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Based on observation, interview, and record review, the facility failed to follow their policy and procedures for 12 of 30 sampled patients (Patients 1, 2, 3, 4, 5, 6, 8, 9,13, 15, 28, and 30) when:

1. For Patient 1, a code blue (a medical emergency, specifically a cardiac or respiratory arrest, requiring immediate resuscitation efforts) was not initiated when Patient 1 had no pulse (see A 0398);

2. For Patients 3, 4, and 13, the continuous cardiac monitoring was initiated without a physician's order (see A 0398);

3. For Patients 1, 2, 5, 6, and 15, the physician's order for continuous cardiac monitoring did not include diagnosis and parameters (see A 0398);

4. For Patients 1, 2, 8, and 9, the cardiac monitoring strips were not verified by a Registered Nurse (RN) (see A 0398);

5. For Patient 3, there was no evidence that a fall risk re assessment was conducted following a fall (see A 0398);

6. For Patient 3, physician's order for a 1:1 sitter was not implemented as ordered (see A 0398);

7. For Patients 28, and 30, nutritional assessments were not completed within the required timeframe (see A 0398);

8. For Patient 28, there was no documentation that the nutritional recommendations were implemented (see A 0398);

9. For Patient 28, weekly weights were not obtained as required (see A 0398);

10. For Patient 28, all recommended interventions to support wound healing were not utilized (see A 0398);

11. For Patient 30, there was no documentation of physician notification regarding a change in patient condition (see A 0398);

12. For Patient 30, documentation was incomplete with no record of interventions performed or medications administered during a code blue event (see A 0398);

13. For Patient 30, sedating medication was administered without documented assessment of the Richmond Agitation Sedation Scale (RASS, tool used to assess a patient's level of sedation, ranging from combativeness [+4] to unarousable sedation [ 5]) score; (see A 0398); and

14. For Patient 30, there was no evidence of a nursing assessment conducted following a change in patient condition (see A 0398).

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 observation, interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for 12 of 30 sampled patients (Patients 1, 2, 3, 4, 5, 6, 8, 9, 13, 15, 28, and 30), when:

1. For Patient 1, a code blue (a medical emergency, specifically a cardiac or respiratory arrest, requiring immediate resuscitation efforts) was not initiated when Patient 1 had no pulse;

2. For Patients 3, 4, and 13, the continuous cardiac monitoring was initiated without a physician's order;

3. For Patients 1, 2, 5, 6, and 15, the physician's order for continuous cardiac monitoring did not include diagnosis and parameters;

4. For Patients 1, 2, 8, and 9, the cardiac monitoring strips were not verified by a Registered Nurse (RN);

5. For Patient 3, there was no evidence that a fall risk re assessment was conducted following a fall;

6. For Patient 3, physician's order for a 1:1 sitter was not implemented as ordered;

7. For Patients 28, and 30, nutritional assessments were not completed within the required timeframe;

8. For Patient 28, there was no documentation that the nutritional recommendations were implemented;

9. For Patient 28, weekly weights were not obtained as required;

10. For Patient 28, all recommended interventions to support wound healing were not utilized;

11. For Patient 30, there was no documentation of notification to the physician regarding a change in patient condition;

12. For Patient 30, documentation was incomplete with no record of interventions performed or medications administered during a code blue event;

13. For Patient 30, sedating medication was administered without documented assessment of the Richmond Agitation Sedation Scale (RASS,tool used to assess a patient's level of sedation, ranging from combativeness [+4] to unarousable sedation [ 5]) score; (see A 0398); and

14. For Patient 30, there was no evidence of a nursing assessment conducted following a change in patient condition.

These failures had the potential to cause a delay in patient care and harm for the patients including death.

Findings:

1. A review of Patient 1's medical record was conducted on April 1, 2025, at 2:23 p.m., with the Radiology Manager (RM). The facility document titled, "Patient registration data," reflecting April 1, 2025, was reviewed and indicated, "Admit: 12/10/2024 [December 10, 2024]...Diagnosis: ACUTE AND CHR [chronic] RESPIRATORY FAILURE [condition where the lungs are unable to perform adequate gas exchange], UNS [unspecified] W [with] HYPOXIA [insufficient oxygen in the blood]..."

