 0395

4. Hospital nursing staff failed to follow policies to evaluate a patient's change in condition requiring emergent treatment for 1 of 32 sampled patients (#17) and failed to follow post procedure guidelines following a heart catheterization for 2 of 32 sampled patients (#17, #15)

Cross refer to 482.23 Nursing Standard: Tag A 0398

5. Emergency Department (ED) staff failed to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport from the ED to an inpatient unit for 1 of 12 emergency department patients reviewed (Patient #10).

Cross refer to §482.55: Emergency Services Standard Tag A 1103.

Based on hospital policy review, medical record review, and staff and provider interviews, the hospital failed to protect and promote patients' rights by failing to ensure care in a safe environment for 3 of 32 patients reviewed (Pt #10, #14, #24).

The findings included:

1. Hospital staff failed to provide a safe environment for 3 of 32 patients reviewed by failing to ensure systems were in place and functioning for continuous pulse oximetry monitoring of a patient during transport (Patient #10), to provide timely response and patient evaluation to telemetry monitor alarms (Patient #14) and to provide accurate patient identification during initial quick registration and promptly correct the electronic misidentification and mitigate the associated risks (Patient #24).

Cross refer to §482.13 Patient Rights' Standard: Tag A 0144.

Based on policy review, medical record review, video monitor review, CMU (Central Monitoring Unit) documentation, hospital documents and staff and provider interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to patients for 5 of 32 records reviewed (Pts #14, #10, #34, #17, #15). .

The findings included:

1. The hospital failed to ensure adequate staff was available to assess and respond to a monitored telemetry patient with leads off and the patient subsequently expired for 1 of 32 patients reviewed (Patient #14).

Cross refer to 482.23 Nursing Standard: Tag A 0392.

2. Nursing staff failed to supervise and monitor care by failing to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport (Pt #10) and failing to prevent and control infections. Nursing staff failed to identify and communicate accurate and timely COVID precautions on an inpatient unit creating an unsafe environment for patient care (Pt #34) and exposure to COVID.

Cross refer to 482.23 Nursing Standard: Tag A 0395

3. Hospital nursing staff failed to follow policies to evaluate a patient's change in condition requiring emergent treatment for 1 of 32 sampled patients (#17) and failed to follow post procedure guidelines following a heart catheterization for 2 of 32 sampled patients (#17, #15)
..
Cross refer to 482.23 Nursing Standard: Tag A 0398

Based on policy review, internal document review, observation, closed medical record review, and staff interviews, the Emergency Department (ED) staff failed to have effective emergency services to meet the needs of patients that presented to the Emergency Department.

The findings include:

1. The Emergency Department (ED) staff failed to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport from the ED to an inpatient unit for 1 of 12 ED patients reviewed (Patient #10).

~cross refer to 482.55 Emergency Services Standard: Tag 1103

Based on policy review, observation, medical record review and staff and physician interviews, the hospital staff failed to provide a safe environment for 3 of 32 patients reviewed by failing to ensure systems were in place and functioning for continuous pulse oximetry monitoring of a patient during transport (Patient #10), to provide timely response and patient evaluation to telemetry monitor alarms (Patient #14) and to provide accurate patient identification during initial quick registration and promptly correct the electronic misidentification and mitigate the associated risks (Patient #24).

The findings include:

1. Review of hospital policy "Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring - 1PC.NRS.0001," effective 08/19/2025, revealed, " ... III. Transport of Monitored Patients. 1. Interruption in cardiac monitoring should not occur during transport for patients with active orders for telemetry monitoring. a. Patients with active monitoring orders should continue to be remotely monitored, and the Monitor/Telemetry Technician should be notified of unit travel, destination, primary contact for duration of travel, and anticipated time of return ... V. Telemetry Escalation Process ... 3. In the event a non-lethal arrhythmia is detected, pulse oximetry (SPO2) reading <87%, OR patient's cardiac rhythm is not transmitting, the Monitor/Telemetry Technician will initiate the following procedure: a. The Monitor/Telemetry Technician will initiate a multi-level escalation process, requiring loop closure/alarm resolution within 5 minutes of the initial arrhythmia alarm ..."

Review of hospital policy attachment "Example Telemetry Escalation Pathways," effective 08/16/2025, revealed, "Immediate Escalation & 5 Minute Resolution: Non-lethal Rhythm, Loss of Signal (no transmission) or SPO2 <87%. TT (Telemetry Tech) immediately call Primary Nurse - Unable to reach Primary Nurse and/or issue not resolved within 2 minutes - TT to call Charge Nurse - Unable to reach Charge Nurse and/or issue not resolved within 3 minutes - Call overhead Telemetry Alert, repeat once per minute until resolved ..."

Observation of the Emergency Department (ED) on 09/23/2025 at 1159 revealed a patient was switched from ED telemetry monitoring to the CMU (Central Monitoring Unit) for monitoring during transport to inpatient holding. Observation revealed the portable telemetry box did not display a visual or have an audible alarm for any changes during transport.

Closed medical record review on 09/17/2025 for Patient #10 revealed a 48-year-old presented to the ED on 09/04/2025 at 1441 with complaints of chest pain and shortness of breath. The patient's pain was documented at 1442 as 8 out of 10. The Provider's MSE (Medical Screening Exam) Note at 1445 revealed, "Patient with chest pain and shortness of breath. On home oxygen normally. chest tube in place. Patient is alert, in no acute distress but is moaning in discomfort." The patient's oxygen saturation (O2 sat) at 1500 was 90%. The ED Provider's Note at 1534 revealed the patient had a history of metastatic lung cancer with a chest tube on the right with "chronic pain at the tube site now with worsening shortness of breath for the past day." The patient's O2 sat at 1630 was 92%, and the patient was placed on 3 liters of oxygen via nasal cannula. The patient's O2 sat at 1715 was 93%. An order for Morphine (a pain medication) 4 milligrams IV (intravenous) was placed at 1729. An order was placed at 1731 for continuous pulse oximetry (measures how much oxygen is in the blood for uninterrupted periods). The patient's O2 sat at 1745 was 89% and at 1750 was 90%. A broadcast notification was sent to a Stepdown unit at 1803 with the room number the patient was assigned to and the box number for continuous pulse oximetry. The patient's blood pressure at 1807 was 84/57 with a comment by the Nurse that the Provider was notified at that time. The patient's pain was assessed at 1808 as 10 out of 10. A comment was documented on the MAR (Medication Administration Report) at 1809 that Morphine was not given as the patient's blood pressure was "too low to administer," and the Provider was notified. The patient's oxygen was increased to 4 liters at 1820 with an O2 sat of 94%. ED Nurse Note at 1830 revealed the patient was transported by transport staff. The patient was on an "O2 monitor, awake and alert" with an O2 sat of 93% prior to transport. Record review failed to reveal documented evidence of the patient's time of arrival to the unit and initial O2 sat on the unit.
Review of a Code Record revealed a code blue (the initiation of resuscitative efforts in a cardiac or respiratory arrest) was called with initiation of CPR (cardiopulmonary resuscitation) at 1842 and initial ECG (electrocardiogram, a noninvasive test that records the electrical activity of the heart) rhythm of asystole (no heartbeat). The patient was intubated at 1853, and a rhythm of PEA (Pulseless Electrical Activity, a condition where the heart is still producing electrical signals, but there is no pulse or blood pressure) was noted at 1901. The patient expired at 1907. Record review failed to reveal evidence of continuous pulse oximetry monitoring during the patient's transport and failed to reveal documented evidence of the patient's heart rate and O2 sats during transport.

Interview on 09/16/2025 at 1300 with RN #4 revealed the CMU monitored patients on continuous pulse oximetry (pulse ox), but they did not record the patients' O2 sats.

Telephone interview on 09/22/2025 at 1422 with Staff #7 revealed they were not aware of any alarm that could be heard with the telemetry box during a patient's transport.

Telephone interview on 09/23/2025 at 1313 with Tech #5 revealed they recalled RN #27 called to verify the pulse ox for Patient #10 could be visualized by the CMU prior to transport from the ED to a Stepdown unit. Interview revealed they were on the phone for a few minutes troubleshooting the pulse ox probe as there were issues with the signal going in and out. Interview revealed Wi-Fi connection issues, such as the signal cutting in and out, could occur when a patient was transported. Tech #5 revealed during Patient #10's transport, the signal was again cutting in and out, and there was not a solid reading. Tech #5 revealed there were drops in Patient #10's O2 sats, but they could not get a clear reading due to signal issues. Interview revealed the CMU pod was very busy that day as there were multiple patients being transferred and admitted, as well as multiple escalations at that time. Tech #5 revealed any time there were O2 sats dropping or signal loss, the monitor techs should notify the Nurse as soon as they see it with a resolution time of 5 minutes. Interview revealed the Stepdown unit was not notified that Patient #10's pulse oximetry had signal issues, a loss of signal during transport, or drops in the patient's O2 sats.

Interview on 09/25/2025 at 0934 with Nursing Administrative Staff (AS) #6 revealed there was no action plan needed related to Patient #10 as the pulse oximetry signal could be intermittent while transporting patients in the elevator. The telemetry staff should follow the loss of signal pathway, which would give the staff time to contact the Nurse.

Follow-up interview on 09/25/2025 at 1715 with AS #6 revealed there were potential opportunities for signal issues with telemetry during transport, but they were not aware that it was a "profuse issue."


