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Based on interview and record review, the facility failed to ensure patient rights were maintained for two of 34 patients (Patients 7, and 26) when:

1. For Patient 26, was not continuously monitored while on cardiac telemetry (see A- 144).

2. For Patient 7, a physician's order for restraints (devices or methods that restrict a patient's movement) was not obtained prior to Patient 7 being placed in restraints (see A- 168).

3. For Patient 7, while in restraints, Patient 7 was not was monitored and reassessed every 15 minutes as ordered (see A-175).

The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.

Based on interview and record review, the facility failed to follow their policy and procedures for four of 34 sample patients (Patients 2, and 26), when:

1. For Patient 2, consent was not obtained before sending a specimen for drug screen (see A-398).

2. For Patient 26, was not continuously monitored while on cardiac telemetry (see A-398).

The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.

Based on interview and record review, the facility failed to ensure patients received care in a safe setting for one of 34 sample patients (Patient 26), when Patient 26 was not continuously monitored while on cardiac telemetry (method to monitor a patient's heart activity and other vital signs remotely).

This failure resulted in a delay of treatment for Patient 26, and could have contributed to Patient 26's death.

Findings:

On January 7, 2025, at 9:30 a.m., a concurrent interview and record review were conducted with the Accreditation and Regulatory Manager (ARM). The facility document titled, "History and Physical," dated November 5, 2023, at 4:13 p.m., indicated Patient 26 was admitted to the facility on November 5, 2023, with diagnoses of acute chronic heart failure (weakening of the heart that limits its function), pulmonary edema (a condition that is caused by excess fluid in the lungs), and Atrial fibrillation with rapid ventricular response (A fib with RVR, an irregular heart rhythm that causes the ventricles to beat too quickly).

The facility document titled, "Emergency Department Note-Physician," dated November 5, 2023, indicated, "...There is 1+ edema [swelling] to the bilateral lower extremities that extends to the knees. EKG [electrocardiogram, a test that measures electrical activity of the heart] shows atrial fibrillation with RVR [rapid ventricular response, an irregular heart rhythm that occurs when the heart beats too fast], ventricular rate [the rate at which the heart's lower chambers, or ventricles beat] of 154. Patient's rate treated with Diltiazem [medication to treat irregular heart rate] 20 mg [milligrams, a unit of measurement] here in the emergency department which dropped heart rate to 120. Thus patient was started on a Diltiazem drip...MEDICTIONS ORDERED...Continuous...Diltiazem iv [intravenous] additive 125 mg [5 mg/hr.] (per hour) + ns [normal saline] 0.9% [percentage] Premix Diluent 125 ml [milliliters- unit of measurements...IV, 5 ml/hr..."

The facility document titled, "ORDER SHEET," dated November 5, 2023, 6:14 p.m., indicated, "...Routine Vital Signs...Q [every] 4 hr [four hours]...Telemetry Class...Acute Congestive Heart Failure, Maintain telemetry when patient off unit..."

An undated facility document titled, "Encounter Location History," indicated, Patient 26 was admitted to the Telemetry Unit on November 5, 2025 at 5:44 p.m.

The facility document titled, "Vital Signs," dated November 5, 2023 at 5:21 PM through November 6, 2023 at 5 a.m., indicated the following;

-On November 5, 2023, at 5:21 p.m., heart rate 130 (a fib), respiratory rate 22, blood pressure 126/76, 02 saturation [the percentage of hemoglobin in your blood that is carrying oxygen] 96%;

-On November 5, 2023, at 6 p.m., heart rate 85 (a fib), respiratory rate 18, blood pressure 103/52, 02 saturation 95%;

-On November 5, 2023, at 7:48 p.m., heart rate 96 (a fib), respiration rate 18, blood pressure 100/58, 02 saturation 94%;

-On November 5, 2023, at 8:05 p.m., 02 saturation 99% on 3 liters of oxygen;

-On November 5, 2023, at 8:16 p.m., blood pressure 100/58;

-On November 5, 2023, at 10 p.m., heart rate 78 (a fib), respiration rate 20, blood pressure 102/63, 02 saturation 99% on 3 liters oxygen per nasal cannula [medical device that provides supplemental oxygen to patients through their nose];

-On November 5, 2023, at 11:20 p.m., 02 saturation 99% on 4 liters oxygen per nasal cannula;

-On November 6, 2023, at 12:31 a.m., heart rate 72 (a fib), respiration rate 18, blood pressure 144/101, 02 saturation 94%, temperature 36.6 degrees celsius; and

-On November 6, 2023, at 5 a.m., heart rate 88 (a fib), respiratory rate 20, blood pressure 99/65, 02 saturation 94% on 3 liters nasal cannula.

