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Based on review of medical records, facility documents, observation, and interviews, the facility failed to ensure the safety of patients on telemetry. The facility failed to ensure that patients on telemetry were continuously monitored in 11 (Emergency room patients) of 119 facility patients. The facility failed to ensure that fatal changes in cardiac rhythms were identified, acted upon in accordance with policies in 1 (Patient #1) of 10 patients reviewed.

Refer to A0144, Standard.

This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Patient #1,and resulted in the determination of Immediate Jeopardy on 03/14/2025. Based on the immediate action of the facility, the findings of Immediate Jeopardy were determined to be removed on 04/10/2025.

Verification of the facility's removal plan was conducted by the survey team on 04/10/2025.

Facility immediate actions to remove the Immediate Jeopardy included:

Nursing Telemetry Competency:
1. The charge nurse will sign off all telemetry strips until 04/30/2025 or until the team member passes the telemetry interpretation exam.
2. Contracted nurses will be tested upon arrival, if they do not pass the exam, the charge nurse will sign off the telemetry strips until the nurse passes.

Off Telemetry Test:
1. Charge nurse verifies patients have off telemetry test orders prior to leaving the unit.
2. Charge nurse to sign off on transport log.

Audit Plan for QAPI:
1. As soon as a serious safety event is identified, Risk, Quality, and Patient Safety will huddle and do the following:
a. review the event and identify if an immediate action is needed.
b. If so, develop an immediate containment plan to include required education, actions and auditing that needs to be in place until the full investigation is completed.
c. Identify and include key stakeholders required for the containment plan.

2. Risk Leadership will complete a verification of the medical record and timeline of the Code 15 Event Summary prior to submission.

3. Include a team resource representative in the RCA Meeting.

Verification of the immediate actions was confirmed through interviews conducted with floor staff and leadership and thru signatures obtained by 3 of 3 charge nurses currently working validating the understanding of signing off all telemetry strips until 04/30/2025. Observations were also made verifying all ED (Emergency Department) patients on continuous heart monitoring are 100% monitored by a designated qualified employee.

Based on facility documents, policy review, medical record review, and interviews conducted, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, including a complete analysis of an adverse event and the development of an effective plan of correction involving staff failure to recognize and respond to a change in cardiac rhythm. Failure to develop a complete analysis of the adverse event and plan of correction could result in injury or death to other patients in similar situations. Refer to A286, A297

This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Patient #1,and resulted in the determination of Immediate Jeopardy on 03/14/2025. Based on the immediate action of the facility, the findings of Immediate Jeopardy were determined to be removed on 04/10/2025.
Verification of the facility's removal plan was conducted by the survey team on 04/10/2025.

Facility immediate actions to remove the Immediate Jeopardy included:

Nursing Telemetry Competency:
1. The charge nurse will sign off all telemetry strips until 04/30/2025 or until the team member passes the telemetry interpretation exam.
2. Contracted nurses will be tested upon arrival, if they do not pass the exam, the charge nurse will sign off the telemetry strips until the nurse passes.

Off Telemetry Test:
1. Charge nurse verifies patients have off telemetry test orders prior to leaving the unit.
2. Charge nurse to sign off on transport log.

Audit Plan for QAPI:
1. As soon as a serious safety event is identified, Risk, Quality, and Patient Safety will huddle and do the following:
a. review the event and identify if an immediate action is needed.
b. If so, develop an immediate containment plan to include required education, actions and auditing that needs to be in place until the full investigation is completed.
c. Identify and include key stakeholders required for the containment plan.
2. Risk Leadership will complete a verification of the medical record and timeline of the adverse event reporting summary prior to submission to the state.
3. Include a team resource representative in the event analysis meeting.

Verification of the immediate actions was confirmed through interviews conducted with floor staff and leadership and through signatures obtained by 3 of 3 charge nurses currently working validating the understanding of signing off all telemetry strips until 04/30/2025. Observations were also made verifying all ED patients on continuous heart monitoring are 100% monitored by a designated qualified employee.

Based on of medical record review, facility documents, facility policies and interviews conducted, the facility failed to provide immediate nursing care to a patient with a change in cardiac rhythm on the telemetry monitoring for 1 (Patient #1) of 10 patients sampled. Failure to provide immediate nursing care for Patient #1 resulted in death.

The hospital actions resulted in an Immediate Jeopardy starting on 03/19/2025. The Immediate Jeopardy was removed on 04/10/2025, the day of exit.

