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Based on a review of facility documents and policies, a review of the medical record for Patient #3, and staff interviews it was determined that the facility failed to have a governing body that monitored nursing services to provide treatment and follow MD orders.


Cross refer A-0385 as it relates to the failure of the facility's nursing services to initiate telemetry as ordered by the MD to ensure that patient was on continuous cardiac monitoring, which resulted in harm to Patient #3 who expired on [DATE] at 6:26 a.m.

Cross refer A-0115 as it relates to the failure of the facility's governing body to protect and promote the right of a patient to receive care in a safe environment.

Based on a review of medical records, facility's policies and procedure, and staff interviews the facility failed to protect and promote a patient's right to care in a safe setting for Patient #3. The patient was ordered telemetry by MD #10 to continuously monitor the patient's cardiac status. The order was not initiated by RN #4 and the patient expired on [DATE] at 6:26 a.m.


Cross refer A-0385 as it relates to the failure of the facility's nursing services to initiate telemetry orders by MD #10 to ensure that patient was on continuous cardiac monitoring, which resulted in harm to Patient #3 who expired on [DATE] at 6:26 a.m.

Cross refer A-0043 as it relates to the failure of the facility to have a Governing Body that had oversight of the facility's nursing services to treat patients and follow MD orders, for the Governing Body to protect and promote a patient's right to care in a safe setting.

Based on a review of medical records, facility's policies and procedure, and staff interviews the facility's nursing services failed to initiate telemetry monitoring as ordered by MD #10 for Patient #3 which resulted in harm to Patient #3 who expired on [DATE] at 6:26 a.m. secondary to a lack of continuous cardiac monitoring.

Findings: -

Cross refer A-0043 as it related to the failure of the facility to have a governing body that had oversight and monitored nursing services to provide treatment and follow MD orders for Patient #3.

Cross refer A-0115 as it relates to the failure of the facility to protect and promote the right of Patient #3 to receive care in a safe environment.

A review of Patient # 3's Medical Record revealed that she was brought into the facility's Emergency Department (ED) by ambulance on 09/11/18 at 1:21 p.m. from a local rehabilitation facility with complaints of hypoxia (oxygen deficiency in the body), nausea, vomiting, diarrhea and possible clostridium difficile (c-diff - a bacterium that causes symptoms ranging from diarrhea to inflammation in the intestines). The record revealed that Patient #3 had a history of heart failure and an abnormal heart rhythm. Intravenous (IV- tubes put in the vein through the skin to deliver fluids and medicines directly to the patient) lines were inserted and fluids were administered. Tests that were performed in the Emergency Department included blood cultures (blood testing to identify infections in the blood), chest and abdominal X-Rays, and a 12-lead Electrocardiogram (electrocardiogram - a representation of the heart's electrical activity recorded from electrodes placed on the body surface).
Patient #3 was transferred from the ED to the medical surgical unit on 9/11/18 at 5:41 p.m.

The medical record further revealed that Patient #3 arrived from the ED to the medical-surgical unit on 9/11/18 at 6:18 p.m. Admission orders for Patient #3 were written by NP #11 on 9/11/18 at 5:41 p.m., and electronically co-signed by MD #10 on 9/11/18 at 5:52 p.m. The orders included telemetry (transmission of signals from one electronic unit to another by radio waves using a device that provides real-time measurement of the electrical activity of the patient's heart rhythm. The heart rhythm is monitored by putting patches on the patient, wires are attached to the patient and to a box that sends information about the heart beat to a screen that is being watched continuously) monitoring and contact isolation precautions (the protocol whereby healthcare workers are required to wear gloves, and in some cases, a gown when coming into contact with a patient with an actual or suspected contagious disease).

Further review of the medical record for Patient #3 failed to reveal that telemetry was initiated by the nurse for Patient #3 at any point during Patient 3's stay in the medical surgical unit.

Review of Patient #3's medical record revealed the following vital signs at 6:39 p.m.: -

Temperature (T) -98.4 F,
Pulse (P) - 68,
Respirations (R) -16, and
Blood Pressure (BP) - 122/67.
At 8:01 p.m., the following vital signs were recorded -:
O2 Sat - 91%.

A physical examination of Patient #3 by NP #10 on 09/11/18 at 6:50 p.m. revealed that Patient #3 was alert, cooperative and in no distress.

