HospitalInspections.org

Based on review of clinical records, review of facility policies and procedures, and interviews, the facility failed to provide care in a safe setting by failure to ensure telemetric cardiac monitoring transmitters were available for patients with orders for telemetry monitoring. An at-risk patient was not afforded the nursing care required to detect an adverse cardiac event when a physician's order for continuous cardiac monitoring was not completed due to a lack of monitoring equipment. The ordering physician was not informed that an order for continuous telemetric cardiac monitoring was not implemented.

From 1/15/23 at 10:39 a.m. to 1/16/23 at 7:00 a.m. nursing did not implement an order for telemetric cardiac monitoring due to lack of equipment. The nursing staff did not resolve the inability to implement the order. The nursing staff did not communicate the failure to implement the order to the ordering physician. The nursing staff did not adequately assess the at-risk patient for change in condition in the absence of continuous cardiac monitoring.

The patient was found unresponsive at shift change at 7:00 a.m. on 1/16/23 and a Code blue (code for cardiac arrest response) was called. The patient was resuscitated, but later died. The lack of monitoring equipment was not alleviated by the hospital leadership. Staff did not follow through by acquiring the ordered medical equipment and left the search unresolved for two shifts.

The noncompliance at the Condition of Participation of Patient Rights is due to the Hospital did not fulfill the order for telemetry. Hospital leadership did not ensure the physician was notified of the hospital's inability to complete the order for telemetry. Hospital did not address the care needed for an at-risk patient in the absence of continuous cardiac monitoring which resulted in Immediate Jeopardy. The Immediate Jeopardy began on 1/15/22. The hospital was informed of the Immediate Jeopardy on 2/10/2023 at 6:40 p.m. and was ongoing as of the survey exit on 2/10/2023. (Cross Refer A0144, A0263, A0385).

Based on observation, review of clinical records, review of facility policies and procedures, and interview, the facility failed to provide patient care in a safe setting for 1 (Patient #1) of 4 patients reviewed for nursing staff failing to initiate telemetry cardiac monitoring as ordered by a physician. due to lack of equipment for two consecutive shifts. The nursing staff did not resolve the inability to implement the order. The nursing staff did not communicate the failure to implement the order to the ordering physician. The nursing staff did not adequately assess the at risk patient for change in condition in the absence of continuous cardiac monitoring. The patient was found unresponsive at shift change at 7:00 a.m. on 1/16/23 and a Code blue was called. The patient was resuscitated, but later died. (Cross refer A0115).

The findings include:

The Comprehensive Telemetry policy, approved on 6/4/22, stated the purpose of the policy was to provide a comprehensive policy pertaining to telemetry monitoring that promoted patient safety. It further stated the primary care nurse was responsible for ensuring the patient was started on telemetry monitoring. The primary care nurse was also responsible for assessing the patient for a change in rhythm, communicating the changes to the provider and documenting rhythm changes and provider notification in the electronic medical record.

The Telemetry Monitoring Remotely policy, approved on 6/4/22, stated the purpose of the policy was to provide comprehensive policy to telemetry monitoring that promoted patient safety. The scope of the policy pertained to the initiation, continuation, discontinuation, documentation related to the telemetry. The policy stated telemetry monitoring should be performed when ordered by the physician to provide continuous cardiac monitoring of patients at risk for cardiac arrhythmias (irregular heart beat) or condition disturbances.

Review of hospital clinical records for Patient #1, revealed an 86-year-old male, was admitted to a neurological and stroke telemetry unit on 1/12/23, after an elective transforaminal interbody fusion posterior column osteotomy and posterior segmental instrumented fusion of Lumbar 3 to 5 (a fusion of the vertebras of the Lumbar segment of the spine). On 1/14/23, post-op day (POD) 2 the primary care physician (PCP) wrote in his progress note, Patient #1 observed in an acute confused state, encephalopathy (altered brain function), and slurred speech. The PCP ordered lab work and Computed Tomography (CT) scan of the head to be completed for Patient #1.

On 1/15/23, POD #3 the PCP wrote in his progress note Patient #1 symptoms were worsening since January 14. The PCP wrote physician orders on 1/15/23 at 10:39 a.m. to, "repeat CT scan of the head, MRI (Magnetic Resonance Imaging) scan of the brain, and place Patient #1 on telemetry for monitoring for arrhythmia management interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes and notify him for chest pain, PVCs (premature ventricular contractions) greater than 12 to 15 beats per minute, symptomatic bradycardia (slow heart rate) for heart rate below 40, and for sustained tachycardia (fast heart rate)".

The critical care physician wrote in his progress note dated 1/16/23 at 10:11 a.m., on the morning of 1/14/23 Patient #1 was noted to have dysarthria 9difficulty in speech) with mild confusion. "Code Save a Brain" was called, and a CT of the head was performed showing no hemorrhage (bleeding) or acute core infarct (obstruction of blood flow). On 1/15/23, Patient #1 was noted to have worsening neurologic status with increased confusion from the day prior. A repeated CT of the head was completed, and MRI of the brain was preformed, both showing minimal hyperdensity, concerning for minimal intraventricular hemorrhage. On the morning of 1/16/23, the primary care RN found Patient #1 unresponsive in bed and initiated a Code Blue (code for cardiac arrest response). CPR (cardiopulmonary resuscitation) was started at 7:15 a.m., and Patient #1 was transferred to the critical care unit. At 7:28 a.m., Patient #1's monitor showed atrial fibrillation (an irregular and often very rapid heart rhythm) and sustained ventricular tachycardia and was successfully cardioverted (low energy shock to restore heart rhythm) at 7:30 a.m. At 7:51 a.m. and 8:09 a.m. on 1/16/23 telemetry monitoring showed an abnormal rhythm and CPR was resumed each time. Patient #1 went into asystole (a condition in which the heart ceases to beat) and was pronounced dead at 8:45 a.m.