Refer to tag 395.

This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Patient #1,and resulted in the determination of Immediate Jeopardy on 03/14/2025. Based on the immediate action of the facility, the findings of Immediate Jeopardy were determined to be removed on 04/10/2025.

Verification of the facility's removal plan was conducted by the survey team on 04/10/2025.

Facility immediate actions to remove the Immediate Jeopardy included:
Nursing Telemetry Competency:
1. The charge nurse will sign off all telemetry strips until 04/30/2025 or until the team member passes the telemetry interpretation exam.
2. Contracted nurses will be tested upon arrival, if they do not pass the exam, the charge nurse will sign off the telemetry strips until the nurse passes.

Off Telemetry Test:
1. Charge nurse verifies patients have off telemetry test orders prior to leaving the unit.
2. Charge nurse to sign off on transport log.

Audit Plan for QAPI:
1. As soon as a serious safety event is identified, Risk, Quality, and Patient Safety will huddle and do the following:
a. review the event and identify if an immediate action is needed.
b. If so, develop an immediate containment plan to include required education, actions and auditing that needs to be in place until the full investigation is completed.
c. Identify and include key stakeholders required for the containment plan.

2. Risk Leadership will complete a verification of the medical record and timeline of the Code 15 Event Summary prior to submission.

3. Include a team resource representative in the RCA Meeting.

Verification of the immediate actions was confirmed thru interviews conducted with floor staff and leadership and thru signatures obtained by 3 of 3 charge nurses currently working validating the understanding of signing off all telemetry strips until 04/30/2025. Observations were also made verifying all ED patients on continuous heart monitoring are 100% monitored by a designated qualified employee.

Based on observation, interviews, record review, facility documents and policy review, the facility failed to:

1. Provide a safe setting for 1 (Patient #1) of 10 patients sampled.
2. Provide a safe setting for patients on telemetry in the Emergency Department in 11 of 107 Patients

The facility's actions contributed to the death of Patient #1, and put patients in the Emergency Department at risk of potential harm which resulted in Immediate Jeopardy.

Findings included:

1.

Review of Patient #1's medical record revealed on 03/14/2025 the patient was admitted to the hospital for a gangrene/necrotic (dead or dying tissue) on the left 5th toe. Upon admission the patient had an order for continuous telemetry monitoring (a technique used to track heart activity) for 48 hours. The telemetry order expired on 3/16/25 and the nursing staff was alerted to renew the order but failed to follow through. The patient remained on the cardiac telemetry monitor. On 3/19/25 at 1:23pm the Telemetry Monitor Technologist informed Staff A, RN (Registered Nurse) the patient developed a significant ST depression (A ST depression can be a sign of underlying condition that can lead to lethal rhythm disturbances). Staff A, RN failed to document and notify the physician of the ST depression. During shift change, Staff A, RN reported to Staff G, RN but failed to mention the ST depression. Staff D, RN signed the night shift telemetry strip (a printout of the cardiac rhythm) and failed to identify the ST depression. On 03/20/2025 at 9:20 PM, Patient #1 reported complaints of jaw pain and acetaminophen (over the counter pain medication) was given. At 10:20 PM, Patient #1 complained of 7/10 jaw pain (0 to 10 pain scale where 10 in the most pain). Staff B, APRN (Advanced Practice Registered Nurse) was made aware of jaw pain and drop in blood pressure (70/48). Staff B, APRN ordered CT of the Head (a diagnostic imaging procedure that uses X-rays to create detailed images of the brain, skull, and other structures within the head) STAT (immediately; without delay). At 1:00 AM, the patient was taken off the continuous telemetry monitor and transported to Radiology by a transporter. After the CT of the head, the transporter was assisting the patient back onto the stretcher from the CT machine, the patient became diaphoretic, stated "I do not feel well" and started vomiting. At 1:13 AM, a rapid response (a program designed to intervene swiftly when a patient's condition deteriorates, often before a major medical emergency like cardiac arrest or respiratory failure occurs) was initiated then at 1:18 AM, a code blue (cardiac arrest) was called. Patient expired on 03/20/2025 at 2:15 AM.

Review of telemetry event log dated 3/19/2025, reveals no cardiac event noted for Patient #1.

Review of cardiac rhythm strip dated 03/19/2025 at 1:23 PM, revealed Sinus Rhythm (the normal, regular pattern of electrical activity in the heart that starts in the sinus node, the heart's natural pacemaker) with a ST depression (ST segment depression typically indicates that a person has an underlying condition that affects the heart. The condition may be relatively benign or potentially life threatening).

