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Based on record review, interviews, policy review, and observation it was determined the hospital failed to ensure life saving measures were activated in a timely manner for one patient (#1) during a heart attack, resulting in the death of Patient #1, and the hospital failed to ensure continuous cardiac telemetry monitoring for 75 patients on cardiac telemetry monitoring.
Refer to A0144 Patient Rights, Care in a Safe Setting.

The facility provided an Immediate Jeopardy removal plan on 07/10/2025. The immediacy was determined to be removed 5:08 PM on 07/10/2025.
The actions included:
1. Immediate Containment: Safety Tip- Provider notification of changes cardiac condition
2. Immediate Containment: Team Resources review/Peer Review
3. Review and Revise SFBH- NUR-124 STEMI Alert policy
4. Educate all inpatient nursing units on revised STEMI alert process, chain of command and STEMI case study
5. Review and Revise the STEMI Activation process
6. New hire education (RNs) r/t STEMI Alert policy and the STEMI Activation process
7. CMU Responsibilities attestation
8. Central Monitoring Unit break coverage
The signatures and education were reviewed and interviews conducted with 13 nurses to verify education received.

Based on record review, observation, interviews, and policy review the hospital failed to oversee the effectiveness of process improvement for ensuring the safety of patients on continuous telemetry monitoring, resulting in death for Patient #1, after a similar occurrence in April 2025.
Refer to A0286.
The facility provided an Immediate Jeopardy removal plan on 07/10/2025. The immediacy was determined to be removed 5:08 PM on 07/10/2025.
The actions included:
1. Immediate Containment: Safety Tip- Provider notification of changes cardiac condition
2. Immediate Containment: Team Resources review/Peer Review
3. Review and Revise SFBH- NUR-124 STEMI Alert policy
4. Educate all inpatient nursing units on revised STEMI alert process, chain of command and STEMI case study
5. Review and Revise the STEMI Activation process
6. New hire education (RNs) r/t STEMI Alert policy and the STEMI Activation process
7. CMU Responsibilities attestation
8. Central Monitoring Unit break coverage
The signatures and education were reviewed and interviews conducted with 13 nurses to verify education received.

Based on record review, interviews, and policy review, the hospital failed to ensure Medical Staff acted appropriately when they were informed of a change in a patient's condition. This failure to respond resulted in the death of Patient #1.
Refer to A0347.

The facility failed to ensure all patients on telemetry were continuously monitored and failed to ensure the staff were aware of the STEMI (ST elevation myocardial infarction,a severe type of heart attack characterized by a complete blockage of a coronary artery, leading to significant oxygen deprivation and potential damage to the heart muscle) process. Failure to inform staff of the STEMI process was associated with the death of Patient #1. Refer to A0396.

The facility provided an Immediate Jeopardy removal plan on 07/10/2025. The immediacy was determined to be removed 5:08 PM on 07/10/2025.
The actions included:
1. Immediate Containment: Safety Tip- Provider notification of changes cardiac condition
2. Immediate Containment: Team Resources review/Peer Review
3. Review and Revise SFBH- NUR-124 STEMI Alert policy
4. Educate all inpatient nursing units on revised STEMI alert process, chain of command and STEMI case study
5. Review and Revise the STEMI Activation process
6. New hire education (RNs) r/t STEMI Alert policy and the STEMI Activation process
7. CMU Responsibilities attestation
8. Central Monitoring Unit break coverage
The signatures and education were reviewed and interviews conducted with 13 nurses to verify education received.

Based on record review, interviews, policy review, and observation, the hospital failed to ensure:

1. a change in rhythm and notify a cardiologist for 1(patient #1) of 2 sampled, resulting in the death, and
2. the cardiac telemetry monitors were continuously monitored for 75 of 146 patients on continuous telemetry monitoring.

Findings included:

1.
Review of Patient #1 medical record revealed he came to the hospital ED (Emergency Department) on 06/15/2025 for a chief complaint of shortness of breath for a week. He had a past medical history of CHF (congestive heart failure), cardiac stent, atrial fibrillation (A-fib), and pericardiectomy (open heart surgery to remove part of the sac surrounding the heart). While Patient #1 was in the ED, cardiac enzymes (Troponins-a biomarker to assess and detect heart muscle damage), were obtained, and were: 10:13 AM 773, 12:45 1285, 3:08 PM 2636. Patient #1 was started on a heparin drip (heparin is a blood thinner) and admitted to the PCU (progressive care unit) on cardiac telemetry monitoring, with plans to perform a cardiac catheter the next morning. At 2:38 AM on 06/16/2025 the RN (registered nurse) noted ST elevation (an upward deviation of the ST segment indicating myocardial ischemia-a heart attack where a coronary artery is completely blocked) on the cardiac monitor. The RN obtained an ECG (electrocardiogram-a test that measures the heart's electrical activity) and confirmed there was ST elevation. The RN then called the on-call APRN (Advanced Practice Registered Nurse). APRN notified the hospitalist who was in the ED at the time. The hospitalist gave an order to continue the current treatment plan. At 03:12 AM the monitor technician called to report the ST elevation. There was no further action documented until 03:39 AM when the RN noted Patient #1 was lethargic and had a change of rhythm. CPR (cardiopulmonary resuscitation) was started. At 03:48 AM, ROSC (return of spontaneous circulation) was achieved. Patient #1 continued to have rhythm changes with loss of his pulse 2 more times. The on-call interventional cardiologist was paged for a STEMI (ST elevated MI-myocardial infarction-heart attack). At 04:43 AM, Patient #1 was then taken to the Catheter Lab on a Lucas device (a device that provides automated chest compressions during CPR). An Impella was placed (Impella is a ventricular assist device that helps the heart pump blood), and a cardiac catheterization was performed. The interventional cardiologist found a thrombus (blood clot) in the LAD (left anterior descending) artery with stenosis (constriction) of the middle LAD and total occlusion (blockage) of the distal LAD. The interventional cardiologist proceeded with PCI (percutaneous coronary intervention) with balloon angioplasty (a procedure to open the vessels). Patient #1 was placed on full life support and transported by air to [another hospital] and expired 2 days later.

During a telephone interview on 07/09/2025 at 4:25 PM, Staff C, RN stated she notified the charge nurse first to see who to call. Staff C, RN then called the APRN . The APRN said she was looking at the EKG, and she would call back. The APRN spoke to Staff A, MD and acknowledged they were seeing the same thing, and to continue the current treatment plan on heparin with plans to cath (cardiac catheterization) the next morning. Patient #1 was complaining of back pain 3 out of 10. He had a history of back surgeries. She said when she saw the ST elevation she checked on him and he was asymptomatic. Staff C, RN got the EKG and called the provider. He coded (respirations and pulse stopped) about an hour after that happened. Staff C, RN stated she did not notify anyone else; she said she notified the charge nurse and the hospitalist. She updated the charge nurse on what the hospitalist said. Staff C. RN said she was not aware of the policy for STEMI at all and that is why she notified the charge nurse.

