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Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to ensure that nursing personnel configured adequate volume settings on Patient ID #1's bedside telemetry monitor, preventing the staff from being alerted to the patient's lethal arrhythmia (irregular heartbeat) (A-0395); and failed to ensure that nursing personnel adhered to hospital policies related to the documentation and nursing care of a patient requiring continuous telemetry monitoring, (A-0398). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients.

The hospital's Director of Practice Improvement and Risk Manager were informed of the Immediate Jeopardy, which was identified on 6/5/2025 and were provided with the Immediate Jeopardy template at approximately 2:00 PM on this date.

On 6/5/2025, the hospital submitted the Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring.

This IPOC indicated that the following would be immediately implemented:

- Biomedical Engineering reviewed each bedside monitor to ensure the audible alarms are at the factory setting. This is discussed at the ED safety Huddle at 7 AM, 3 PM and 7 PM.

- The ED nurses will be educated on the telemetry policy via a "Did You Know" and sign-off on said education beginning June 5, 2025 with the completion date Monday June 9, 2025.

- All ED staff working on June 6, 7, 8 & 9 will be re-educated to the policy.

- All staff not working, on vacation or on an LOA will be re-educated prior to the start of their first shift back. Compliance will be monitored by the Quality Department.

On 6/10/2025, it was confirmed by the State Surveyors during multiple observations in the emergency department that bedside telemetry monitors along with the central station telemetry monitors at the nurses' station had audible alarms. Interviews conducted with staff on duty in the emergency department confirmed that staff received and reviewed the hospital's telemetry policy. As of 6/10/2025, the IJ was removed.

Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to meet the Condition of Participation for Physical Environment, after the following was identified:

- The hospital failed to maintain the emergency department's monitoring equipment in a manner that ensures the safety and well-being of patients. Biomedical Engineering staff did not identify improperly connected cables, leading to the loss of audible alarms at the central telemetry station in the emergency department at the nurses' station. This failure resulted in the inability to alert staff with an audible alarm when Patient ID #1 experienced a lethal arrhythmia (irregular heartbeat), (Refer to A-0701).

Findings are as follows:

As a result of the identified non-compliance, Patient ID #1 experienced Asystole (a severe form of cardiac arrest that requires immediate medical attention) unrecognized by staff at 6:38 AM on 5/27/2025 who did not enter the room until 7:14 AM and found the patient pulseless and cyanotic (blue).


45769

Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to meet the requirements of §482.55 Condition of Participation: Emergency Services, related to the central telemetry monitoring system which failed to alert staff with an audible alarm that would have alerted them to a patient experiencing a lethal arrhythmia (irregular heartbeat). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients.

As a result of the identified non-compliance, Patient ID #1 experienced Asystole (a severe form of cardiac arrest that requires immediate medical attention) unrecognized by staff at 6:38 AM on 5/27/2025, who did not enter the room until 7:14 AM and found the patient pulseless and cyanotic. (Refer to A-1103)

The hospital's Director of Practice Improvement and Risk Manager were informed of the Immediate Jeopardy, which was identified on 6/5/2025 and were provided with the Immediate Jeopardy template at approximately 2:00 PM on this date.

On 6/5/2025, the hospital submitted the Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented:

- Biomedical Engineering has implemented color-coding, and labeling of all cables and ports to prevent cables being plugged into the incorrect connector.

- The ED Charge nurse will print a sample telemetry strip at 7:00 AM and 7:00 PM to validate the central monitor is working, effective June 6, 2025.

- The house supervisor will ensure it is conducted. This data will be monitored by the Quality Department.

- The Hospital's telemetry policy will be reviewed by nursing management to standardize the process house wide.

On 6/10/2025, it was confirmed by the State Surveyors, during multiple observations in the emergency department that bedside telemetry monitors along with the central station telemetry monitors at the nurses' station had audible alarms. Additionally, that all cables in the server closet were color coded, labeled and secured, sample telemetry rhythm strips were printed to validate that the central monitor was working, and interviews with staff on duty in the emergency department confirmed that staff received and reviewed the hospital's telemetry policy. As of 6/10/2025, the IJ was removed.