Review of the Policy "Cardiac Monitoring (Telemetry), Initiation and Discontinuation" last revised 07/2024, revealed the purpose is "To identify and treat various dysrhythmias ".... Discontinuation of Telemetry Monitoring includes: 1. A provider order is required. 2, Telemetry orders are reviewed every shift by a registered nurse. 3, If the telemetry skill validated RN reviewing the strip or the RN caring for the patient at the time of telemetry order expiration has a rhythm concern, continue telemetry, and review the rhythm concerns with provider to obtain a new order for telemetry monitoring and document why telemetry was not removed in patient record.... Emergency response includes: ... monitor technician notifies the nurse when a change in patient's rhythm is identified, a skilled validated nurse must assess the patient immediately. Initiate Rapid Response or Code Blue as condition dictates.

During an interview on 04/08/2025 at 12:00 PM, Staff C, Nurse Manager stated on 3/19/25 at 1:36 PM the telemetry technician called the nurse regarding a rhythm change. He stated he sent up the strip and recommended an EKG (electrocardiogram is a test that measures the electrical activity of your heart) to confirm. There was no documentation or reassessment noted in the EMR (Electronic Medical Record) regarding a rhythm change, including no follow up with the physician or EKG obtained.

During an interview on 04/09/2025 at 2:40 PM, Staff C, Nurse Manager stated the night nurse failed to properly identify the rhythm strip. Staff C, Nurse Manager stated the rhythm strip clearly reveals "sinus rhythm with ST depression".

During an interview on 4/10/15 at 11:30 AM, Staff A, RN stated "I received a call from CMU [Cardiac Monitoring Unit] about a change in rhythm for my patient, I didn't hear what was said and I just hung up and continued with my other patients. I know I was supposed to act on it, but I was very busy."

During an interview on 04/11/2025 at 1:44 PM, the APRN (Advanced Practice Registeren Nurse) stated the expectation is when a patient is on continuous cardiac monitoring, he/she is being monitored 24/7. If there is a change in the patient rhythm, then I expect monitor tech to notify the bedside RN and the bedside RN to notify us (cardiology). I did not receive a phone call that day regarding Patient #1 having any changes on the monitor.

During an interview on 4/14/25 at 3:15 PM Staff D,RN stated I usually review the strips at the beginning of the shift. That day I didn't have time because his blood pressure started to drop, and he started to complain of right jaw pain. I notified the APRN and she ordered a STAT CT (Computed Tomography scan is an imaging test that uses a series of X-rays and a computer to create detailed images) head. The patient went down to CT then I got a call from the APRN stating I should be down there with the patient. I went down then the patient coded. After the patient expired, I looked at the rhythm strip and signed off sinus rhythm. I didn't know I had to document the "ST depression" too.

During an interview on 04/17/2025 at 5:40PM, Staff H, MT (monitor technician) stated I documented on the strip "SR with ST depression's", the nurse that I spoke with was advised to get a 12 lead to confirm and that was pretty much it. It was a very busy shift, and I forgot to put this event on the log, I only wrote it on the telemetry strip.

2.

During a tour on 04/09/2025 at 2:33 PM in the ED (Emergency Department), 3-screen telemetry mirror monitors were noted at the red zone (one of two nursing areas) nurse and physician station, next to the charge desk. No one was sitting at the charge desk. There was a PST (Patient Service Technician) sitting at a computer with her back facing the monitors. There was no one else behind the desk during the observation. This was confirmed by the ED Nurse Manager who was interviewed during the observation. ED Nurse Manager said the charge was in the rest room. The PST is a unit clerk, who listens for alerts while the charge is away. The nurse manager disclosed the PST was not telemetry certified.

During an interview on 4/9/2025 at 11:25 AM, the ED nurse manager stated the charge watches the telemetry monitors. They are not monitored by the central monitoring unit. They are supposed to be stationary, but they are doing multiple jobs. There is no log of telemetry events. The nurse manager of the ED stated there was no way to track and trend telemetry issues in the ED.

During an interview on 4/9/2025 at 12:12 PM, the DON (Director of Nursing) stated central telemetry does not monitor the ED; the charge nurse does.