Further review of the medical record revealed vital signs for Patient #3 on 9/11/18 at 11:20 p.m. as follows: -
BP 106/55,
O2 Sat-97%.

The Patient Care Technician provided personal hygiene at 12:45 a.m. on 09/12/18.

At 3:11 a.m. on 09/12/18 RN #4 administered Solu-Medrol IV as ordered.
At 5:22 a.m., RN #4 administered eye drops and Lopressor (blood pressure medication) as ordered by the physician.
At 5:39 a.m., the record revealed that a new bag of IV fluids was hung.

Review of the discharge note by MD #12 on 9/12/2018 at 7:42 a.m. revealed that in the morning of 9/12/18, while nurses were doing their AM checks, it was noted that Patient #3 was noted to was not breathing and had no pulse. Patient #3 was not responding to stimuli (a thing that evokes a reaction. A Code Blue (an emergency announced in an institution in which a patient is in cardiopulmonary arrest, requiring a team of providers [a 'code team'] to rush to the specific location and begin immediate resuscitative efforts) was called at 6:07 a.m. and resuscitative efforts started as per protocol. Patient #3 was pronounced dead at 6:26 a.m. on 9/12/18.

A tour of the 7th floor Medical-Surgical unit with Staff #3, Director of Quality on 09/20/18 at 4:00 p.m. revealed a clean and orderly unit. Hallways were clear and without clutter. Staff was observed attending to patients or documenting at the nurse's station. Call lights were answered without delay.

During an interview in the facility's Main Conference Room on 09/19/18 at 4:34 p.m. with RN #1, she stated she had been with the facility for 5 years. After a brief review of the medical record for Patient #3, RN #1 recalled the day that Patient #3 came to the floor with /her family. RN #1 recalled that Patient #3 was calm, pleasant, alert and oriented and in no apparent distress. RN #1 recalled conducting bedside rounds (change of shift reports given at the patient bedside) with RN #4, the oncoming nurse, and going over MD's orders for Patient #3. RN #1 said she told RN #4, that RN #1 had hung fluids and obtained vital signs, but that telemetry had not been initiated for Patient #3. RN #1 stated that it was the responsibility of the receiving (oncoming) nurse to take orders off the chart. RN #1 had taken some of the quick orders off (the process of acknowledging and implementing doctor's orders), such as hanging fluids and getting vital signs but had left the rest of the orders for the nightshift nurse (RN #4) to execute. RN #1 said the nurse can acknowledge orders electronically.

RN #1 further stated that orders by medical providers for specific departments go to those specific departments (e.g. Respiratory, Laboratory, Radiology, Imaging, or Pharmacy). The only order RN #1 remembers for which the nurse had to call the respective department to obtain is the order for telemetry, and RN #1 had not made that call. RN #1 said she did not sign off that she had acknowledged any of Patient #3's orders.
RN #1 further stated that if an order is directed towards a department, it goes directly to that department and that telemetry is not a department. Central supply is not a department either, and if something from central supply were to be ordered, the nurse would need to order them as she signed the orders off the chart. RN #1 said that sometimes, the night shift charge nurse will go through the charts and assist, to be certain that the orders are taken off.

