The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| JEWISH HOSPITAL & ST MARY'S HEALTHCARE | 200 ABRAHAM FLEXNER WAY LOUISVILLE, KY 40202 | Feb. 26, 2014 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to protect and promote patient rights and provide care in a safe setting for one (1) of fourteen (14) sampled patients. Patient #1 was admitted to the Intensive Care Unit (ICU) for close monitoring of cardiac problems on 02/04/14 with diagnoses of Cardiogenic shock, A-Fib, Hypotension, and Seizures. Staff interviews and nursing assessments revealed the patient was alert, responsive, and following commands on 02/10/14 between 4:00 AM - 8:00 PM. The patient's heart rate was 120-140 until 9:00 PM when it dropped to the 90's. On 02/10/14, at approximately 11:23 PM, Registered Nurse (RN) #1 found the patient unresponsive with no pulse or respirations. The nursing staff initiated cardiopulmonary resuscitation (CPR) at 11:25 PM and coded the patient for twenty (20) minutes. A heart rhythm returned and a peripheral pulse was obtained. The patient was placed on the ventilator. However, the patient showed no neurological response after the code. The ventilator was stopped the next day and the patient was pronounced clinically dead at 10:43 AM on 02/11/14. Review of the progress notes of the physician, who responded to the code on 02/10/14, revealed it appeared the patient had been in asystole (absent of heart beat) for ten (10) minutes prior to the code called, but the patient's cardiac monitor alarms had not activated due to pacemaker activity. Review of the emergency phone alert detail reports, for the date of 02/10/14 from 7:00 PM until 11:25 PM, revealed there were fifteen (15) red alert messages sent to RN #1's emergency phone. However, the messages failed and the report documented no response to ring command and indicated the phone was either turned off or out of range. Interview with RN #1 revealed she had the phone turned on, but it had not rang and she had not heard Patient #1's monitor alarm from his/her room. The nurse stated she was in another patient's room and the only other nurse (RN #2) was on the phone regarding a new admission to the unit. There were no other staff available because the unit secretary had been pulled to another unit. In addition, the monitor room was to be utilized as a second back-up system for the ICU where the monitor tech would notify the unit of any red alerts. Interview with the monitor tech, who was working the night of 02/10/14 and responsible for the ICU monitors, revealed she had called the unit but had not spoken with RN #1 who was responsible for the patient. The facility could not produce a policy for the use of the emergency phones nor evidence of any routine monitoring or oversight of the nurses to ensure they carried the phones and had them turned on. The facility's failure to ensure Patient #1 received care in a safe setting, failure to develop policy and procedures for the emergency phones, failure to identify root cause analysis and implement corrective actions placed Patient #1 and all patients in the ICU at risk for serious injury, harm, impairment or death. Refer to A 0144 |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to protect and promote patient rights and provide care in a safe setting for one (1) of fourteen (14) sampled patients. Patient #1 was admitted to the Intensive Care Unit (ICU) for close monitoring of cardiac problems on 02/04/14 with diagnoses of [DIAGNOSES REDACTED]'s. On 02/10/14, at approximately 11:23 PM, Registered Nurse (RN) #1 found the patient unresponsive with no pulse or respirations. The nursing staff initiated cardiopulmonary resuscitation (CPR) at 11:25 PM and coded the patient for twenty (20) minutes. A heart rhythm returned and a peripheral pulse was obtained. The patient was placed on the ventilator. However, the patient showed no neurological response after the code on the next day, the ventilator was stopped and the patient was pronounced clinically dead at 10:43 AM on 02/11/14. Review of the progress notes of the physician, who responded to the code on 02/10/14, revealed it appeared the patient had been in asystole (absent of heart beat) for ten (10) minutes prior to the code called, but the patient's cardiac monitor alarms had not activated due to pacemaker activity. The facility identified the event to be a serious safety event; however, the investigation was still ongoing and the facility had not identified a root cause analysis with corrective actions implemented. The facility determined the red alert messages to RN #1's phone failed and the monitor in Patient #1's room did not alarm. Both were checked by Bio-med and were determined to be working correctly; however, the facility had not provided any oversight of the staff to ensure the nurses had the phones with them and that they were turned on since the event. The findings include: Review of the facility's policy titled Telemetry Monitoring and Patient Transport, effective October 2007 and last reviewed on January 2013, revealed the purpose of the policy was to provide guidelines for cardiac monitoring of patients with