During an observation on 04/09/2025 at 2:38 PM, observation of the mirror monitors next to the charge desk revealed rooms 3, 10, 11, 18, 21, 22, 23 and 24 leads were off. The alarms were activated, and the screens were flashing. No one was at the desk watching the monitors to alert nursing staff to check on their patients. The ED nurse manager was present during the observation.

During an observation on 04/09/2025 at 2:46 PM of the red zone station charge desk, no one was sitting at the charge desk, and no one was watching the telemetry monitors. Staff F, PST was on the phone at the charge desk. The nurse manager, who was present during the observation, stated that the charge went to get Tylenol.

During an interview on 4/9/25 at 2:47 PM, Staff E, Charge RN (Registered Nurse) stated when she is at her desk she watches the monitors. She had a headache and went to get some Tylenol. She does have to use the restroom. She talks to paramedics when they bring patients in. She does participate in codes, but the resuscitation rooms are right here. Someone relieves her for lunch. "There should be someone watching these monitors. What is realistic and what we do as nurses aren't the same." I have to talk to the paramedics. She confirmed she is a resource for nurses. She confirmed there is not a communication log for the telemetry monitors.

During an observation on 04/09/25 at 2:59 PM, the charge RN was getting report from paramedics who just brought a patient in. No one was watching the telemetry monitor screens.

During an interview on 4/9/25 at 2:55 PM, Staff F, PST (Patient Services Technician) stated she acts as a health unit clerk/coordinator. She answers EMS calls. She answers the phones, prints discharge papers and makes calls for the doctors. She listens for the telemetry alarms. She would call the nurse to check the patient. She is not telemetry certified. She does not watch the monitors. She has other duties to attend to.

During an observation on 04/09/25 at 2:59 PM, the charge RN was getting report from paramedics who just brought a patient in. No one was watching the telemetry monitor screens.

During an interview on 4/10/25 at 8:37 AM, the Director of Nursing, and the Regional Director of Quality both stated that is not our standard or expectation for our telemetry patients in the ED.

Based on medical record review, facility documents, facility policies, and interviews conducted, the facility failed to identify opportunities for improvement and develop an effective plan of correction for an adverse event involving staff failure to recognize and respond to a change in cardiac rhythm and without prompt intervention to seek effective preventive measures to protect in 1 of 1 QAPI program.

Findings included:

Review of Patient #1's medical record revealed on 03/14/2025 the patient was admitted to the hospital for a gangrene/necrotic (dead or dying tissue) on the left 5th toe. Upon admission the patient had an order for continuous telemetry monitoring (a technique used to track heart activity) for 48 hours. The telemetry order expired on 3/16/25 and the nursing staff was alerted to renew the order but failed to follow through. The patient remained on the cardiac telemetry monitor. On 3/19/25 at 1:23pm the Telemetry Monitor Technologist informed Staff A, RN the patient developed a significant ST depression (A ST depression can be a sign of underlying condition that can lead to lethal rhythm disturbances). Staff A, RN failed to document and notify the physician of the ST depression. During shift change, Staff A, RN reported to Staff G, RN but failed to mention the ST depression. Staff D, RN signed the night shift telemetry strip (a printout of the cardiac rhythm) and failed to identify the ST depression. On 03/20/2025 at 9:20 PM, Patient #1 reported complaints of jaw pain and acetaminophen (over the counter pain medication) was given. At 10:20 PM, Patient #1 complained of 7/10 jaw pain (0 to 10 pain scale where 10 in the most pain). Staff B, APRN (Advanced Practice Registered Nurse) was made aware of jaw pain and drop in blood pressure (70/48). Staff B, APRN ordered CT of the Head (a diagnostic imaging procedure that uses X-rays to create detailed images of the brain, skull, and other structures within the head) STAT (immediately). At 1:00 AM, the patient was taken off the continuous telemetry monitor and transported to Radiology by a transporter. After the CT of the head, the transporter was assisting the patient back onto the stretcher from the CT machine, the patient became diaphoretic (sweating), stated "I do not feel well" and started vomiting. At 1:13 AM, a rapid response (a program designed to intervene swiftly when a patient's condition deteriorates, often before a major medical emergency like cardiac arrest or respiratory failure occurs) was initiated then at 1:18 AM, a code blue (cardiac arrest) was called. Patient expired on 03/20/2025 at 2:15 AM.