In interview was conducted with RN #4, the incoming night shift nurse who had the charge of Patient #3 on 9/11/18. During the interview in the 7th floor conference room on 9/20/18 at 5:08 p.m., RN #4 stated that she began his/her employment at the facility in March of 2018.
RN #4 stated that at the beginning of RN #4's shift on 9/11/18, RN #1 gave report on Patient #3 at Patient #3's bedside with Patient #3's family also present. Patient #3 was a new admission for day shift and RN #1 was finishing up the admission process. Included in RN #1's report was Patient #3's history of congestive heart failure (a progressive disease that makes the heart weak and makes it difficult to pump blood through the body), diabetes (a condition that makes it difficult to regulate the blood sugar in the body), and hypertension (high blood pressure). RN #1 told RN #4 that Patient #3 was on telemetry (for [DIAGNOSES REDACTED]- an irregular heart beat that may lead to stroke). RN #4 recalled that RN #1 had said that Patient #3 came from a rehabilitation facility and was on a clear liquid diet. RN #4 further stated that RN #4 went to see her other patients on the floor while RN #1 finished up. RN #4 also recalled that Patient #3 was on contact precautions (the protocol whereby healthcare workers are required to wear gloves, and in some cases, a gown when coming into contact with a patient with an actual or suspected contagious disease). RN #4 recalled that Patient #3 was cooperative and followed commands and even helped pull herself up in the bed by using the bedrails. RN #4 said that at some point in time, Patient #3 had a blood sugar check that was low. RN #4 stated that she could not recall the timeline of the events. RN #4 recalled that the blood sugar reading was around 55 milligrams/deciliter (mg/dl - blood sugar normal range 70 mg/dl to 140 mg/dl per the Merck Manual). RN #4 said she had to give D 50 (Glucose in water to be injected directly into the body to increase blood sugar). RN #4 had to recheck blood sugar very often after that to make sure it was going up. RN #4 remembers Patient #3's vital signs were 'okay', but her hands were very cold. She said none of the staff could get the pulse oximeter (small clip-like device attached to the body that is used to measure the amount of oxygen in the blood by using light beams to read through the blood of the finger, ear lobe or even the toes) to read an oxygen level. She said respiratory therapy came and said the oxygen saturation was fine according the pulse oximeter when placed on the earlobe. RN #4 did not remember what the results were. RN #4 stated that she was in the room 'a lot' all during her shift with giving the patient a bath, blood sugar checks, taking oxygen off so the respiratory therapist could check the oxygen saturation on room air, and passing medications. Patient #3 had IV (intravenous) fluids going (fluids being administered directly into the veins of the body through a plastic tubing). The Charge Nurse (RN #6) came in the room when the patient's blood sugar was low and told RN #4 that she needed to start a new IV line to administer fluids and medications. RN #4 said the skin surrounding the IV site on the patient's body was red, and that it was difficult to get the new line started. RN #4 as well as well as Staff #6 attempted it, before a nurse from another floor came to start the new line. RN #4 stated that the process took a while. RN #4 further stated that she went in early on 9/12/18 to give the morning medications to Patient #3, and Patient #3 was just sitting in bed with her eyes open but would not respond. RN #4 said she sat the patient up further to take the pills that were ordered, but the patient was not following commands and did not seem to be able to swallow the pills. RN #4 went to finish giving her other patients' medicines and to crush Patient # 3's medicines and take them back to him/her later. RN #4 later spoke with RN #6 (Charge Nurse) and told her about the patient not responding. RN #4 was not able to give a timeline of when she spoke with Staff #6. RN #6 told RN #4 to go back to Patient #3's room and call a Rapid Response (Emergency Code for a patient who is in a critical condition and needs urgent care). When RN #4 returned to the room, Patient #3 was slumped over and not breathing or responding. RN #4 said a Rapid Response was called. RN #4 said she did not document all that she had done during the shift. The only documentation that she did was an assessment around midnight and vital signs.

During an interview with the Director of Quality and Safety (Staff #3), in the facility's first floor conference room on 09/19/18 at 10:30 a.m., Staff #3 stated that the facility had notified the state agency of the incident on 9/13/18 at 3:00 p.m.
Staff #3 further stated that the facility leadership had initiated an investigation the next day (9/13/18) and were currently going through the process of determining where the breakdown occurred in the care of Patient #3 and what the consequences will be. The facility's corporate office was also aware of the incident. Staff #3 stated that the investigation was on-going, and that further corrections will be made with staff. Staff #3 said the investigation is leading towards communication breakdown and that the facility has already put steps in place to prevent further situations like this. She said that the facility system had recently determined that there were areas for improvement in telemetry services and that there was an overall performance improvement project for all facilities within the system on that topic. Staff #3 said the current facility is starting the project sooner because of the incident regarding Patient #3. Staff #3 stated that there have been no complaints from the family of Patient #3 regarding Patient #3's care.

A review of the nursing staffing on the floor where Patient #3 was admitted , from 09/09/18 to 09/15/18 revealed that the unit was staffed according to the facility's policy.

Review of the Facility Medical Staff Rules and Regulations (08/13/18) revealed that advanced practice registered nurse and Physician Assistants may perform part or all of the history and physical examination, provided that their findings are reviewed and signed by a qualified licensed independent practitioner within 24 hours. The history and physical would include a review of systems, personal medical history, physical exam and plan of treatment.