Further review of Patient #1's clinical records revealed the telemetry monitoring for arrhythmia (irregular heart beat) was not initiated for more than 20 hours after being ordered by his PCP on 1/15/23 at 10:39 a.m.

On 2/7/23 at 9:15 a.m. during an interview, Register Nurse (RN) Staff C said she was Patient #1's nurse on 1/15/23 from 7:00 p.m. to 7:00 a.m. She said around 11:00 p.m. she noted Patient #1's PCP had written physician orders dated 1/15/23 at 10:39 a.m. to include placing Patient #1 on telemetry for monitoring for arrhythmia management interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes and notify him for chest pain, PVCs greater than 12 to 15 beats per minute, symptomatic bradycardia for heart rate below 40, and for sustained tachycardia. She said she went to initiate the telemetry order but was unable to find a telemetry monitoring box so she told the nightshift charge nurse Staff D, who then assisted her in looking for a telemetry monitoring box for Patient #1. She said they were unable to locate a telemetry monitoring box and because Patient #1 was stable she continued to conduct routine assessments. She said during the morning shift change when she was conducting walking rounds with the dayshift nurse, she discovered Patient #1 was unresponsive, so she initiated a Code Blue for Patient #1 and when the Code Blue team arrived, they initiated CPR. Staff C confirmed she did not initiate the telemetry monitoring for arrhythmia management with the telemetry monitoring box as ordered by the physician. She further stated she did not notify Patient #1's PCP that the telemetry monitoring was not initiated as ordered on 1/15/23 at 10:39 a.m.

On 2/7/23 at 10:25 a.m. during an interview, RN Staff A, said she was Patient #1's nurse on 1/15/23 from 7:00 a.m. to 7:00 p.m. She said she was informed sometime in the morning Patient #1's primary care physician had ordered a repeated CT scan of the head, MRI (Magnetic Resonance Imaging) scan of the brain, and to place Patient #1 on telemetry for monitoring for arrhythmia management interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes and notify him for chest pain, PVCs (premature ventricular contractions) greater than 12 to 15 beats per minute, symptomatic bradycardia for heart rate below 40, and for sustained tachycardia. She said she went to initiate the telemetry monitoring order but was unable to find a telemetry monitoring box, so she told Staff B, the dayshift charge nurse, who then assisted her in looking for telemetry monitoring box for Patient #1. She said they were unable to locate a telemetry monitoring box and the charge nurse told her Patient #1's physician was aware telemetry was not started. Staff A said she did not document her conversation with the charge nurse in Patient #1's clinical record about initiating his telemetry monitoring orders and did not call Patient #1's PCP for clarification regarding the active telemetry monitoring orders for Patient #1 dated 1/15/23 at 10:39 a.m. She confirmed it was not possible to do accurate continuous cardiac monitoring without a telemetry monitoring box attached to the patient. She further said she did not remember informing the oncoming nurse Staff C that Patient #1 had an active order for telemetry monitoring dated 1/15/23 at 10:39 a.m. which had not been initiated.

On 2/7/22 at 3:34 p.m. during an interview with RN Staff D, she said she was the charge nurse working the nightshift from 7:00 p.m. to 7:00 a.m. on 1/15/23. She said she remembered Staff C telling her Patient #1's telemetry for monitoring for arrhythmia management was not initiated because she was unable to find a telemetry monitoring box. She said she also searched for a telemetry monitoring box but was unable to find one, so she notified the nightshift Administrative Coordinator a telemetry monitoring box was needed for a patient on their unit. She said the Administrative Coordinator Staff F was unable to locate a telemetry monitoring box for Patient #1. Charge Nurse Staff D said since Patient #1 was stable, and Staff C was conducting routine monitoring rounds she thought everything was okay. She said she did not become aware Patient #1 was found unresponsive 1/16/23 at 7:00 a.m. and had died until the next day when she was called by the hospital administration. She said she did not call Patient #1's PCP to inform him they were unable to initiate the telemetry monitoring for arrhythmia management as ordered. She confirmed it was not possible to do accurate continuous cardiac monitoring without a telemetry monitoring box attached to the patient.

On 2/8/22 at 10:40 a.m. during an interview with RN Staff B, she said she was the charge nurse working the dayshift from 7:00 a.m. to 7:00 p.m. on 1/15/23. She said she remembered Staff A telling her Patient #1's telemetry for monitoring for arrhythmia management was not initiated because she was unable to find a telemetry monitoring box. She said she also searched for a telemetry monitoring box for Patient #1 but was unable to find a telemetry monitoring box on the nursing unit, so she notified the dayshift Administrative Coordinator a telemetry monitoring box was needed. She said the Administrative Coordinator Staff E was unable to locate a telemetry monitoring box for Patient #1. She said she did not escalate the finding of a telemetry monitoring box beyond asking the dayshift Administrative Coordinator. Charge Nurse Staff B said she didn't remember speaking with Patient #1's PCP to inform him telemetry monitoring was not initiated as ordered. She said Patient #1's PCP should have been notified that the telemetry monitoring order was not initiated as ordered. She confirmed it was not possible to do accurate continuous cardiac monitoring without a telemetry monitoring box attached to the patient.