During a telephone interview on 07/09/2025 at 7:39 PM, Staff E, CNC (charge nurse) stated the patient came in a with a non-STEMI and cardiology was aware. Staff C told me and the on-call cardiologist answering center about the ST elevation. Staff C did not speak to the cardiologist; she spoke to Staff A, MD. Staff A, MD called cardiology, it was doctor to doctor communication. Patient #1 was stable; he never complained of chest pain. The plan was medication and monitor. Patient #1 just changed very quickly and drastically.

During a telephone interview on 07/09/2025 at 6:30 PM, Staff B, APRN stated she did not speak to a cardiologist. The nurse called and said the MT (Monitor Technician) called and noticed some ST elevation. They woke Patient #1 up to do a 12 lead EKG. Patient #1 came in with elevated troponins and was placed on a heparin drip. They spoke to the cardiologist when he was in the ED, he was aware of the troponins and wanted him on a heparin drip and to take aspirin with plans to do a catheterization in the morning. The patient was asymptomatic. Staff B, APRN stated she printed out the EKG. Patient #1 went from a left bundle block (a heart condition where electrical signals are delayed or blocked as they travel through the heart's conduction system, specifically the right or left bundle branches) to a right bundle block. He was asymptomatic. Vital signs were stable. Staff B, APRN said she called Staff A, MD who is her supervisor. Staff A, MD reviewed the EKG and his labs and said we can keep doing what we are doing, because he is on heparin, aspirin and is having a cardiac cath in the morning. Staff B, APRN said she does not think Staff A, MD spoke to cardiology. About an hour later Patient #1 coded. The floor will usually call the cardiologist and send the 12-lead to the cardiologist. Cardiology then tells them whether to do a STEMI alert.

During a telephone interview on 07/10/2025 at 8:35 AM, Staff A, MD stated she did not call a cardiologist. Staff B,APRN was notified. Staff A, MD then said she was admitting other patients and talking to the ED physician about them when Staff B, APRN brought 2 EKGs to her. The first was A-fib with RVR (rapid ventricular response). The second was left heart block. No EKG was obtained between the first and second. The second EKG showed right incomplete bundle branch block. Patient #1 was on a heparin drip and was stable and sleeping. It could indicate PE (pulmonary embolus) or LAD ischemia. He had a cardiac cath scheduled in the morning. While she was on her way upstairs to see the first patient who was admitted, the code was called. The LAD was blocked with a thrombus. He should have went to cath lab from the ED. He might have had a chance. He had a poor chance of survival because of his history. His cardiac indicator was 10. He was very, very high risk. He had very advanced cardiac disease.

During an interview on 07/10/2025 at 11:14 AM, Staff J, cardiologist stated he was not complaining of chest pain, he was hemodynamically stable, no ST changes, and he received Eliquis the night before, and that made him very high risk for any invasive procedure unless it is emergent. Staff J, cardiologist said he would expect to be notified if there were changes in their cardiac rhythm. He said he also expects that when telemetry is ordered, it is continuously monitored.


During an interview on 07/10/25 at 3:20 PM, the supervisor of risk management stated the patient came in on June 15th with for shortness of breath. He was admitted for non-STEMI. He went to a tele unit; PCU (progressive care unit). His outside cardiologist had been consulted. They did serial troponins on him, which were not good; over 700, 1500, 2000 something. His cardiologist was aware of the troponins and that the patient was on Eliquis. The plan was to take him to cath the next morning. His vital signs were stable. He was on room air and doing ok. At 2:30 AM when the nurse was charting she notice he had ST elevations. He was supposed to have another EKG in the morning, so she just went ahead and did the EKG. When she saw it, her interpretation was that it was a STEMI. She was concerned but is a newer nurse. At this point she had not received a call from CMU, and she was upset about that. She talked to the charge who told her to call the hospitalist. Staff B, APRN, looked up the EKGs; one from June 15th and the new one. She was not comfortable with it, so she called Staff A, MD who said he was already on heparin and he was getting a cath in the morning. That was the plan. The patient was not symptomatic. The vital signs were normal. He was still having ST elevations. Then he coded at 3:40 something. By this time, CMU (central monitoring room) had called. It was around 3:10 AM and Staff C was very short with the MT because Staff C already knew about the ST elevation. Staff A, MD came up for the code. After ROSC they did another EKG and it read STEMI. The AOD (Adminstrator on Duty) was there because of the code, and she had a call out to the on call interventional cardiologist. He came in to take Patient #1 to the cath lab, and then he coded again. The problem was that he had changes in the cardiac rhythm and EKG, and he had a cardiologist, but that cardiologist was not consulted to make the decision on Patient #1's care, resulting in a potential delay. He did not meet criteria for the STEMI alert because the old policy did not specify the criteria for a STEMI alert. It was not written in the policy that they should call cardiology. The executive review really did feel that this was something the physician did exercise control over. The cardiologist said he would like to have been notified. He said he does not know if he would have taken the patient to the cath lab or not, but he would have liked to have been able to make that decision. He said he is the specialist, and he should have been consulted. Even though the patient was asymptomatic, the staff were not even aware of the STEMI process.

Review of the Policy, STEMI Alert, dated 7/23, revealed no specific instructions when ST elevation is identified without chest pain. However, the following was found in the policy:
For an admitted patient with new or worsening onset of chest pain or other anginal equivalent, obtain a stat EKG and initiate a rapid response by dialing 66.
The rapid response team will respond and the AOD (administrator on duty) and/or ICU RN will review the EKG and notify the STEMI MD on call for interpretation of the EKG.
If the EKG has been interpreted as a STEMI, alert the rapid response team or designee by calling 66 and activate STEMI alert.
When STEMI alert is activated the hospital operator will put out one STEMI alert page that goes to the individuals listed below:
AOD, ICU charge (Intesive Care Unit Charge Nurse), interventional services lab, IR on call team, interventional services manager, ICU manager, ED medical director, ED nurse manager, education codes pager, Education Manager, pharmacy.

2.
During an observation on 07/09/2025 at 10:15 AM, in the CMU (central monitoring unit) was one MT (monitor tech) with a trainee present. There were 2 monitor stations. Staff H, MT was sitting in front of the 4-screen station nearest to the door. The second 4 screen monitoring station toward the back of the room, had no one monitoring it. There was still no one monitoring the station when the surveyor exited the room at 10:21 AM, a total of 6 minutes.