A facility document titled, "Central Monitor Telemetry Log," dated November 5, (no year), 7 a.m.- 7 p.m., indicated, "...[Patient's last name] expired 5:35 a.m...Comments...pt [patient] keep taking off leads 3:48 a.m. until 4 a.m..."

The facility untitled document, dated November 5, 2023, at 10:46 p.m., indicated, "...Physician Communication Notified of : Medication, Patient condition, other: pt is c/o [complaining of] sob [shortness of breath], nausea. chest pain ekg done, (afib) , sic 3l [liters] o2 [oxygen] nc [nasal canula]..."

The facility document titled, "Code Blue Record," dated November 6, 2023, time event recognized 5:13a.m., indicated, "...5:13 a.m...PEA [pulseless electrical activity, condition where the heart stops beating, but the heart's electric activity is still present]...5:17 a.m...asystole [the heart's electrical and mechanical activity stops completely]...5:19 a.m...asystole...5:21 a.m...asystole...5:23 a.m...PEA...5:25 a.m...PEA...5:27 a.m...PEA...5:29 a.m...PEA...5:31 a.m...asystole...5:33 a.m...asystole...5:35 a.m...Time Resuscitation Event Ended...5:35 a.m...Status...Deceased..."

The facility document titled, "Discharge Summary...Death Summary," dated November 6, 2023, at 4:37 p.m., indicated, "...Patient was anxious and taking off monitor lines and NC [Nasal Cannula]...given morphine [a narcotic drug which relieves pain] and Benadryl [a medication that can treat pain or assist with sleep] at night time, he was still restless and was given 0.5mg ativan [a medication that relieves anxiety] at midnight, at 2:30 am pt [patient] was still restless per nurse documentation, pt redirected and no medication given...At 05:13AM, pt was found in asystole, code blue called, ACLS [advanced cardiac life support, a set of procedures and techniques used to treat life-threatening condition] started and lasted until 5:15AM, given epinephrine/calcium/sodium bicarb/magnesium [medications used during a code blue], bagged during the code, no shockable rhythm per code team, pt pronounced expired at 5:15AM..."

During further review of Patient 26's medical record with the ARM, there was no documented evidence of the following:

-That Patient 26 received continuous cardiac monitoring leading up to the code blue;

-That the Monitor Technician (MT) completed an event log for November 5, 2023, through November 6, 2023, night shift for Patient 26;

-That the MT notified the Primary Nurse (PN) to inform her Patient 26's heart rate fell below 50 bpm (beats per minute);

-That the MT notified the PN to inform her Patient 26 was taking his cardiac telemetry leads off;

-That the MT notified the PN of Patient 26's cardiac rhythm which was PEA;

Continued review of Patient 26's record indicated that there was no documentation that the PN had received a call from the MT to inform her of Patient 26's heart rate of 50 bpm, or that Patient 26 was removing his cardiac telemetry leads.


-Additionally, there was no documentation in Patient 26's record to indicate that the Charge Nurse (CN) had received a call from the MT to inform her Patient 26's heart rate fell below 50 bpm or what led the CN to go into Patient 26's room and thus finding Patient 26 unresponsive necessitating a call for code blue response.

Review of Patient 26's record indicated that there were no printed telemetry strips for changes in heart rate or telemetry strips that were obtained during the code blue response nor documentation regarding Patient 26's cardiac status after 5 a.m. on November 6, 2023, until 5:13 a.m. when the code blue was called.

On January 8, 2025, at 9:11 a.m., an interview was conducted with the Primary Nurse (PN). The PN stated the patient was taking off the monitor leads, 02 tubing, and was very anxious. The PN stated the patient was placed on continuous monitoring and needed reinforcement to keep leads on, and the MT did not call about any problems. The PN further stated, "I do not remember if I documented if the patient (Patient 26) was taking the leads off."

On January 8, 2025, at 1:08 p.m., an interview was conducted with the MT. The MT stated there was no event log at that time, if there was a problem, we would call the nurse. The MT further stated, "I did not fill out an event log at the time." The MT further stated, "I do not remember calling the nurse about this patient (Patient 26)."