45769

Based on review of medical records, review of facility documents, and staff interviews, it was determined that the hospital failed to ensure that nursing personnel configured adequate volume settings on a patient's bedside telemetry monitor, preventing the staff from being alerted to the patient's lethal arrhythmia (irregular heartbeat), for 1 of 4 patients reviewed who were on continuous cardiac monitoring and awaiting transfer from the emergency department (ED) to the Progressive Care Unit, (Patient ID #1).

Findings are as follows:

Review of the patient's medical record revealed that the patient arrived at the ED by rescue on 5/26/2025 at 6:37 PM.

According to the record, based on the patient's bloodwork, chest x-ray, and electrocardiogram results, it was determined that the patient would be admitted to the inpatient Progressive Care Unit with a diagnosis of a Non-ST Segment Myocardial Infarction (heart attack) and congestive heart failure.

Review of a Significant Event Note dated 5/27/2025 by Employee H, Internal Medicine Resident, revealed that at 7:15 AM, nursing staff found the patient unresponsive, cyanotic (blue) and pulseless and a Code Blue was initiated. At 8:11 AM, on 5/27/2025, the patient was pronounced dead.

During a surveyor interview on 6/5/2025 at 12:00 PM with Employee C, Registered Nurse (RN), she indicated that she came in for her shift the morning of 5/27/2025 and received report at the nurses' station. She explained that after morning huddle, she "looked up at the monitor and saw that the patient's heart beat was 20" but did not remember hearing the monitor alarm, nor if the monitor was flashing red. She stated that she then entered the patient's room, she saw the patient lying on the stretcher with his/her head "in between the railing" and the patient's face was blue. She stated that she then hit the code button and started compressions. She indicated that upon entering the patient's room, she did not pay attention to the bedside monitor and indicated that she did not know if the bedside monitor was alarming. She revealed that Employee E, another nurse, went back to central station to see when things changed for the patient and determined that at 6:38 AM, the patient "went asystolic (a cardiac rhythm characterized by the complete absence of electrical activity in the heart, resulting in a flatline on an electrocardiogram constituting a severe form of cardiac arrest that requires immediate medical attention)" but they were unable to print the telemetry strip that showed this.

During a surveyor interview on 6/9/2025 at 9:56 AM with Employee D, RN, she indicated that she was the Charge Nurse for the day shift on 5/27/2025. She explained that when she sat down at the nurses' station, she looked up at the central station telemetry monitors and noticed a rhythm that looked like asystole, but stated that it did not feel real since there was no alarm. She then looked at Employee C, RN, asked her what she had received in report for this patient and questioned whether the rhythm she was looking at was real. She stated that Employee C started to walk down to the room, and then they all took off running into the patient's room. She stated that when she ran into the room, the patient was "blue-gray" and "halfway off the stretcher, as if trying to get off it". She then picked up the patient's legs, placed them onto the bed, and cardiopulmonary resuscitation (a life-saving technique used when someone's heart stops beating) was started. She revealed that another nurse checked central station and "saw that at 6:38 AM, the patient went asystolic." When asked if she heard the bedside monitor alarming when she entered the patient's room, she stated, "everything was silent" but when she looked at the rhythm on the bedside monitor, it was the same one she saw at central station.

During a surveyor interview on 6/4/2025 at 1:05 PM with the Director of Practice Improvement, she stated that they did not find out the alarm to central station was down until after the event occurred. She explained that the monitors at central station in the emergency department had visual alarms, but no audible alarms, and further explained that the bedside monitor had both audio and visual alarms. She revealed that a team of staff, including the Biomedical Manager, checked the patient's bedside monitor, increased its volume as it was identified that the volume was low, and then increased the volume on all bedside monitors.

Based on review of medical records, review of facility documents, and staff interviews, it was determined that the hospital failed to ensure that nursing personnel adhered to hospital policies related to the documentation and nursing care of a patient requiring continuous telemetry monitoring, for 1 of 4 patients in the emergency department reviewed who were on continuous cardiac monitoring and awaiting transfer to the Progressive Care Unit (PCU), (Patient ID #1). Following this event the hospital failed to reeducate the nursing staff on the hospital's policy titled, "Continuous Electrocardiographic Monitoring; Telemetry".