During an interview while observing at 10:18 AM, Staff H, MT stated the other MT was in the rest room. The DON was present during the observation and interview.

During an interview on 07/09/2025 at 10:21 AM, Staff H, MT stated he is monitoring 38 to 39 patients. We watch for each other during bathroom breaks; it's always been that way. It would be difficult to get someone to come in and cover every time one has to go to the bathroom because he is on a diuretic and in the bathroom frequently.

During an interview on 07/09/2025 at 10:25 AM, Staff G, MT said they cover each other for bathroom breaks. They have never designated anyone for the bathroom. The number varies. He has 40 patients he is monitoring today; the max is in the 40's. All alarms are shown on both screens and there is a notification for alarms that displays on both stations. For ST elevation, we call the nurse, document and notify the charge nurse. Then it goes on the call log.

During an interview on 07/09/2025 at 10:34 AM, the Staff I, Nurse Manager stated the monitor techs cover themselves. If it is more than a quick run to the bathroom then they have been told to call the charge nurse, assistant nurse manager or herself. Lunch is scheduled with someone covering. They can see the other one's alarms. The census has been low. If it were high, then they are expected to call for coverage. She agreed, monitoring 76 patients is not ok. They should be calling for relief. There was a delay from CMU and the nurse found it within a few minutes. That monitor tech was put on investigative leave with a written warning. They are to call the nurse immediately, and the charge nurse. They should be giving each other report before taking their bathroom break.

During an interview on 07/09/2025 at 1:37 PM, the DON (Director of Nursing) said ideally, someone would be sitting there to cover, but the bathroom is right there. The DON said she is comfortable with it because any arrythmias would show up on the other tech's screen. He can see it.

Based on record review, facility documents, observation, interviews and policy review, the hospital failed to ensure appropriate measures were implemented in order to prevent a second serious safety event involving a telemetry patient (Patient #1) for 1 of 1corrective action plans.

Findings included:

Review of Patient #1 medical record revealed he came to the hospital ED (Emergency Department) on 06/15/2025 for a chief complaint of shortness of breath for a week. He had a past medical history of CHF (congestive heart failure), cardiac stent, atrial fibrillation (A-fib), and pericardiectomy (open heart surgery to remove part of the sac surrounding the heart). While Patient #1 was in the ED, cardiac enzymes (Troponins-a biomarker to assess and detect heart muscle damage), were obtained, and were: 10:13 AM 773, 12:45 1285, 3:08 PM 2636. Patient #1 was started on a heparin drip (heparin is a blood thinner) and admitted to the PCU (progressive care unit) on cardiac telemetry monitoring, with plans to perform a cardiac catheter the next morning. At 2:38 AM on 06/16/2025 the RN (registered nurse) noted ST elevation (an upward deviation of the ST segment indicating myocardial ischemia-a heart attack where a coronary artery is completely blocked) on the cardiac monitor. The RN obtained an ECG (electrocardiogram-a test that measures the heart's electrical activity) and confirmed there was ST elevation. The RN then called the on-call APRN (Advanced Practice Registered Nurse). APRN notified the hospitalist who was in the ED at the time. The hospitalist gave an order to continue the current treatment plan. At 03:12 AM the monitor technician called to report the ST elevation. There was no further action documented until 03:39 AM when the RN noted Patient #1 was lethargic and had a change of rhythm. CPR (cardiopulmonary resuscitation) was started. At 03:48 AM, ROSC (return of spontaneous circulation) was achieved. Patient #1 continued to have rhythm changes with loss of his pulse 2 more times. The on-call interventional cardiologist was paged for a STEMI (ST elevated MI-myocardial infarction-heart attack). At 04:43 AM, Patient #1 was then taken to the Catheter Lab on a Lucas device (a device that provides automated chest compressions during CPR). An Impella was placed (Impella is a ventricular assist device that helps the heart pump blood), and a cardiac catheterization was performed. The interventional cardiologist found a thrombus (blood clot) in the LAD (left anterior descending) artery with stenosis (constriction) of the middle LAD and total occlusion (blockage) of the distal LAD. The interventional cardiologist proceeded with PCI (percutaneous coronary intervention) with balloon angioplasty (a procedure to open the vessels). Patient #1 was placed on full life support and transported by air to [another hospital] and expired 2 days later.

During an observation on 07/09/2025 at 10:15 AM, in the CMU (central monitoring unit) was one MT (monitor tech) with a trainee present. There were 2 monitor stations. Staff H, MT was sitting in front of the 4-screen station nearest to the door. The second 4 screen monitoring station toward the back of the room, had no one monitoring it. There was still no one monitoring the station when the surveyor exited the room at 10:21 AM, a total of 6 minutes.

During an interview while observing at 10:18 AM, Staff H, MT stated the other MT was in the rest room. The DON was present during the observation and interview.

During an interview on 07/09/2025 at 10:21 AM, Staff H, MT stated he is monitoring 38 to 39 patients. We watch for each other during bathroom breaks; it's always been that way. It would be difficult to get someone to come in and cover every time one has to go to the bathroom because he is on a diuretic and in the bathroom frequently.

During an interview on 07/09/2025 at 10:25 AM, Staff G, MT said they cover each other for bathroom breaks. They have never designated anyone for the bathroom. The number varies. He has 40 patients he is monitoring today; the max is in the 40's. All alarms are shown on both screens and there is a notification for alarms that displays on both stations. For ST elevation, we call the nurse, document and notify the charge nurse. Then it goes on the call log.

During an interview on 07/09/2025 at 10:34 AM, the Staff I, Nurse Manager stated the monitor techs cover themselves. If it's more than a quick run to the bathroom then they have been told to call the charge nurse, assistant nurse manager or herself. Lunch is scheduled with someone covering. They can see the other one's alarms. The census has been low. If it were high, then they are expected to call for coverage. She agreed, monitoring 76 patients is not ok. They should be calling for relief. There was a delay from CMU and the nurse found it within a few minutes. That monitor tech was put on investigative leave with a written warning. They are to call the nurse immediately, and the charge nurse. They should be giving each other report before taking their bathroom break.

During an interview on 07/09/2025 at 1:37 PM, the DON (Director of Nursing) said ideally, someone would be sitting there to cover, but the bathroom is right there. The DON said she is comfortable with it because any arrythmias would show up on the other tech's screen. He can see it.