A review of the facility document titled, "History and Physical," dated December 10, 2025, indicated, "...Past medical history...Hypertension [high blood pressure], polycythemia vera[type of blood cancer]...Assessment...Acute hypoxic respiratory failure...COVID [Coronavirus Disease infection of the lungs] pneumonia [lung infection]...Plan... Patient is COVID positive..."

A review of the facility document titled, "Physician's orders," dated December 10, 2024, indicated, "...Telemetry cardiac monitoring...start 12/10/2024 [December 10, 2025] 18:10 [6:10 p.m.], stop after 3 days..."

A review of the facility document titled, "Physician's order," dated February 5, 2025, indicated,"...Code status: CPR [cardiopulmonary resuscitation]:no...Life sustaining treatments desired: Antimicrobials [substances that inhibit or kill microorganisms], Artificial feeding and hydration, Blood products, Vasopressors [a drug or other agent which causes the constriction of blood vessels], Anti arrhythmic [class of drugs that are used to suppress abnormally fast rhythms], Hemodialysis [a process of filtering the blood of a person whose kidneys are not working normally]...start today 02/05/2025 [February 5, 2025]..."

There was no documented evidence in Patient 1's medical record of Patient 1's February 7, 2025, 8 a.m., vital signs. The RM stated the last vital signs for Patient 1 was at 4 a.m., on February 7, 2025.

A review of the facility document titled, "Respiratory care," dated February 7, 2025, indicated, "...07:43 [7:43 a.m.] Pulse oximetry, continuous...Oximeter pulse...116/min [minute]..."

A review of the facility document titled, "Compressed Wave Rec.[record]," dated February 7, 2025, indicated the following:

On February 7, 2025, at 8:17 a.m., heart rate 67 beats per minute (bpm);

On February 7, 2025, at 8:18 a.m., heart rate 63 bpm;

On February 7, 2025, at 8:19 a.m., heart rate 65 bpm;

On February 7, 2025, at 8:20 a.m., heart rate 60 bpm;

On February 7, 2025, at 8:21 a.m., heart rate 48 bpm;

On February 7, 2025, at 8:22 a.m., heart rate 47 bpm;

On February 7, 2025, at 8:24 a.m., heart rate 37 bpm;

On February 7, 2025, at 8:25 a.m., heart rate 40 bpm;

On February 7, 2025, at 8:26 a.m., heart rate 28 bpm;

On February 7, 2025, at 8:27 a.m., heart rate 0 bpm;

On February 7, 2025, at 8:28 a.m., heart rate 30 bpm;

On February 7, 2025, at 8:29 a.m., heart rate 30 bpm;

On February 7, 2025, at 8:30 a.m., heart rate 34 bpm;

On February 7, 2025, at 8:31 a.m., heart rate 33 bpm;

On February 7, 2025, at 8:32 a.m., heart rate 27 bpm;

On February 7, 2025, at 8:33 a.m., heart rate 16 bpm;

On February 7, 2025, at 8:34 a.m., heart rate 16 bpm;

On February 7, 2025, at 8:35 a.m., heart rate 0 bpm;

On February 7, 2025, at 8:36 a.m., heart rate 0 bpm;

On February 7, 2025, at 8:37 a.m., heart rate 0 bpm rapid response (specialized team designed to intervene early when a patient's condition is deteriorating or at risk of deteriorating) was called; and

On February 7, 2025, at 8:42 a.m., heart rate TOD (time of death).

A concurrent interview was conducted on April 1, 2025, at 3:45 p.m., with the RM. The RM stated there was no documented evidence in Patient 1's medical record that a nursing assessment was completed following Patient 1's change of condition. The RM further stated there was no documented evidence Registry Registered Nurse (RNN) 1, assessed Patient 1, while Patient 1's heart rate was declining.

A review of the facility document titled, "Rapid Response Team and Code H Record," dated February 7, 2025, indicated, "...Room location...Intensive Care Unit [ICU -a unit that provides the critical care and life support for acutely ill and injured patients] Room A...Time called...0837 [8:37 a.m.]...Event ended...0842 [8:42 a.m.]...Situation/ Reason for call...Asystole...Medications...Epinephrine [medication used for medical emergency](subcutaneous)...0838 [8:38 a.m.]...Other...patient expired pronounced at 0842 [8:42 a.m.]..."