On 2/8/23 at 11:57 a.m. during an interview with the dayshift Administrative Coordinator Staff E, she said a part of their job duties was to assist the nursing staff to find/locate medical equipment to include telemetry monitoring box. She said she worked as the dayshift Administrative Coordinator on 1/15/23 and remembered assisting other nursing units in locating telemetry monitoring box for their patients. She reviewed her notes for 1/15/23 and said she was unable to find documentation the dayshift charge nurse Staff B had requested a telemetry monitoring box for her unit. She said when asked she had always been able to locate a telemetry monitoring box for the nursing staff. Administrative Coordinator Staff E said, it was expected if the nurse was unable to initiate a physician's order they were required to inform the physician and document their conversation in the patient's clinical record.

On 2/9/23 at 8:30 p.m. during an interview with the nightshift Administrative Coordinator Staff F, he confirmed he was the nightshift Administrative Coordinator on 1/15/23. He said as part of his duties he was required to assist the nursing staff in finding medical equipment to include telemetry monitoring box. He said on 1/15/23 the charge nurse, Staff D had requested a telemetry monitoring box for a patient on her unit. He said during his search, they called him stating they had located a telemetry monitoring box for the patient, so he stopped looking for a telemetry monitoring box for the unit. He said when asked for assistance by the nursing staff he had always been able to locate a telemetry monitoring box. He said when a physician ordered telemetry monitoring for their patient, the nursing staff was required to initiate the physician's orders. Administrative Coordinator Staff F said if a nursing was unable to initiate the physician orders they were required to notify the physician and document the conversation in the patient's clinical record.

On 2/8/23 at 1:05 p.m. during an interview with Patient #1's PCP, he confirmed Patient #1 was admitted on 1/12/23 to the neurosurgical unit for monitoring after an elective transforaminal interbody fusion posterior column osteotomy and posterior segmental instrumented fusion of Lumbar 3 to 5. He also confirmed he observed a decline on 1/14/23 in Patient #1's condition so he ordered lab work and a CT of the head. On 1/15/23 during morning rounds he observed a further decline in Patient #1's condition so he ordered another CT of the head for comparison, MRI of the brain and to start Patient #1 on telemetry to monitor for arrhythmia management, interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes, and notify him for chest pain, PVCs greater than 12 to 15 beats per minute, symptomatic bradycardia for heart rate below 40, and for sustained tachycardia. Patient #1's PCP said it was not until a couple of days after the death of the patient he was made aware Patient #1's telemetry monitoring was not initiated as he had ordered on 1/15/23 at 10:39 a.m. He said he had ordered telemetry monitoring for Patient #1 as part of his plan of care and the nursing staff should have called him if they were unable to initiate the tele-monitoring as ordered.

On 2/9/23 at 10:25 a.m. during an interview the Director of Patient Safety and Risk Management and Director of Accreditation, confirmed the Comprehensive Telemetry policy approved on 6/4/22 stated the primary care nurse was responsible for ensuring the patient was started on telemetry monitoring as ordered. The primary care nurse was responsible for assessing the patient for a change in rhythm, communicating the changes in rhythm to the PCP and documenting the rhythm change and provider notification change in the patient's clinical record. They also confirmed the Telemetry Monitoring policy approved on 6/4/22 stated telemetry monitoring shall be performed when ordered by the physician to provide a continuous cardiac monitoring of patients at risk for cardiac arrhythmias.

The Director of Patient Safety and Risk Management and Director of Accreditation said during their investigation of the incident, Patient #1 had elective surgery on 1/12/23 and was admitted to the neuro-stoke unit. They said on 1/15/23 at 10:39 a.m., Patient #1's PCP ordered cardiac telemetry monitoring due to a continuous decline in Patient #1's medical condition from 1/14/23 to 1/15/23. They said Patient #1 cardiac telemetry monitoring was not initiated for more than 20 hours after it was ordered by his physician. They confirmed Patient #1 was found unresponsive on 1/16/23 at 7:00 a.m. and pronounced dead on 1/16/23 at 8:45 a.m.

Based on record review, interviews, review of facility documents, and review of policy and procedure, the hospital failed to ensure that clear expectations for patient safety were implemented by the Quality Assurance and Performance Improvement (QAPI) Program. The QAPI system failed to ensure a complete and thorough investigation of a serous sentinel event involving patient death related to unavailability of telemetric cardiac monitoring equipment and lack of nursing assessment and care of at-risk patients when telemetry equipment and is not available. The facility failed to educate staff regarding nursing communication and issue resolution. The facility failed to implement protocols for assessing and caring for at-risk patient when continuous cardiac monitoring equipment is unavailable.