During a telephone interview on 07/09/2025 at 4:25 PM, Staff C, RN stated she notified the charge nurse nurse first to see who to call. Staff C, RN then called the APRN . The APRN said she was looking at the EKG, and she would call back. The APRN spoke to Staff A, MD and acknowledged they were seeing the same thing, and to continue the current treatment plan on heparin with plans to cath (cardiac catheterization) the next morning. Patient #1 was complaining of back pain 3 out of 10. He had a history of back surgeries. She said when she saw the ST elevation she checked on him and he was asymptomatic. Staff C, RN got the EKG and called the provider. He coded (respirations and pulse stopped) about an hour after that happened. Staff C, RN stated she did not notify anyone else; she said she notified the charge nurse and the hospitalist. She updated the charge nurse on what the hospitalist said. Staff C. RN said she was not aware of the policy for STEMI at all and that is why she notified the charge nurse.

During a telephone interview on 07/09/2025 at 7:39 PM, Staff E, CNC (charge nurse) stated the patient came in a with a non-STEMI and cardiology was aware. Staff C told me and the on-call cardiologist answering center about the ST elevation. Staff C did not speak to the cardiologist; she spoke to Staff A, MD. Staff A, MD called cardiology, it was doctor to doctor communication. Patient #1 was stable; he never complained of chest pain. The plan was medication and monitor. Patient #1 just changed very quickly and drastically.

During a telephone interview on 07/09/2025 at 6:30 PM, Staff B, APRN stated she did not speak to a cardiologist. The nurse called and said the MT (Monitor Technician) called and noticed some ST elevation. They woke Patient #1 up to do a 12 lead EKG. Patient #1 came in with elevated troponins and was placed on a heparin drip. They spoke to the cardiologist when he was in the ED, he was aware of the troponins and wanted him on a heparin drip and to take aspirin with plans to do a catheterization in the morning. The patient was asymptomatic. Staff B, APRN stated she printed out the EKG. Patient #1 went from a left bundle block (a heart condition where electrical signals are delayed or blocked as they travel through the heart's conduction system, specifically the right or left bundle branches) to a right bundle block. He was asymptomatic. Vital signs were stable. Staff B, APRN said she called Staff A, MD who is her supervisor. Staff A, MD reviewed the EKG and his labs and said we can keep doing what we are doing, because he is on heparin, aspirin and is having a cardiac cath in the morning. Staff B, APRN said she doesn't think Staff A, MD spoke to cardiology. About an hour later Patient #1 coded. The floor will usually call the cardiologist and send the 12-lead to the cardiologist. Cardiology then tells them whether to do a STEMI alert.

During a telephone interview on 07/10/2025 at 8:35 AM, Staff A, MD stated she did not call a cardiologist. Staff B,APRN was notified. Staff A, MD then said she was admitting other patients and talking to the ED physician about them when Staff B, APRN brought 2 EKGs to her. The first was A-fib with RVR (rapid ventricular response). The second was left heart block. No EKG was obtained between the first and second. The second EKG showed right incomplete bundle branch block. Patient #1 was on a heparin drip and was stable and sleeping. It could indicate PE (pulmonary embolus) or LAD ischemia. He had a cardiac cath scheduled in the morning. While she was on her way upstairs to see the first patient who was admitted, the code was called. The LAD was blocked with a thrombus. He should have went to cath lab from the ED. He might have had a chance. He had a poor chance of survival because of his history. His cardiac indicator was 10. He was very, very high risk. He had very advanced cardiac disease.

During an interview on 07/10/2025 at 11:14 AM, Staff J, cardiologist stated he was not complaining of chest pain, he was hemodynamically stable, no ST changes, and he received Eliquis the night before, and that made him very high risk for any invasive procedure unless it's emergent. Staff J, cardiologist said he would expect to be notified if there were changes in their cardiac rhythm. He said he expects that when telemetry is ordered, it is continuously monitored.

During an interview on 07/10/25 at 3:20 PM, the supervisor of risk management stated the patient came in on June 15th with for shortness of breath. He was admitted for non-STEMI. He went to a tele unit; PCU (progressive care unit). His outside cardiologist had been consulted. They did serial troponins on him, which were not good; over 700, 1500, 2000 something. His cardiologist was aware of the troponins and that the patient was on Eliquis. The plan was to take him to cath the next morning. His vital signs were stable. He was on room air and doing ok. At 2:30 AM when the nurse was charting she notice he had ST elevations. He was supposed to have another EKG in the morning, so she just went ahead and did the EKG. When she saw it, her interpretation was that it was a STEMI. She was concerned but is a newer nurse. At this point she had not received a call from CMU, and she was upset about that. She talked to the charge nurse who told her to call the hospitalist. Staff B, APRN, looked up the EKGs; one from June 15th and the new one. She was not comfortable with it, so she called Staff A, MD who said he was already on heparin and he was getting a cath in the morning. That was the plan. The patient was not symptomatic. The vital signs were normal. He was still having ST elevations. Then he coded at 3:40 something. By this time, CMU (central monitoring room) had called. It was around 3:10 AM and Staff C was very short with the MT because Staff C already knew about the ST elevation. Staff A, MD came up for the code. After ROSC they did another EKG and it read STEMI. The AOD was there because of the code, and she had a call out to the on call interventional cardiologist. He came in to take Patient #1 to the cath lab, and then he coded again. The problem was that he had changes in the cardiac rhythm and EKG, and he had a cardiologist, but that cardiologist was not consulted to make the decision on Patient #1's care, resulting in a potential delay. He didn't meet criteria for the STEMI alert because the old policy did not specify the criteria for a STEMI alert. It was not written in the policy that they should call cardiology. The executive review really did feel that this was something the physician did exercise control over. The cardiologist said he would like to have been notified. He said he doesn't know if he would have taken the patient to the cath lab or not, but he would have liked to have been able to make that decision. He said he is the specialist, and he should have been consulted. Even though the patient was asymptomatic, the staff were not even aware of the STEMI process.

Review of Sentinel Events Policy last revised 05/2024 states:
Comprehensive Systematic Analysis - A process for identifying the most basic or causal factor or factors that underlie variation in performance, including the occurrence of a sentinel event or serious occurrence. The response to the event includes:
a. Formalized team response that stabilizes the patient, discloses the event to the patient and/or patient representative, and provides support for the patient representative and family as well as team members involved in the event
b. Notification of hospital leadership
c. Immediate investigation
d. Completion of a comprehensive systematic analysis for identifying the causal and contributory factors
e Corrective actions derived from the identified causal and contributing factors that eliminate or control system hazards or vulnerabilities and result in sustainable improvement overtime
f. Timeline for implementation of corrective actions
g. Systemic improvement
Comprehensive Systematic Analysis investigations are conducted within the Patient Safety Evaluation System (PSES) for the purpose of reporting to the PSO. Documents generated by these investigations are considered Patient Safety Work Product (PSWP) unless individually designated otherwise.


