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Based on staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure that patients at risk for cardiac arrhythmias are kept safe by maintaining continuous cardiac (telemetry) monitoring and providing assessments and interventions when abnormal cardiac rhythms are present.

Findings include:

1. The facility failed to ensure that monitor technicians assess patients and alert the nurse when abnormal cardiac rhythms are present.

2. The facility failed to ensure that staff assess patients on cardiac telemetry monitoring when there is a loss of the telemetry signal.

(Cross refer to Tag A-144)

Based on medical record review (#1), staff interviews, and review of facility documents, it was determined the facility failed to ensure that patients at risk for cardiac arrhythmias are kept safe by maintaining continuous cardiac (telemetry) monitoring and assessing patients and providing interventions when abnormal cardiac rhythms are present.

Findings include:

Reference: Facility policy titled, "Continuous Cardiac Monitoring (Telemetry) dated 06/2021 states, " ... 1. Cardiac monitoring is ... c. Once initiated, qualified staff maintain visual surveillance 24 hours a day of monitors. Clinical changes related to cardiac monitoring, including rhythm changes and alarms are identified and communicated in a consistent and timely [sic] ... g. A qualified staff member competent in cardiac rhythm interpretation will assess each strip and measure and record the rate, rhythm, PR interval, QRS width, and QT interval. A qualified and competent RN will validate the rhythm strip. ... h. The nurse assigned to the patient responds immediately if any of the following occurs: i. Notice of an alarm at the central monitoring station by a telemetry technician or other staff member. ... ii. Any observed change in the patient's cardiac rhythm. ... iii. Loss of telemetry signal. ... iv. Unreadable signal due to artifact. ... v. Intermittent signal loss. ... ."

During the entrance conference on 11/07/22 at 10:03 AM, Staff #1 (Director, Quality Management) and Staff #2 (Chief Clinical Officer) were questioned if they were aware of a recent incident in the facility where a patient expired and it was found that his/her alarms were turned off. Staff #1 stated, "We had a recent incident reported on Friday by a staff member. The patient expired, but the telemetry alarm was not turned off. We did find that there was a delay in telemetry response, but the alarm was not turned off. There is an investigation currently being done, but it is not finished yet because we just learned about this on Friday." This surveyor then asked Staff #1 and Staff #2 to confirm that the patient's telemetry alarms were not turned off at the time the patient expired. Staff #2 stated, "No, but they were silenced. We checked the monitors and found that the telemetry alarm had been silenced, but it wasn't turned off." Staff #1 and Staff #2 indicated that telemetry monitors are located in a centralized location and are monitored at all times by a Monitor Technician (Tech).

Review of Medical Record #1 on 11/09/22 at 9:40 AM, in the presence of Staff #6 (Market Chief Clinical Officer) revealed the following:

Patient #1 (P1) was admitted to the facility on 10/24/22. The History and Physical, dated 10/25/22 indicated the patient had a past medical history significant for pulmonary hypertension, pulmonary embolism, COPD (chronic obstructive pulmonary disease), and congestive heart failure. The patient was on high-flow oxygen (O2).

Review of the EKG (electrocardiogram) Event Report revealed that on 10/29/22 at 6:25 AM, P1's telemetry monitoring indicated that he/she was in a rapid A-Flutter. Upon interview on 11/09/22 at 9:40 AM, Staff #6 indicated that this arrhythmia (an abnormal heart rhythm) should have prompted the telemetry alarms to sound, and the monitor tech should have assessed the patient and alerted the nurse. Staff #6 stated, "I would identify the rhythm as a rapid A-Flutter. This rhythm would definitely prompt a response and require an intervention. The nurse should have been made aware and a strip should have been pulled. We also have an escalation log for monitor techs. This is a log of abnormal EKG strips. When a patient has an abnormal rhythm, the tech is supposed to pull the strip, place it in the log, and let the nurse know. There was no evidence that the monitor tech did this. We don't see that [he/she] notified the nurse or placed a strip in the escalation log regarding the patient's rapid A-Flutter."

The EKG Event Report revealed the patient was in a rapid A-Flutter from 6:25 AM to 6:28 AM. At 6:29 AM, the telemetry monitoring indicated artifact (no identifiable rhythm; typically attributed to patient movement). P1's telemetry monitoring was then off for 40 minutes, from 6:30 AM until 7:10 AM. The patient was placed back on telemetry at 7:10 AM, when a code blue was called for the patient. The patient expired at 7:26 AM. Upon interview on 11/09/22 at 9:50 AM, Staff #6 stated, "I interviewed both the nurse and the monitor tech working that night. The nurse [Staff #15] said he/she was in the room cleaning the patient at 6:30 AM, but I think he/she was mistaken. If you look at the strips, you see a lot of artifact around 6:00 AM. I think that's the time he/she was in there with the CNA [certified nurse's aide] cleaning the patient. [Staff #15] stated that he/she was in and out the patient's room numerous times because the patient kept pulling off [his/her] O2, gown, and tele (telemetry) leads. [Staff #15] also stated that [he/she] was busy with an admission during the night and that the monitor tech would tell [him/her] if the patient's monitor was off. [Staff #15] said [he/she] didn't know about the patient's tele alarm being silenced. When I interviewed Staff #14 (Monitor Tech), [he/she] stated that [he/she] silenced P1's telemetry alarms a few times throughout the night. [Staff #14] also stated that he/she did not ask the nurse [Staff #15] to check on the patient because 'the nurse was busy with an admission' and Staff #14 'felt bad for [him/her].' "

Nurse's notes entered on 10/29/22 at 7:00 AM state, "Pt [patient] is stable. No signs of acute distress. A Flutter on tele. On HFNC [high flow nasal canula]) 60L/100 [60 liters, 100% oxygen] O2 sat [saturation] 90%." The patient was off telemetry monitoring from 6:30 AM to 7:10 AM. The patient was placed back on telemetry at 7:10 AM, when a code blue was called for the patient. The patient expired at 7:26 AM.

On 11/09/22 at 9:58 AM, Staff #6 stated that per facility policy, the monitor tech should have assessed the patient and alerted the nurse at 6:25 AM due to the patient's abnormal cardiac rhythm, and again assess the patient at 6:30 AM, when the patient's telemetry monitoring was off. Staff #6 confirmed that there was no evidence the monitor tech alerted the nurse about P1's abnormal cardiac rhythm or that the patient was assessed by the monitor tech or the nurse during the patient's rapid A-Flutter commencing at 6:25 AM. Staff #6 confirmed that there was no evidence the monitor tech or the nurse assessed the patient from 6:30 AM to 7:10 AM, when the patient's telemetry monitoring was off.

On 11/09/22 at 4:42 PM, an Immediate Jeopardy (IJ) was identified for the facility's failure to provide continuous telemetry monitoring of a patient with a physician's order for telemetry monitoring and the facility's failure to assess the patient and alert the nurse when abnormal cardiac rhythms are present. The facility was notified of the IJ on 11/09/22 at 3:07 PM and provided with the IJ template at 3:07 PM. On 11/09/22 at 4:42 PM, an acceptable IJ removal plan was received. On-site verification of the implementation of the removal plan included the following: Review of staff re-education to the facility's policy regarding telemetry monitoring and the procedure for the escalation of alarms, review of staff telemetry tests, and staff interviews confirming that re-education to the facility's policy regarding telemetry monitoring and testing for telemetry competency, was performed. The IJ was lifted on 11/09/22.