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2. Review of hospital policy titled "Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring" last approved 06/04/2025 revealed " ...PURPOSE ... C. Identify which rhythms or arrhythmias require RN (registered nurse) notification/intervention and identification of proper escalation procedures ...ALARM RESPONSE AND ESCALATION PROCESS A. ...a defined escalation pathway is used to ensure timely notification and treatment ...II. Rhythm Transmitting with ...Leads Off ... A. First Escalation Attempt: 1. MTII (monitor tech) calls Primary Nurse. 2. Within 5 minutes the Primary Nurse will assess the patient and call the monitor tech and give an update ...4. The MTII records the notification ... B. Second Escalation Attempt: 1. If unable to reach Primary Nurse or unresolved within 5 minutes from the time of initial notification, the MTII call the Primary Nurse again and enter notification time ... C. Third Escalation Attempt: 1. If unable to reach Primary Nurse, or unresolved after 5 minutes, the MTII will call the CNC (clinical nurse coordinator)/Relief Charge Nurse. 2. If no resolution after 1 minute, send broadcast to unit. 3. If no resolution after 2 minutes, start escalation over until resolved.

Review of hospital policy titled "Assessment and Reassessment" last approved 05/13/2025 revealed "Purpose The organization assesses and reassess the patient and the patient's condition according to defined timeframes ... Policy ... C. The assessment process is a continuous, collaborative effort with departments functioning as an interdisciplinary team ... Assessment Framework A ...2. As individual patient condition changes ..."

Review of hospital document titled "ADULT INTERMEDIATE CARE STANDARDS OF CARE GUIDELINES-NURSING", revealed " ...Reassessment intervals and parameters are presented as the minimum times, measurements, and evaluation criteria ... Patient Rounding A. Safety Rounds to occur as recommended - every 1-2 hours ... Safety A. The patient can expect appropriate safety precautions while in the hospital ..."

Closed medical record review revealed Patient (Pt) #14 was a 72-year-old male readmitted on 07/23/2025 at 1715 for shortness of breath and chest pain. At 1742 there was an order for telemetry monitoring. Per documentation the patient was placed on telemetry and telemetry tech was notified. On 07/26/2025 at 0021 vital signs revealed temperature 98.1 (oral), heart rate (HR) 76, blood pressure (BP) 99/57, (oxygen saturation) SpO2 93% on 60L (liters) oxygen (O2) high flow humidified. At 0320 the RRT (registered respiratory therapist) documented the patients HR 78, respirations (RR) 18, SpO2 93% on 60L O2 high flow humidified. Review of a Provider Note at 0415 revealed "CODE BLUE called overhead on this patient ... Was not notified by staff of any issues overnight or notified of patient being found on the floor prior to CODE BLUE being called. CPR was in progress when I walked in the room. Per the patients nurse, he was found on the floor without his Vapotherm (high flow humidified O2) on and without telemetry on for an unknown period of time ... During discussion with Dr. (named) it was decided to stop the code as we never obtained a pulse. Time of death was called at 0403 ..." Review of the Code Blue documentation revealed code time started at 0347, the patient was intubated at 0354, and the code stopped at 0403. Record review did not reveal a bed/chair alarm was documented on the evening shift of 07/25/2025.

Review of video footage dated 07/26/2025 revealed footage of unit 4 heart. Review revealed a view of the nursing station, a hallway view of Patient #14's room (E433). From 0012 through 0024 staff were noted to be in Patient #14's room and the 2 staff members exited at 0024. At 0231 a female staff (identified as CNC #14) was seen sitting at the nurse station computer. At 0305 a male staff (identified as [registered respiratory therapist] RRT #21) entered the patient's room and was seen exiting the room also at 0305. At 0313 CNC #14 still observed at nurse station, observed answering the desk phone. At 0322 CNC #14 left the nurse station and walked to another patient's room. At 0346 male staff (identified as unit PCT) entered Patient #14's room. At 0348 the code team arrived via stairwell. Review did not reveal any nursing staff in Patient #14's room between 0024 and 0346, only the Respiratory Therapist at 0305.

Review of the facility investigation on 09/18/2025 at 1535 with Director #13, Director #9, and Nurse Administrative Staff (AS) #6 revealed a timeline of events. The timeline revealed on 07/25/2025 at 1900 an RN rounded on the patient and noted no distress. On 07/26/2025 at 0012 staff were in the patient's room. At 0242 the RN was notified by the CMU tech (central monitoring unit technician) that the telemetry leads were off. At 0244 the RN was notified by the CMU tech again. At 0305 the RRT rounded on the patient and noted no distress. At 0309 the CMU tech sent a text to the RN. At 0312 the CMU tech notified the CNC to reinforce the leads. At 0317 the CMU tech called the RN but did not get an answer. At 0320 the RRT documented HR 78, RR 18, SpO2 93%, Vapotherm at 60L/minute. At 0326 CMU tech called the CNC. The CNC told the CMU tech they were in a rapid response and would get to the patient after they transferred the rapid response patient off the unit. At 0341 the CMU tech reached out to the PCT (patient care technician) asking for the telemetry leads to be checked. At 0345 the PCT entered the room and found the patient on the floor. At 0347 a Code Blue was initiated. At 0354 the patient was intubated. At 0403 the Code ended. Further interview revealed that the RRT was interviewed after the incident. The RRT entered the patient's room at 0305 the RRT noted the patient was resting and did not have his telemetry leads on. The RRT used his pocket pulse oximetry to assess the patients SpO2 and noted the RRT had no issues and that he assumed the RN was aware of the leads being off and would get to them. Interview revealed that the CMU tech was interviewed after the incident. The CMU tech revealed that the RN stated someone would get to the patient, so the CMU tech was giving the RN the benefit of the doubt. The CMU tech revealed that it was a busy night, and multiple telemetry patients required his attention at that time. Also, the placement of each patient (patient in the upper right corner of screen vs patient in the left corner of the screen) on his telemetry monitor made it difficult to follow. Interview revealed that the Primary RN and CNC were dealing with another rapid response patient and transfer to the ICU (intensive care unit). Further interview revealed that the RRT and CMU tech were no longer employed at the facility.

Review of CMU tech documentation on 07/26/2025 revealed at 0242 the RN was notified leads were off. At 0309 "called no answer left text". At 0312 RN notified. At 0326 "called rn [sic] she said we will get pt we are transporting right now". Per an interview with AS #6 the CMU tech did not write down all communication between the RN and CMU tech.

Interview on 09/18/2025 at 0900 with AS #6 and Director #9 revealed that the CMU staff work 12-hour shifts (7am-7pm or 7pm to 7am), 3 days a week. The CMU has 10 pods and the staffing goal was to have 10 CMU techs, one for each pod, 2 rovers (staff available to assist), and a supervisor/team lead. Interview revealed that the CMU tech can monitor up to 45 telemetry and/or continuous pulse oximetry patients, but the average was 35 patients.

Interview on 09/18/2025 at 1020 with AS #6 revealed that the CMU techs have different escalation pathways to follow depending on the situation. Interview revealed that when all the leads were off the patient needs to be evaluated by the primary RN/nursing staff. When there was no resolution by nursing staff the CMU tech should reach out to the CNC. If no resolution, then the CMU tech calls an overhead telemetry alert page throughout the specific unit. The escalation process should be repeated until there was a resolution. The expectation of the overhead call was for all staff to respond. Interview revealed that on 07/26/2025 the CMU tech reached out to the RN and CNC but they were busy with another rapid response patient. Interview revealed when there was no resolution the CMU tech did not follow the escalation pathway and call overhead, nor did the RN delegate the responsibility to get the patient assistance.

Interview on 09/22/2025 at 1415 with CNC (Charge Nurse) #14 revealed the CNC recalled the patient and incident. Interview revealed that the CNC was not aware that the patient was off telemetry until CMU called the CNC and by that time the CNC was in the rapid response. The CNC stated that she informed CMU they were in a rapid response and to call overhead and CMU said ok, but the CNC did not recall if that happened. The CNC stated she was not aware that CMU had been calling the primary RN because the RN didn't tell the CNC or delegate someone to check on the patient. Interview revealed that on the (named) unit all the RNs are paired with a buddy and that the primary RN should have called the buddy to check the patient. The CNC stated that the RN buddy was not in the rapid response and should have been available. Interview revealed that telemetry monitors can also be seen at the nurse station. The CNC did not recall any unit staff member on 07/26/2025 mention seeing the patient in E433 off of his telemetry monitor. Interview revealed that during the Code Blue debrief the RRT mentioned he told someone about the patient leads being off, but the CNC was not aware of the RRT alerting anyone. Further interview revealed that during the day shift rounding should take place every hour, and overnights between 10pm and 6am, the patient should be rounded on every two hours by either the RN or PCT. Interview revealed that the staffing ratio on the unit was one RN to five patients. On 07/26/2025 the CNC recalled that none of the RNs had more than five patients. Interview revealed that although the staff were within ratio the CNC felt the unit still had a staffing shortage and while staff do their best to provide care, it was not always safe care.



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3. Review of the policy titled "Patient Identification...", last approved 08/09/2024, revealed "...POLICY: A. This policy establishes a mechanism to assure that all patients of (hospital) are positively identified using two patient-specific identifiers at every encounter. B. Name and date of birth....are the two preferred identifiers....C. Whenever possible, the patient should be asked to state name and date of birth. The patient may also be asked to spell the last name....F. The staff member placing the identification....bracelet on the patient will verify the identity of the patient or have the patient's legal representative do so. ..."