Findings are as follows:

The hospital's policy titled, "Continuous Electrocardiographic Monitoring; Telemetry" last revised on 3/2024, states in part,

"...Policy

...7. Rhythm strips are printed and posted in the patient's medical record every 4 hours and with any rhythm change or significant arrhythmia. Analysis and documentation on the strip include:

a. Patient specific label
b. PR interval [the brief pause in your heart's electrical activity that occurs between the contraction of the upper chambers (atria) and the lower chambers (ventricles)] if applicable
c. QRS interval [represents the rapid contraction of the heart's lower chambers, known as the ventricles]
d. QT interval [measures the time it takes for your heart's lower chambers (ventricles) to contract and then relax]
e. Rhythm identification
f. RN signature ..."

Record review for Patient ID #1 revealed that an admission order was entered into the record at 9:20 PM on 5/26/2025 for further management and monitoring. However, the patient remained in the ED due to lack of an available bed in the Progressive Care Unit.

The record failed to reveal evidence that a rhythm strip was printed and posted in the patient's medical record every 4 hours and with any rhythm change or significant arrhythmia in accordance with the hospital's policy.

During a surveyor interview with the Nursing Director of the ED on 6/10/2025, she was unable to provide evidence that staff printed and posted rhythm strips for this patient in accordance with the hospital's policy.

Based on review of medical records, review of facility documents, and staff interviews, it was determined that the hospital failed to maintain the emergency department's monitoring equipment in a manner that ensures the safety and well-being of patients. Biomedical Engineering staff were unable to identify improperly connected cables, leading to the loss of audible alarms at the central telemetry station in the emergency department. This failure resulted in the inability to alert staff with an audible alarm when a patient experienced a lethal arrhythmia (irregular heartbeat), for 1 of 4 patients in the emergency department reviewed who were on continuous cardiac monitoring and awaiting transfer from the emergency department (ED) to the Progressive Care Unit, (Patient ID #1).

Findings are as follows:

During a surveyor interview on 6/4/2025 at 11:02 AM with Employee F, Interim Biomedical Manager, he stated that on 5/27/2025 when he was informed by staff that central station in the emergency department was not alarming, he went to the server closet. He stated that while in the server closet, he pulled the computer from the server, which provides remote access to central station in the ED, and connected his external speaker identifying that he was unable to hear the alarm. He then went behind the server, checked all connections, ensured everything was plugged in, but did not check for correct cable placement. He then reset the server but was still unable to hear the alarm. He revealed that when the manufacturer representative came to the hospital on 5/28/2025, it was the representative who determined that the external speaker cable was connected into the microphone port instead of the external speaker port.

During an additional surveyor interview with Employee F, on 6/9/2025 at 9:23 AM, and review of the Central Display Annual Maintenance work order for the emergency department, he confirmed that a vendor completed maintenance on the system on 3/21/2025. The vendor cleaned the unit and documented that it was functioning properly. Employee F indicated that he was unable to determine who entered the server closet and may have incorrectly connected the cable into the incorrect port, nor how long the cable was transposed.

During a surveyor interview with the Director of Practice Improvement on 6/4/2025, she was unable to provide a report regarding the findings identified by the manufacturers representative who presented to the hospital on 5/28/2025.

An outreach was attempted by the Survey investigation team to the manufacturer but went unanswered.

45769

Based on record review and staff interviews it was determined that the Hospital failed to ensure the emergency department's (ED) central telemetry monitoring system was functioning properly after it failed to alert staff with an audible alarm that would have alerted them to a patient experiencing a lethal arrhythmia (irregular heartbeat), resulting in the failure of staff to respond timely to an emergent event and render appropriate emergency care since central station tele-monitors did not alarm as they should have when the patient experienced a severe cardiac arrythmia for 1 of 4 patients in the emergency department reviewed who were on continuous cardiac monitoring and awaiting transfer to the Progressive Care Unit, (Patient ID #1).

Findings are as follows:

Review of the patient's medical record revealed the patient arrived at the ED by rescue on 5/26/2025 at 6:37 PM.