The issue of not following through to a resolution of the unavailability of equipment was not identified as contributing to a serous sentinel event. Lack of communication to the physician of uncompleted orders was not identified in the assessment of the incident. Under these circumstances described above, one patient died and placed other patients at a likelihood of serious harm, illness, and/or death. For two consecutive shifts the equipment was looked for and not found leaving an at-risk patient without continuous cardiac monitoring as ordered. Three levels of nursing supervision on two shifts did not resolve the issue and did not communicate the problem to incoming staff or higher level of management. Protocols for assessment and management of at-risk patients without ordered equipment were not implemented.

The noncompliance at the Condition of Participation of QAPI due to the hospital's failure to have an effective QAPI program resulted in Immediate Jeopardy. The Immediate Jeopardy began on 1/15/22. The hospital was informed of the Immediate Jeopardy on 2/10/2023 at 6:40 p.m. and was ongoing as of the survey exit on 2/10/2023. (Cross Refer to A0286, A0115, A0395).

Based on record review, staff interview, review of clinical records, and review of facility policies and procedures the facility failed to effectively investigate an adverse incident and develop and implement a Root Cause Analysis (RCA) report and Action Plan with effective preventive actions for the adverse incident event reviewed for Patient #1 who died. The facility could not ensure that when the physician ordered cardiac telemetry monitoring the nursing staff were initiating the order and/or notifying the physician when there was a delay initiating their orders. The delay in initiating tele-monitoring could lead to actual serious harm or death to a patient. Cross Refer to A0263, A0115, A0395)

The findings include:

The Variance Reporting policy with an effective date of 4/8/2020 and last approved on 6/4/22 stated the facility was required to establish and implement a process for investigating and reporting all events affecting the healthcare environment. The facility was required to maximize patient safety, define variance/occurrence events and the parameters under which they are to be reported and investigated and provide data to review effectiveness of safety and risk management programs and the need for preventive actions. In the Manager/Director section, the policy stated they needed to review the facts and investigate to fully understand the sequence of the events, implement corrections to prevent recurrence of the event at the unit level and document additional facts.
The Comprehensive Telemetry policy approved, on 6/4/22, stated the purpose of the policy was to provide a comprehensive policy pertaining to telemetry monitoring that promoted patient safety. It further stated the primary care nurse was responsible for ensuring the patient was started on telemetry monitoring. The primary care nurse was also responsible for assessing the patient for a change in rhythm, communicating the changes to the provider and documenting the rhythm change and provider notification in the electronic medical record.

The Telemetry Monitoring Remotely policy approved on 6/4/22 stated the purpose of the policy was to provide comprehensive policy to telemetry monitoring that promoted patient safety. The scope of the policy pertained to the initiation, continuation, discontinuation, and documentation related to the telemetry. The policy stated telemetry monitoring should be performed when ordered by the physician to provide continuous cardiac monitoring of patients at risk for cardiac arrhythmias (irregular heart beat) or condition disturbances.

Review of hospital clinical records for Patient #1, revealed an 86-year-old male, was admitted to a neurological and stroke telemetry unit, on 1/12/23 after an elective transforaminal interbody fusion posterior column osteotomy and posterior segmental instrumented fusion of Lumbar 3 to 5 (fusion of the vertebras in the Lumbar segment of the spine) .

On 1/15/23, post-op day (POD) #3 the Primary Care Physician (PCP) wrote in his progress note Patient #1 symptoms were worsening since January 14. The PCP wrote physician orders on 1/15/23 at 10:39 a.m. to repeat CT scan of the head, MRI (Magnetic Resonance Imaging) scan of the brain, and place Patient #1 on telemetry for monitoring for arrhythmia management interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes and notify him for chest pain, PVCs (premature ventricular contractions) greater than 12 to 15 beats per minute, symptomatic bradycardia (slow heart rate) for heart rate below 40, and for sustained tachycardia (fast heart rate).

On the morning of 1/16/23 at 7:00 a.m., the primary care RN found Patient #1 unresponsive in bed and initiated a Code Blue (code for cardiac arrest response). CPR (cardio pulmonary resuscitation) was started at 7:15 a.m., and Patient #1 was transferred to the critical care unit. At 7:28 a.m., Patient #1's monitor showed atrial fibrillation (an irregular and often very rapid heart rhythm) and sustained ventricular tachycardia and was successfully cardioverted (low energy shock to restore regular heart rhythm) at 7:30 a.m. At 7:51 a.m. and 8:09 a.m. on 1/16/23 telemetry monitoring showed an abnormal rhythm and CPR was resumed each time. Patient #1 went into asystole( a condition in which the heart ceases to beat) and was pronounced dead at 8:45 a.m.

Further review of Patient #1's clinical records revealed the telemetry monitoring for arrhythmia was not initiated for more than 20 hours after being ordered by his PCP on 1/15/23 at 10:39 a.m.