Review of a policy, reference number "PARA.HSC.FB.24", effective 10/21/2024, revealed "...DEFINITION: TRUE OVERLAY/ PATIENT OVERLAY - One individual person/patient's information is mixed in with or on top of another patient's information. This occurs when a patient is registered for a visit or service on another patient's medical record number. PURPOSE:....a standardized method of correcting patient medical records when an overlay has occurred.... The HIMD (Director Health Information Management) will notify.... to review the clinical information in the record on both records for accuracy.... must be remedied within 45 days of the EMPI (Combine) Team's sending of the overlay notification... ."

Medical record review on 09/18/2025 revealed Patient (Pt) #24, a 73-year-old, arrived to the hospital on 08/19/2025 at 0003 via EMS (Emergency Medical Services) as a transfer from an outside hospital. Pt #24 fell off a truck and sustained a pelvic fracture. Record review revealed a "COMBINE" note, signed on 08/20/2024 at 1443, that noted "...This patient had a duplicate Medical Record Number and/or Community Person ID number. A combine was done and the following was changed...._X_ Financial Number.... This patient's encounter was moved.... Incorrect patient chosen during registration."

Review of an "ER Report" service date/time 08/19/2025 at 0018, revealed Pt #24 "...was on top of a barrel of hay and pulling a tarp on it, he lost his balance falling off the truck and landed on his right hip and back. He was taken to an outside hospital, had CT scan (Computed Tomography - type of imaging procedure) of the pelvis showing right pelvic fractures ....He has been unable to stand or bear weight.... Will admit to the hospitalist for pain control, PT/OT (Physical Therapy/Occupational Therapy) and potentially rehab placement. ..." Review of the "Hospital Medicine Admission H&P (History and Physical)", service date 08/19/2025 at 0217, revealed addenda signed 09/10/2025 at 1011(22 days after arrival). The first addendum stated "...Correction to the H&P above: Patient has never smoked tobacco and the problem 'former tobacco use' should be removed from his social history and problem list above." The second addendum noted "Please see corrections to the medical H&P below: Please note and remove the following from the H&P above. There is no prior history of coronary artery disease, no history of peripheral arterial (circulatory condition with narrowed blood vessels and reduced blood flow to the limbs); no history of tobacco use, and no history of hypothyroidism (thyroid gland does not produce enough thyroid hormone), and no history of BPH (Benign Prostatic Hyperplasia - enlarged prostate gland). [space] Past Medical History: Type 2 Diabetes mellitus (chronic disease when the body does not produce enough insulin or does not use insulin effectively resulting in elevated blood sugar), Hypercholesterolemia (elevated cholesterol), Hypertension (elevated blood pressure)... ." An "Orthopedic trauma consultation..." note, originally signed on 08/19/2025 at 1952, revealed an Addendum on 09/17/2025 at 1231 that stated "Please note that due to a clerical error at the time of the original date of service, a portion of the consultation note above contains inaccurate information. Specifically, I have just now been informed that a portion of the past medical history as documented above is inaccurate, and actually applicable to a separate patient of a similar nature. ..." On 08/19/2025 at 1727 an electronic system generated order was for "Order: Chart Merge Notification Order Date/Time 8/19/2025 17:27 EDT.... Order Comment: Immediate medication history and allergy review required due to patient chart merger. ..." The action was documented as complete 08/19/2025 at 2112 (21 hours after the patient's arrival). Review of a "Progress Note", dated 08/19/2025 at 2109 revealed "...Pt has remained in the ED throughout the day....Pt denies significant pain, no med changes or medical issues. Discussed plan of care ....all questions answered. ..." Review of "Allergies - Medications" revealed documentation that allergies were reviewed and validated by an RN on 08/19/2025 at 0013 and were again reviewed on 08/20/2025 at 0734. On 08/20/2025 at 0758, under "Notifications", the note read "...Admission is complete. Med Rec was already done. Med Hx updated for you to review.... has an allergy to codeine. I've added that in. ..." Review of the Discharge Summary, service date/time 08/20/2025 at 1244, revealed an Addendum dated 09/12/2025 at 0229 that noted "Patient has no history of coronary artery disease, BPH, tobacco abuse, peripheral vascular disease. Patient has a history of T2DM (type 2 diabetes) hypertension (high blood pressure), hyperlipidemia presented with pelvic fracture.... fracture was closed by consulting orthopedics and recommended nonsurgical management. His home med list is inaccurate as well. Chart mixup happened at arrival. Patient's med list is inaccurate except for pain medications. Updated medical conditions of her (sic) pelvic fracture, T2DM, HTN (hypertension, high blood pressure) and hypokalemia (low potassium)." Further review of Pt #24's medical record revealed scanned documents from the transferring hospital which noted Pt #24's full given name. It was unclear when these records were received. Patient #24 was discharged on 08/20/2025.

The Triage Nurse was requested but was not available for interview.

Interview with Registration Staff (Staff #34) on 09/19/2025 at 0935 revealed Patient #24 came through the ambulance entrance and was quick registered by the ED HUC (Health Unit Coordinator). Interview revealed "once the doctor has signed up for the patient we (registration staff) can register the patient (complete the registration process)." Interview revealed registration asked patient/family "is this (patient's first name)" and the answer was no. Interview revealed Staff #34 verified that the patient name that was chosen in the system was not the same as the patient currently in the ED. Staff #34 went back out and explained to the HUC and Charge Nurse that the patient name in the system was not the patient in the ED. Staff #34 stated "I cannot register this patient due to this being someone else's chart... last name and date of birth were correct, first name was not correct." Interview revealed they discussed if there was identification that could confirm the correct name; the answer was yes and noted the patient was a transfer. Interview further revealed staff went to the patient's family apologized that they could not register the patient now but would get it fixed. Staff #34 stated the patient's correct name and the incorrect patient name both were listed on the "board". Interview revealed they could not initially register Pt #24 with the patient's correct name because labs and orders had already been recorded in the other record. Interview revealed they "can't do anything, would lose everything." Reg Staff #34 further indicated that Pt #24's armband had the correct sticker placed on top of the armband that had incorrect information.

Telephone interview on 09/19/2025 at 1130 with MD #36, revealed the MD was involved in the care of Pt #24. Interview revealed it was an overnight admission. Interview revealed MD #36 had no idea Pt #24 was registered under the wrong name. MD #36 stated s/he met with the patient only the one time, around 0200 for the admission H&P. Interview revealed physicians went in and did addendums to correct the medical record afterwards.

Telephone Interview with MD #1(a physician leader), also at 1130 on 09/19/2025 revealed MD #1 was notified of the error and reached to MD #36 to discuss it.

Interview with Registration Staff #35 on 09/19/2025 at 1155, revealed Staff #35 remembered another staff member had attempted to register the patient and learned the computer encounter in the system for Pt #24 was incorrect. Staff #35 pulled up the encounter and it was the wrong person. Orders had already been entered. Interview revealed "it is not something I can fix." Staff #35 stated there was a combine team and noted "it's an urgent thing but my only avenue to fix it was to reach out to the team." Interview revealed it happens on a regular basis and "...if orders are already in, it is very difficult to correct. Before orders, the chart can be errored out...quick fix.... If beyond that....has to be dealt with by another group."

Telephone interview with HUC #37 on 09/19/2025 at 1220 revealed Pt #24 came through and EMS gave patient's name and DOB. Interview revealed the HUC did not recall but did not think there was paperwork with the patient. Interview revealed the HUC mostly asked EMS and if unable to locate the name would then get more information. Interview revealed HUC #37 put in the patient's last name, then stated a first name (incorrect first name) and they said yes so that record was selected. A few hours later, the HUC stated, family members came and said it was wrong and gave Pt #24's ID. The patient received a new medical record number and a new bracelet and stickers, interview revealed. HUC #37 indicated the "Combine team" was e-mailed because "they are the ones who do changes." Interview revealed the next day the patient still had two accounts. Interview further revealed tonight "...would still ask EMS ... if can't find ask the patient."

Telephone interview with MD #38 on 09/19/2025 at 1300 revealed the physician recalled the patient and stated that issues like this do happen. The MD stated generally if no orders had been placed they can correct; in this case the issue wasn't caught until a couple of hours later and the orders and consults were already in. Interview revealed MD #38 did not have any concerns related to the misidentification and care. About a week later, MD #38 stated, they received information on revising the record.

Interview with Director #44 on 09/22/2025 at 1545 revealed the process to be followed when a patient was incorrectly registered was for whoever identified the error to send an email to EMPI/Combine team, a corporate team that managed these types of errors. Interview revealed the team was available from 0600 in the morning to about 0100 (unavailable approximately 5 hours each weeknight). Once the EMPI/Combine team got the notification email, they reviewed and would reach back out to the requestor with any questions. Interview revealed Director #44 did not receive e-mails sent to the Combine team. In this particular case the Director received a call from the patient's family voicing concerns and Director #44 got involved. After the medical record was combined, Director #44 reached out to clinical leaders until all notes in the medical record had been reviewed and corrected.

Interview on 09/23/2025 at 1425 with ED Manager #39 revealed that when the manager arrived to work around 0600 on 08/19/2025, and the issue related to the patient and misidentified name had not been corrected. Interview revealed a message had gone to the combine team earlier and the manager tried sending the information to them again. Later in the day it was still unresolved and Manager #39 escalated it, first to the House Supervisor, then the ED Director. At 1700, the VP was notified, who immediately escalated it farther and it got resolved. Manager #39 stated both charts were up and working, the charts just needed to be merged. Interview further revealed that Manager #39 did not know the processes that were being followed at the time.