orders for an intermediate or a low-level monitored bed. This did not include the Intensive Care Units. However, interview with the Quality and Risk Management staff who had oversight of the Monitoring room and the Technicians (Tech) revealed this was the only policy to date. She revealed when the policy was developed, the Intensive Care Units (ICU) conducted their own monitoring. The facility then added monitors from the ICU in the monitoring room and the monitor tech monitored those from the ICU. She stated the process of notification to the ICU was different from the other units in the hospital. However, that was not included in this policy. There were no procedural directions on how to notify the ICU nurses of any red alert alarms (life threatening dysrhythmia or change in cardiac rhythm or rate). The policy stated the monitoring tech would communicate alarms that remain unresolved to the patient's Nurse, Charge Nurse, or Nurse Manager/House Supervisor. Review of the facility's policy for Sentinel/Serious Safety Events, effective date of September 2006 and last reviewed June 2012, revealed the purpose was to examine underlying factors of the sentinel/adverse event and develop a risk reduction strategy; to provide documentation in a consistent and systematic manner with a primary focus on the systems and processes; not on the individual performance; to initiate an investigation and/or a root cause analysis to understand the causes of the event; and to identify changes that could be made in systems and processes which could reduce the risk of such events occurring in the future. The policy stated an occurrence was considered a sentinel event if it had resulted in an unanticipated death. The occurrence was considered a Serious Safety Event (SSE) if there was a deviation from the generally accepted performance standards, or if the deviation had caused moderate to severe harm or death. The Risk Management would conduct an initial investigation to determine if the event was a Sentinel Event or an SSE. Risk Manager coordinates a task force and facilitates a root cause analysis (RCA). Director of Quality and RCA task force would develop any necessary corrective actions to address the RCA of the event and assign responsible leaders to ensure effective implementation in a designated time frame. Based on interviews with staff the facility was unable to provide a policy for the use of the emergency phones. Review of Patient #1's clinical record revealed the patient presented to the facility's Emergency Department, on 02/04/14 at 9:59 PM, with complaints of syncope and abdominal pain. The patient was found to be tachycardiac with a heart rate of 140. The patient was placed on a cardiac monitor that revealed frequent premature ventricular contractions (PVC's). The patient was admitted to ICU for close hemodynamic monitoring with diagnoses of [DIAGNOSES REDACTED]. Review of Neurology Physician note, dated 02/10/14 at 1430 (2:30 PM), revealed the patient had a normal EEG and the physician signed off the case and ordered the facility to make an appointment for the patient at the Epilepsy Clinic after discharge. On 02/10/14 at approximately 11:23 PM, RN #1 went into Patient #1's room and found the patient unresponsive with no pulse or respirations. Cardiopulmonary resuscitation (CPR) was initiated. Review of the Code Blue documentation revealed the code started at 11:25 PM. The code ran for twenty (20) minutes and a pulse was obtained. The patient was intubated and placed on a ventilator. Review of the Physician's progress note, who had responded to the code documented the patient appeared to be in Asystole (absent of pulse) for over ten (10) minutes prior to the code, but it was not captured by the monitor alarms because the pacemaker was activated. The Physician documented twenty (20) minutes of Brain Hypoxia given intubation was not achieved until 11:38 - 11:40 PM. On 02/11/14, the Physician notes revealed the patient showed no neurological response after the code. The patient was removed from the ventilator and allowed to die naturally. The patient was pronounced clinically dead at 10:43 AM on 02/11/14. Review of the alert report revealed on 02/10/14, the computerized monitor in Patient #1's room sent fifteen (15) red line alert messages to RN #1's emergency phone between 9:00 PM to 11:16 PM (before the patient coded). Review of the alert detail report revealed all of those messages failed with the message of "handset did not respond to the ring command. It may be turned off or out of range". These messages reported [DIAGNOSES REDACTED] and low oxygen saturation levels. The report revealed, on 02/11/14 at 7:47 AM, after shift change, the phone received and read messages from the monitor alarms. Interview with RN #1, on 02/26/14 at 10:12 AM, revealed she was the nurse responsible for Patient #1 on 02/10/14. She stated she received an emergency phone that night and it had a working screen. She stated the phones would only receive red line alarms to the phones. She indicated there were many red line alarms from the monitor that night due to the patient's elevated heart rate and low sats. The