On 2/7/23 at 9:15 a.m. during an interview, Register Nurse (RN) Staff C said she was Patient #1's nurse on 1/15/23 from 7:00 p.m. to 7:00 a.m. She said around 11:00 p.m. she noted Patient #1's PCP had written physician orders dated 1/15/23 at 10:39 a.m. to include placing Patient #1 on telemetry for monitoring for arrhythmia management interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes and notify him for chest pain, PVCs (premature ventricular contractions) greater than 12 to 15 beats per minute, symptomatic bradycardia for heart rate below 40, and for sustained tachycardia. She said she went to initiate the telemetry order but was unable to find a telemetry monitoring box so she told the nightshift charge nurse Staff D, who then assisted her in looking for a telemetry monitoring box for Patient #1. She said they were unable to locate a telemetry monitoring box and because Patient #1 was stable she continued to conduct routine assessments. She said during the morning shift change when she was conducting walking rounds with the dayshift nurse, she discovered Patient #1 was unresponsive, so she initiated a Code Blue for Patient #1 and when the Code Blue team arrived, they initiated CPR. Staff C confirmed she did not initiate the telemetry monitoring for arrhythmia management with the telemetry monitoring box as ordered by the physician. She further stated she did not notify Patient #1's PCP that the telemetry monitoring was not initiated as ordered on 1/15/23 at 10:39 a.m. Staff C said she was interviewed by the Risk Manager (RM) within 24 hours after Patient #1 had expired. Staff C said the RM asked her several questions about how Patient #1 was doing throughout the night and reminded her to follow the facility Escalation Process for Telemetry Box Needs the next time she needed a telemetry monitoring box for a patient. RN Staff C said she had not received any education and/or in-services related to following physician's orders, what steps to take when a telemetry monitoring box could not be located in a timely manner, or notifying the physician when their telemetry monitoring order was not initiated in a timely manner.

On 2/7/23 at 10:25 a.m. during an interview, RN Staff A, she said she was Patient #1's nurse on 1/15/23 from 7:00 a.m. to 7:00 p.m. She said she was informed sometime in the morning Patient #1's primary care physician had ordered a repeated CT scan of the head, MRI (Magnetic Resonance Imaging) scan of the brain, and to place Patient #1 on telemetry for monitoring for arrhythmia management, interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes, and notify him for chest pain, PVCs (premature ventricular contractions) greater than 12 to 15 beats per minute, symptomatic bradycardia for heart rate below 40, and for sustained tachycardia. She said she went to initiate the telemetry monitoring order but was unable to find a telemetry monitoring box, so she told Staff B the dayshift charge nurse, who then assisted her in looking for telemetry monitoring box for Patient #1. RN Staff A said they were unable to locate a telemetry monitoring box and the charge nurse told her Patient #1's physician was aware telemetry was not started. Staff A said she did not document her conversation with the charge nurse in Patient #1's clinical record about initiating his telemetry monitoring orders and did not call Patient #1's PCP for clarification regarding the active telemetry monitoring orders for the patient dated 1/15/23 at 10:39 a.m. She confirmed it was not possible to do accurate continuous cardiac monitoring without a telemetry monitoring box attached to the patient. She further said she did not remember informing the oncoming nurse Staff C, Patient #1 had an active order for telemetry monitoring dated 1/15/23 at 10:39 a.m. which had not been initiated. Staff A said she was interviewed by the Risk Manager within 24 hours after Patient #1 had expired. She the RM had asked her a few questions about how Patient #1 was doing throughout the shift and reminded her to follow the facility Escalation Process for Telemetry Box Needs and follow the chain of command the next time she was trying to locate a telemetry monitoring box for a patient. Staff A said she had not received education and/or an in-service related to following physician's orders, what steps to take when a telemetry monitoring box could not be located in a timely manner, or notifying the physician when their telemetry monitoring order was not initiated in a timely manner.

On 2/7/2023 at 8:25 a.m. during an interview with the Patient Safety Officer/Risk Manager (RM), she said on the morning of 1/16/23 the Administrative Direct of Clinical Care contacted her by phone to inform her about an adverse event. He told her his team responded to a Code Blue with the patient expiring. He said from review of the clinical record, it was revealed the patient had an order for telemetry monitoring the day prior which had not been initiated. The RM said she interviewed Staff A and Staff C about the event, and they confirmed Patient #1 had a physician order to initiate telemetry monitoring which had not been initiated because they were unable to find a telemetry monitoring box. The RM said she reminded them of the Escalation Process for Telemetry Box Need and to follow the chain of command as noted in the policy to obtain a telemetry monitoring box. She said she did not do any other education with Staff A or Staff C. The RM said called a Serious Safety Event meeting which was held on 1/17/23 at 1:00 p.m. with the following findings. The team determined the Root Cause Analysis was the telemetry monitoring box were not always available to the staff and the adverse incident was related to a resource management situation, so they posted the Escalation Process for Telemetry Box Need at each nursing station and they implemented a telemetry monitoring box tracking log sheet to identify as part of their lost prevention and tracking of the telemetry monitoring box. They also reminded the nursing staff to use the Escalation Process for Telemetry Box Need procedure when they are unable to find the telemetry monitoring box for their patient.

On 2/9/2023 at 11:13 a.m. during an interview, the Director of the Neuro-Stoke Unit (NSU) said she was not at work when Patient #1 had a cardiac arrest while on her unit and expired on 1/16/23 at 8:45 a.m. She stated when she arrived to work the next day, she was informed Patient #1 had a physician order for cardiac telemetry monitoring which had not been initiated by Staff A and Staff C. She said during the Serious Safety Event meeting held at 1:00 p.m. it was determined that telemetry monitoring boxes were not always available to the nursing staff and the adverse incident was related to a resource management situation. The Director of NSU said in response to the adverse event, the Escalation Process for Telemetry Box Need was posted at each nursing station and all Directors implemented a telemetry monitoring box tracking log sheet to identify as part of their lost prevention and tracking of the telemetry monitoring box. She reminded the nursing staff during the morning huddles of the Escalation Process for Telemetry Box Needs. The Director of NSU said as of 2/9/23 at 11:13 a.m., she had not conducted any formal education with her staff related to the nursing staff not initiating physician orders and/or notifying the physician in a timely manner of orders not completed because the root cause analysis team had not developed and approved staff education related to the 1/16/23 adverse event.