On January 9, 2025, at 9:57 a.m., an interview was conducted with the Director of Progressive Care Unit/Telemetry and Monitor Technicians (D 1). D 1 stated, "I cannot find the event log or any telemetry strip changes, or telemetry strips during the code for this patient (Patient 26)." D 1 further stated the nurses are expected to document their findings in the Electronic Medical Record (EMR).

On January 9, 2025, at 10:05 a.m., an interview was conducted with the ARM. The ARM stated there was no event log for this shift found, or telemetry strips, per the facility policy. She further stated there is no documentation of the event from the monitor technician and the charge nurse per policy.

A review of the P&P titled, "DYSRHYTHMIA MONITORING," dated November 22, 2023, was conducted. The P&P indicated, "...Documentation...Monitor Techs will document any arrhythmias on the Event Log and notify the RN [registered nurse]. The RN will document actions in the EMR [electronic Medical Record]...When notification parameters are not ordered and the patient's heart rate exceeds or below the standard alarm limits (50-120), the physician must be notified. The Monitor Technician will notify the patient's nurse for reportable rhythm changes, no waveforms, and/or sustained artifact. The MT will document in the event log and notify the Clinal Manager/Charge Nurse if necessary to obtain timely and necessary response ...The Monitor Technician will obtain, evaluate, and print a rhythm strip for each patient record. The RN will verify, validate, and co-sign all printed strips...with any dysrhythmia that is new, symptomatic or reflective of a change from a previous rhythm, or that requires immediate interventions...MT will document all events on the Event Log and the RN will document events in the EMR..."

A review of the P&P titled, "CODE BLUE," dated August 18, 2021, was conducted. The P&P indicated, "...If a patient on a monitor is found to be in a lethal rhythm (Red Alarm), the monitor tech will call a Code Blue and notify the operator of the patient room location...Interprets the monitored cardiac rhythm and assesses the patient's hemodynamic status...Completes documentation..."

Based on interview and record review the facility failed to ensure a physician's order for soft wrist restraints (a device designed to limit the movement of wrists) was obtained prior to the patient being placed in restraints, for one of 34 sample patients (Patient 7).

This failure had the potential to cause physical or psychological harm and injury to Patient 7.

Findings:

A review of Patient 7's medical record was conducted on January 8, 2025, at 10:18 a.m., with the Quality Assistant (QA) 1.

A review of the facility document titled, "History and Physical," dated November 14, 2024, indicated "...ASSESSMENT/PLAN...hypertension Emergency [high blood pressure]...Mental health disorder...endorses suicidal ideation [thoughts of hurting oneself]..."

A review of the facility document titled, "IView / I&O [Intake and Output]," dated November 20, 2024, indicated, "...Restraint Placement/Monitoring...11/20/2024 [November 20,2024] 20:00 [8 p.m.]...Behavior Requiring Restraint...Interference with medical device...Nonviolent Restraints....2 point...soft limb..."

During a review of Patient 7's medical record with the QA 1, there was no documented evidence a physician's order was obtained on November 20, 2024, for the use of soft wrist restraints on Patient 7. During a concurrent interview with the QA 1, the QA 1 stated there was no documentation an order for the restraints was given by the physician for the use of soft wrist restraints on Patient 7 on November 20, 2024. The QA 1 further stated a physician's order is needed for restraints per the facility policy.

An interview was conducted on January 8, 2025, at 2:56 p.m., with the Clinical Manager (CM) 2. The CM 2 stated based on her record review, there was no documented evidence a physician's order was obtained for Patient 7's restraints on November 20, 2024.

A review of the facility's P & P titled, "DES ADM 749 Restraints & Seclusion," dated January 18, 2024, was conducted. The P&P indicated, "...Restraints and Seclusion require an order from a physician or other authorized Licensed Practitioner responsible for the care of the patient..."

Based on interview and record review the facility failed to ensure patients were monitored and reassessed every 15 minutes as ordered while in restraints, for one of 34 sampled patients (Patient 7).

This failure had the potential to cause harm, injury, and/or death to Patient 7.

Findings:

A review of Patient 7's medical record was conducted on January 8, 2025, at 10:18 a.m., with the Quality Assistant (QA) 1.

A review of the facility document titled, "History and Physical," dated November 14, 2024, indicated "...ASSESSMENT/PLAN...hypertension Emergency [high blood pressure]..Mental health disorder...endorses suicidal ideation [thoughts of harming self]..."

A review of facility document titled, "Order,", dated November 29, 2024, indicated," ...Restraint Initiation Violent Adult...Details...Reason for Restraints...Imminent risk to self...Criteria for Release...No longer Imminent risk to self ...Restraints...Soft Limb...Points of Restraints ..2 Point Restraints...Restraint Location...Bilateral Upper Extremity..."