patient had been tachycardiac with heart rates of 130-140. She acknowledged there had been a phone call from the monitor room. The physician was in the room at that time. She stated she received no messages from the emergency phone that night. She stated she went into the patient's room at approximately 11:00 PM, to hang intravenous (IV) Potassium. She stated the patient was awake, coughed and then turned over in bed. At approximately 11:25 PM, she heard the IV pump beeping in Patient #1's room. She went in and found the patient unresponsive. She stated the patient did not look right so she called the patient's name with no response, and shook the patient gently with no response. She checked and found no pulse or respiration. A code was called and CPR was initiated. She stated she looked at the monitor and saw it was pacing and the patient's heart rate had dropped to in the 90's. She noticed the [DIAGNOSES REDACTED] (PA) was not reading on the monitor. She stated the (PA) monitor had been working before, but was not at that time. She stated that would have activated a red alarm. This was the first time RN #1 had cared for Patient #1, but she knew the patient had a pacemaker. Interview with RN #2, on 02/25/14 at 8:57 AM, revealed he had worked the night of 2/10/14 when Patient #1 had coded. He was working with RN #1. At the beginning of the work shift (7P-7A) they had a staffing of 2:1 ratio, two patients to one nurse. The patient census was four (4) patients, but they were getting a new admission from the ER. He was on the phone regarding the new admission when the code occurred. He confirmed the nurses carried emergency phones and validated his phone was working that night. The nurses pick up the phones at the beginning of the shift. He stated RN #1 was given a phone. He stated he recalled the patient had multiple red line alerts that night. The patient's heart rate was high (160-170) and oxygen sats were low 90's. He recalled receiving a call from the monitoring room. He informed the monitoring tech the patient's physician was aware. He revealed the combo staff (staff who can work as Unit Secretary or CNA) was pulled at 11:00 PM and that left the two (2) nurses caring for five (5) patients. He stated RN#1 was in another patient's room and when she came out she was going to go next door for supplies, but then she noticed Patient #1's heart rate had dropped to the 90' s and had been there for a while. This was unusual for this patient. RN #2 stated the monitor alarms were not sounding. RN #1 went into Patient #1's room and found the patient unresponsive with no pulse or respirations. RN#2 went into the room and saw the monitor was showing paced rhythm with a heart rate in the 90's. CPR was initiated and a Code Blue was called. RN #2 commented the patient's monitor had red alarmed a lot that night. Interview with Charge Nurse #1, on 02/26/14 at 9:33 AM, revealed he was off the unit the night Patient #1 coded. He stated all nurses in the ICU must carry an emergency phone. They were given to the nurses at shift change. The charge nurse ensures the batteries are changed out and is responsible for faxing the daily phone log to the monitoring room. Each phone had a four-digit number that correlated with the patient room numbers. The monitoring room receives this information each shift and the nurse is assigned a specific phone with a number. He validated the two (2) nurses in ICU that night were assigned phones. The Charge Nurse continued to say when he heard the code called, he returned to the unit and participated in the code. Upon entrance to Patient #1's room, he looked at the monitor and saw either V-tach or a paced rhythm. He looked at the history of the monitor and it appeared the patient's rhythm had changed right before the code. He stated a red alarm would not have activated because the patient's heart rate was down and the pacemaker was spiking on the monitor. The electric part of the heart was working, but not the mechanical part that would pump blood to the body. He was not told by either nurses of any unusual activity with this patient. He did say the combo staff had been pulled from the unit at 11:00 PM prior to the code, which left the two (2) nurses to care for the patients. Observation of the monitoring room, on 02/25/14 at 1:40 PM, revealed four (4) pods of monitors (six monitors each) with four (4) monitoring tech's. The ICU monitors were located in the fourth pod. This was a locked area with security clearance required. Observation continued to reveal the red phones used to call the units in the monitoring room. Interview with Monitor Tech #1, on 02/25/14 at 2:12 PM via telephone, revealed she worked the 7P-7A shift. She had been trained to recognize abnormal changes on the monitor. She stated she had the ICU pod the night of 02/10/14. She recalled having to call three (3) times to the ICU unit to report increased heart rate and low sats and the third call was for the rhythm change. She called the desk phone not the red phone. She stated the ICU was different than the other telemetry units because she had to call the desk phone and not the red phone. The