Review of the Policy, STEMI Alert, dated 7/23, revealed no specific instructions when ST elevation is identified without chest pain. However, the following was found in the policy:
For an admitted patient with new or worsening onset of chest pain or other anginal equivalent, obtain a stat EKG and initiate a rapid response by dialing 66.
The rapid response team will respond and the AOD (Administrator on Duty) and/or ICU RN will review the EKG and notify the STEMI MD on call for interpretation of the EKG.
If the EKG has been interpreted as a STEMI, alert the rapid response team or designee by calling 66 and activate STEMI alert.
When STEMI alert is activated the hospital operator will put out one STEMI alert page that goes to the individuals listed below:
AOD, ICU charge (Intesive Care Unit Charge Nurse), interventional services lab, IR on call team, interventional services manager, ICU manager, ED medical director, ED nurse manager, education codes pager, Education Manager, pharmacy.

Based on review of medical record, interviews, and policy reviews, the hospital failed to ensure the Medical Staff recognized and responded to a change of condition that required emergent action for 1 (Patient #1) of 2 patients sampled for mortality.

Findings included:

Review of Patient #1 medical record revealed he came to the hospital ED (Emergency Department) on 06/15/2025 for a chief complaint of shortness of breath for a week. He had a past medical history of CHF (congestive heart failure), cardiac stent, atrial fibrillation (A-fib), and pericardiectomy (open heart surgery to remove part of the sac surrounding the heart). While Patient #1 was in the ED, cardiac enzymes (Troponins-a biomarker to assess and detect heart muscle damage), were obtained, and were: 10:13 AM 773, 12:45 1285, 3:08 PM 2636. Patient #1 was started on a heparin drip (heparin is a blood thinner) and admitted to the PCU (progressive care unit) on cardiac telemetry monitoring, with plans to perform a cardiac catheter the next morning. At 2:38 AM on 06/16/2025 the RN (registered nurse) noted ST elevation (an upward deviation of the ST segment indicating myocardial ischemia-a heart attack where a coronary artery is completely blocked) on the cardiac monitor. The RN obtained an ECG (electrocardiogram-a test that measures the heart's electrical activity) and confirmed there was ST elevation. The RN then called the on-call APRN (Advanced Practice Registered Nurse). APRN notified the hospitalist who was in the ED at the time. The hospitalist gave an order to continue the current treatment plan. At 03:12 AM the monitor technician called to report the ST elevation. There was no further action documented until 03:39 AM when the RN noted Patient #1 was lethargic and had a change of rhythm. CPR (cardiopulmonary resuscitation) was started. At 03:48 AM, ROSC (return of spontaneous circulation) was achieved. Patient #1 continued to have rhythm changes with loss of his pulse 2 more times. The on-call interventional cardiologist was paged for a STEMI (ST elevated MI-myocardial infarction-heart attack). At 04:43 AM, Patient #1 was then taken to the Catheter Lab on a Lucas device (a device that provides automated chest compressions during CPR). An Impella was placed (Impella is a ventricular assist device that helps the heart pump blood), and a cardiac catheterization was performed. The interventional cardiologist found a thrombus (blood clot) in the LAD (left anterior descending) artery with stenosis (constriction) of the middle LAD and total occlusion (blockage) of the distal LAD. The interventional cardiologist proceeded with PCI (percutaneous coronary intervention) with balloon angioplasty (a procedure to open the vessels). Patient #1 was placed on full life support and transported by air to [another hospital] and expired 2 days later.

During a telephone interview on 07/09/2025 at 4:25 PM, Staff C, RN stated she notified the charge nurse first to see who to call. Staff C, RN then called the APRN . The APRN said she was looking at the EKG, and she would call back. The APRN spoke to Staff A, MD and acknowledged they were seeing the same thing, and to continue the current treatment plan on heparin with plans to cath (cardiac catheterization) the next morning. Patient #1 was complaining of back pain 3 out of 10. He had a history of back surgeries. She said when she saw the ST elevation she checked on him and he was asymptomatic. Staff C, RN got the EKG and called the provider. He coded (respirations and pulse stopped) about an hour after that happened. Staff C, RN stated she did not notify anyone else; she said she notified the charge nurse and the hospitalist. She updated the charge nurse on what the hospitalist said. Staff C. RN said she was not aware of the policy for STEMI at all and that is why she notified the charge nurse.

During a telephone interview on 07/09/2025 at 7:39 PM, Staff E, CNC (charge nurse) stated the patient came in a with a non-STEMI and cardiology was aware. Staff C told me and the on-call cardiologist answering center about the ST elevation. Staff C did not speak to the cardiologist; she spoke to Staff A, MD. Staff A, MD called cardiology, it was doctor to doctor communication. Patient #1 was stable; he never complained of chest pain. The plan was medication and monitor. Patient #1 just changed very quickly and drastically.

During a telephone interview on 07/09/2025 at 6:30 PM, Staff B, APRN stated she did not speak to a cardiologist. The nurse called and said the MT (Monitor Technician) called and noticed some ST elevation. They woke Patient #1 up to do a 12 lead EKG. Patient #1 came in with elevated troponins and was placed on a heparin drip. They spoke to the cardiologist when he was in the ED, he was aware of the troponins and wanted him on a heparin drip and to take aspirin with plans to do a catheterization in the morning. The patient was asymptomatic. Staff B, APRN stated she printed out the EKG. Patient #1 went from a left bundle block (a heart condition where electrical signals are delayed or blocked as they travel through the heart's conduction system, specifically the right or left bundle branches) to a right bundle block. He was asymptomatic. Vital signs were stable. Staff B, APRN said she called Staff A, MD who is her supervisor. Staff A, MD reviewed the EKG and his labs and said we can keep doing what we are doing, because he is on heparin, aspirin and is having a cardiac cath in the morning. Staff B, APRN said she doesn't think Staff A, MD spoke to cardiology. About an hour later Patient #1 coded. The floor will usually call the cardiologist and send the 12-lead to the cardiologist. Cardiology then tells them whether to do a STEMI alert.

During a telephone interview on 07/10/2025 at 8:35 AM, Staff A, MD stated she did not call a cardiologist. Staff B,APRN was notified. Staff A, MD then said she was admitting other patients and talking to the ED physician about them when Staff B, APRN brought 2 EKGs to her. The first was A-fib with RVR (rapid ventricular response). The second was left heart block. No EKG was obtained between the first and second. The second EKG showed right incomplete bundle branch block. Patient #1 was on a heparin drip and was stable and sleeping. It could indicate PE (pulmonary embolus) or LAD ischemia. He had a cardiac cath scheduled in the morning. While she was on her way upstairs to see the first patient who was admitted, the code was called. The LAD was blocked with a thrombus. He should have went to cath lab from the ED. He might have had a chance. He had a poor chance of survival because of his history. His cardiac indicator was 10. He was very, very high risk. He had very advanced cardiac disease.