Review of the facility's Root Cause Analysis (RCA) Summary Report dated 1/30/23 reviewed in the RCA meeting for the adverse event on 1/16/23 reported the immediate and remedial actions taken found 15 telemetry monitoring boxes in the biomed department and placed them back into service. They required the Dayshift and Nightshift charge nurses to review all active telemetry orders with patient on telemetry. telemetry monitoring box tracking log was to be completed by Monitor Tech and validation by dayshift and nightshift charge nurses between each shift. Staff were required to follow the Escalation Process if they were unable to locate a telemetry monitoring box for their patient. The RCA Summary Report listed the proximate causes were the primary nurse acknowledged order promptly, they notified the charge nurse and did not place the telemetry box on the patient due to unavailability of the telemetry monitoring box. The primary nurse on the nightshift did not place the telemetry monitoring box on Patient #1 after deciding to place a telemetry monitoring box on a higher acuity patient without communication of additional need for another telemetry monitoring box. The corrective action stated to prevent recurrence of root cause was to improve resource gap in availability of telemetry monitoring box, escalation to the chain of command and use of a portable monitoring device.

The Action Plan dated 1/30/23, for the adverse incident identified on 1/16/23 stated education of the dayshift and nightshift required reconciliation of active telemetry monitoring orders and completing a log of equipment at each shift should have been completed by the due date of 1/17/23. Telemetry monitoring box tracking log education to be completed by the Monitor Tech and validated by the dayshift and nightshift by 1/17/23. The Action Plan further stated the Implement Accountability Acknowledgement form, physician education for utilization, and staff education related to a completion during a skills fair and education updates are still in progress.

On 2/9/23 at 5:09 p.m., the RM said the RCA team had identified as part of the RCA Summary Report dated 1/30/23 as one of the proximate causes for the adverse event on 1/16/23 the primary care nurses for Patient #1 did not initiate cardiac telemetry monitoring for over 20 hours as ordered by Patient #1's physician. She confirmed they had not created and/or implemented an educational plan and/or in-services with the nursing staff to ensure they maximized patient safety, improved quality of care, with data to review the effectiveness of their plan.

Based on observation, clinical record review, review of facility policies and procedures, and interviews, the facility failed to ensure Registered Nurses provided care to meet the needs of one patient (Patient #1) requiring continuous telemetric cardiac monitoring. This lack of supervision resulted in the primary nurses on two shifts failing to implement an order for telemetry for an at-risk patient. The nurses failed to acquire the required equipment and discontinued efforts to obtain the equipment through the remainder of each shift. The nurses failed to safeguard the at-risk patient by providing nursing assessment when monitoring equipment was not available. The nurses did not communicate to the ordering physician that the order for telemetry monitoring could not be implemented.

As a result of inadequate nursing oversight from 1/15/23 at 10:39 a.m. to 1/16/23 at 7:00 a.m., nursing did not implement an order for telemetric cardiac monitoring due to lack of equipment. The nursing staff did not resolve the inability to implement the order. The nursing staff did not communicate the failure to implement the order to the ordering physician. The nursing staff did not safeguard the at-risk patient by failing to adequately assess for change in condition in the absence of continuous cardiac monitoring. Under these circumstances the patient was found unresponsive at 7:00 a.m. Cardiopulmonary resuscitation was attempted but was unsuccessful and the patient died.

The hospital's noncompliance with the Conditions of Participation of Nursing Services due to the hospital's failure to provide appropriate nursing oversight resulted in Immediate Jeopardy. The Immediate Jeopardy began on 1/15/22. The hospital was informed of the Immediate Jeopardy on 2/10/2023 at 6:40 p.m. and was ongoing as of the survey exit on 2/10/2023.
Cross Reference to A0395, A0115 and A0263.

Based on record review, interviews and hospital policy review the hospital failed to ensure the Registered Nurses initiated cardiac telemetry monitoring for 1 (Patient #1) of 4 patients reviewed for the implementation of cardiac telemetry monitoring ordered by the physician. This lack of Registered Nurses completing s physician's order, lack of communication with the Physician of uncompleted orders, and lack of nursing care and assessment of an at-risk patient for one patient (Patient #1) of four inpatients sampled who had orders for Telemetric cardiac monitoring. Patient #1 remained for over 20 hours without continuous cardiac monitoring and was found by nursing staff unresponsive. After unsuccessful attempts at cardiopulmonary resuscitation the patient died.

The findings include:

The Comprehensive Telemetry policy, approved on 6/4/22, stated the purpose of the policy was to provide a comprehensive policy pertaining to telemetry monitoring that promoted patient safety. It further stated the primary care nurse was responsible for ensuring the patient was started on telemetry monitoring. The primary care nurse was also responsible for assessing the patient for a change in rhythm, communicating the changes to the provider and documenting rhythm changes and provider notification in the electronic medical record.