Review of cardiac rhythm strip dated 03/19/2025 at 1:23PM, the strip revealed Sinus Rhythm (the normal, regular pattern of electrical activity in the heart that starts in the sinus node, the heart's natural pacemaker) with a ST depression (ST segment depression typically indicates that a person has an underlying condition that affects the heart. The condition may be relatively benign or potentially life threatening)

Review of telemetry event log dated 3/19/2025, reveals no cardiac event noted for Patient #1.

Review of facility event investigation completed on 04/03/2025 revealed the root cause is failure to acknowledge and response to rhythm change.

Review of facility improvement plan revealed actions taken did not include recognizing or education for cardiac rhythm changes.

Review of facility policy, Sentinel [Adverse] Events, last revision 5/2024, revealed: upon identification of a sentinel event or possible sentinel event, an analysis is conducted to understand the causes of the event, and when appropriate, to make changes in systems and processes to reduce the probability of a future event. A sentinel event is a patient safety event, not primarily related to the natural course of the patient's illness or underlying condition, that reaches a patient and results in any of the following: a. death.....

A review of the Risk Management Plan, last reviewed 1/2023, revealed the following: Purpose- The plan promotes the development of processes that identify, prevent, and mitigate organizational risks. Scope and Implementation- a. Audit reports and review findings are analyzed and tracked to identify operational deficiencies and potential areas or risk. B. Based on site visit audits and reviews, leadership identifies corrective action plan options to revise operational deficiencies and mitigate risks. Monitors the Effectiveness of the Action Taken- Action plans incorporate specific measures to demonstrate effectiveness of actions. On-going Activities- To meet plan objectives leadership focuses on: 1. Proactively reviewing operations and near-misses to identify opportunities for process improvement. 2. Investigating and trending adverse events to assess and determine how similar events might be averted and to control the loss related to the adverse outcome. A. Events are analyzed using the following criteria: frequency of occurrence, severity of occurrence, intense analysis, and corrective actions to improve care and services and environmental condition

During an interview on 04/08/25 at 2:30 PM, Staff G, Manager of Quality stated "We have not started anything yet. We are waiting for the RCA [Root Cause Analysis] to be completed."

During an interview on 4/9/2025 at 11:25 AM, the ED (Emergency Department) Nurse Manager stated the charge watches the telemetry monitors. They are not monitored by the central monitoring unit. They are supposed to be stationary, but they are doing multiple jobs. There is no log of telemetry events. The nurse manager of the ED stated there was no way to track and trend telemetry issues in the ED.

During an interview on 04/09/2025 at 2:47 PM, Staff E,Charge RN (Registered Nurse) stated when she is at her desk she watches the monitors. "There should be someone watching these monitors. What is realistic and what we do as nurses aren't the same. I have to talk to the paramedics. I am a resource for nurses. There is not a communication log for the telemetry monitors."

During an interview on 4/9/25 at 2:55 PM, Staff F, PST (Patient Safety Attendant) stated she acts as a HUC (health unit clerk/coordinator). "I answer EMS calls, answer the phones, print discharge papers and makes calls for the doctors. I listen for the telemetry alarms. I would call the nurse to check the patient. I am not telemetry certified. I do not watch the monitors."

During an interview on 04/09/2025 at approximately 3:00 PM, Staff I/Regional Quality Director stated she recognized the risk manager did not complete a thorough investigation regarding Patient #1.

Based on record review, facility documents and interviews, the facility failed to maintain an effective QAPI (Quality Assurance Program Improvement) program related to telemetry events, resulting in a multi system failure for one (#1) out of 10 sampled patients. The hospital failed to ensure tracking of telemetry events and failed to ensure appropriate and effective documentation, resulting in a death for one patient and patients on telemetry were continuously
monitored in 11 (Emergency room patients) of 119 facility patients.



Findings included:

