HospitalInspections.org

Based on interviews, medical record, document and policy review, the hospital failed to effectively organize and deliver safe, quality care to patients on the medical until as evidenced by:

A. The facility failed to ensure that the policy for pulse oximetry monitoring of patients on the Medical Unit was implemented for one of 23 sampled patients (Patient 2) on the morning of 1/20/24. (Refer to A 0144)

B. The facility failed to ensure Licensed Nursing Staff were notified when Patient 2's oxygen saturation was below 84%.

C. The facility failed to ensure monitor alarms were consistently responded to by the Monitor Technician (MT) and/or nursing staff on 1/20/24 as per facility policy and physician's orders.

D. The facility failed to ensure the Monitor Technician (MT) was trained and qualified to respond to changing patient conditions.

E. The facility failed to ensure the nursing staff on the medical unit adhered to facility policies and procedures.

F. The facility failed to ensure the monitor alarms at the nursing station were loud enough to be heard clearly.

These failures put patients on the medical unit at increased risk for poor health outcomes, injuries, adverse events, and death. These failures contributed to Patient 2's death by staff failing to respond to monitor alarms on the morning of 1/20/2024.

The cumulative effect of these failures resulted in the hospital's inability to provide effective, lifesaving care in accordance with the statutorily-mandated Conditions of Participation Patient Rights.

Based on interviews and record review, the facility failed to protect patients on the medical/surgical unit from harm when the staff failed to respond to a physiological monitor alarm (a monitor used to measure heart rate, breathing and temperature) in order to provide necessary, lifesaving interventions for 1 of 23 sampled patients (Patient 2) when:

a. Monitor alarms were not consistently responded to by the Monitor Technician (MT) and/or nursing staff on 1/20/24 as per facility policy and physician's orders.

b. Camera footage of the MT's desk shows the MT sitting at the monitor clicking on the boxes on the screen, the MT did not attempt to contact nursing staff regarding the alarms sounding.

c. The facility failed to ensure medical/surgical nursing staff adhered to facility policies and procedures.

d. The facility failed to ensure the monitor alarms at the nursing station were loud enough to be heard clearly.


These failures contributed to the death of a patient (Patient 2) and resulted in an unsafe environment for patients in the facility when neither the MT, nor the licensed nursing staff responded to a monitor alarm indicating Patient 2's oxygen saturation was dropping to dangerously low levels.

Findings:

A review of Patient 2's History and Physical (H&P), dated 12/3/23, indicated Patient 2 was admitted to the hospital on 12/3/2023 after "multiple cardiac arrests, stroke, heart failure, pulmonary tuberculosis (bacterial infection that affects the lungs) and pulmonary hypertension (type of high blood pressure that affects the arteries in the heart and lungs). The H&P indicated Patient 2 had a tracheostomy (an opening in the neck into the windpipe for breathing) and was placed on "room air T mist at 5 liters per minute (the amount of supplemental oxygen a patient is receiving) (liter is a unit of measure)." The "ABG" (Arterial Blood Gas- blood drawn from an artery to check oxygen levels) was reported as "normal on room air." The H& P included an electrocardiogram (EKG- tracing of the electrical activity of the heart) which showed "rate controlled afib" (atrial fibrillation- a heart condition causing irregular and rapid heartbeat). The document indicated Patient 2 was a "partial code: do not do chest compressions, do not defibrillate or perform synchronized cardioversion (administration of a controlled electric shock to restart a person's heart); do not perform temporary transcutaneous pacing (a device used to temporarily pace a patient's heart during a medical emergency)."

Further review of the H&P indicated, "alert, nonverbal, neuro [relating to the nervous system], cannot be tested patient does not follow command, flat affect, suspected of anoxic brain injury [death of brain cells caused by a lack of oxygen] effect ..."

During an interview on 6/25/24 at 1:05 p.m. with chief operating officer (COO), COO indicated there was a delay in staff responding to the monitor alarm that indicated Patient 2 was having trouble breathing. COO further indicated MT 1 had not notified the nursing staff for 20-25 minutes that the oxygen sensor was alarming, or Patient 2 was in distress. COO further indicated it was the responsibility of the MT to notify nursing staff when there was an alarm so the nurse could check the status of the patient.