A review of the facility document titled, "RESTRAINT CARE PLAN (NON VIOLENT NON SELF DESTRUCTIVE BEHAVIOR," dated February 7, 2025, indicated, "...Type of Restraint...Mitten...Left Hand...Right Hand...time...8 a.m....RN 30 Minutes Post Restraint Application Safety Check...time..8:30 a.m..."

A review of the facility document titled," Restraint Monitoring (non violent, non self destructive behavior)," dated February 7, 2025, indicated , "...safety checks and monitoring (at least q 2 hours) initialed by RRN1 at 0800 (8 a.m.), 1000 (10 a.m.), 1200 (12 N),1400 (2 p.m.),1600 (4 p.m.) and 1800 (6 p.m.)..."

Further review of Patient 1's medical record indicated there was no documented evidence a code blue was called when Patient 1's heart rate was 0. The Director of Pharmacy (DOP) stated the Pharmacy usually keeps a copy of a code blue sheet, but there was none for February 7, 2025.

A concurrent interview and record review was conducted on April 1, 2025, at 1:33 p.m., with the Monitor Technician (MT). The MT provided her notes on a document titled, "T. Trend Rec (record)", dated February 7, 2025. The document indicated the following: Patient 1's Name and medical record number.

On February 7, 2025, at 8:15 a.m., HR (heart rate) 82 , blood pressure 68/37 mmHg (millimeter mercury unit of measurement);

On February 7, 2025, at 8:16 a.m., HR 69, blood pressure 69/34 mmHg;

On February 7, 2025, at 8:21 a.m., HR 45, notified (RN) HR low 40s;

On February 7, 2025, at 8:24 a.m., HR 37 MT was notified by (RN) pt (patient) was DNR (do not resuscitate);

On February 7, 2025, at 8:27 a.m., HR 0 RN was notified asystole;

On February 7, 2025, at 8:28 a.m., HR 30 RN was notified HR picking up;

On February 7, 2025, at 8:33 a.m., RN was notified HR low 10's;

On February 7, 2025, at 8:36 a.m., (Name of ICU RN) told MT to call RR (Rapid Response); RR was called;

On February 7, 2025, at 8:42 a.m., (Name of MD) was paged TOD.

The MT stated RRN 1 was assigned to Patient 1 on February 7, 2025. The MT stated RRN 1 was seated beside her in the ICU nurse's station and was able to see the monitor, however, RRN1 did not respond to her several notifications of Patient 1's low heart rate. The MT stated she was informed by RRN 1 that Patient 1 was a DNR. The MT further stated it was ICURN 4 who instructed her to call a rapid response when she learned Patient 1's code status was DNR with life sustaining measures.

An interview was conducted on April 2, 2025, at 9:30 a.m., with the Director of Nursing (DON). The DON stated the facility has no Code Blue Policy but uses the American Heart Association Advance Cardiac Life Support guidelines for patients needing emergency care such as patients without a pulse.

A concurrent interview and record review was conducted on April 2, 2025, at 11:53 a.m., with the DON. The facility document titled, "American Heart Association: Adult Cardiac Arrest Circular Algorithm," dated 2020, was reviewed. The document indicated, "...Drug Therapy ...Epinephrine IV [intravenous[/IO [intraosseous]...1 mg [milligram unit of measurement] every 3 5 minutes..." The DON stated the document did not indicate Epinephrine can be given subcutaneously during a cardiac arrest.

An interview was conducted on April 2, 2025, at 1:32 p.m., with ICURN 2. ICURN 2 stated she was not assigned to Patient 1 but witnessed the interaction between MT and RRN 1. ICURN 2 stated she heard MT inform RRN 1 of Patient 1's low heart rate however, RRN 1 did not respond. ICURN 2 further stated she did not see RRN 1 enter Patient 1's room to assess Patient 1, nor was there a sense of urgency. ICURN 2 stated she heard ICURN 4 question RRN 1 the reason for the vasopressor (medication that constricts bloodflow) when she (RRN 1) said
Patient 1 was a DNR (Do Not Resuscitate). ICURN 2 further stated, "We don't wait 20 minutes to call the MD [Medical Doctor] during situations like this..."

A concurrent interview and review was conducted on April 2, 2025, at 2:15 p.m., with the DON. The facility document titled, "Rapid Response Team and Code H Record," dated February 7, 2025, was reviewed. The document indicated reason for the rapid response called for Patient 1 was Asystole (no pulse). The DON stated, based on this document a Code Blue should have been called rather than a rapid response.