According to the record, based on the patient's blood work, chest x-ray, and electrocardiogram results, it was determined that the patient would be admitted to the inpatient Progressive Care Unit with a diagnosis of a non-ST segment myocardial infarction, (heart attack) and congestive heart failure. On 5/26/2025 at 9:21 PM, an inpatient bed was requested for further management and monitoring and the plan was discussed with patient. However, the patient remained in the ED due to the lack of an available bed in the Progressive Care Unit.

Review of a Significant Event Note dated 5/27/2025 by the Internal Medicine Resident, Employee H, revealed that at 7:15 AM on 5/27/2025, the nursing staff found the patient unresponsive, cyanotic (blue) and pulseless; a Code Blue was initiated. At 8:11 AM, on 5/27/2025, the patient was pronounced dead.

During a surveyor interview on 6/5/2025 at 12:00 PM with Employee C, Registered Nurse (RN), she explained that she came in for her shift the morning of 5/27/2025 and was assigned to Patient ID #1. After morning report was over, she looked up at the monitor and saw that Patient ID #1's heart rate was 20, but did not remember hearing the monitor alarm sound nor if the monitor was flashing red. She stated that she then entered the patient's room, she saw the patient lying on the stretcher with his/her head "in between the railing" and the patient's face was blue. She stated that she then hit the code button and started compressions. She indicated that upon entering the patient's room, she did not pay attention to the bedside monitor and indicated that she did not know if the bedside monitor was alarming. She revealed that Employee E, RN, went back to the central station to review Patient ID #1's cardiac rhythm event history which identified that at 6:38 AM, the patient "went asystolic (a severe form of cardiac arrest that requires immediate medical attention)" but they were unable to print the telemetry rhythm strip that showed this.

During a surveyor interview on 6/9/2025 at 9:56 AM with Employee D, RN, she explained that she was the Charge Nurse for the day shift on 5/27/2025. She stated that after the morning huddle, she sat down at the nurses' station, looked up at the central station monitors and noticed a rhythm that looked like asystole, but stated that it did not feel real since there was no alarm. She then looked at Employee C, RN, and asked her what she had received in report for this patient, wondering whether the rhythm she was looking at was real. Both she and Employee C ran into the room, and Patient ID #1 was "blue gray" and "halfway off the stretcher, as if trying to get off it". She then picked up the patient's legs, placed them onto the bed, and cardiopulmonary resuscitation (a life-saving technique used when someone's heart stops beating) was started. She indicated that one of the ED Attending Physicians, Employee K, and Employee E, RN, reviewed the telemetry monitor at central station and "saw that at 6:38 AM, the patient went asystolic." When asked if she heard the bedside monitor alarming when she entered the room, she stated, "everything was silent" but when she looked at the rhythm on the bedside monitor, it was the same one she saw at central station.

During a surveyor interview on 6/9/2025 at 10:25 AM with Employee E, RN, she stated that on 5/27/2025, she came in for her shift and clocked in at 6:32 AM. She indicated that after huddle, she looked up at the central station telemetry monitors and noticed that Patient ID #1 was asystolic. She indicated that she and other staff were questioning if the patient's rhythm was real since the monitor was not alarming and when they went into the patient's room, "he was found to be deceased." When asked what she saw upon entering the patient's room, she stated that the patient was lying on the stretcher, she/he was blue, and his/her head was against the railing. She indicated that she did not remember if the bedside telemetry monitor was alarming. She explained that she went to central station and noticed that Patient ID #1's display was "frozen" and so she unplugged the mouse with the help of a nursing assistant and plugged it back in. When the monitor started working, she reviewed the event history and saw that at 6:38 AM, the patient went asystolic. She explained that she was unable to print the waveform because the option to print was not working. After identifying that the patient went asystolic at 6:38 AM, she revealed that she then went into the patient's room and let the ED physician and the code team residents who were present, know.

During a surveyor interview on 6/4/2025 at 1:05 PM with Employee J, the Emergency Department Medical Director, he stated that he was made aware that the patient had voided and shortly after was found unresponsive but was unable to indicate how long the patient had been unresponsive.