Telephone interview on 09/23/2025 at 1510 with RN #40 revealed when RN #40 came on duty at 1500, there was a patient with 2 charts, Pt #24. The orders and Medication Administration Record (MAR) remained in the incorrect record. There were no medication orders or MAR under the correct patient named record. The patient had a corrected ID bracelet on but could not scan the bracelet because the orders were in the incorrect record. RN #40 needed to give medications to Pt #24 so the nurse had a second RN verify the medication to ensure it was correct. Interview revealed RN #40 documented the medication in the MAR of the incorrect record with the note of a second verifier. In the correct patient record, interview revealed, the RN wrote a nursing note indicating medication was administered and called the hospitalists who said they would put orders in the correct chart.

Based on review of hospital policies and procedures, closed medical records, video review, the facility investigation, CMU (Central Monitoring Unit) documentation, and staff interviews, the hospital failed to ensure adequate staff was available to assess and respond to a monitored telemetry patient with leads off and the patient subsequently expired for 1 of 32 patients reviewed (Patient #14).

The findings include:

Review of hospital policy titled "Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring" last approved 06/04/2025 revealed " ...PURPOSE ... C. Identify which rhythms or arrhythmias require RN (registered nurse) notification/intervention and identification of proper escalation procedures ...ALARM RESPONSE AND ESCALATION PROCESS A. ...a defined escalation pathway is used to ensure timely notification and treatment ...II. Rhythm Transmitting with ...Leads Off ... A. First Escalation Attempt: 1. MTII (monitor tech) calls Primary Nurse. 2. Within 5 minutes the Primary Nurse will assess the patient and call the monitor tech and give an update ...4. The MTII records the notification ... B. Second Escalation Attempt: 1. If unable to reach Primary Nurse or unresolved within 5 minutes from the time of initial notification, the MTII call the Primary Nurse again and enter notification time ... C. Third Escalation Attempt: 1. If unable to reach Primary Nurse, or unresolved after 5 minutes, the MTII will call the CNC (clinical nurse coordinator)/Relief Charge Nurse. 2. If no resolution after 1 minute, send broadcast to unit. 3. If no resolution after 2 minutes, start escalation over until resolved.

Review of hospital policy titled "Assessment and Reassessment" last approved 05/13/2025 revealed "Purpose The organization assesses and reassess the patient and the patient's condition according to defined timeframes ... Policy ... C. The assessment process is a continuous, collaborative effort with departments functioning as an interdisciplinary team ... Assessment Framework A ...2. As individual patient condition changes ... Interdisciplinary Plan of Care (IPOC) ...D. Nursing maintains the responsibility and accountability ..."

Review of hospital document titled "ADULT INTERMEDIATE CARE STANDARDS OF CARE GUIDELINES-NURSING", revealed " ...Reassessment intervals and parameters are presented as the minimum times, measurements, and evaluation criteria ... Patient Rounding A. Safety Rounds to occur as recommended - every 1-2 hours ... Safety A. The patient can expect appropriate safety precautions while in the hospital ..."

Closed medical record review revealed Patient (Pt) #14 was a 72-year-old male readmitted on 07/23/2025 at 1715 for shortness of breath and chest pain. At 1742 there was an order for telemetry monitoring. Per documentation the patient was placed on telemetry and telemetry tech was notified. On 07/26/2025 at 0021 vital signs revealed temperature 98.1 (oral), heart rate (HR) 76, blood pressure (BP) 99/57, (oxygen saturation) SpO2 93% on 60L (liters) oxygen (O2) high flow humidified. At 0320 the (registered respiratory therapist) RRT documented the patients HR 78, respirations (RR) 18, SpO2 93% on 60L O2 high flow humidified. Review of a Provider Note at 0415 revealed "CODE BLUE called overhead on this patient ... Was not notified by staff of any issues overnight or notified of patient being found on the floor prior to CODE BLUE being called. CPR was in progress when I walked in the room. Per the patients nurse, he was found on the floor without his Vapotherm (high flow humidified O2) on and without telemetry on for an unknown period of time ... During discussion with Dr. (named) it was decided to stop the code as we never obtained a pulse. Time of death was called at 0403 ..." Review of the Code Blue documentation revealed code time started at 0347, the patient was intubated at 0354, and the code stopped at 0403. Record review failed to reveal that a bed/chair alarm was documented on the evening shift of 07/25/2025.

Review of video footage dated 07/26/2025 revealed footage of unit 4 heart. Review revealed a view of the nursing station, a hallway view of Patient #14's room (E433). From 0012 through 0024 staff were noted to be in Patient #14's room and the 2 staff members exited at 0024. At 0231 a female staff (identified as CNC #14) was seen sitting at the nurse station computer. At 0305 a male staff (identified as [registered respiratory therapist] RRT #21) entered the patient's room and was seen exiting the room also at 0305. At 0313 CNC #14 still observed at nurse station, observed answering the desk phone. At 0322 CNC #14 left the nurse station and walked to another patient's room. At 0346 male staff (identified as unit PCT) entered Patient #14's room. At 0348 the code team arrived via stairwell. Review did not reveal any nursing staff in Patient #14's room between 0024 and 0346, only the Respiratory Therapist at 0305.

Review of the facility investigation on 09/18/2025 at 1535 with Director #13, Director #9, and Nurse Administrative Staff (AS) #6 revealed a timeline of events. The timeline revealed on 07/25/2025 at 1900 an RN rounded on the patient and noted no distress. On 07/26/2025 at 0012 staff were in the patient's room. At 0242 the RN was notified by the CMU tech (central monitoring unit technician) that the telemetry leads were off. At 0244 the RN was notified by the CMU tech again. At 0305 the RRT rounded on the patient and noted no distress. At 0309 the CMU tech sent a text to the RN. At 0312 the CMU tech notified the CNC to reinforce the leads. At 0317 the CMU tech called the RN but did not get an answer. At 0320 the RRT documented HR 78, RR 18, SpO2 93%, Vapotherm at 60L/minute. At 0326 CMU tech called the CNC. The CNC told the CMU tech they were in a rapid response and would get to the patient after they transferred the rapid response patient off the unit. At 0341 the CMU tech reached out to the PCT (patient care technician) asking for the telemetry leads to be checked. At 0345 the PCT entered the room and found the patient on the floor. At 0347 a Code Blue was initiated. At 0354 the patient was intubated. At 0403 the Code ended. Further interview revealed that the RRT was interviewed after the incident. The RRT entered the patient's room at 0305 the RRT noted the patient was resting and did not have his telemetry leads on. The RRT used his pocket pulse oximetry to assess the patients SpO2 and noted the RRT had no issues and that he assumed the RN was aware of the leads being off and would get to them. Interview revealed that the CMU tech was interviewed after the incident. The CMU tech revealed that the RN stated someone would get to the patient, so the CMU tech was giving the RN the benefit of the doubt.

Review of CMU tech documentation on 07/26/2025 revealed at 0242 the RN was notified leads were off. At 0309 "called no answer left text". At 0312 RN notified. At 0326 "called rn [sic] she said we will get pt we are transporting right now." Per an interview with AS #6 the CMU tech did not write down all communication between the RN and CMU tech.

Interview on 09/18/2025 at 1020 with AS #6 revealed that the CMU techs have different escalation pathways to follow depending on the situation. Interview revealed that when all the leads were off the patient needs to be evaluated by the primary RN/nursing staff. When there was no resolution by nursing staff the CMU tech should reach out to the CNC. If no resolution, then the CMU tech calls an overhead telemetry alert page throughout the specific unit. The escalation process should be repeated until there was a resolution. The expectation of the overhead call was for all staff to respond. Interview revealed that on 07/26/2025 the CMU tech reached out to the RN and CNC but they were busy with another rapid response patient. Interview revealed when there was no resolution the CMU tech did not follow the escalation pathway and call overhead, nor did the RN delegate the responsibility to get the patient assistance.

Interview on 09/22/2025 at 1415 with CNC #14 revealed the CNC recalled the patient and incident. Interview revealed that the CNC was not aware that the patient was off telemetry until CMU called the CNC and by that time the CNC was in the rapid response. The CNC stated that she informed CMU they were in a rapid response and to call overhead and CMU said ok, but the CNC did not recall if that happened. The CNC stated she was not aware that CMU had been calling the primary RN because the RN didn't tell the CNC or delegate someone to check on the patient. Interview revealed that on the (named) unit all the RNs are paired with a buddy and that the primary RN should have called the buddy to check the patient. The CNC stated that the RN buddy was not in the rapid response and should have been available. Interview revealed that telemetry monitors can also be seen at the nurse station. The CNC did not recall any unit staff member on 07/26/2025 mention seeing the patient in E433 off of his telemetry monitor. Interview revealed that during the Code Blue debrief the RRT mentioned he told someone about the patient leads being off, but the CNC was not aware of the RRT alerting anyone. Further interview revealed that during the day shift rounding should take place every hour, and overnights between 10pm and 6am, the patient should be rounded on every two hours by either the RN or PCT. Interview revealed that the staffing ratio on the unit was one RN to five patients. On 07/26/2025 the CNC recalled that none of the RNs had more than five patients. Interview revealed that although the staff were within ratio the CNC felt the unit still had a staffing shortage and while staff do their best to provide care, it was not always safe care.