During an interview on 07/10/2025 at 11:14 AM, Staff J, cardiologist stated he was not complaining of chest pain, he was hemodynamically stable, no ST changes, and he received Eliquis the night before, and that made him very high risk for any invasive procedure unless it's emergent. Staff J, cardiologist said he would expect to be notified if there were changes in their cardiac rhythm. He said he expects that when telemetry is ordered, it is continuously monitored.
During an interview on 07/10/25 at 3:20 PM, the supervisor of risk management stated the patient came in on June 15th with for shortness of breath. He was admitted for non-STEMI. He went to a tele unit; PCU (progressive care unit). His outside cardiologist had been consulted. They did serial troponins on him, which were not good; over 700, 1500, 2000 something. His cardiologist was aware of the troponins and that the patient was on Eliquis. The plan was to take him to cath the next morning. His vital signs were stable. He was on room air and doing ok. At 2:30 AM when the nurse was charting she notice he had ST elevations. He was supposed to have another EKG in the morning, so she just went ahead and did the EKG. When she saw it, her interpretation was that it was a STEMI. She was concerned but is a newer nurse. At this point she had not received a call from CMU, and she was upset about that. She talked to the charge nurse who told her to call the hospitalist. Staff B, APRN, looked up the EKGs; one from June 15th and the new one. She was not comfortable with it, so she called Staff A, MD who said he was already on heparin and he was getting a cath in the morning. That was the plan. The patient was not symptomatic. The vital signs were normal. He was still having ST elevations. Then he coded at 3:40 something. By this time, CMU (central monitoring room) had called. It was around 3:10 AM and Staff C was very short with the MT because Staff C already knew about the ST elevation. Staff A, MD came up for the code. After ROSC they did another EKG and it read STEMI. The AOD was there because of the code, and she had a call out to the on call interventional cardiologist. He came in to take Patient #1 to the cath lab, and then he coded again. The problem was that he had changes in the cardiac rhythm and EKG, and he had a cardiologist, but that cardiologist was not consulted to make the decision on Patient #1's care, resulting in a potential delay. He did not meet criteria for the STEMI alert because the old policy did not specify the criteria for a STEMI alert. It was not written in the policy that they should call cardiology. The executive review really did feel that this was something the physician did exercise control over. The cardiologist said he would like to have been notified. He said he does not know if he would have taken the patient to the cath lab or not, but he would have liked to have been able to make that decision. He said he is the specialist, and he should have been consulted. Even though the patient was asymptomatic, the staff were not even aware of the STEMI process.

Review of the Policy, STEMI Alert, dated 7/23, revealed no specific instructions when ST elevation is identified without chest pain. However, the following was found in the policy:
For an admitted patient with new or worsening onset of chest pain or other anginal equivalent, obtain a stat EKG and initiate a rapid response by dialing 66.
The rapid response team will respond and the AOD (administrator on duty) and/or ICU RN will review the EKG and notify the STEMI MD on call for interpretation of the EKG.
If the EKG has been interpreted as a STEMI, alert the rapid response team or designee by calling 66 and activate STEMI alert.
When STEMI alert is activated the hospital operator will put out one STEMI alert page that goes to the individuals listed below:
AOD, ICU charge (Intensive Care Unit Charge Nurse), interventional services lab, IR on call team, interventional services manager, ICU manager, ED medical director, ED nurse manager, education codes pager, Education Manager, pharmacy.

Based on observation, interviews and record reciew, the facility failed to ensure:
1. staff continuously monitored cardiac rhythms of hospitalized patients on telemetry in 76 of 110 patients and
2. failed to ensure nurses providing care to patients adhered to the policies and procedures related to changes in cardiac rhythms 1 (#1) of 1 patient reviewed for adverse events.

Findings included:

Review of the policy Cardiac Monitoring (Telemetry) Initiation, and Discontinuation (Adult), Last reviewed 1/2024 stated ... PURPOSE: 1. To provide patients with cardiac telemetry monitoring when ordered by the provider. 2. To establish guidelines, including indications and clinical criteria, to evaluate the need for continued telemetry. 3. To record cardiac electrical activity for diagnostic or documentation purposes. 4. To identify and treat various dysrhythmias. . . Emergency Response: 1. Monitor Tech (MT) notifies nurse when a change in patient's rhythm is identified. 2. Telemetry skill validated nurse assesses the patient immediately. 3. If patient is symptomatic, notify the provider regarding the patient's condition. 4. Initiate Rapid Response or Code Blue as patient condition dictates.

1.On 7/9/25 at 10:15 AM the CMU (central monitoring unit) was observed. There was one MT (monitor tech) with a trainee present. There were 2 monitor stations. MT H was sitting in front of the 4-screen station nearest to the door. The second 4 screen monitoring station toward the back of the room, had no one monitoring it. MT H was interviewed during the observation at 10:18 AM. He stated the other MT was in the rest room. The DON was present during the observation. There was still no one monitoring the station when the surveyor exited the room for an interview with MT H at 10:21 AM, a total of 6 minutes.

During an interview on 07/09/2025 at 10:21 AM with Monitor Technician (MT) H, he said he is monitoring 38 to 39 patients. Watch for each other during bathroom breaks. It's always been that way. It would be difficult to get someone to come in and cover every time he has to go to the bathroom because he is on a diuretic and in the bathroom frequently. If it's a STEMI call a nurse or charge nurse. If it's lethal, call code blue.

During an interview with MT G at 10:25 AM on 07/09/2025, he said they cover each other for bathroom breaks. They have never designated anyone for the bathroom. The number varies. He has 40 patients he is monitoring today. The max is in the 40's. All alarms are shown on both screens. There is a notification for alarms that are displayed on both stations. For ST elevation, call the nurse. Document it. Also, notify the charge nurse. It goes on the call log and in the patient chart. The side by the door normally watches less than 40.

During an interview with Nurse Manager I on 07/09/2025 at 10:34 AM, she stated the MT's cover themselves. If it is more than a quick run to the bathroom then they have been told to call the charge nurse, assistant nurse manager or herself. Lunch is scheduled with someone covering. They can see the other one's alarms. The census has been low. If it were high, then they are expected to call for coverage. She agreed, 76 patients to watch is not ok. They should be calling for relief. There was a delay from CMU. The nurse found it within a few minutes. That monitor tech was put on investigative leave with a written warning. She said she did not know it was new. They are to call the nurse immediately, and the charge nurse. Within 5 minutes they should be laying eyes on the patient. They have to document it in the chart. They should be giving each other a report before taking their bathroom break.