The Telemetry Monitoring Remotely policy ,approved on 6/4/22, stated the purpose of the policy was to provide comprehensive policy to telemetry monitoring that promoted patient safety. The scope of the policy pertained to the initiation, continuation, discontinuation, and documentation related to the telemetry. The policy stated telemetry monitoring should be performed when ordered by the physician to provide continuous cardiac monitoring of patients at risk for cardiac arrhythmias (irregular heart beat) or condition disturbances.

Review of hospital clinical records for Patient #1, revealed an 86-year-old male, was admitted to a neurological and stroke telemetry unit on 1/12/23 after an elective transforaminal interbody fusion posterior column osteotomy and posterior segmental instrumented fusion of Lumbar 3 to 5 (fusion of the vertebras in the Lumbar section of the spine).

On 1/14/23, post-op day (POD) 2 the primary care physician (PCP) wrote in his progress note, Patient #1 observed in an acute confused state, encephalopathy (altered brain function), and slurred speech. The PCP ordered lab work and computed tomography (CT) scan of the head to be completed for Patient #1.

On 1/15/23, POD #3 the PCP wrote in his progress note Patient #1 symptoms were worsening since January 14. The PCP wrote physician orders on 1/15/23 at 10:39 a.m. to repeat CT scan of the head, MRI (Magnetic Resonance Imaging) scan of the brain, and place Patient #1 on telemetry for monitoring for arrhythmia management, interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes, and notify him for chest pain, PVCs (premature ventricular contractions) greater than 12 to 15 beats per minute, symptomatic bradycardia (slow heart rate) for heart rate below 40, and for sustained tachycardia (fast heart rate).

The critical care physician wrote in his progress note dated 1/16/23 at 10:11 a.m., on the morning of 1/14/23 Patient #1 was noted to have dysarthria (difficulty in speech) with mild confusion. "Code Save a Brain" was called, and a CT of the head was performed showing no hemorrhage (bleeding) or acute core infarct (obstruction of blood flow). On 1/15/23, Patient #1 was noted to have worsening neurologic status with increased confusion from the day prior. A repeated CT of the head was completed, and MRI of the brain was preformed, both showing minimal hyperdensity, concerning for minimal intraventricular hemorrhage. On the morning of 1/16/23, the primary care RN found Patient #1 unresponsive in bed and initiated a Code Blue (code for cardiac arrest response). CPR (cardiopulmonary resuscitation) was started at 7:15 a.m., and Patient #1 was transferred to the critical care unit. At 7:28 a.m., Patient #1's monitor showed atrial fibrillation (an irregular and often very rapid heart rhythm) and sustained ventricular tachycardia and was successfully cardioverted (low energy shock to restore regular heart rhythm) at 7:30 a.m. At 7:51 a.m. and 8:09 a.m. on 1/16/23 telemetry monitoring showed an abnormal rhythm and CPR was resumed each time. Patient #1 went into asystole (a condition in which the heart ceases to beat) and was pronounced dead at 8:45 a.m.

Further review of Patient #1's clinical records revealed the telemetry monitoring for arrhythmia was not initiated for more than 20 hours after being ordered by his PCP on 1/15/23 at 10:39 a.m.

On 2/7/23 at 9:15 a.m. during an interview, Register Nurse (RN) Staff C said she was Patient #1's nurse on 1/15/23 from 7:00 p.m. to 7:00 a.m. She said around 11:00 p.m. she noted Patient #1's PCP had written physician orders dated 1/15/23 at 10:39 a.m. to include placing Patient #1 on telemetry for monitoring for arrhythmia management, interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes, and notify him for chest pain, PVCs greater than 12 to 15 beats per minute, symptomatic bradycardia for heart rate below 40, and for sustained tachycardia. She said she went to initiate the telemetry order but was unable to find a telemetry monitoring box (telemetry monitoring box) so she told the nightshift charge nurse Staff D, who then assisted her in looking for a telemetry monitoring box for Patient #1. She said they were unable to locate a telemetry monitoring box and because Patient #1 was stable she continued to conduct routine assessments. She said during the morning shift change when she was conducting walking rounds with the dayshift nurse, she discovered Patient #1 was unresponsive, so she initiated a Code Blue for Patient #1 and when the Code Blue team arrived, they initiated CPR. Staff C confirmed she did not initiate the telemetry monitoring for arrhythmia management with the telemetry monitoring box as ordered by the physician. She further stated she did not notify Patient #1's PCP the telemetry monitoring was not initiated as ordered on 1/15/23 at 10:39 a.m.