Based on policy review, observation, medical record review and staff and provider interviews, nursing staff failed to supervise and monitor care for 2 of 32 patients reviewed by failing to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport (Pt #10) and failing to prevent and control infections. Nursing staff failed to identify and communicate accurate and timely COVID precautions on an inpatient unit creating an unsafe environment for patient care (Pt #34) and exposure to COVID.

The findings include:

1. Review of hospital policy, "Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring - 1PC.NRS.0001," effective 08/19/2025, revealed, " ... III. Transport of Monitored Patients. 1. Interruption in cardiac monitoring should not occur during transport for patients with active orders for telemetry monitoring. a. Patients with active monitoring orders should continue to be remotely monitored, and the Monitor/Telemetry Technician should be notified of unit travel, destination, primary contact for duration of travel, and anticipated time of return ..."

Review of hospital policy, "Assessment and Reassessment, 1PC.ADM.0013," effective 05/13/2025, revealed, " ... 6. The interdisciplinary team provides information concerning patient assessment relevant to their scope of care, as well as areas of concern or patient special needs. Further assessment and reassessment is based on their plan of care or changes in their condition ... Reassessment may be at specified/regular intervals, triggered by key decision points, and at any interval(s) specified by the departments/ancillary disciplines directly involved in providing patient treatment and/or care ..."

Review of hospital Guidelines for Patient Transport revealed, " ...If a patient's condition appears to be questionable, always let the nurse know that you are non-clinical staff and ask if they feel that it is safe for you to transport the patient ..."

Observation of a patient elevator from the Emergency Department (ED) to a Stepdown unit on 09/19/2025 at 1345 revealed an alarm button in the elevator which rang only in the immediate elevator area. Observation revealed a red phone button in the elevator; an operator answered after approximately 45 seconds and asked if assistance was needed.

Observation of the Emergency Department (ED) on 09/23/2025 at 1159 revealed a patient was switched from ED telemetry monitoring to the CMU (Central Monitoring Unit) for monitoring during transport to inpatient holding. Observation revealed the portable telemetry box did not display a visual or have an audible alarm for any changes during transport.

Closed medical record review on 09/17/2025 for Patient #10 revealed a 48-year-old presented to the Emergency Department (ED) on 09/04/2025 at 1441 with complaints of chest pain and shortness of breath. The patient's pain was documented at 1442 as 8 out of 10. The Provider's MSE (Medical Screening Exam) Note at 1445 revealed, "Patient with chest pain and shortness of breath. On home oxygen normally. chest tube in place. Patient is alert, in no acute distress but is moaning in discomfort." The patient's oxygen saturation (O2 sat) at 1446 was 97% and at 1500 was 90%. The ED Provider's Note at 1534 revealed the patient had a history of metastatic lung cancer with a chest tube on the right with "chronic pain at the tube site now with worsening shortness of breath for the past day." The patient's O2 sat at 1630 was 92%, and the patient was placed on 3 liters of oxygen via nasal cannula. The patient's O2 sat at 1715 was 93%. An order for Morphine (a pain medication) 4 milligrams IV (intravenous) was placed at 1729. An order was placed at 1731 for continuous pulse oximetry (measures how much oxygen is in the blood for uninterrupted periods). The patient's O2 sat at 1745 was 89% and at 1750 was 90%. A broadcast notification was sent to the Stepdown unit at 1803 with the room number the patient was assigned to and the box number for continuous pulse oximetry. The patient's blood pressure at 1807 was 84/57 with a comment by the Nurse that the Provider was notified at that time. The patient's pain was assessed at 1808 as 10 out of 10. A comment was documented on the MAR (Medication Administration Report) at 1809 that Morphine was not given as the patient's blood pressure was "too low to administer," and the Provider was notified. The patient's oxygen was increased to 4 liters at 1820 with an O2 sat of 94%. ED Nurse Note at 1830 revealed the patient was transported by transport staff. The patient was on an "O2 monitor, awake and alert. Prior to patient leaving emergency department this RN (Registered Nurse) spoke with transport leadership regarding blood pressure parameters for transport personnel. Transport leadership stated, 'We do not have parameters for blood pressure as long as you feel patient is stable for transport' ..." The patient's O2 sat prior to transport at 1830 was 93%. Record review failed to reveal documented evidence of the patient's heart rate and O2 sats during transport and failed to reveal documented evidence of the patient's time of arrival to the unit and initial O2 saturation on the unit. Review of a Code Record revealed a code blue (the initiation of resuscitative efforts in a cardiac or respiratory arrest) was called with initiation of CPR (cardiopulmonary resuscitation) at 1842 and initial ECG (electrocardiogram, a noninvasive test that records the electrical activity of the heart) rhythm of asystole (no heartbeat). Check boxes for the initial condition were selected as "Yes" for conscious, breathing, and pulse, as well as "Witnessed Arrest." A check box for "Monitored" was selected "No." The patient was intubated at 1853, and a rhythm of PEA (Pulseless Electrical Activity, a condition where the heart is still producing electrical signals, but there is no pulse or blood pressure) was noted at 1901. Discharge Summary dated 09/06/2025 at 2226 revealed the patient was admitted to a medical floor for further evaluation and management of acute respiratory failure. The patient "coded as soon as she transferred to the medical floor ..." and was pronounced dead at 1907 on 09/04/2025.

Interview on 09/18/2025 at 1335 with RN #26 revealed Patient #10 was transported from the ED and was brought to their assigned room. Interview revealed Staff #7 called for help, because "something did not look right." A Nurse in the hallway responded and hit the Staff Assist button in the room, which sent an overhead alarm and blinked red outside the room. RN #26 responded at that time and observed the patient on the stretcher, and the patient appeared to be having seizure-like activity. The patient had their head back and was convulsing. RN #26 revealed the patient was moved to the bed, a code blue was called, and chest compressions were started immediately. Interview revealed Staff #7 reported the patient had been speaking to their family member in Spanish during transport, and when they arrived to the patient's room on the Stepdown unit, the seizure-like event occurred.

Telephone interview on 09/19/2025 at 0939 revealed nursing staff had "huge concerns" with signal loss in the elevators for their patients on remote telemetry.

Interview on 09/19/2025 at 1713 with Director #8 revealed Staff #7 reported RN #27 called the transport dispatch to ask if there were blood pressure parameters for transport and was informed there were not parameters for blood pressure. Staff #7 then transported Patient #10 to the Stepdown unit. When Staff #7 arrived to the unit, the Nurse was not in the patient's room, so Staff #7 pressed the call bell to alert the Nurse the patient had arrived. Interview revealed Patient #10 was in pain, so Staff #7 stepped out in the hallway to ask for help and a Nurse in the hallway responded. Staff #7 informed Director #8 that Patient #10's family was present, and assisted with translation from Spanish that the patient was in pain during transport.

Telephone interview on 09/22/2025 at 1422 with Staff #7 revealed Patient #10 had a family member with them at the bedside who assisted with translating from Spanish for Patient #10. Interview revealed Patient #10's family verified the patient's name and date of birth in English for Staff #7. Staff #7 revealed RN #27 asked if there were blood pressure parameters for transport, but Staff #7 was unaware of any parameters for blood pressure. Staff #7 called the transport dispatch, put them on speaker phone, and was informed there were not blood pressure parameters for transport. Transport dispatch informed RN #27 that the patient must be stable for non-clinical staff to transport; RN #27 checked the blood pressure again and signed off on Staff #7 transporting the patient. Staff #7 was not aware of any alarm that could be heard with the telemetry box during a patient's transport. Staff #7 revealed when they were in the elevator, the patient was moaning in pain and spoke in Spanish to their family. The family then translated in English to Staff #7 that the patient was in pain; Staff #7 reassured the patient and family that Staff #7 would get the patient help. Interview revealed when they arrived to the Stepdown unit, the patient was still moaning in pain, and the family asked, "Can you please help? You're a Nurse." Staff #7 informed the family they were not a Nurse but would get the patient help. Staff #7 noticed the patient showed signs of a seizure, and the family was "frantic, asking for help." Staff #7 pushed the Staff Assist button on the wall and stepped into the hallway for help. A Nurse approached and asked if they needed help, and then staff "were coming from everywhere into the room." Staff #7 then stepped out into the hallway, the stretcher was pushed out of the room, and Staff #7 was informed that they could leave.

Interview on 09/23/2025 at 0925 with RN #27 revealed Patient #10 had a significant other at the bedside, and RN #27 spoke in Spanish to them. RN #27 revealed the patient's blood pressure had dropped a little, and MD #28 had ordered fluids. Interview revealed the patient's blood pressure was not "at standard to give" Morphine. RN #27 revealed the patient was complaining of pain in the ED; RN #27 explained to the patient and their significant other that RN #27 could not give Morphine due to their blood pressure. Interview revealed the patient complained of generalized pain and stated, "everywhere hurts." Interview revealed RN #27 called the CMU prior to Staff #7 transporting the patient to ensure the CMU could visualize Patient #10 on their O2 monitor. The CMU verified visualization and provided the patient's heart rate and O2 sat. RN #27 did not recall the exact values but stated they were within normal limits. RN #27 revealed the telemetry boxes for transport did not have an alarm.