first call she was told the nurse was in the patient's room. The second call was for low sats and she was told the nurse was in the room. The third call was for the change in rhythm and she was told the physician was in the patient's room. The person she talked to did not identify themselves. She indicated when she called the ICU unit, she did not know who she was speaking with and did not know if the nurse responsible for that patient received the information. She stated she recorded the calls on the monitoring room log; however, review of the log revealed she documented A-Fib with paced beats, low sats, increased heart rate. However, there was no times of the calls or names of staff members listed on the log. Interview with the Quality/Risk Management and Manager over the Monitoring room, on 02/25/14 at 1:50 PM, revealed the monitor tech's must complete training just as the nurses and pass a test. The tech's spend two to three weeks with a preceptor. She stated she provided oversight of the monitor tech's by visibly checking the monitoring room 3 to 4 times a week. The House Supervisor was responsible for that area at nights. The system was connected to a software program where the monitors send automatic messages to the emergency phones. The monitor tech would call the ICU units when a red alert was received. Only in the ICU units are the desk phones called. All other telemetry units call the red phone. She had never had a reported incident when the phones had not been answered. With the system in place at this time, she could not ensure the nurse caring for a particular patient would get the red alarm message. She stated she had implemented a new log after this event that would include the time of the call and who the monitor tech spoke with. In addition, a new process implemented on 02/20/14 revealed the monitor room had the capacity to see if any of the monitors in the ICU were turned off. It would show up as a red "x". The monitor tech would then call the unit and ask why the monitor was turned off. The monitor tech's were to check for this every two hours. Interview with the Risk Manager, on 02/25/14 at 3:30 PM, revealed he found out about the incident through IRIS (internal reporting system) regarding the concern about a delay in treatment for Patient #1. He contacted the ICU Nurse Manager and they met in a daily Huddle meeting. He said Charge Nurse #1 had already brought this to the Manager's attention. The Risk Manager started the investigation on 02/11/14. He stated he went to the monitor room to print strips and speak with the Monitor Technician (Tech #1) who had called the unit that night. The Monitor Tech told him she had called the desk phone to the ICU unit to inform them Patient #1's heart rate was high and oxygen saturation (sats) were low. She told him she had called earlier and then heard the code being called. She told him there were multiple red alarms for this patient that night. The Risk Manager explained the ICU was set up differently than the other telemetry units. The monitor room was only a second line review for them. The nurses in the unit were the first. He stated if a yellow line alarm was received, the Monitor Tech would call the unit desk, if a red line alarm was received, they would call the red phone. He stated Monitor Tech #1 had called the desk, not the red phone that night. He stated his investigation was ongoing and he had not concluded a root cause analysis. He indicated part of the root cause analysis was looking at implementing where the Monitor Tech would have to speak directly to the nurse caring for the patient instead of calling the desk as was the process now. The Risk Manager stated he had identified an eight (8) minute delay in treatment because Patient #1's monitor had not alarmed due to the patient's pacemaker pacing. He considered the event to be a serious safety event. Interview with the Risk Manager and the Director of Nursing (DON) of Critical Care, on 02/25/14 at 4 PM, revealed the monitors in the ICU were new and working properly. He had the Bio-med Department check the monitors on 02/11/14 and they found no problems with the alarms. In addition, the emergency phones were checked and found to be working properly. The Risk Manager stated the emergency phones were a new system that connected the monitor alarms in the patients' rooms to emergency phones the nurses are supposed to carry with them at all times. Each emergency phone had a four-digit number that coincided with patients' monitors. Each nurse was assigned a phone at the beginning of the work shift. When a monitor activated a red alarm, it would activate the emergency phone the nurse was carrying to alert them that the patient's monitor was alarming with changes. A message was sent to the phone stating what the problem was: oxygen sats too low, heart rate elevated, changes in heart rhythm or blood pressure. The monitors in the ICU have parameters the staff could set according to what the Physician wanted. The DON stated she felt the [DIAGNOSES REDACTED] (PA) alarm had been turned off. The patient had an A-line (arterial) inserted and if that alarm was turned on, it