During an interview with the CEO on 6/25/24 at 1:05 p.m., CEO stated the monitor alarms were not loud enough for staff to hear with the rest of the noise around the monitoring station. CEO further indicated MT 1 had multiple tasks including answering the phone, reading, and interpreting cardiac rhythm strips, answering questions from nursing staff and visitors. CEO further indicated MT 1 and nursing were suffering from "alarm fatigue" (a term used when workers are busy and become desensitized to safety alerts and as a result ignore or fail to respond).

Review of a computer generated report titled, "Patient Trend Analysis Report (PTAR)" with a Report Start Date 1/20/24 6a.m. and Report End Date 1/20/24 10a.m., PTAR indicated Patient 2 had an SpO2 (percentage of oxygen in the blood, normal is 90% or higher) less than 88% for 28 minutes and 40 seconds. Further review of the document indicated Patient 2 had 11 episodes of SpO2 below 88% with the lowest at 46% at 9:19 a.m. on 1/20/24, with the longest episode of low SpO2 lasting 23 minutes and 40 seconds.

During an interview on 6/25/24 at 1:30 p.m. with Director of Nurses (DON), DON indicated she had given MT 1 a break at from 8:13 a.m. until 8:30 a.m. The DON indicated she did not receive a "hand off" report from MT 1 nor does she remember hearing a specific patient's monitor alarm sounding. The DON indicated she looked at the monitor while doing break relief and believes Patient 2 was "saturating okay". DON indicated the MT or the person sitting at the monitor is responsible to ensure the patients are receiving enough oxygen , "the monitors alarming are not the responsibility of the licensed nurse (LN) but of the MT."

During an interview and concurrent document review of Patient 2's medical record on 6/26/24 at 3:00p.m., with the Infection Prevention/Employee Development Nurse (IC/ED), IC/ED stated oxygen saturation below 90% and heart rate below 60 beats per minute (normal heart rate is 60 beats per minute or above) was to be reported to the LN. The IC/ED stated when notified, the LN is to "go to the bedside and check on the patient or make sure someone does". IC/ED stated the LN is ultimately responsible for the safety of the patient which includes responding to monitor alarms. The IC/ED stated Patient 2 had not received his morning medications and that the licensed nurse had not confirmed Patient 2's vital signs which were completed at 6:44 a.m., on 1/20/24 by the Certified Nurse's Aide (CNA). The IC/ED indicated the record reflected the only intravenous (IV - through the vien) insertion site Patient 2 had been a "22 angio cath" (size and type of intravenous catheter) which was placed in Patient 2's right antecubital site (area between the upper and lower arm, the anterior surface of the elbow) on 12/25/23. IC/ED was not able to locate documentation of the condition of the IV site or if it was a functioning IV. The IC/ED confirmed the IV site and care should be documented on the IV flow sheet per facility policy.

Review of an undated, untimed facility document, the chief executive officer (CEO ) had identified as "notes" of the review of the camera footage of the nurse's station and monitors on 1/20/24 indicated MT 1 returned from his break at 8:32 a.m. and began "doing tasks". At 8:40 a.m., the same document indicated the monitor "stops transmitting data." The note further indicated at 8:53 a.m., MT 1 appears to notice the lack of transmission and clicks on Patient 2's monitor box and "scrolls back to look at data" and at 9:24 a.m., MT 1 "sees the RN [registered nurse]" (LN3) and tells her to go check on the patient. The document further read at 9:28 a.m., staff "rush to room for code blue (used to indicate the critical nature of a patient usually one who is in immediate need of care related to cardiac or respiratory arrest)."

Review of Patient 2's medical record document titled, "Resuscitation [process of reviving someone] Order Form (ROF)", dated 12/3/23 at 8:30 a.m., ROF indicated, "Limited code, Limitations to Resuscitation" and "Do not do chest compressions, Do not defibrillate, or perform synchronized cardioversion ..."

Review of Patient 2's medical record a document titled "Rapid Response Team Care Record (RRTCR)", dated 1/20/24 at 9:20 a.m., RRTCR indicates "patient not responding, no vital signs, no pulse, no BP."

Review of a document titled "Emergency Cardio-Pulmonary Record (ECPR), dated 1/20/24 at 9:20 a.m., ECPR indicated, Patient 2 received 6 doses of "Epinephrine 1mg", (primary drug used for cardiac arrest to increase cardiac output, mg- Milligram unit of measure) first dose was given at 9:23 a.m., the last dose at 9:38 a.m., and 1 dose of Sodium Bicarbonate at 9:33 a.m.. The EKG rhythm was documented as "flat line" 6 times with no cardiac rhythm identified. Further documentation indicated "no vital signs" 6 times. End of code was documented at 9:40 a.m., Patient 2 was pronounced deceased by the physician.