Telephone interview on 09/23/2025 at 1313 with Tech #5 revealed they recalled RN #27 called to verify the pulse ox for Patient #10 could be visualized by the CMU prior to transport from the ED to a Stepdown unit. Interview revealed they were on the phone for a few minutes troubleshooting the pulse ox probe as there were issues with the signal going in and out. Interview revealed Wi-Fi connection issues, such as the signal cutting in and out, could occur when a patient was transported. Tech #5 revealed during Patient #10's transport, the signal was again cutting in and out, and there was not a solid reading. Tech #5 revealed there were drops in Patient #10's O2 sats, but they could not get a clear reading due to signal issues. Interview revealed the CMU pod was very busy that day as there were multiple patients being transferred and admitted, as well as multiple escalations at that time. Tech #5 revealed any time there were O2 sats dropping or signal loss, the monitor techs should notify the Nurse as soon as they see it with a resolution time of 5 minutes. Interview revealed the Stepdown unit was not notified that Patient #10's pulse oximetry had signal issues, a loss of signal during transport, or drops in the patient's O2 sats.


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2. A tour of the pulmonary medical unit was conducted 09/18/2025 at 1320. Prior to tour hospital staff noted the unit had served at one time as a COVID unit. The staff stated there were currently no (zero) COVID patients on the unit. Observation during the tour revealed some patient rooms were labelled with contact precaution signs, including Pt #34's room. Observation did not reveal any signage for enhanced COVID precautions and hospital staff again indicated there were no current COVID patients on the area being toured.

Medical record review for Patient #34, an inpatient on the unit during tour, revealed Patient #34 arrived to the ED and was admitted 09/16/2025. Medical record review revealed Pt #34 was tested for COVID, among other infectious diseases, and the COVID PCR resulted postitive on 09/16/2025. Review confimed Patient #34 was COVID positive on 09/18/2025 at the time of the tour.

According to hospital data, fifteen staff were assigned or potentially exposed to COVID.

Family interview 09/18/2025 indicated hospital staff failed to inform the family of a COVID positive PCR on 09/16/2025 and appropriate precautions until 09/18/2025.

Interview on 09/19/2025 at 1425 with Director #47 revealed the enhanced precaution sign was in place until the morning of 09/18/2025 when the order was cancelled in error. Interview revealed enhanced COVID precautions included a N95 respirator (protective device designed to achieve a very close facial fit and efficient filtration of airborne particles) among other protective devices.

Interview on 09/26/2025 at 1830 with Director #47 and Nursing Adminstrative Staff (AS) #46, revealed the signage error occurred due to a computer programming error where the isolation precautions were changed to contact based on a different positive result and overrode the enhanced isolation sign order. Interview revealed that should not have happened, the enhanced isolation precautions should have remained in place. The patient's nurse, interview revealed, acknowledged the computer order for contact precautions and removed an enhanced precaution sign, replacing it with a contact isolation sign. Interview revealed an infectious disease doctor came in later that day, noticed the discrepancy and reordered and implemented the enhanced COVID precautions.

In summary, there was no indication nursing staff were aware of a COVID positive patient on the unit before or during the observational tour since no one acknowledged a current COVID patient. There was no evidence nursing understood the need to question a change in the isolation precautions for a COVID positive patient. It was a physician who discovered and corrected the precautions.

Based on review of policy, medical records and staff and provider interviews, hospital nursing staff failed to follow policies to evaluate a patient's change in condition requiring emergent treatment for 1 of 32 sampled patients (#17) and failed to follow post procedure guidelines following a heart catheterization for 2 of 32 sampled patients (#17, #15)

The findings include:

1. Review of hospital policy titled "Assessment and Reassessment" last approved 05/13/2025 revealed "Purpose The organization assesses and reassess the patient and the patient's condition ... Policy ... C. The assessment process is a continuous, collaborative effort ... Assessment Framework A ...2. As individual patient condition changes ...D. Nursing maintains the responsibility and accountability ..."

Review of policy on 09/25/2025 titled "Clinical Documentation" with revision date of 07/26/2024, revealed "Purpose: A. Provides guidelines for documentation of patient care, patient data, and patient outcomes within the electronic medical record, by members of the clinical team as indicated.... Clinical documentation should be: 1. Completed during or immediately after care is provided, if possible, but not to exceed end of shift.... Documentation is: ...2. Based on professional observation and assessment. 3. Individualized to identify problems and actions taken. 4. Based on the patient's current status...."

Closed medical record review on 09/15/2025 of Patient #17 revealed a 69 year old female transferred from an outside facility on 06/07/2025 at 1752 via EMS to be evaluated for "NSTEMI (Non ST elevation Myocardial Infarction--possible heart attack without ST elevation of the ST waves on the heart monitor) and SEPSIS" Patient arrived at the ED (emergency department) with complaints of nausea after a fall 2 days prior. Patient #17's past medical history included afib (atrial fibrillation--irregular rhythm of the heart with inadequate pumping) with ablation (procedure to attempt to place the heart in normal rhythm) and hypertension.

Review of the patient's medical record revealed on 06/09/2025 at 0740 vital signs were documented as HR 124 (elevated) Temperature 102 (elevated), oxygen at 2 liters with pulse Oximetry at 90% (normal is 90 or above). At 0743, an order for an EKG (Electrocardiogram--tracing of the heart rhythm) was received from MD #45. At 0750 Tylenol was administered for elevated temperature by RN #25. At 0753, the EKG was completed. The results of the EKG were: "ST elevation more prominent. Sinus tach (tachycardia--fast heart rate) with occasional PVCs (premature ventricular contractions--abnormal rhythm). Old MI (myocardial infarction--heart attack). Abnormal EKG." Review of a communication from the Central Monitoring Unit (CMU) dated 06/09/2025 at 0758 revealed, "getting EKG per (RN #25). Freq (frequent) atrial and ventricular ectopy (irregular heart rhythm). The RN daily shift assessment was completed at 0800 by RN #25, noting "CV (cardiovascular) irregular. Diaphoretic." Review of the record revealed no evidence of notification to the physician regarding the EKG results. Review of the medical record, timed at 0840, revealed a Rapid Response was called (Rapid Response--emergency team to assist with patient's emergency). Review of a Rapid response note documented at 0840 stated: "Source of RRT (Rapid Response Team). Nurse request. Rapid response reason: Staff generalized concern. Husband requested the Rapid Response team be called. Increase in ST elevation. Noted elevated fevers decreasing plt (platelet) ct (count) down to 42 on a heparin (anticoagulant medication) gtt (drip) po (by mouth) ASA (Aspirin) given. Code STEMI (Process to alert emergency team to assist with heart attack patient.) ST elevation Myocardial infarction--heart attack with abnormal rhythm on the EKG) called and cath (Heart catheter department) lab at bedside to take pt (patient) to cath lab. We brought the husband to the cath lab waiting area." Review of the provider orders revealed at 0842 (two minutes after the rapid response was called), a cardiac cath was ordered by the Nurse Practitioner (NP #3). Patient #17 was taken to the cath lab for a cardiac catherization. Review of the record (nursing or progress notes) revealed no assessment of the patient's condition from the NP or nursing staff to describe the condition of the patient. The patient was taken to the cardiac cath lab at 0855. Review of the cardiac cath revealed "Pattern typical for Takotsubo cardiomyopathy (known as broken heart syndrome--a heart condition that causes a sudden weakening of the heart's pumping function). Review revealed no evidence of an assessment of the patient's change in condition or evaluation of the patient when the rapid response was called. Review revealed no notes from the nurses or provider during the rapid response.

Interview on 09/17/2025 at 1545 with RN #25, the patient's primary nurse, revealed there was no notification to the provider of the patient's EKG results and no documentation of the patient's change in condition. The nurse stated she would usually assess and document a patient's change in condition and abnormal results. The nurse was unable to remember the patient.

Interview on 09/18/2025 at 1115 with RN #2, Nursing Director, revealed no assessment or evaluation of the patient's change in condition or notification to the provider regarding the EKG results. Interview revealed the hospital policy was not followed.

Interview with NP #3 on 09/18/2025 at 1550 revealed NP #3 may have received a phone call for concerns about Patient #17, but did not recall. Interview revealed NP #3 did not have an explanation regarding the lack of documentation of assessment and treatment for Patient #17 during the Rapid Response.

Interview on 09/18/2025 at 1600 with MD #1 revealed no assessment documentation from the NP was located in Patient #17's medical record.

Interview on 09/18/2025 at 1215 with RN #2 revealed vital signs were not taken per policy. Interview revealed no documentation of the occlusive dressing being placed on the puncture site. Interview revealed policy was not followed.

2. Review on 09/16/2025 of Guidelines titled "Radial Compression Band (TR Band) Radial Compression Device Removal Guidelines" with a "Created" Date of "Feb 2018" revealed "For Diagnostic cases, the TR band should be left on with appropriate compression for 1.5 hours post procedure or as ordered by Physician....Assess and document vital signs, site condition, pulse, color, temperature, sensation, capillary refill q (every) 15 x 4 (4 times), q 30 x 2 (2 times), q hr x 4 (4 times). NOTE*While the TR band is in place, an oxygen saturation probe must be placed on the patient's thumb/pointer finger to monitor adequate hand perfusion .... REMOVAL PROCESS: 1. Once it is time to remove the TR Band, withdraw 3 ml (milliliter) of air over 1 minute observing for bleeding. Observe for additional 1 minute for bleeding after each 3 ml of air removed. Repeat every 10 minutes until band is fully deflated. Perform site condition, pulse, color, temperature sensation and capillary refill checks q 15 x 2. (In addition to post procedural vital signs) .... 2. Once TR band is completely deflated and homeostasis is maintained: Leave deflated band in place for 1 hour and continue to perform post procedure vital signs and site checks. Remove and discard TR band after 1 hour and place a protective covering (Tegaderm--clear occlusive dressing) over the radial percutaneous site. Inpatients: continue to evaluate the site for bleeding/hematoma q 15 x 4, then per unit routine. 3. The patient should be instructed not to manipulate the wrist for 48 hours....."