Review of Patient #1 ' s medical record revealed on 03/14/2025 the patient was admitted to the hospital for a gangrene/necrotic (dead or dying tissue) on the left 5th toe. Upon admission the patient had an order for continuous telemetry monitoring (a technique used to track heart activity) for 48hours. The telemetry order expired on 3/16/25 and the nursing staff was alerted to renew the order but failed to follow through. The patient remained on the cardiac telemetry monitor. On 3/19/25 at 1:23pm the Telemetry Monitor Technologist informed, Staff A, RN the patient developed a significant ST depression (A ST depression can be a sign of underlying condition that can lead to lethal rhythm disturbances). Staff A, RN failed to document and notify the physician of the ST depression. During shift change, Staff A, RN reported to Staff G, RN but failed to mention the ST depression. Staff D, RN signed the night shift telemetry strip (a printout of the cardiac rhythm) and failed to identify the ST depression. On 03/20/2025 at 9:20 PM, Patient #1 reported complaints of jaw pain and Tylenol given. At 10:20 PM, Patient complains of 7/10 jaw pain. Staff B, APRN (Advanced Practice Registered Nurse) was made aware of jaw pain and drop in blood pressure (70/48). Staff B, APRN ordered CT of the Head (a diagnostic imaging procedure that uses X-rays to create detailed images of the brain, skull, and other structures within the head) STAT (immediately; without delay). At 1:00 AM, the patient was taken off the continuous telemetry monitor and transported to Radiology by a transporter. After the CT of the head, the transporter was assisting the patient back onto the stretcher from the CT machine, the patient became diaphoretic, stated "I do not feel well" and started vomiting. At 1:13 AM, a rapid response (a program designed to intervene swiftly when a patient's condition deteriorates, often before a major medical emergency like cardiac arrest or respiratory failure occurs) was initiated then at 1:18 AM, a code blue (cardiac arrest) was called. Patient expired on 03/20/2025 at 2:15 AM.

Review of cardiac rhythm strip dated 03/19/2025 at 1:23pm, the strip revealed Sinus Rhythm (the normal, regular pattern of electrical activity in the heart that starts in the sinus node, the heart's natural pacemaker). with a ST depression (ST segment depression typically indicates that a person has an underlying condition that affects the heart. The condition may be relatively benign or potentially life threatening)

Review of telemetry event log dated 3/19/2025, reveals no cardiac event noted for Patient #1.

Review of the RCA (Root Cause Analysis) revealed it was completed on 4/3/2025. No participates documented and the identified cause was failure to acknowledge and response to rhythm change.

Review of facility improvement plan revealed actions taken did not include recognizing or education for cardiac rhythm changes. A review of the Risk Management Plan, last reviewed 1/2023, revealed the following: Purpose. The plan promotes the development of processes that identify, prevent, and mitigate organizational risks. Scope and Implementation a. Audit reports and review findings are analyzed and tracked to identify operational deficiencies and potential areas or risk. b.Based on site visit audits and reviews, leadership identifies corrective action plan options to revise operational deficiencies and mitigate risks. 4. Monitors the Effectiveness of the Action Taken a.Action plans incorporate specific measures to demonstrate effectiveness of actions. On-going Activities To meet plan objectives leadership focuses on: Proactively reviewing operations and near-misses to identify opportunities for process improvement. Investigating and trending adverse events to assess and determine how similar events might be averted and to control the loss related to the adverse outcome. Events are analyzed using the following criteria: frequency of occurrence, severity of occurrence, intense analysis, and corrective actions to improve care and services and environmental conditions.

Review of facility policy, Sentinel [Adverse] Events, last revision 5/2024, revealed: upon identification of a sentinel event or possible sentinel event, an analysis is conducted to understand the causes of the event, and when appropriate, to make changes in systems and processes to reduce the probability of a future event. A sentinel event is a patient safety event, not primarily related to the natural course of the patient ' s illness or underlying condition, that reaches a patient and results in any of the following: a. death..... 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: Notification of hospital leadership, Immediate , investigation, Completion of a comprehensive systematic analysis for identifying the causal ad contributory factors, Corrective actions derived from the identified causal and contributing factors that eliminate or control system hazards or vulnerabilities and result in sustainable improvement over time, Timeline for implementation of corrective actions and Systemic improvement. Procedure: The team utilizes tools that include but are not limited to: review of the applicable policies and procedures and/or clinical standards provided by the Unit Manager/Team Lead where the event occurred. d. The following may be included in the comprehensive systematic analysis process: III. Analysis to determine the root causes by continuously asking "why" until no additional logical answer can be identified, resulting in identification of root cause (s). Identification of risk reduction strategies and action plans for process improvement through redesign or development of new systems and processes that may improve performance and reduce the risk of future adverse events.

During an interview on 04/08/25 at 2:30 PM, Staff G, Manager of Quality stated we have not started anything yet, we are waiting for the RCA (Root Cause Analysis) to be completed. However, we are going to develop and create an interview-based audit to ensure staff can speak (verbalize) the telemetry process. We are going to track, and trend acknowledge of understanding the process through notification and escalation. We are going to initiate new hire orientation training on telemetry.