would have activated a red alarm even when the cardiac monitor did not. The DON had interviewed RN #1 regarding the events and the nurse told her the alarms did not go off and indicated that her phone did not activate. When she interviewed the other nurse working in the unit that night, the nurse told her they did not recall if the red alarm was sounding because he was on the phone about a new admission he was getting on the unit. Interview with the DON of Critical Care, on 02/26/14 at 4:12 PM, revealed she had reviewed the alert detail and determined RN #1 had turned the phone off. The phone was working at the beginning of the nurse's shift and when the phone was passed off to the next shift nurse, it started recording received messages. She stated every phone was pulled and detailed records reviewed and this was the only phone that had failed messages and only during RN#1's shift. She stated the units had safety Huddle meetings each shift to discuss any safety issues. The charge nurses give the emergency phones to the nurses and it was the responsibility of the staff nurse to ensure it was working. The charge nurse would fax the phone log to the monitoring room to let them know which nurse had a specific phone. The DON stated she had conducted random checks to ensure the nurses were carrying the phones and had found they were not. Disciplinary actions were taken when this occurred. However, she had no routine schedule to check and she had not implemented any since this event. She stated her expectation would be the nurses carried the phones. She stated the facility implemented this process in December 2012, but some nurses still didn't like to carry them because they were annoying. She stated there were four (4) safety system checks in place to ensure patients received care in a safe setting: 1. monitors at the desk, 2. monitor linked to each patient's room and staff are encouraged to use, 3. emergency phones-red alarms to phones, and 4. monitoring tech as back-up. The DON stated all of these systems failed for this patient. The DON said she suspected the nurse turned off the PA monitor because it was alarming so much instead of adjusting it. She stated she looked at the monitor strips and found some of the EKG changes were due to artifact. The patient was alert and awake until just before the code. If the PA monitor had been turned on, the red alarms would have alarmed even though the cardiac monitor did not due to the pacemaker. She indicated some of the staff nurses had been re-educated on phone use and not turning off monitors as 1:1 talking sessions. No documentation of those teaching sessions was completed nor provided. Another interview with the Risk Manager, on 02/26/14 at 11:57 AM, revealed there would be three safety meetings for root cause analysis. The first was an initial meeting to determine if the event was sentinel or serious. The facility made the decision it was a serious safety event. The second meeting will be held next Monday, March 3, 2014 to review fact findings and identify root cause analysis and implement corrective actions. The third meeting would be within a week, to evaluate the corrective actions. This had to occur within thirty (30) days. The Quality Steering committee would meet monthly. He stated he was waiting for the meeting on Monday for root cause analysis and then implement corrective actions. He stated he could not ensure this event would not happen again before the root cause analysis meeting. |
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| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to provide adequate staffing to meet one (1) of fourteen (14) sampled patients needs. Patient #1 was admitted to the Intensive Care Unit (ICU) for close monitoring of cardiac problems. Staff interviews and nursing assessments revealed the patient was alert, responsive, and following commands on 02/10/14 between 4:00 AM - 8:00 PM. The patient's heart rate was 120-140 until 9:00 PM where it dropped to the 90's. On 02/10/14, at approximately 11:23 PM, Register Nurse (RN) #1 found the patient unresponsive with no pulse or respirations. The nursing staff initiated cardiopulmonary resuscitation (CPR) at 11:25 PM and coded the patient for twenty (20) minutes. The patient was revived, but there was no neurological response after the code on the next day the ventilator was stopped and the patient was pronounced clinically dead at 10:43 AM on 02/11/14. Interview with RN#1 revealed the nurse was busy in another patient's room and did not hear the resident's monitor alarm nor received any message on the emergency phone. RN #2 was on the telephone getting information about a patient to be admitted to the unit from the Emergency Department. A combo staff person had been pulled to another unit prior to the code. The facility's failure to ensure adequate staffing to care for Patient #1, failure of the red alarms to sound, and availability of other resources for nurses, placed all patients in the ICU at risk for serious injury, harm, impairment or death. Refer to A0392 |