A review of the facility document titled, " Order," dated November 29, 2024, indicated,"...Restraint Monitoring Violent Adult...Details...Frequency Q[every]15 min [minutes]-int...Special Instructions...for 4 hours..."

A facility document titled, "IView/I&O [Intake & Output]" dated, November 20, 2024, through November 30, 2024, was reviewed. There was no documentation to show that Patient 7 was monitored or re-assessed every 15 minutes as ordered. During a concurrent interview with QA 1 at the time of the record review, QA 1 stated there was no documented evidence Patient 7 was re-assessed or monitored every 15 minutes as ordered, from November 29, 2024, at 10 p.m., through November 30, 2024, at 6 a.m.

An interview was conducted with the Clinical Manager (CM) 1, on January 8, 2025, at 2:19 p.m. The CM 1 stated there was no documented evidence Patient 7 was monitored every 15 minutes because the restraint order was entered wrong. The CM 1 stated the physician ordered the wrong restraint order because behavioral restraints are not used in the Intensive Care Unit (ICU). The CM1 further stated the policy was not followed because the restraint order was wrong and should have been changed from Behavioral to Non-Behavioral restraints.

A review of the facility's policy and procedure (P&P), titled, "DES ADM 749 RESTRAINTS & SECLUSION," dated January 18, 2024, indicated, "...Monitoring and Reassessment...Appropriate interval for re-assessment is based on patient's needs, condition, and type of restrained used...When Restraints or Seclusion is used there must be documentation in the patient's medical record of the following...A description of the patient's behavior and the interventions used...Alternative or other less restrictive interventions attempted...The patient's condition or symptom(s) that warranted the use of the Restraint...The patient's response to the intervention(s) used, including the rationale for continued use of the intervention...Individual patient assessment and re-assessment..."

Based on interview and record review, the facility failed to implement their policies and procedures (P&P) for two of 34 sample patients (Patients 2, and 26) when:

1. For Patient 2, consent was not obtained before sending a specimen for drug screen;

2. For Patient 26, was not continuously monitored while on cardiac telemetry.

These failures had the potential to compromise patient safety and cause delays in medical care, and may have contributed to patients death.


Findings:

1. A review of Patient 2's medical record was conducted on January 7, 2025, at 10 a.m., with the Quality Analyst (QA) 1.

A review of the facility's document titled, "History and Physical," dated July 5, 2024, indicated, Patient 2 was admitted to the facility on July 5, 2024, due to eminent delivery of a baby.

A review of the facility document titled, " Order," dated July 5, 2024, indicated, "...Drug Screen Urine...Status Change 07/05/2024 [July 5, 2024]...02:22 PDT (Pacific daylight time)...Department status..In La..."

A review of the facility document titled, "CONSENT TO SURGERY/SPECIAL PROCEDURES (WITH PHYCISIAN CERTIFICATION," dated July 5, 2024, indicated, "...Your physician has recommended the following operation or procedure...vaginal delivery with possibility of episiotomy and/or repair, blood analysis, urine for toxicology...date 07/05/2024 [July 5, 2024]...time 2:35 a.m...signature..."

An interview was conducted on January 8, 2025, at 10:14 a.m., with the Perinatal Services Clinical Manager (PSCM). The PSCM stated the facility did not follow the process based on the policy when the urine specimen was sent to the lab for testing before consent was obtained from Patient 2.

A review of the facility's policy and procedure (P&P), titled, "DES PNS 643 PERINATAL DRUG SCREEN," dated December 15, 2023, indicated, "...It is the policy of Perinatal Services to obtain specimen for drug toxicology on all women admitted to the Perinatal unit. Consents must be signed before the specimen may be sent..."


2. On January 7, 2025, at 9:30 a.m., a concurrent interview and record review were conducted with the Accreditation and Regulatory Manager (ARM). The facility document titled, "History and Physical," dated November 5, 2023, at 4:13 p.m., indicated Patient 26 was admitted to the facility on November 5, 2023, with diagnoses of acute chronic heart failure (weakening of the heart that limits its function), pulmonary edema (a condition that is caused by excess fluid in the lungs), and Atrial fibrillation with rapid ventricular response (A fib with RVR, an irregular heart rhythm that causes the ventricles to beat too quickly).