The Director of Nursing (DON) was interviewed on 7/9/25 at 1:37 PM. The DON said she saw it. Ideally, someone would be sitting there to cover, but the bathroom is right there. They might be 5 minutes. The DON said she is comfortable with it because any arrythmias would show up on the other tech's screen. He can see it.



2.Review of the Policy, STEMI Alert, dated 7/23, revealed no specific instructions when ST elevation is identified without chest pain. However, the following was found in the policy: ... For an admitted patient with new or worsening onset of chest pain or other anginal equivalent, obtain a stat EKG and initiate a rapid response by dialing 66...The rapid response team will respond and the AOD (administrator on duty) and/or ICU RN will review the EKG and notify the STEMI MD on call for interpretation of the EKG ...If the EKG has been interpreted as a STEMI, alert the rapid response team or designee by calling 66 and activate STEMI alert ...When STEMI alert is activated the hospital operator will put out one STEMI alert page that goes to the individuals listed below: AOD, ICU charge nurse, interventional services lab, IR on call team, interventional services manager, ICU manager, ED medical director, ED nurse manager, education codes pager, Education Manager, pharmacy.

Review of Patient #1's medical record revealed he came to the hospital ED (Emergency Department) on 06/15/2025 for a chief complaint of shortness of breath for a week. He had a past medical history of CHF (congestive heart failure), cardiac stent, atrial fibrillation (A-fib), and pericardiectomy (open heart surgery to remove part of the sac surrounding the heart). While Patient #1 was in the ED, cardiac enzymes (Troponins-a biomarker to assess and detect heart muscle damage), were obtained, and were: 10:13 AM - 773, 12:45 - 1285, 3:08 PM - 2636. Patient #1 started on a heparin drip (heparin is a blood thinner) and was admitted to the PCU (Progressive Care Unit) on cardiac telemetry monitoring, with plans to perform a cardiac catheter the next morning. On 06/16/2025 at 2:38 AM the RN (Registered Nurse) noted ST elevation (an upward deviation of the ST segment indicating myocardial ischemia-a heart attack where a coronary artery is completely blocked) on the cardiac monitor. The RN obtained an ECG (electrocardiogram-a test that measures the heart's electrical activity) and confirmed there was ST elevation. The RN then called the on-call APRN (Advanced Practice Registered Nurse). APRN notified the hospitalist who was in the ED at the time. The hospitalist gave an order to continue the current treatment plan. At 03:12 AM the monitor technician called to report the ST elevation. There was no further action documented until 03:39 AM when the RN noted Patient #1 was lethargic and had a change of rhythm. CPR (cardiopulmonary resuscitation) was started. At 03:48 AM, ROSC (return of spontaneous circulation) was achieved. Patient #1 continued to have rhythm changes with loss of his pulse 2 more times. The on-call interventional cardiologist was paged for a STEMI (ST elevated MI-myocardial infarction-heart attack). At 04:43 AM, Patient #1 was then taken to the Catheter Lab on a Lucas device (a device that provides automated chest compressions during CPR). An Impeller was placed (Impella is a ventricular assist device that helps the heart pump blood), and a cardiac catheterization was performed. The interventional cardiologist found a thrombus (blood clot) in the LAD (left anterior descending) artery with stenosis (constriction) of the middle LAD and total occlusion (blockage) of the distal LAD. The interventional cardiologist proceeded with PCI (percutaneous coronary intervention) with balloon angioplasty (a procedure to open the vessels). Patient #1 was placed on full life support and transported by air to [another hospital] and expired 2 days later.

RN C was interviewed by telephone at 4:25 PM on 7/9/25 regarding Patient #1. RN C said she notified the charge nurse first, to see who to call. RN C then called the hospitalist on-call, APRN B. APRN B said she was looking at the EKG, and she would call back. APRN B spoke to Dr. A, MD and acknowledged they were seeing the same thing, and to continue the current treatment plan on heparin with plans to cath (cardiac catheter) the next morning. He was complaining of back pain 3 out of 10. He had a history of back surgeries. When she saw the ST elevation she checked on him. He was asymptomatic. RN C got the EKG and called the provider. He coded (respirations and pulse stopped) about an hour after that happened. RN C confirmed she did not notify anyone else; she said she notified the charge nurse and the hospitalist. She updated the charge nurse on what the hospitalist said. RN C said she was not aware of the policy for STEMI at all and that is why she notified the charge nurse.

On 7/9/25 at 4:45 PM a telephone interview was conducted with MD F, Cardiologist on-call regarding Patient #1. The main reason why they called was for the ST elevation. From the time they called about the ST elevation to the time we did the cath was a couple hours. As far as STEMI guidelines go, it was within time. From STEMI it was within the 90 minutes. It did not carry over to the STEMI timeframe because he coded. He was not admitted to us. I was called in because it was a STEMI and a code. Looking back, he was admitted around 5 pm. The ICU and ED physician reviewed the case at that point. Dr A, MD called us about the ST changes after the code. He had high troponins to start with, and pulmonary edema and was treated with heparin. From the time we were activated, it was within time. We put the Impella first because he already coded. He became hemodynamically stable and was transferred to another hospital. There weren't any cardiology notes, probably because he was admitted late in the afternoon that day. Maybe the cardiology consult should have been stat (immediate).

On 7/9/25 at 7:39 PM a telephone interview was conducted with charge nurse, RN E. The patient came with non-STEMI. Cardiology was aware. RN E, charge nursesaid RN C told him and the on-call cardiologist answering center about the ST elevation. RN C did not speak to the cardiologist. She spoke to Dr A, MD. Dr A, MD called cardiology and Dr Saadi answered. It was doctor to doctor communication. Patient #1 was stable. He never complained of chest pain. The plan was medication and monitor. He just changed very quickly and drastically. We have an app called Air Strip that gives more of a point of view of the leads. It's ICU (intensive care unit) view. The monitor technician (MT) only has telemetry view, and it did not capture it right away. The MT called when they saw it.

APRN B was interviewed at 6:30 AM on 7/10/25 by telephone. APRN B said she did not speak to a cardiologist. The nurse called and said the MT called and noticed some ST elevation. They woke Patient #1 up to do a 12 lead EKG. He came in with elevated troponins and was placed on a heparin drip. They spoke to the cardiologist when he was in the ED, who was aware of the troponins and wanted him on a heparin drip and aspirin with plans to do a cath in the morning. The patient was asymptomatic. APRN B stated she printed out the EKG. Patient #1 went from a left bundle to a right bundle block. He was asymptomatic. Vital signs were stable. APRN B said she called Dr A, MD who is her supervisor. Dr A, MD reviewed the EKG and his labs and said we can keep doing what we are doing, because he is on heparin and aspirin and is having a cardiac cath in the morning. APRN B said she does not think Dr A, MD spoke to cardiology. About an hour later Patient #1 coded. They usually call the cardiologist and send the 12-lead to the cardiologist. Cardiology tells them whether to do a STEMI alert.