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| VIOLATION: STAFFING AND DELIVERY OF CARE | Tag No: A0392 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to provide adequate staffing to meet one (1) of fourteen (14) sampled patient's needs. Patient #1 was admitted to the Intensive Care Unit (ICU) for close monitoring of cardiac problems. Staff interviews and nursing assessments revealed the patient was alert, responsive, and following commands on 02/10/14 between 4:00 AM - 8:00 PM. The patient's heart rate was 120-140 until 9:00 PM where it dropped to the 90's. On 02/10/14, at approximately 11:23 PM, Register Nurse (RN) #1 found the patient unresponsive with no pulse or respirations. The nursing staff initiated cardiopulmonary resuscitation (CPR) at 11:25 PM and coded the patient for twenty (20) minutes. The patient was revived, but there was no neurological response after the code. The next day the ventilator was stopped and the patient was pronounced clinically dead at 10:43 AM on 02/11/14. Interview with RN#1 revealed the nurse was busy in another patient's room and did not hear the resident's monitor alarm and did not receive any message on the emergency phone. RN #2 was on the telephone getting information about a patient to be admitted to the unit from the Emergency Department. A combo staff person had been pulled to another unit prior to the code. The facility identified the event to be a serious safety event; however, the investigation was still ongoing and the facility had not conducted a root cause analysis with corrective actions implemented. The facility determined the red alert messages to RN #1's phone failed and the monitor in Patient #1's room did not alarm. Both were checked by Bio-med and were determined to be working correctly; however, the facility had not provided any oversight of the staff to ensure the nurses had the phones with them, that they were turned on and responding to the messages since the event. The findings include: Review of the facility's policy for Sentinel/Serious Safety Events, effective date of September 2006 and last reviewed June 2012, revealed the purpose was to examine underlying factors of the sentinel/adverse event and develop a risk reduction strategy; to provide documentation in a consistent and systematic manner with a primary focus on the systems and processes, not on the individual performance; to initiate an investigation and/or a root cause analysis to understand the causes of the event; and to identify changes that could be made in systems and processes which could reduce the risk of such events occurring in the future. The policy stated an occurrence was considered a sentinel event if it had resulted in an unanticipated death. The occurrence was considered a Serious Safety Event (SSE) if there was deviation from a generally accepted performance standard and the deviation caused moderate to severe harm or death. Risk management would conduct an initial investigation to determine if the event was a Sentinel Event or a SSE. The Risk Manager coordinates a task force and facilitates a root cause analysis (RCA). Director of Quality and RCA task force would develop any necessary corrective actions to address the RCA of the event and assign responsible leaders to ensure effective implementation in a designated time frame. The facility did not provide a policy on Nursing Services. Per the DON they use the Professional Standard of Practice for Nursing. Review of Patient #1's clinical record revealed the patient presented to the facility's Emergency Department, on 02/04/14 at 9:59 PM, with complaints of syncope and abdominal pain. The patient was found to be tachycardiac with a heart rate of 140. The patient was placed on a cardiac monitor that revealed frequent premature ventricular contractions (PVC's). The patient was admitted to ICU for close hemodynamic monitoring with diagnoses of [DIAGNOSES REDACTED]. On 02/10/14 at approximately 11:23 PM, RN #1 went into Patient #1's room and found the patient unresponsive with no pulse or respirations. Cardiopulmonary resuscitation (CPR) was initiated. Review of the Code Blue documentation revealed the code started at 11:25 PM. The code ran for twenty (20) minutes and a pulse was obtained. The patient was intubated and placed on a ventilator. Review of the Physician's progress note, who had responded to the code, documented the patient appeared to be in Asystole (absent of pulse) for over ten (10) minutes prior to the code, but it was not captured by the monitor alarms because the pacemaker was activated. The Physician documented twenty (20) minutes of Brain Hypoxia given intubation was not achieved until 11:38 - 11:40 PM. On 02/11/14, Physician notes revealed the patient showed no neurological response after the code. The patient was removed from the ventilator and allowed to die naturally. The patient was pronounced clinically dead at 10:43 AM on 02/11/14. Interview with RN #1, on 02/26/14 at 10:12 AM, revealed she was the nurse responsible for Patient #1 on 02/10/14. She stated she received an emergency phone that night and stated only red line alarms would automatically send a message to the phone. She indicated Patient #1 alarms were sounding frequently