An interview was conducted on April 3, 2025, at 10:08 a.m., with ICURN 3. ICURN 3 stated she heard the MT inform RRN 1 several times about Patient 1's low heart rate while RRN 1 was busy talking to the dialysis nurse in another patient room. ICURN 3 stated she did not see any sense of urgency from RRN 1, until the rapid response was called.

A telephone interview was conducted on April 7, 2025, at 11:26 a.m., with ICURN 4. ICURN 4 stated she was sitting at the ICU nurse's station when she heard the MT notify RRN 1 of Patient 1's low heart rate multiple times, but RRN 1 did stand up and check on Patient 1. ICURN 4 stated she heard RRN 1 inform the MT that Patient 1 was a DNR. ICURN 4 also stated, she became suspicious when RRN 1 asked for her help to enter a vasopressor order in the computer, which triggered her to verify Patient 1's code status. ICURN 4 further stated, when she learned Patient 1 had an order for life sustaining measures, she immediately asked the MT to call for a rapid response team, when the house supervisor checked on the patient (Patient 1), the patient (Patient 1) had already died.

A review of the facility document titled, "ICU Staffing Assignment Sheet," dated February 7, 2025, was conducted. The document indicated RRN 1 was the RN assigned to Patient 1.

A review of the facility policy and procedure (P&P) titled, "CORE: Emergency Care," dated June 2023, was conducted. The P&P indicated, "...When a patient requires emergency intervention which includes resuscitation, current ACLS guidelines are initiated until the time the physician assumes medical direction of the emergent care..."

2a. A review of Patient 3's medical record was conducted on April 2, 2025, at 2:30 p.m., with the Radiology Manager (RM).

A facility document titled, "Patient registration data," reflecting, April 2, 2025, indicated, "Admit: 02/10/2025 [February 10, 2025]...Diagnosis: OSTEOMYELITIS [a bone infection] UNSPECIFIED..."

A facility document titled, "History and Physical," dated February 10, 2025, indicated, "...Patient...comes to us from [Name of hospital] where he was admitted there around January 29, 2025 for right foot swelling and pain. Was diagnosed with osteomyelitis and diabetic foot underwent a right BKA [below the knee amputation]... PMH [primary medical history]: coronary artery disease [condition where heart arteries are narrowed or blocked]...congestive heart failure [condition where the heart cannot pump enough blood]..."

A review of Patient 3's recorded cardiac rhythm strips (a test that records the electrical activity of the heart) was conducted on April 2, 2025, at 11:10 a.m., with the RM.

The recorded cardiac rhythm strip dated March 6, 2025, indicated, "...20:16 [8:16 p.m.] SR [sinus rhythm normal heart rhythm] 84...BBB [Bundle branch block, a block or disruption to the electrical impulse that contracts your heart's lower chambers], 1° AVB [First degree atrioventricular block, a condition of abnormally slow electrical conduction in the heart]..."

The recorded cardiac rhythm strip dated March 13, 2025, indicated, "...19:35 [7:35 p.m.] SR 80...1° AVB...BBB..."

The cardiac rhythm strip dated March 15, 2025, indicated, "...20:16 [8:16 p.m.] SR 74..."

A concurrent interview and record review of Patient 3's record was conducted on April 3, 2025, at 1:33 p.m., with the RM. The facility document titled,"Physician's orders," were reviewed. The RM stated there was no documented evidence that continuous cardiac monitoring was ordered for Patient 3.

2b. A review of Patient 4's medical record was conducted on April 3, 2025, with the RM.

A facility document titled, "Patient registration data," reflecting, April 3, 2025, indicated, "Admit: 03/06/2025 [March 6, 2025]...Diagnosis: ACUTE AND CHR [chronic] RESPIRATORY FAILURE [condition where lungs are unable to perform adequate gas exchange], UNS [unspecified] W [with] HYPOXIA [insufficient oxygen in the blood] OR HYPERCAPNIA [too much carbon dioxide in the blood]..."

A facility document titled, "History and Physical," dated February 10, 2025, indicated, "...Patient...comes to us from [Name of hospital] where he was admitted there around January 13, 2025, for abdominal pain hematemesis [vomiting blood] and subsequently weakness and shortness of breath and swallow difficulty...required intubation...have trach [tracheostomy opening in the windpipe]..."