Review of a document titled "Statement Taken from MT" dated 1/23/24, not timed, MT 1 indicated when he was relieved for break at about 8:15 a.m., he noticed that Patient 2 was "satting" (saturating, a percentage of oxygen within the blood) "around 84 [%]". MT 1 indicated he "assumed DON would tell the respiratory therapist (RT)." When MT 1 returned from break at 8:30 a.m., MT 1 noticed Patient 2 was still "satting, low in the 80's." Approximately "20 minutes later" MT 1 noticed the monitor was not transmitting data for Patient 2. MT 1 indicated he was working on a task approximately 20 minutes before he "saw the primary RN and notified her to check" Patient 2.

Review of the facility's policy and procedure (P&P) titled, "Nursing, Clinical Alarms", dated 1/13 [January 2013] and updated 12/23 [December 2023], the P& P indicated, "All clinical alarms and medical equipment alarm systems utilized for patient care are properly operational and alarms are activated when the appropriate settings are in use ... "Clinical staff will perform routine testing of clinical alarms prior to use of medical equipment/devices on the patient population:" ... "An environmental assessment of the alarm will be performed annually to assure the alarm can be heard within an appropriate distance and with competing noise in the unit where the medical device/equipment is being used" ... "Clinical staff will not silence alarms without first checking on the patient" ...

During a concurrent interview and document review on 6/27/24 at 1:41 p.m., with Human Resource Director(HRD) , HRD indicated MT 1 was hired on 9/11/2023 as a monitor technician.

A review of a document titled "Telemetry Monitor Tech" (observes and records the activity of monitors attached to patients in the hospital) dated January 16, 2023 was identified by HRD as the "job description for MT 1's position". The document indicated the following: "Responsible for continual monitoring of telemetry units and promptly alerting appropriate personnel of significant changes in readings. Additional Qualification/Skills: One (1) year of experience in healthcare with previous telemetry monitoring experience and/or equivalent education in telemetry monitoring and reading ..." "Completion of Medical Terminology course ... Job Function: Continually observe and analyze telemetry monitors and immediately report significant changes in rhythms to the appropriate personnel."

During the continued concurrent interview and document review on 6/27/24 at 1:41 p.m., with HRD, copies of MT 1's training and monitor technician class completion document were requested and were not provided. MT 1's resume was reviewed with HRD with no evidence of prior health care experience, medical terminology, or monitor technician training found.

Based on interview, patient record review, and facility document review, the hospital failed to ensure nursing staff developed and maintained a nursing care plan (CP) which accurately reflected the needs of 2 of 23 sampled patients (patients 1 and 2).

These failures had the potential to negatively impact the care of the patients.

Patient 1 was admitted to the hospital on 4/20/24 with a nasogastric tube (NGT a plastic tube through the nose, down into the stomach) to provide nutritional support and administration of medications.

During a review of Patient 1's "Note Discipline: Registered Nurse (NDRN)", dated 5/17/24, the NDRN indicated, "NG tube removed."

During a concurrent interview and patient record review on 6/26/24, at 9:55 a.m. with Licensed Nurse (LN) 8, LN 8 confirmed Patient 1's CP initiated on 4/21/24, indicated, "Alteration in Nutrition and Hydration related to tube feeding as evidenced by the presence of NGT." LN 8 stated, Patient 1's NG tube was removed on 5/17/24. On 5/20/24, Patient 1's CP had not been updated to reflect this change of condition.

During an interview on 6/26/24 at 1:20 p.m. with the Director of Nursing (DON), DON stated, Patient 1's CP should have been updated on 5/17/24 to reflect the NGT removal.

Patient 2 was admitted to the hospital on 12/3/23 with a peripherally inserted central line (PICC) (long catheter that is inserted through a vein in the arm, ends in a large vein near the heart. Used to administer medications or draw blood).

During a review of Patient 2's medical record on 6/26/24 at 3:00 p.m., with Infection Control/Educator (IC/ED), the IC/ED indicated the PICC was no longer in place, CP was not updated to reflect this change in condition.

During an interview on 6/26/24 at 1:20 p.m. with the DON, DON stated, Patient 2's CP should have been updated to reflect the PICC line removal.

During a review of the facility's policy and procedure (P&P) titled, "Care Planning", dated 12/23, the P&P indicated, "The plan of care is maintained and updated based upon ongoing patient assessments and the patient's response to care, treatment and services."