Dr A, MD was interviewed at 8:35 AM on 7/10/25 by telephone. Dr A, MD confirmed she did not call a cardiologist. The patient was admitted during the day by ED who had a cardiology consult. The patient was on aspirin, Plavix and Eliquis. About 11 AM his troponin was in the 700s. Around 1:00 PM it was inthe1000s, and about 3:00 PM it was 2700. The nurse noted cardiology consulted, cardiac cath in the morning if the patient is stable. APRN B answers the calls. The patient was asymptomatic. Telemetry (monitor) did not notice any changes. The bedside nurse was watching the monitor. After the patient received an albuterol treatment, the nurse noticed a change on the monitor. APRN B was notified. Dr A, MD said she was admitting other patients and talking to the ED physician about them. APRN B brought 2 EKGs to her. The first was A-fib with RVR (rapid ventricular response). The second was left heart block. No EKG was obtained between the first and second. The second EKG showed right incomplete bundle branch block. Patient #1 was on a heparin drip and was stable and sleeping. It could indicate PE (pulmonary embolus) or LAD ischemia. He had a cardiac cath scheduled in the morning. While she was on her way upstairs to see the first patient who was admitted, the code was called. Patient #1 received several doses of Lasix and magnesium. When she arrived he was in Torsades (ventricular tachycardia-rapid irregular ventricular rate). He had QTC prolongation after ROSC, and ST elevation, caused by electrolyte abnormalities. Dr A, MD said she gave him multiple doses of magnesium. The Albuterol treatment and electrolyte imbalance could have caused it. His potassium was 2.9 (normal is 3.5-5.0). He was already on digoxin, heparin, coreg, and aspirin. He was admitted to PCU because he was stable. They continued to provide resuscitation and took the patient to cardiac cath. The LAD was severely occluded and the RCA. The cardiologist wasn't even able to put the balloon in. Patient #1 had a resected pericardium and had a window done. His anatomy was completely obstructed. This was not acute MI. This was an arrhythmia caused by electrolyte imbalance. He had a large thrombosis in the LAD. Eliquis has a black box warning that discontinuation of Eliquis can cause a thrombus. He hadn't been feeling well, and there is no way to know if they are taking their medications at home. He was flown out. He did not die here. The LAD was blocked with a thrombus. He should have went to cath lab from the ED. He might have had a chance. It was not ischemia, it was Torsades. He had 5 mg of magnesium, calcium gluconate, atropine, ACLS (advanced cardiac life support) and she escorted him to cardiac cath. He had a poor chance of survival because of his history. His cardiac indicator was 10. He was very, very high risk. He was completely asymptomatic , and vital signs were stable. He had very advanced cardiac disease. They have a new policy to call cardiology directly and not the hospitalist. This is an excellent policy, and it will save lives. The nurse has to call the answering service and wait for answering service to call the on-call, and the on-call to call back. This was 20 minutes wasted. No one called her. She just looked at the EKG. She is in the ED all night. She is available from 6 PM to 6 AM. They choose not to call her. The patient was on maximum therapy. 70% occluded LAD by thrombus, and RCA completely occluded. Right heart block is even more serious than left. The cardiologist put in an Impella and 2 stents. Albuterol can precipitate cardiac arrythmias. He had it 10 minutes prior to the event. She said she does not know why he was on albuterol.

At 11:14 AM on 7/10/25 Dr J, cardiologist was interviewed. He was not complaining of chest pain, hemodynamically stable, no ST changes, and he received Eliquis the night before, and that made him very high risk for any invasive procedure unless it is emergent. Dr J, cardiologist said he would expect that cardiology would be notified if there were changes in their cardiac rhythm. He said he also expects that when telemetry is ordered, it is being continuously monitored.

On 7/10/25 at 3:20 PM the supervisor of risk was interviewed. The patient came in on June 15th with a cardiac history, 1 stent, CHF, and pericarditis with surgery, and history of ascites. The pericardiectomy surgery resolved the ascites. He came in for shortness of breath. He was admitted for non-STEMI. He went to a tele unit; PCU. His outside cardiologist had been consulted, because he comes here. They did serial troponins on him, which were not good; over 700, 1500, 2000 something. Outside cardiologist was aware of the troponins and that the patient was on Eliquis. The plan was to take him to cath the next morning. His vital signs were stable. He was on room air and doing ok. At 2:30 in the morning when the nurse was charting she pulled up her air strips, and just happened to notice he had ST elevations on his tracings. He was supposed to have another EKG in the morning, so she just went ahead and did the EKG. When she saw it, her interpretation was that it was a STEMI. She was concerned. She is a newer nurse. She was recently out of the critical care internship program. At this point she had not received a call from CMU, and she was upset about that. She talked to the charge nurse who told her to call the hospitalist. Inpatient is supposed to call the nurse practitioner first. APRN B pulled up the patient. She looked up the EKGs; one from June 15th and the new one. She was not comfortable with it, so she called Dr A, MD who said he was already on heparin and he was getting a cath in the morning. That was the plan. The patient was not symptomatic. The vital signs were normal. He was still having ST elevations. Then he coded at 3:40 something. By this time, CMU (central monitoring room) had called. It was around 3:10 AM and RN C was very short with the MT because RN C already knew about the ST elevation. Dr A, MD came up for the code. After ROSC they did another EKG and it read STEMI. The AOD was there because of the code, and she had a call out to Dr F, cardiologist, who came in to take Patient #1 to the cath lab, and then he coded again. It did take a few minutes to get him to the Cath lab because he was really unstable after they coded him. They did the cath and he coded again. Dr F, cardiologist did an Impella and stabilized the patient and sent him to another hospital. The problem was that he had changes in the cardiac rhythm and EKG, and he had a cardiologist, but that cardiologist was not consulted to make the decision on Patient #1's care, resulting in a potential delay. He did not meet criteria for the STEMI alert because the old policy did not specify the criteria for a STEMI alert. It was not written in the policy that they should call cardiology. The ST elevation started 10 minutes before the nurse found it. Even if CMU had called, it would not have changed who was called. The executive review really did feel that this was something the physician did exercise control over. The cardiologist said he would like to have been notified. He said he does not know if he would have taken the patient to the cath lab or not, but he would have liked to have been able to make that decision. He said he is the specialist, and he should have been consulted. Even though the patient was asymptomatic, the staff were not even aware of the STEMI process.