that night due to the patient's elevated heart rate and low sats. The patient had been tachycardiac with heart rates of 130-140. She acknowledged there had been a phone call from the monitor room, but the Physician was in the patient's room at that time. She stated she received no messages from the emergency phone that night. She stated she went into the patient's room approximately 11:00 PM, to hang intravenous (IV) Potassium. She stated the patient was awake, coughed and then turned over. At approximately 11:25 PM, she heard the IV pump beeping in Patient #1's room. She went in and found the patient unresponsive. She stated the patient did not look right so she called the patient's name with no response, and shook the patient gently with no response. She checked and found no pulse or respiration. A Code Blue was called and CPR was initiated. She stated she looked at the monitor and saw it was pacing and the patient's heart rate had dropped to the 90's. She noticed the [DIAGNOSES REDACTED] (PA) was not reading on the monitor. She stated the PA monitor had been working before, but was not at that time. She stated that would have activated a red alarm. This was the first time RN #1 had cared for Patient #1, but she knew the patient had a pacemaker. She stated she had been busy in another patient's room before Patient #1 coded. Review of the alert detail report revealed on 02/10/14, the computerized monitor in Patient #1's room sent fifteen (15) red line alert messages to RN #1's emergency phone between 9:00 PM to 11:16 PM (before the patient coded). Review of the alert detail report revealed all of those messages failed with the message of "handset did not respond to the ring command. It may be turned off or out of range". These messages reported [DIAGNOSES REDACTED] and low oxygen saturation levels. The report revealed, on 02/11/14 at 7:47 AM, after shift change, the phone received and read messages from the monitor alarms. Interview with RN #2, on 02/25/14 at 8:57 AM, revealed he had worked the night of 2/10/14 when Patient #1 had coded. He was working with RN #1. At the beginning of the work shift (7P-7A) they had staffing of 2:1 ratio, two patients to one nurse. The patient census was four (4) patients, but they were getting a new admission from the ER. He was on the phone regarding the new admission when the code occurred. He stated he recalled the patient had multiple red line alerts that night. The Patient's heart rate was high (160-170) and oxygen sats were low 90's. He recalled receiving a call from the monitoring room. He informed the monitoring tech the patient's physician was aware. He revealed the combo staff (staff who can work as unit secretary or CNA) was pulled at 11:00 PM and that left the two (2) nurses caring for five (5) patients. He stated RN #1 was in another patient's room and when she came out she was going to go next door for supplies, but then she noticed Patient #1's heart rate had dropped to the 90's and had been there for a while. This was unusual for this patient. RN #2 stated the monitor alarms were not sounding. RN #1 went into the Patient #1's room and found the patient unresponsive with no pulse or respirations. RN #2 went into the room and saw the monitor was showing paced rhythm with a heart rate in the 90's. CPR was initiated and a Code Blue was called. RN #2 commented the patient's monitor had red alarmed a lot that night. Interview with Charge Nurse #1, on 02/26/14 at 9:33 AM, revealed he was off the unit the night Patient #1 coded. The Charge Nurse continued to say when he heard the code called, he returned to the unit and participated in the code. He stated he had pulled the combo staff from this unit at 11:00 PM prior to the code, which left the two (2) nurses to care for the patients. Interview with the Risk Manager, on 02/25/14 at 3:30 PM, revealed he found out about the incident through IRIS (internal reporting system) regarding the concern about a delay in treatment for Patient #1. He contacted the ICU Nurse Manager and they met in a daily Huddle meeting. He said Charge Nurse #1 had already brought this to the manager's attention. The Risk Manager started the investigation on 02/11/14. He stated he went to the monitor room to print strips and speak with the Monitor Technician (Tech #1) who had called the unit that night. The Monitor Tech told him she had called the desk phone to the ICU unit to inform them Patient #1's heart rate was high and oxygen saturation (sats) were low. She told him she had called earlier and then heard the code being called. She told him there were multiple red alarms for this patient that night. The Risk Manager explained the ICU was set up different than the other telemetry units. The monitor room was only a second line review for them. The nurses in the unit were the first. He stated if a yellow line alarm was received, the Monitor Tech would call the unit desk, if a red line alarm received, they would call the red phone. He stated Monitor Tech #1 had called the desk, not the red phone that night. He stated his investigation was ongoing and he had not concluded a root cause analysis. He indicated part