During an interview on 04/09/2025 at 11:25 AM, the ED (Emergency Department) Nurse Manager stated the charge nurse watches the telemetry monitors. They are not monitored by the central monitoring unit. They are supposed to be stationary, but they are doing multiple jobs. There is no log of telemetry events. The nurse manager of the ED confirmed there was no way to track and trend telemetry issues in the ED.

During an interview on 04/09/2025 at 2:47 PM, Staff E/Charge RN (Registered Nurse) stated when she is at her desk she watches the monitors. She had a headache and went to get some acetaminophen. She does have to use the restroom. She talks to paramedics when they bring patients in. She does participate in codes, but the resuscitation rooms are right here. Someone relieves her for lunch. "There should be someone watching these monitors. What is realistic and what we do as nurses aren' t the same. I have to talk to the paramedics. She confirmed she is a resource for nurses. She confirmed there is not a communication log for the telemetry monitors."

During an interview on 04/09/2025 at 2:55 PM, Staff F, PST (Patient Services Technician) stated she acts as a health unit clerk/coordinator. She answers EMS calls, answers the phones, prints discharge papers and makes calls for the doctors. She listens for the telemetry alarms. She would call the nurse to check the patient. She is not telemetry certified. She does not watch the monitors. She has the other duties to attend to.

Based on medical record review, interview, policy review, and observation, the facility failed to 1. Respond to changes in cardiac rhythm and provide immediate nursing care for a patient on telemetry monitoring resulting in the death of 1 Patient (#1) of 10 sampled patients for telemetry, and 2. Ensure cardiac monitors on patients in the ED (Emergency Department) were being observed for 11 patients in the ED of 119 patients in the hospital.

Findings included:

1.
Review of Patient #1's medical record revealed on 03/14/2025 the patient was admitted to the hospital for a gangrene/necrotic (dead or dying tissue) on the left 5th toe. Upon admission the patient had an order for continuous telemetry monitoring (a technique used to track heart activity) for 48hours. The telemetry order expired on 3/16/25 and the nursing staff was alerted to renew the order but failed to follow through. The patient remained on the cardiac telemetry monitor. On 3/19/25 at 1:23PM the Telemetry Monitor Technologist informed Staff A, RN (Registered Nurse) the patient developed a significant ST depression (A ST depression can be a sign of underlying condition that can lead to lethal rhythm disturbances). Staff A, RN failed to document and notify the physician of the ST depression. During shift change, Staff A, RN reported to Staff G, RN but failed to mention the ST depression. Staff D, RN signed the night shift telemetry strip (a printout of the cardiac rhythm) and failed to identify the ST depression. On 03/20/2025 at 9:20 PM, Patient #1 reported complaints of jaw pain and Tylenol given. At 10:20 PM, Patient complains of 7/10 jaw pain. Staff B, APRN (Advanced Practice Registered Nurse) was made aware of jaw pain and drop in blood pressure (70/48). Staff B, APRN ordered CT of the Head (a diagnostic imaging procedure that uses X-rays to create detailed images of the brain, skull, and other structures within the head) STAT (immediately). At 1:00 AM, the patient was taken off the continuous telemetry monitor and transported to Radiology by a transporter. After the CT of the head, the transporter was assisting the patient back onto the stretcher from the CT machine, the patient became diaphoretic (sweaty), stated "I do not feel well" and started vomiting. At 1:13 AM, a rapid response (a program designed to intervene swiftly when a patient's condition deteriorates, often before a major medical emergency like cardiac arrest or respiratory failure occurs) was initiated then at 1:18 AM, a code blue (cardiac arrest) was called. Patient expired on 03/20/2025 at 2:15 AM.

During an interview on 04/08/2025 at 12:00PM, Staff C, Nurse Manager stated on 3/19/25 at 1:36PM the telemetry technician called the nurse regarding a rhythm change. Stated he sent up the strip and recommended an EKG to confirm. There was no documentation or reassessment noted in the EMR regarding a rhythm change, including no follow up with the physician or EKG obtained.

During an interview on 04/09/2025 at 2:40 PM, Staff C, Nurse Manager stated the night nurse failed to properly identify the rhythm strip. He stated the rhythm strip clearly reveals "sinus rhythm with ST depression".

During an interview on 4/10/15 at 11:30AM, Staff A, RN stated "I received a call from CMU (Cardiac Monitioring Unit) about a change in rhythm for my patient, I didn't hear what was said and I just hung up and continued with my other patients. I know I was supposed to act on it, but I was very busy."