On 2/7/23 at 10:25 a.m. during an interview, RN Staff A, said she was Patient #1's nurse on 1/15/23 from 7:00 a.m. to 7:00 p.m. She said she was informed sometime in the morning Patient #1's primary care physician had ordered a repeated CT scan of the head, MRI (Magnetic Resonance Imaging) scan of the brain, and to place Patient #1 on telemetry for monitoring for arrhythmia management, interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes, and notify him for chest pain, PVCs (premature ventricular contractions) greater than 12 to 15 beats per minute, symptomatic bradycardia for heart rate below 40, and for sustained tachycardia. She said she went to initiate the telemetry monitoring order but was unable to find a telemetry monitoring box, so she told the Staff B the dayshift charge nurse, who then assisted her in looking for telemetry monitoring box for Patient #1. She said they were unable to locate a telemetry monitoring box and the charge nurse told her Patient #1's physician was aware telemetry was not started. Staff A said she did not document her conversation with the charge nurse in Patient #1's clinical record about initiating his telemetry monitoring orders or call Patient #1's PCP for clarification regarding the active telemetry monitoring orders for Patient #1 dated 1/15/23 at 10:39 a.m. She confirmed it was not possible to do accurate continuous cardiac monitoring without a telemetry monitoring box attached to the patient. She further said she did not remember informing the oncoming nurse Staff C that Patient #1 had an active order for telemetry monitoring dated 1/15/23 at 10:39 a.m. which had not been initiated.

On 2/8/23 at 11:57 a.m. during an interview, the dayshift Administrative Coordinator Staff E, said part of their job duties was to assist the nursing staff to find/locate medical equipment to include telemetry monitoring box. She said she worked as the dayshift AC on 1/15/23 and remembered assisting other nursing units locating Telemetry monitoring boxes for their patients. Administrative Coordinator Staff E reviewed her notes for 1/15/23 and said she was unable to find documentation dayshift charge nurse Staff B had requested a telemetry monitoring box for her unit. She said when a request was made, she had been always able to locate a telemetry monitoring box for the nursing staff. Administrative Coordinator Staff E said nursing staff were required initiate all physician orders, if the nurse was unable to initiate a physician's order, they were required to inform the physician and document their conversation in the patient's clinical record.

On 2/9/23 at 8:30 p.m. during an interview with the nightshift Administrative Coordinator Staff F, he confirmed he was the nightshift Administrative Coordinator on 1/15/23. He said as part of his duties he was required to assist the nursing staff in finding medical equipment to include telemetry monitoring box. He said on 1/15/23 the charge nurse, Staff D had requested a telemetry monitoring box for a patient on her unit, however, during his search they called him stating they had located a telemetry monitoring box for the patient, so he stopped looking for a telemetry monitoring box for the unit. He said when asked by the nursing staff he had always been able to locate a telemetry monitoring box. He said when a physician ordered telemetry monitoring for their patient, the nursing staff were required to initiate the physician's orders. If the nursing staff were unable to initiate the physician orders they were required to notify and document the conversation in the patient's clinical record.

On 2/8/23 at 1:05 p.m. during an interview with Patient #1's PCP, he confirmed Patient #1 was admitted on 1/12/23 to the neurosurgical unit for monitoring after an elective transforaminal interbody fusion posterior column osteotomy and posterior segmental instrumented fusion of Lumbar 3 to 5. He also confirmed he observed a decline on 1/14/23 in Patient #1's condition so he ordered lab work and a CT of the head. On 1/15/23 during morning rounds he observed a further decline in Patient #1's condition so he ordered another CT of the head for comparison, MRI of the brain and to start Patient #1 on telemetry for monitoring for arrhythmia management, interpret and document cardiac rhythm every 6 hours and as needed with rhythm changes, and notify him for chest pain, PVCs greater than 12 to 15 beats per minute, symptomatic bradycardia for heart rate below 40, and for sustained tachycardia. He said he had ordered telemetry monitoring for Patient #1 as part of his plan of care and if the nursing staff were unable to initiate any of his orders, to include initiating telemonitoring he would have expected the nursing staff to notify him as soon as possible.

On 2/9/23 at 10:25 a.m. during an interview with Director of Patient Safety and Risk Management and Director of Accreditation, they confirmed the Comprehensive Telemetry policy approved on 6/4/22 stated the primary care nurse was responsible for ensuring the patient was started on telemetry monitoring as ordered. The primary care nurse was responsible for assessing the patient for a change in rhythm, communicating the changes in rhythm to the PCP and documenting the rhythm change and provider notification change in the patient's clinical record. They also confirmed the Telemetry Monitoring policy approved on 6/4/22 stated telemetry monitoring should be performed when ordered by the physician to provide a continuous cardiac monitoring of patients at risk for cardiac arrhythmias.

The Director of Patient Safety and Risk Management and Director of Accreditation said during their investigation of the incident they found Patient #1 had elective surgery on 1/12/23 and was admitted to the neuro-stoke unit. They said on 1/15/23 at 10:39 a.m. Patient #1's PCP ordered cardiac telemetry monitoring due to a continuous decline in Patient #1's medical condition from 1/14/23 to 1/15/23. They said Patient #1's cardiac telemetry monitoring was not initiated for more than 20 hours after it was ordered by his physician. They confirmed Patient #1 was found unresponsive on 1/16/23 @ 7:00 a.m. and pronounced dead on 1/16/23 at 8:45 a.m.

The Director of Patient Safety and Risk Management and Director of Accreditation said via their investigation they determined Staff A and Staff C had not initiated cardiac telemetry monitoring as ordered by Patient #1's PCP on 1/15/23 at 10:39 a.m. for more than 20 hours and was not completed as required per their Telemetry Monitoring facility policy. They also confirmed Staff A, and Staff C did not notify Patient #1's PCP that Patient #1's cardiac telemetry monitoring was not initiated as ordered on 1/15/23 a.m. as required per in their Comprehensive Telemetry facility's policy.