A review of Patient 4's recorded cardiac rhythm strips was conducted on April 3, 2025, at 3 p.m., with the RM.

The cardiac rhythm strip dated March 7, 2025, indicated, "...00:14 [12;14 a.m.]...New admit...SR 84..."

The recorded cardiac rhythm strip dated March 15, 2025, indicated, "...19:30 [7:30p.m.] SR 87..."

A concurrent interview and review of Patient 4's medical record was conducted on April 3, 2025, at 1:50 p.m., with the RM. The facility document titled, "Physician's orders," was reviewed. The RM stated there was no documented evidence in Patient 4's medical record that continuous cardiac monitoring was ordered.

2c. A tour of the Intensive Care Unit (ICU - unit that provides the critical care and life support for acutely ill and injured patients) was conducted on April 1, 2025, at 8:45 a.m., with the Director of Pharmacy (DOP). A concurrent observation and interview was conducted in the ICU nurse's station with the Monitor Technician (MT). The MT was observed monitoring multiple patients on a cardiac (heart ) monitor, including Patient 13. The MT stated Patient 13's cardiac rhythm had been normal.

A concurrent observation and interview was conducted on April 1, 2025, at 9:10 a.m., in Patient 13's room. Patient 13 was observed to be awake, alert, and verbally responsive, sitting in bed connected to a cardiac monitor. Patient 13 stated she has been attached to the cardiac monitor since she was admitted to this facility.

A review of Patient 13's record was conducted on April 2, 2025, at 3:05 p.m., with the RM.

A facility document titled, "Patient registration data," dated April 3, 2025, indicated, "Admit: 01/09/2025 [January 9, 2025]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE AND HYPOXIA..."

A facility document titled, "History and Physical," dated January 1, 2025, indicated Patient 13 was admitted to the facility with a diagnosis which include respiratory failure, pneumonia (infection of the lungs) and heart failure ( a condition where the heart does not pump enough blood in the body).

A concurrent interview and review of Patient 13's record was conducted on April 3, 2025, at 3:06 p.m., with the RM. The facility document titled,"Physician's orders," was reviewed. The RM stated there was no documented evidence in Patient 13's medical record that continuous cardiac monitoring was ordered by a physician.

An interview was conducted on April 7, 2025, at 8:35 a.m., with the Director of Nursing (DON) and Chief Operating Officer (COO). The DON stated nurses can start patients on continuous cardiac monitoring before calling the physician for an order because it's a noninvasive procedure. The COO stated there should be a physician's order for cardiac monitoring on admission or before starting a patient on continuous cardiac monitoring.

A review of the facility P&P titled, "CORE: Continuous Cardiac Monitoring (Telemetry)," dated June 2023, was conducted. The P&P indicated, "...Cardiac Monitoring...Is ordered by a physician..."

3a. A review of Patient 1's record was conducted on April 1, 2025, with the RM.

A facility document titled,"Patient registration data," reflecting, April 1, 2025, indicated, "Admit:12/10/2024 [December 10, 2024]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA..."

A facility document titled, "History and Physical," dated December 10, 2025, indicated, "...Past medical history...Hypertension, polycythemia vera [type of blood cancer]...Assessment...Acute hypoxic respiratory failure...COVID Coronavirus Disease [infection of the lungs] pneumonia [lung infection]...Plan...Patient is COVID positive..."

A concurrent interview and review of Patient 1's record was conducted on April 1, 2025, at 2:40 p.m., with the RM. A facility document titled,"Physician's orders, dated December 10, 2024, indicated, "...Telemetry cardiac monitoring...start 12/10/2024 [December 10, 2025] 18:10 [6:10 p.m.], stop after 3 days..." The RM stated the order did not indicate diagnosis and alarm parameters.

3b. A review of Patient 2's medical record was conducted on April 2, 2025, at 10 a.m., with the RM.

A facility document titled,"Patient registration data," reflecting, April 2, 2025, indicated, "Admit: 8/24/2024 [August 24, 2024]...Diagnosis: RESPIRATORY FAILURE, UNSP, W HYPOXIA OR HYPERCAPNIA..."

A facility document titled,"History and Physical," dated August 24, 2024, indicated, "...The patient...came to us from [Name of hospital]...for respiratory distress...sepsis [severe blood infection] pneumonia...PMH [primary medical history] dementia [a condition characterized by progressive or persistent loss of intellectual functioning] and stroke [a loss of blood flow to part of the brain, which damages brain tissue] with weakness in the legs...Heart failure..."