During an interview on 04/11/2025 at 1:44 PM, Staff, APRN stated the expectation is when a patient is on continuous cardiac monitoring, he/she is being monitored 24/7. If there is a change in the patient rhythm, then "I expect monitor tech to notify the bedside RN and the bedside RN to notify us (cardiology). I did not receive a phone call that day regarding Patient #1 having any changes on the monitor."

During an interview on 4/14/25 at 3:15PM Staff D, RN stated I usually review the strips at the beginning of the shift. That day "I didn't have time because his blood pressure started to drop, and he started to complain of right jaw pain. I notified the APRN and she ordered a STAT CT head. The patient went down to CT then I got a call from the APRN stating I should be down there with the patient. I went down then the patient coded. After the patient expired, I looked at the rhythm strip and signed off sinus rhythm. I didn't know I had to document the "ST depression" too."

Review of Assessment/Reassessment of (Adult) Patients policy last revision date 7/2024, the Registered Nurse (RN) assess for signs and symptoms of pain, performs initial assessment, plan of care and reassessments in the medical record. The patient reassessed at regular intervals. Reassessment is triggered by changes in patient ' s condition or needs and document in the patient ' s medical records.

Review of the Cardiac Monitoring (Telemetry) policy last revision date 7/2024, the RN interprets and evaluates rhythm strip, every shift or more often for changes in patient condition and/or if rhythm, rate changes occur.... Emergency Response: Monitor tech notifies nurse when a change in patient ' s rhythm is identified. Telemetry skill validated nurse assesses the patient immediately......

2.

During an interview on 04/09/2025 at 11:25 AM, the ED (emergency department) nurse manager stated the charge nurse watches the telemetry monitors. They are not monitored by the central monitoring unit. They are supposed to be stationary, but they are doing multiple jobs. There is no log of telemetry events. The nurse manager of the ED confirmed there was no way to track and trend telemetry issues in the ED.

During an interview on 04/09/25 at 12:12 PM, the DON (Director of Nursing) stated the central telemetry does not monitor the ED. The Charge nurse does. Once they are admitted to inpatient, central telemetry monitors them even if they ' re in the ED.

During a tour of the ED on 04/09/2025 at 2:33 PM, 3-screen telemetry mirror monitors were noted at the red zone nurse and physician station, next to the charge desk. No one was sitting at the charge desk. There was a PST (Patient Services Technician) sitting at a computer with her back facing the monitors. There was no one else behind the desk during the observation. This was confirmed by the nurse manager who was interviewed during the observation. She said the Charge nurse was in the rest room. The PST listens for alerts while the charge is away. The nurse manager disclosed the PST was not telemetry certified.

During an observation on 04/09/2025 at 2:38 PM, the mirror monitors next to the charge desk revealed rooms 3, 10, 11, 18, 21, 22, 23 and 24 leads were off. The alarms were activated, and the screens were flashing. No one was at the desk watching the monitors to alert nursing staff to check on their patients. The ED nurse manager was present during the observation.

During an observation on 04/09/2025 at 2:46 PM, no one was sitting at the charge desk and no one was watching the telemetry monitors. The PST, Staff F was on the phone at the charge desk. The nurse manager, who was present during the observation, said that the charge went to get Tylenol.

During an interview at 04/09/2025 at 2:47 PM, Staff E, charge RN stated when she is at her desk she watches the monitors. She has a headache and went to get some acetaminophen. She does have to use the restroom. She talks to paramedics when they bring patients in. She does participate in codes, but the resuscitation rooms are right here. Someone relieves her for lunch. "There should be someone watching these monitors. What is realistic and what we do as nurses aren't the same. I have to talk to the paramedics. She confirmed she is a resource for nurses. She confirmed there is not a communication log for the telemetry monitors."

During an interview on 04/09/2025 at 2:55 PM, Staff F, PST stated she acts as a health unit clerk/coordinator. She answers EMS (Emergency Medical Services) calls. She answers the phones, prints discharge papers and makes calls for the doctors. She listens for the telemetry alarms. She would call the nurse to check the patient. She is not telemetry certified. She does not watch the monitors. She has the other duties to attend to.

During an observation on 04/09/2025 at 2:59 PM, the charge nurse was getting report from paramedics who just brought a patient in. No one was watching the telemetry monitor screens.

During an interview on 04/10/25 at 8:37 AM, the DON, and the regional Director of Quality both stated that is not our standard or expectation for our telemetry patients in the ED.