of the root cause analysis was looking at implementing where the Monitor Tech would have to speak directly to the nurse caring for the patient instead of calling the desk as was the process now. The Risk Manager stated he had identified an eight (8) minute delay in treatment because Patient #1's monitor had not alarmed due to the patient's pacemaker pacing. He considered the event to be a serious safety event. Interview with the Risk Manager and the Director of Nursing (DON) of Critical Care, on 02/25/14 at 4 PM, revealed the monitors in the ICU were new and working properly. He had the Bio-med Department check the monitors on 02/11/14 and they found no problems with the alarms. In addition, the emergency phones were checked and found to be working properly. The Risk Manager stated the emergency phones were a new system that connected the monitor alarms in the patients' rooms to emergency phones the nurses are supposed to carry with them at all times. Each emergency phone had a four-digit number that coincides with the patient's monitor. Each nurse was assigned a phone at the beginning of the work shift. When a monitor activated a red alarm, it would activate the emergency phone the nurse was carrying to alert them that the patient's monitor was alarming with changes. A message was sent to the phone stating what the problems were: oxygen sats too low, heart rate elevated, changes in heart rhythm or blood pressure. The monitors in the ICU had parameters the staff could set according to what the Physician wanted. The DON stated she felt the [DIAGNOSES REDACTED] (PA) alarm had been turned off. The patient had an A-line (arterial) inserted and if that alarm was turned on, it would have activated a red alarm even when the cardiac monitor did not. The DON had interviewed RN #1 regarding the events and the nurse told her the alarms did not go off and indicated to her the phone did not activate. When she interviewed the other nurse working in the unit that night, the nurse told her they did not recall if the red alarm was sounding because he was on the phone about a new admission he was getting on the unit. Interview with the DON of Critical Care, on 02/26/14 at 4:12 PM, revealed she had reviewed the alert detail and determined RN #1 had turned the phone off. The phone was working at the beginning of the nurse's shift. When the phone was passed off to the next shift nurse, it started recording received messages according to the DON. She stated every phone was pulled and detailed records reviewed and this was the only phone that had failed messages and only during RN #1's shift. She stated the units have safety Huddle meetings each shift to discuss any safety issues. The charge nurses give the emergency phones to the nurses and it was the responsibility of the staff nurse to ensure the phones were working. The charge nurse would fax the phone log to the monitoring room to let them know which nurse had a specific phone. The DON stated she had conducted random checks to ensure the nurses were carrying the phones and had found they were not. Disciplinary actions were taken when this occurred. However, she had no routine schedule to check and she had not implemented any since this event. She stated her expectation would be the nurses carried the phones. She stated the facility implement this process in December 2012, but some nurses still didn't like to carry them because they were annoying. She stated there were four (4) safety system checks in place to ensure patients received care in a safe setting: 1. monitors at the desk; 2. monitor linked to each patient's room and staff are encouraged to use; 3. emergency phones with red alarms to phones; and 4. a monitoring tech as a back-up. She further stated all the systems failed for this resident. The DON said she suspected the nurse turned off the PA monitor because it was alarming so much instead of adjusting it. She stated she looked at the monitor strips and found some of the EKG changes were due to artifact. The patient was alert and awake until just before the code. If the PA monitor had been turned on, the red alarms would have alarmed even though the cardiac monitor did not due to the pacemaker. She indicated some of the staff nurses had been re-educated on the use of the phones and not turning off monitors as 1:1 talking sessions. According to the DON no documentation of the teaching sessions was completed. Continued interview with the DON revealed she normally staffed the ICU with a ratio of 2:1, two patients to one nurse. She stated she was aware the combo person was pulled at 11:00 PM and there was a new admission to the unit that night. She stated that would occasionally occur, but that was not normal. She stated the Charge Nurse would assist as needed, but does not normally take patients. Review of the nursing staffing of the ICU for 02/10/14 for the 7 PM to 7 AM shift revealed two (2) nurses for five (5) patients. A combo staff member was assigned to assist the nurses; however, interview revealed the combo staff was pulled to another unit at 11:00 PM, prior to the code. |
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