The facility document titled, "Emergency Department Note-Physician," dated November 5, 2023, indicated, "...There is 1+ edema [swelling] to the bilateral lower extremities that extends to the knees. EKG [electrocardiogram, a test that measures electrical activity of the heart] shows atrial fibrillation with RVR [rapid ventricular response, an irregular heart rhythm that occurs when the heart beats too fast], ventricular rate [the rate at which the heart's lower chambers, or ventricles beat] of 154. Patient's rate treated with Diltiazem [medication to treat irregular heart rate] 20 mg [milligrams, a unit of measurement] here in the emergency department which dropped heart rate to 120. Thus patient was started on a Diltiazem drip...MEDICTIONS ORDERED...Continuous...Diltiazem iv [intravenous] additive 125 mg [5 mg/hr.] (per hour) + ns [normal saline] 0.9% [percentage] Premix Diluent 125 ml [milliliters- unit of measurements...IV, 5 ml/hr..."

The facility document titled, "ORDER SHEET," dated November 5, 2023, 6:14 p.m., indicated, "...Routine Vital Signs...Q [every] 4 hr [four hours]...Telemetry Class...Acute Congestive Heart Failure, Maintain telemetry when patient off unit..."

An undated facility document titled, "Encounter Location History," indicated, Patient 26 was admitted to the Telemetry Unit on November 5, 2025 at 5:44 p.m.

The facility document titled, "Vital Signs," dated November 5, 2023 at 5:21 PM through November 6, 2023 at 5 a.m., indicated the following;

-On November 5, 2023, at 5:21 p.m., heart rate 130 (a fib), respiratory rate 22, blood pressure 126/76, 02 saturation [the percentage of hemoglobin in your blood that is carrying oxygen] 96%;

-On November 5, 2023, at 6 p.m., heart rate 85 (a fib), respiratory rate 18, blood pressure 103/52, 02 saturation 95%;

-On November 5, 2023, at 7:48 p.m., heart rate 96 (a fib), respiration rate 18, blood pressure 100/58, 02 saturation 94%;

-On November 5, 2023, at 8:05 p.m., 02 saturation 99% on 3 liters of oxygen;

-On November 5, 2023, at 8:16 p.m., blood pressure 100/58;

-On November 5, 2023, at 10 p.m., heart rate 78 (a fib), respiration rate 20, blood pressure 102/63, 02 saturation 99% on 3 liters oxygen per nasal cannula [medical device that provides supplemental oxygen to patients through their nose];

-On November 5, 2023, at 11:20 p.m., 02 saturation 99% on 4 liters oxygen per nasal cannula;

-On November 6, 2023, at 12:31 a.m., heart rate 72 (a fib), respiration rate 18, blood pressure 144/101, 02 saturation 94%, temperature 36.6 degrees celsius; and

-On November 6, 2023, at 5 a.m., heart rate 88 (a fib), respiratory rate 20, blood pressure 99/65, 02 saturation 94% on 3 liters nasal cannula.

A facility document titled, "Central Monitor Telemetry Log," dated November 5, (no year), 7 a.m.- 7 p.m., indicated, "...[Patient's last name] expired 5:35 a.m...Comments...pt [patient] keep taking off leads 3:48 a.m. until 4 a.m..."

The facility untitled document, dated November 5, 2023, at 10:46 p.m., indicated, "...Physician Communication Notified of : Medication, Patient condition, other: pt is c/o [complaining of] sob [shortness of breath], nausea. chest pain ekg done, (afib) , sic 3l [liters] o2 [oxygen] nc [nasal canula]..."

The facility document titled, "Code Blue Record," dated November 6, 2023, time event recognized 5:13a.m., indicated, "...5:13 a.m...PEA [pulseless electrical activity, condition where the heart stops beating, but the heart's electric activity is still present]...5:17 a.m...asystole [the heart's electrical and mechanical activity stops completely]...5:19 a.m...asystole...5:21 a.m...asystole...5:23 a.m...PEA...5:25 a.m...PEA...5:27 a.m...PEA...5:29 a.m...PEA...5:31 a.m...asystole...5:33 a.m...asystole...5:35 a.m...Time Resuscitation Event Ended...5:35 a.m...Status...Deceased..."