A concurrent interview and review of Patient 2's record was conducted on April 1, 2025, at 2:40 p.m., with the RM. A facility document titled, "Physician's orders,"dated August 25, 2024 indicated, "...Telemetry cardiac monitoring...start 08/25/2024 [August 25, 2024]...stop after 3 days...renewable..." The RM stated the order did not indicate diagnosis and alarm parameters.

3c. A tour of the ICU was conducted on April 1, 2025, at 8:45 a.m. with the DOP.

A concurrent observation and interview was conducted on April 1, 2025, at 9:30 a.m., in Patient 5's room with ICU Registered Nurse (ICURN 1). Patient 5 was observed to have a tracheostomy connected to a ventilator (a breathing machine) and a cardiac monitor. ICURN 1 stated Patient 5 needed to be on a continous cardiac monitoring due to his current diagnosis.

A review of Patient 5's medical record was conducted on April 3, 2025, at 2:28 p.m., with the RM.

A facility document titled,"Patient registration data," reflecting April 3, 2025, indicated, "Admit: 03/29/2025 [March 29, 2025]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA AND HYPERCAPNIA..."

A review of a facility document titled, "History and Physical," dated March 29, 2025, indicated, "...admitted with diagnosis of acute hypoxic respiratory failure, orally intubated, sepsis due to pneumonia and emphysema [a collection of pus that have collected inside a body cavity]...chronic heart failure..."

A concurrent interview and review of Patient 5's medical record was conducted on April 1, 2025, at 2:30 p.m., with the RM. An untitled facility document, dated December 10, 2024, indicated, "...Telemetry cardiac monitoring...start today 03/29/2025 [March 29, 2025], cont. [continuous], stop after 3 days, renewable..." The RM stated the order did not indicate diagnosis and alarm parameters.

3d. A concurrent observation and interview was conducted on April 1, 2025, at 9:35 a.m., in Patient 6's room with ICURN 1. Patient 6 was observed to have a tracheostomy connected to a ventilator and a cardiac monitor. ICURN 1 stated Patient 6 needed to be on a continuous cardiac monitoring due to her current diagnosis.

A review of Patient 6's medical record was conducted on April 3, 2025, with the RM.

A facility document titled, "Patient registration data," reflecting, April 3, 2025, indicated, "Admit: 03/28/2025 [March 28, 2025]...Diagnosis: PERFORATED INTESTINE(NONTRAUMATIC)..."

A review of a facility document titled, "History and Physical," dated March 29, 2025, indicated, "...admitted with diagnosis of large bowel obstruction with perforation...during hospital stay, patient had new code blue [emergency code indicating medical emergency] along with Afib [atrial fibrillation irregular heartbeat]. Patient was intubated, status post trach on a vent..."

A concurrent interview and review of Patient 6's record was conducted on April 3, 2025, at 2:38 p.m., with the RM. A facility document titled,"Physician's orders, dated December 10, 2024, indicated, "...Telemetry cardiac monitoring...start today 03/28/2025 [March 28, 2025], cont., stop after 3 days, renewable..." The RM stated the order did not indicate diagnosis and alarm parameters.

3e. A concurrent observation and interview was conducted on April 1, 2025, at 10:45 a.m., in Patient 15's room. Patient 15 was observed sitting in bed awake, alert, and verbally responsive. Patient 15 was observed to be connected to a cardiac monitor. Patient 15 stated she does not remember how long she has been connected to a monitor.

A review of Patient 15's record was conducted on April 3, 2025, with the RM. A facility document titled, "Patient registration data," reflecting, April 3, 2025, indicated, "Admit: 03/17/2025 [March 17, 2025]...Diagnosis:RESPIRATORY FAILURE, UNSP, W HYPOXIA OR HYPERCAPNIA..."

A review of a facility document titled,"History and Physical," dated March 29, 2025, indicated, "...admitted with diagnosis of acute hypoxic respiratory failure...history of stroke, CHF and Afib..."

A concurrent interview and review of Patient 15's record was conducted on April 3, 2025, at 3:16 p.m.,with the RM. A facility document titled, "Physician's orders, dated March 17, 2025, indicated, "...Telemetry cardiac monitoring...start today 03/17/2025 [March 17, 2025], cont., stop after 3 days, renewable..." The RM stated the order did not indicate diagnosis and alarm parameters.