A review of seven (7) additional medical records (#s 1, 2, 4, 5, 6, 7, 8), revealed as follows: -

-There was a nine-hour delay in initiating telemetry for Patient #2 after the physician's order.
-Telemetry was initiated within six (6) hours for Patient #4 and Patient #7 after the physician's order
-Telemetry was initiated within one (1) hour of physician's orders for Patients #s 6 and 8.
-Telemetry was initiated immediately after bedside monitoring for Patients #4 and #5.

All eight (8) medical records (#s 1, 2, 3, 4, 5, 6, 7, 8) had consent for treatments, consents for special procedures, documentation of notice of patient rights.

A review of the facility policy 51, Nursing Patient Assessment/Reassessment, revised 01/05/17 revealed that the purpose of the policy was to establish guidance for assessing and reassessing patients. The policy was to ensure all patients receive the appropriate assessment (including initial screening and reassessment), assessment would be done as multidisciplinary, and that assessing the patient would be a continuous collaborative effort within all departments functioning as a team. A complete head to toe assessment would be done within 12 hours of admission and a Registered Nurse would initiate an individualized care plan. A Registered Nurse would review assessment date collected each shift to determine if other problems are present and care plans would be updated to reflect any newly identified problems.

A review of the facility policy 39, Rights and Responsibilities of Patients Policy, revised 08/01/14 revealed the purpose of the policy was to acknowledge patients' rights and responsibilities and the healthcare system's responsibility to respond to each person with dignity and respect. Information about the facility's Patient Rights and Responsibilities Policy and related services would be made available to each patient or patient surrogate at the time of admission. Patients, their family members/legal representatives, and the general public would have the right to register a complaint or grievance regarding services, patient safety or quality of care.

A review of the facility policy 92, Complaint/Grievance Process Policy, revised 04/04/17, revealed the purpose of the policy was to establish guidance to the healthcare system and its affiliates for providing consistency across the system for complaint management. The policy to provide specific channels through which patients and families could voice concerns and to provided consistency in complaint management and resolution. The system Board of Directors would delegate the responsibility to review and resolve grievances to a Grievance Committee at each affiliate hospital. The Grievance Committee would include the Chief Executive Officer (CEO), Chief Medical Officer (CMO), Chief Nursing Officer (CNO), Risk Management, Quality, Patient Experience (Patient Advocate), and other representatives as appropriate. The committee would review all grievances monthly, identify trends and report to governing body.

A review of the facility policy 07, Scope of Care: House Telemetry, revised 02/14/18, revealed that house telemetry would be open 24 hours a day seven (7) days a week. Patient Assessment would include assisting nursing staff providing direct patient care by observation of cardiac patients.

A review of the facility policy 64, Inpatient Care Services Medical-Surgical Unit 7 MS, revised 02/15/18, revealed the purpose was to define the function of staffing, patient care assignments, evaluation system, and the budgeted staff for the Medical/Surgical Telemetry Unit 7 MS. The policy revealed that 7 MS manages the care of a diverse population of patients. Medical telemetry patients would comprise a significant population. Nursing Care would be coordinated and directed by a Charge Nurse during each shift. A Registered Nurse (RN) would administer direct patient care, perform initial assessments and collaborate in the formulation of the patients' plans of care based on the initial assessment and reassessment data collected. Reassessment would be performed specific to the patient's needs every shift and as needed.

A review of the facility policy 24, Telemetry, Non-ICU Nursing Areas, effective 06/16/16 revealed the purpose of the policy was to define indications for remote monitoring and would provide instructions on maintaining a standard of care for patients receiving telemetry. The policy directed the procedural guidelines to Lippincott Procedure Manual.

A review of the Lippincott Procedures for Telemetry Non-ICU Nursing Areas that was provided by the facility and was reviewed by the facility on 02/16/18, revealed the purpose of the procedure was to provide guidelines for telemetry in non-ICU nursing areas. The procedure revealed the Primary Nurse would check electrodes and wires once per shift for stability and firm adherence of the electrodes to the skin. The Primary Nurse in a non-cohorted unit would verify and document rhythm in the electronic medical record upon initiation of telemetry and then every shift. In a cohorted cardiac unit, verification and documentation would be done every four hours. Further review of the procedure revealed that the monitor technician would analyze telemetry strips upon initiation of telemetry and then at least every 4 - 6 hours thereafter. The monitor techs would notify the primary nurse of any change in the patients monitoring. Monitor techs would immediately notify the primary nurse or other appropriate staff member of any patient who is unexpectedly unmonitored.