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MIAMI VALLEY HOSPITAL ONE WYOMING STREET DAYTON, OH 45409 Oct. 26, 2017
VIOLATION: NURSING SERVICES Tag No: A0385
Based on medical record review, facility policy review, staff interview, and review of alarm notification system reports, the facility failed to ensure that staff responded to low oxygen saturation and low heart rate alarms (A392). The cumulative affect of this systemic practice resulted in the facility's inability to ensure that the patients' nursing needs would be met.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on medical record review, facility policy review, review of alarm notification system reports, and staff interview, the facility failed to ensure staff followed current facility policy related to management of clinical alarms. This affected Patient #2 and had the potential to affect all patients receiving care in the hospital. The total sample size was ten patients. The facility census was 468.

Findings include:

The facility policy titled "Clinical Alarm Management" was reviewed on 10/25/17 at 10:40 AM. According to the policy every alarm signal should be acknowledged by the assigned caregiver and staff. When a notification system such as Vocera is used, assigned caregivers will be notified and expected to respond when they receive the notification.

Review of an incident report dated 09/13/17 at 04:07 AM stated: "Low SpO2 (oxygen saturation level) alarms were not being checked by nursing staff the entire night, I spoke with the team leader for the night to make sure that all nursing staff were signed up and receiving low SpO2 alerts on their Voceras, he/she re-checked this and assured me that all nurses were receiving these alerts, we rely on nursing to tell us when there are low SpO2 alarms going off because us respiratory therapists do not receive these alerts on our Voceras. After this occurred and the team leader was notified the rest of the night the nursing individuals mentioned above were aware that alarms were going off into dangerous levels (SpO2 levels 80 and below) and no one notified respiratory therapists but instead ignored them. This is a patient safety issue that needs to be addressed."

The Vocera reports for the night of 09/12/17 for the two staff nurses identified in the incident report were reviewed on 10/25/17 at 5:05 PM. Neither staff member acknowledged dozens of alarms that were sent to the Voceras.

Staff C, the Director of Quality Innovation, was interviewed on 10/24/17 at 2:45 PM and was asked to provide documentation of a quality review of the 09/13/17 incident. Staff C reported that a review of this incident report has not been completed. A screen shot of the activity for this incident revealed the incident was first read by a Risk Management staff member on 09/22/17. The log of activity further noted the incident was forwarded to the associate manager of the Advanced Care Pulmonary unit on 09/22/17, nine days after the incident was reported.

Review of a Nurse's Note on 09/16/17 at 2:47 PM stated a patient care technician walked in the Patient #2's room in response to the patient's alarm and found the patient unresponsive and not breathing. A staff emergency was called. Cardiopulmonary resuscitation (CPR) was initiated until the nurse caring for the patient informed staff that the patient was a DNR-CC (Do Not Resuscitate-Comfort Care). Resuscitative efforts were discontinued and the time of death was documented as 3:15 PM.

Review of an incident report dated 09/26/17 at 10:44 AM stated: Event Date 09/16/17 "Patient #2 was a DNR and had been on continuous BiPap. RN at lunch. PCT responded to a BiPap alarming because he/she felt it had been alarming for a while. Found patient with bradycardia and cyanotic. Team Leader pulled staff emergency. CPR initiated very briefly as RN notified the staff that patient was a DNR. Vocera report ran. Patient rang out low heart rate and low SpO2 for 20 minutes before he/she expired. RN and buddy RN did not acknowledge any of these alarms on Vocera or enter room. Both RN and buddy RN said they did not receive any alarms before patient rang out asystole. Per Vocera report, messages were received by Vocera device appropriately."

The Vocera report for Staff Z, the buddy nurse assigned to care for Patient #2, was reviewed on 10/25/17 at 4:05 PM. At 2:25 PM on 09/16/17 an alarm that the patient's SpO2 was low at 81% was sent to the Vocera of the nurse. The alarm was not acknowledged. One minute later, at 2:26 PM, an alarm that the patient's heart rate was low at 46 beats per minute was sent to the nurse's Vocera. The alarm was not acknowledged. It was further noted a second alarm at 2:26 PM notifying the nurse of the patient's low SpO2 at 76% was sent to the Vocera. Again, this alarm was not acknowledged by the nurse. At 2:27 PM an alarm that the patient had an SpO2 of 71% and 68% at 2:28 PM were sent to the nurse's Vocera. Neither alarms were acknowledged by the nurse. At 2:29 PM an alarm that the patient's SpO2 was 63% was sent to the nurse's Vocera but was not acknowledged. At 2:30 PM an alarm that the patient's SpO2 was 66% was sent to the nurse's Vocera but was not acknowledged. More than 20 alarms were sent to the nurse from 2:30 PM to 2:45 PM. None of the alarms were acknowledged by the nurse. At 2:45 PM the Vocera report noted the patient's heart rate was 27 beats per minute. Three more alarms until 2:53 PM were sent to the nurse's Vocera that went unacknowledged.

The Vocera report for Staff Y, the primary nurse caring for Patient #2, was reviewed on 10/26/17 at 11:45 AM. At 9:26 AM on 09/16/17 an alarm was sent to inform the nurse that the patient had exited the bed. This alarm was not acknowledged by the nurse. At 9:28 AM an alarm was sent to the nurse's Vocera that noted the patient's SpO2 at 85%. This alarm was not acknowledged. At 10:48 AM an alarm was sent to the nurses' Vocera that noted the patient's SpO2 at 83%. Again, the alarm was not acknowledged. From 11:02 AM to 1:09 PM there were more than 70 alarms to the nurse's Vocera that the patient's leads failed. None of the alarms were acknowledged by the nurse. At 1:35 PM an alarm was sent to the nurse's Vocera that noted the patient's heart rate was low at 49 beats per minute. Again, this alarm was not acknowledged by the nurse. An alarm that the patient was in asystole was sent to the nurse's Vocera at 2:46 PM. This alarm was also unacknowledged by the nurse.

These findings were confirmed with Staff A on 10/25/17 at 5:10 PM.