The facility document titled, "Discharge Summary...Death Summary," dated November 6, 2023, at 4:37 p.m., indicated, "...Patient was anxious and taking off monitor lines and NC [Nasal Cannula]...given morphine [a narcotic drug which relieves pain] and Benadryl [a medication that can treat pain or assist with sleep] at night time, he was still restless and was given 0.5mg ativan [a medication that relieves anxiety] at midnight, at 2:30 am pt [patient] was still restless per nurse documentation, pt redirected and no medication given...At 05:13AM, pt was found in asystole, code blue called, ACLS [advanced cardiac life support, a set of procedures and techniques used to treat life-threatening condition] started and lasted until 5:15AM, given epinephrine/calcium/sodium bicarb/magnesium [medications used during a code blue], bagged during the code, no shockable rhythm per code team, pt pronounced expired at 5:15AM..."

During further review of Patient 26's medical record with the ARM, there was no documented evidence of the following:

-That Patient 26 received continuous cardiac monitoring leading up to the code blue;

-That the Monitor Technician (MT) completed an event log for November 5, 2023, through November 6, 2023, night shift for Patient 26;

-That the MT notified the Primary Nurse (PN) to inform her Patient 26's heart rate fell below 50 bpm (beats per minute);

-That the MT notified the PN to inform her Patient 26 was taking his cardiac telemetry leads off;

-That the MT notified the PN of Patient 26's cardiac rhythm which was PEA;

Continued review of Patient 26's record indicated that there was no documentation that the PN had received a call from the MT to inform her of Patient 26's heart rate of 50 bpm, or that Patient 26 was removing his cardiac telemetry leads.


-Additionally, there was no documentation in Patient 26's record to indicate that the Charge Nurse (CN) had received a call from the MT to inform her Patient 26's heart rate fell below 50 bpm or what led the CN to go into Patient 26's room and thus finding Patient 26 unresponsive necessitating a call for code blue response.

Review of Patient 26's record indicated that there were no printed telemetry strips for changes in heart rate or telemetry strips that were obtained during the code blue response nor documentation regarding Patient 26's cardiac status after 5 a.m. on November 6, 2023, until 5:13 a.m. when the code blue was called.

On January 8, 2025, at 9:11 a.m., an interview was conducted with the Primary Nurse (PN). The PN stated the patient was taking off the monitor leads, 02 tubing, and was very anxious. The PN stated the patient was placed on continuous monitoring and needed reinforcement to keep leads on, and the MT did not call about any problems. The PN further stated, "I do not remember if I documented if the patient (Patient 26) was taking the leads off."

On January 8, 2025, at 1:08 p.m., an interview was conducted with the MT. The MT stated there was no event log at that time, if there was a problem, we would call the nurse. The MT further stated, "I did not fill out an event log at the time." The MT further stated, "I do not remember calling the nurse about this patient (Patient 26)."

On January 9, 2025, at 9:57 a.m., an interview was conducted with the Director of Progressive Care Unit/Telemetry and Monitor Technicians (D 1). D 1 stated, "I cannot find the event log or any telemetry strip changes, or telemetry strips during the code for this patient (Patient 26)." D 1 further stated the nurses are expected to document their findings in the Electronic Medical Record (EMR).

On January 9, 2025, at 10:05 a.m., an interview was conducted with the ARM. The ARM stated there was no event log for this shift found, or telemetry strips, per the facility policy. She further stated there is no documentation of the event from the monitor technician and the charge nurse per policy.

A review of the P&P titled, "DYSRHYTHMIA MONITORING," dated November 22, 2023, was conducted. The P&P indicated, "...Documentation...Monitor Techs will document any arrhythmias on the Event Log and notify the RN [registered nurse]. The RN will document actions in the EMR [electronic Medical Record]...When notification parameters are not ordered and the patient's heart rate exceeds or below the standard alarm limits (50-120), the physician must be notified. The Monitor Technician will notify the patient's nurse for reportable rhythm changes, no waveforms, and/or sustained artifact. The MT will document in the event log and notify the Clinal Manager/Charge Nurse if necessary to obtain timely and necessary response ...The Monitor Technician will obtain, evaluate, and print a rhythm strip for each patient record. The RN will verify, validate, and co-sign all printed strips...with any dysrhythmia that is new, symptomatic or reflective of a change from a previous rhythm, or that requires immediate interventions...MT will document all events on the Event Log and the RN will document events in the EMR..."

A review of the P&P titled, "CODE BLUE," dated August 18, 2021, was conducted. The P&P indicated, "...If a patient on a monitor is found to be in a lethal rhythm (Red Alarm), the monitor tech will call a Code Blue and notify the operator of the patient room location...Interprets the monitored cardiac rhythm and assesses the patient's hemodynamic status...Completes documentation..."