2a. Closed medical record review on 09/15/2025 of Patient #17 revealed a 69-year-old female transferred from an outside facility on 06/07/2025 via EMS to be evaluated for "NSTEMI (Non ST elevation Myocardial Infarction--possible heart attack without ST elevation of the ST waves on the heart monitor) and SEPSIS." Patient #17 was sent to the Cardiac Catheterization Lab on 06/09/2025 at 0855 and returned to the patient's room at 0950. Review of documentation of the TR band revealed the TR band was placed on the patient at 0926. Vitals signs were documented every 15 minutes times 4 between 0945 and 1030. Assessment of the site condition, color, temperature, sensation and capillary refill was not documented every 15 minutes times four as the policy requires. Vitals signs were documented every 30 minutes times 2 at 1100 and 1130. Assessment of the site condition, color, temperature, sensation and capillary refill was not documented every 30 minutes times two as the policy requires. Vitals signs were not documented every one hour times 4 between 1230 and 1530. Vital signs due at 1330, 1430 and 1530 were not done as per the policy. Assessment of the site condition, color, temperature, sensation and capillary refill was not documented every one hour times four as the policy requires. The assessment was not documented at 1230, 1330, 1430 or 1530. Review of the removal of air from the TR Band started at 1200 with 4 milliliters (ml) of air removed (not consistent with the required 3 ml of air to be removed). There was no documentation of the observation for bleeding at the site for one minute after the air withdrawal. Three ml of air was due to be removed at 1210; however the air was removed at 1215 (not consistent with the policy); three ml of air was due to be removed at 1225; however no air was removed at 1225 (not consistent with the policy); three ml of air was due to be removed at 1235; however no air was removed at 1235 (not consistent with the policy); ); three ml of air was due to be removed at 1245; however no air was removed at 1245 (not consistent with the policy); ); three ml of air was due to be removed at 1255; however no air was removed at 1255 (not consistent with the policy); five ml of air was removed at 1300 (not consistent with the policy that requires only three ml of air to be removed). The TR Band was deflated at 1300. The policy requires the TR Band to remain in place for one hour after it is deflated with vital signs and site assessments to be assessed every 15 minutes times two. Vital signs and site checks were due at 1315 ad 1330. Review revealed the vital signs and site assessments were not done at 1315 and 1330 (not consistent with policy). Review of the record revealed no documentation of a site assessment through 2307 on 06/09/2025. Review of documentation of the TR Band revealed no documentation that an occlusive dressing on the puncture site was applied (not consistent with the policy). In summary, the vital signs and assessment of the puncture site were not completed as per policy. The TR Band was not deflated per policy. The occlusive dressing was not placed on the puncture site per policy.

Interview on 09/18/2025 at 1215 with RN #2 revealed vital signs and site assessments were not done per policy. Interview revealed the deflation was not done according to the policy. Interview revealed no documentation of the occlusive dressing being placed on the puncture site. Interview revealed the policy was not followed.

2b. Open medical record review on 09/18/2025 of Patient #15 revealed a 45-year-old male admitted on 09/13/2025 for chest pain after a fall. Patient #15's admitting diagnosis was NSTEMI, type I versus type II and ground level fall. Patient #15 was sent for a left heart cardiac catheterization on 09/15/2025 at 1508. Review of documentation of the TR band revealed the TR band was placed on the patient on 09/15/2025 at 1525. The TR Band was to remain in place one and one-half hours per policy before the air withdrawal process was to be started. The deflation was scheduled to start at 1655. Review of the record revealed the TR Band deflation was started at 1545 (20 minutes after the band was applied - not consistent with policy). Vital signs and site assessments were to be done every 15 minutes times four (due at 1525, 1540, 1555, and 1610). The patient's vital signs were not done per policy between 1525 and 1610.
The deflation started at 1545, and the patient was to have 3 ml of air removed every ten minutes until the TR Band was fully deflated per the policy. Three ml of air was due for removal at 1555, 1610 and 1620. Review revealed 3 ml of air was removed at 1600 (not consistent with policy), four ml of air was removed at 1615 (not consistent with policy). The TR Band was fully deflated at 1615. Per policy the TR Band should be left deflated for one hour (due to be removed at 1715). Per policy, vital sign assessments should be continued every 15 minutes times two. Vital signs were due at 1630 and 1645. Record review revealed vitals were documented at 1748 (not consistent with policy). The occlusive dressing was not placed on the puncture site per policy.

Interview on 09/18/2025 at 1500 with RN #30 revealed the vital signs and deflation of the TR Band were not obtained according to policy. Interview revealed the occlusive dressing was not documented. Interview revealed the policy was not followed.

An interview for the primary nurse was requested. An interview was not obtained.

Based on review of policies, medical records, and interviews with staff, the provider and nursing staff failed to document during a patient's change in condition for 1 of 1 patients who received a rapid response. (Patient #17).

The findings include:

Review of policy on 09/25/2025 titled "Clinical Documentation" with revision date of 07/26/2024, revealed "Purpose: A. Provides guidelines for documentation of patient care, patient data, and patient outcomes within the electronic medical record, by members of the clinical team as indicated by scope of practice....General Information: A. Clinical staff have a professional obligation to maintain documentation that is timely, clear, concise, comprehensive, and that is an accurate source of information. Clinical documentation should be: 1. Completed during or immediately after care is provided, if possible, but not to exceed end of shift. 2. Completed by the clinical team/caregivers evidenced by signature for paper documentation or login for electronic documentation. 3. Factual, accurate and objective. 4. Prefaced with date and time of care to include recording of late entries, corrections or additions. B. Documentation is patient-centered, focused, and appropriate to the setting in which care is provided. Documentation is: ...2. Based on professional observation and assessment. 3. Individualized to identify problems and actions taken. 4. Based on the patient's current status and preferences...."

Closed medical record review on 09/15/2025 of Patient #17 revealed a 69 year old female transferred from an outside facility on 06/07/2025 via EMS (Emergency Medical Services--ambulance) to be evaluated for "NSTEMI and SEPSIS (Non ST elevation Myocardial Infarction--possible heart attack without ST elevation of the ST waves on the heart monitor)." Patient arrived at ED (Emergency Department) at 1752 with complaints of nausea after a fall 2 days prior. Patient #17's past medical history included afib (atrial fibrillation--irregular rhythm of the heart with inadequate pumping) with ablation (procedure to attempt to place the heart in normal rhythm) and hypertension.

1. Review of documentation of rapid response written by Rapid Response Nurse #29 on 06/09/2025 at 0840 revealed "Source of RRT (Rapid Response Team) Activation: Nurse request. Rapid Response Reason for Call: Staff generalized concern. Husband requested the Rapid Response team to be called--increase in ST elevation--Noted elevated fevers decreasing plt (platelet) ct (count) down to 42 on a heparin gtt (drip) po (by mouth) asa (aspirin) given..Code stemi (st elevated myocardial infarction--heart attack) called and cath Lab at bedside to take pt to cath lab--We brought the husband to the cath lab waiting area." Review revealed no nurses notes of change in condition for Patient #17. Review revealed no nurses notes for rapid response team interventions.

Interview on 09/17/2025 at 1545 with RN #25 revealed there was no documentation of change in condition or notification of the provider.

Interview on 09/18/2025 at 1115 with RN #2 revealed no documentation of change in condition or notification of the provider. Interview revealed documentation was incomplete.

2. Review revealed an order written on 06/09/2025 at 0842 by NP (Nurse Practitioner) #3 for Cardiac Catheterization. Review revealed no provider notes or documentation of the change in condition of Patient #17. Review revealed no assessment from NP #3 of Patient #17.

Interview on 09/18/2025 at 1550 with NP #3 revealed NP #3 may have received a phone call for concerns about the Patient #17. Interview revealed no NP documentation of the assessment of Patient #17.

Interview on 09/18/2025 at 1600 with MD #1 revealed no assessment documentation from the NP was located in Patient #17's medical record.

Based on policy review, internal document review, observation, closed medical record review, and staff interviews, the Emergency Department (ED) staff failed to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport from the ED to an inpatient unit for 1 of 12 ED patients reviewed (Patient #10).

The findings include:

Review of hospital policy, "Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring - 1PC.NRS.0001," effective 08/19/2025, revealed, " ... III. Transport of Monitored Patients. 1. Interruption in cardiac monitoring should not occur during transport for patients with active orders for telemetry monitoring. a. Patients with active monitoring orders should continue to be remotely monitored, and the Monitor/Telemetry Technician should be notified of unit travel, destination, primary contact for duration of travel, and anticipated time of return ..."

Review of hospital policy, "Assessment and Reassessment, 1PC.ADM.0013," effective 05/13/2025, revealed, " ... 6. The interdisciplinary team provides information concerning patient assessment relevant to their scope of care, as well as areas of concern or patient special needs. Further assessment and reassessment is based on their plan of care or changes in their condition ... Reassessment may be at specified/regular intervals, triggered by key decision points, and at any interval(s) specified by the departments/ancillary disciplines directly involved in providing patient treatment and/or care ..."

Review of hospital Guidelines for Patient Transport revealed, " ...If a patient's condition appears to be questionable, always let the nurse know that you are non-clinical staff and ask if they feel that it is safe for you to transport the patient ..."

Observation of the ED on 09/23/2025 at 1159 revealed a patient was switched from ED telemetry monitoring to the CMU (Central Monitoring Unit) for monitoring during transport to inpatient holding. Observation revealed the portable telemetry box did not display a visual or have an audible alarm for any changes during transport.

Closed medical record review on 09/17/2025 for Patient #10 revealed a 48-year-old presented to the Emergency Department (ED) on 09/04/2025 at 1441 with complaints of chest pain and shortness of breath. The patient's pain was documented at 1442 as 8 out of 10. The Provider's MSE (Medical Screening Exam) Note at 1445 revealed, "Patient with chest pain and shortness of breath. On home oxygen normally. chest tube in place. Patient is alert, in no acute distress but is moaning in discomfort." The patient's oxygen saturation (O2 sat) at 1446 was 97% and at 1500 was 90%. The ED Provider's Note at 1534 revealed the patient had a history of metastatic lung cancer with a chest tube on the right with "chronic pain at the tube site now with worsening shortness of breath for the past day." The patient's O2 sat at 1630 was 92%, and the patient was placed on 3 liters of oxygen via nasal cannula. The patient's O2 sat at 1715 was 93%. An order for Morphine (a pain medication) 4 milligrams IV (intravenous) was placed at 1729. An order was placed at 1731 for continuous pulse oximetry (measures how much oxygen is in the blood for uninterrupted periods). The patient's O2 sat at 1745 was 89% and at 1750 was 90%. A broadcast notification was sent to the Stepdown unit at 1803 with the room number the patient was assigned to and the box number for continuous pulse oximetry. The patient's blood pressure at 1807 was 84/57 with a comment by the Nurse that the Provider was notified at that time. The patient's pain was assessed at 1808 as 10 out of 10. A comment was documented on the MAR (Medication Administration Report) at 1809 that Morphine was not given as the patient's blood pressure was "too low to administer," and the Provider was notified. The patient's oxygen was increased to 4 liters at 1820 with an O2 sat of 94%. ED Nurse Note at 1830 revealed the patient was transported by non-clinical transport staff. The patient was on an "O2 monitor, awake and alert. Prior to patient leaving emergency department this RN (Registered Nurse) spoke with transport leadership regarding blood pressure parameters for transport personnel. Transport leadership stated, "We do not have parameters for blood pressure as long as you feel patient is stable for transport ..." The patient's O2 sat prior to transport at 1830 was 93%. Record review failed to reveal documented evidence of the patient's heart rate and O2 sats during transport. Record review failed to reveal documented evidence of the patient's time of arrival to the unit and initial O2 sat. Review of a Code Record revealed a code blue (the initiation of resuscitative efforts in a cardiac or respiratory arrest) was called with initiation of CPR (cardiopulmonary resuscitation) at 1842 and initial ECG (electrocardiogram, a noninvasive test that records the electrical activity of the heart) rhythm of asystole (no heartbeat). Check boxes for the initial condition were selected as "Yes" for conscious, breathing, and pulse, as well as "Witnessed Arrest." A check box for "Monitored" was selected "No." The patient was intubated at 1853, and a rhythm of PEA (Pulseless Electrical Activity, a condition where the heart is still producing electrical signals, but there is no pulse or blood pressure) was noted at 1901. Discharge Summary dated 09/06/2025 at 2226 revealed the patient was admitted to a medical floor for further evaluation and management of acute respiratory failure. The patient "coded as soon as she transferred to the medical floor ..." and was pronounced dead at 1907 on 09/04/2025.

Interview on 09/18/2025 at 1335 with RN #26 revealed Patient #10 was transported from the ED and was brought to their assigned room. Interview revealed Staff #7 called for help, because "something did not look right." A Nurse in the hallway responded and hit the Staff Assist button in the room, which sent an overhead alarm and blinked red outside the room. RN #26 responded at that time and observed the patient on the stretcher, and the patient appeared to be having seizure-like activity. The patient had their head back and was convulsing. RN #26 revealed the patient was moved to the bed, a code blue was called, and chest compressions were started immediately. Interview revealed Staff #7 reported the patient had been speaking to their family member in Spanish during transport, and when they arrived to the patient's room on the Stepdown unit, the seizure-like event occurred.

Telephone interview on 09/19/2025 at 0939 revealed the Nursing staff had "huge concerns" with signal loss in the elevators for their patients on remote telemetry.

Interview on 09/19/2025 at 1713 with Director #8 revealed Staff #7 reported RN #27 called the transport dispatch to ask if there were blood pressure parameters for transport and was informed there were not parameters for blood pressure. Staff #7 then transported Patient #10 to the Stepdown unit. When Staff #7 arrived to the unit, the Nurse was not in the patient's room, so Staff #7 pressed the call bell to alert the Nurse the patient had arrived. Interview revealed Patient #10 was in pain, so Staff #7 stepped out in the hallway to ask for help and a Nurse in the hallway responded. Staff #7 informed Director #8 that Patient #10's family was present and assisted with translation from Spanish that the patient was in pain during transport.

Telephone interview on 09/22/2025 at 1422 with Staff #7 revealed Patient #10 had a family member with them at the bedside who assisted with translating from Spanish for Patient #10. Interview revealed Patient #10's family verified the patient's name and date of birth in English for Staff #7. Staff #7 revealed RN #27 asked if there were blood pressure parameters for transport, but Staff #7 was unaware of any parameters for blood pressure. Staff #7 called the transport dispatch, put them on speaker phone, and was informed there were not blood pressure parameters for transport. Transport dispatch informed RN #27 that the patient must be stable for non-clinical staff to transport; RN #27 checked the blood pressure again and signed off on Staff #7 transporting the patient. Staff #7 was not aware of any alarm that could be heard with the telemetry box during a patient's transport. Staff #7 revealed when they were in the elevator, the patient was moaning in pain and spoke in Spanish to their family. The family then translated in English to Staff #7 that the patient was in pain; Staff #7 reassured the patient and family that Staff #7 would get the patient help. Interview revealed when they arrived to the Stepdown unit, the patient was still moaning in pain, and the family asked, "Can you please help? You're a Nurse." Staff #7 informed the family they were not a Nurse but would get the patient help. Staff #7 noticed the patient showed signs of a seizure, and the family was "frantic, asking for help." Staff #7 pushed the Staff Assist button on the wall and stepped into the hallway for help. A Nurse approached and asked if they needed help, and then staff "were coming from everywhere into the room." Staff #7 then stepped out into the hallway, the stretcher was pushed out of the room, and Staff #7 was informed that they could leave.

Interview on 09/23/2025 at 0925 with RN #27 revealed Patient #10 had a significant other at the bedside, and RN #27 spoke in Spanish to them. RN #27 revealed the patient's blood pressure had dropped a little, and MD #28 had ordered fluids. Interview revealed the patient's blood pressure was not "at standard to give" Morphine. RN #27 revealed the patient was complaining of pain in the ED; RN #27 explained to the patient and their significant other that RN #27 could not give Morphine due to their blood pressure. Interview revealed the patient complained of generalized pain and stated, "everywhere hurts." Interview revealed RN #27 called the CMU prior to Staff #7 transporting the patient to ensure the CMU could visualize Patient #10 on their O2 monitor. The CMU verified visualization and provided the patient's heart rate and O2 sat. RN #27 did not recall the exact values but stated they were within normal limits. RN #27 revealed the telemetry boxes for transport did not have an alarm.

Telephone interview on 09/23/2025 at 1313 with Tech #5 revealed they recalled RN #27 called to verify the pulse ox for Patient #10 could be visualized by the CMU prior to transport from the ED to a Stepdown unit. Interview revealed they were on the phone for a few minutes troubleshooting the pulse ox probe as there were issues with the signal going in and out. Interview revealed Wi-Fi connection issues, such as the signal cutting in and out, could occur when a patient was transported. Tech #5 revealed during Patient #10's transport, the signal was again cutting in and out, and there was not a solid reading. Tech #5 revealed there were drops in Patient #10's O2 sats, but they could not get a clear reading due to signal issues. Interview revealed the CMU pod was very busy that day as there were multiple patients being transferred and admitted, as well as multiple escalations at that time. Tech #5 revealed any time there were O2 sats dropping or signal loss, the monitor techs should notify the Nurse as soon as they see it with a resolution time of 5 minutes. Interview revealed the Stepdown unit was not notified that Patient #10's pulse oximetry had signal issues, a loss of signal during transport, or drops in the patient's O2 sats.

In summary, Patient #10, a 48-year-old, presented to the Emergency Department (ED) on 09/04/2025 at 1441 with complaints of chest pain and shortness of breath. The patient experienced 10 out of 10 pain at 1808 and was unable to receive Morphine due to low blood pressure (84/57). The patient was admitted and transported to a Stepdown unit by a nonclinical transporter at 1830 with an order for continuous pulse oximeter. Findings revealed the pulse oximeter did not have continuous signal once the patient left the ED with a drop in oxygen saturation noted. The patient was moaning in pain and requesting nursing help during transport. The patient arrived to the unit, was transported to their room, observed to have seizure-like activity, and a code blue was called at 1842 (12 minutes after departing the ED). The patient expired at 1907. Emergency Department staff failed to ensure a patient with pain and shortness of breath was safe and appropriate for transport and continuously monitored prior to departing the ED.

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