A concurrent interview and review was conducted on April 3, 2025, at 3:31 p.m., at the Med (Medical) Surg (Surgical) Telemetry Unit Nurse's station with the Med Surg Telemetry RN (MSTRN 1). The facility's document titled, "Physician's order," was reviewed. The document indicated, "...Telemetry cardiac monitoring...start today 03/17/2025 [March 17, 2025], cont., stop after 3 days, renewable..." The MSTRN 1 stated diagnosis and alarm parameters were not included in the order. MSTRN 1 further stated, she does not know why Patient 15 is on a continuous cardiac monitoring and she assumes the alarm parameters are already set.

A concurrent interview and policy review was conducted on April 3, 2025, at 3:40 p.m., with the DON. The policy titled,"CORE: Continuous Cardiac Monitoring (Telemetry)," dated June 2023, was reviewed. The document indicated, "...Initiation and discontinuation of cardiac monitoring...By a Physician's order. All orders must state the diagnosis for which the cardiac monitoring is initiated and the alarm parameters...For electronic medical record orders...state the diagnosis...using the "special instructions" under the Telemetry order screen..." The DON stated diagnosis is in the H&P, and the alarm parameters are already set in the machine, so there is no need to write it on the order.

4a. A tour of the ICU was conducted on April 1, 2025, at 8:45 a.m., with the Director of Pharmacy (DOP).

A concurrent observation and interview was conducted on April 1, 2025, at 8:50 a.m., in the ICU nurse's station with the MT. The MT was observed analyzing and interpreting recorded cardiac rhythm strips. The MT stated, the recorded cardiac rhythm strips are printed, analyzed and interpreted by the MT once a shift, when there is an abnormal rhythm, or a change of condition. The MT further stated, once she has analyzed and interpreted the recorded cardiac rhythm strips, she will give it to the RNs for verification.

A review of Patient 1's medical record was conducted on April 1, 2025, with the RM. A facility document titled, "Patient registration data," reflecting, April 1, 2025, indicated, "Admit: 12/10/2024 [December 10, 2024]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA..."

A facility document titled, "History and Physical," dated December 10, 2025, was reviewed and indicated, "...Past medical history...Hypertension, polycythemia vera [type of blood cancer]...Assessment...Acute hypoxic respiratory failure...COVID [Coronavirus Disease infection of the lungs] pneumonia [lung infection]...Plan...Patient is COVID positive..."

A facility document titled, "Physician's orders," dated December 10, 2024, indicated, "...Telemetry cardiac monitoring...start 12/10/2024 [December 10, 2024] 18:10 [6:10 p.m.], stop after 3 days..."

A review of the facility's recorded cardiac rhythm strips was conducted on April 2, 2025, at 3:26 p.m. There was no documented evidence verification of the cardiac rhythm interpretation was conducted by an RN on the following shifts:

February 7, 2025, day shift (7 a.m. 7 p.m.) 8:15 a.m.;

February 6, 2025, night shift (7 p.m. 7 a.m.) 7:25 p.m.;

February 4, 2025, day shift 7:21 p.m.; and

February 3, 2025, day shift 7:31 a.m.

4b. A review of Patient 2's medical record was conducted on April 2, 2025, with the RM. A facility document titled, "Patient registration data," reflecting, April 2, 2025, indicated, "Admit: 8/24/2024 [August 24, 2024]...Diagnosis: RESPIRATORY FAILURE, UNSP, W HYPOXIA OR HYPERCAPNIA..."

A facility document titled, "History and Physical," dated August 24, 2024, indicated, "...patient...came to us from [Name of hospital]...for respiratory distress...sepsis [severe blood infection] pneumonia ...PMH [primary medical history] dementia [a condition characterized by progressive or persistent loss of intellectual functioning] and stroke [a loss of blood flow to part of the brain, which damages brain tissue] with weakness in the legs...Heart failure..."

A facility document titled, "Physician's orders," dated August 25, 2024, indicated, "...Telemetry cardiac monitoring...start 08/25/2024 [August 25, 2024]...stop after 3 days...renewable..."

A review of the facility's recorded cardiac rhythm strips was conducted on April 2, 2025, at 11:12 a.m. There was no documented evidence verification of the cardiac rhythm interpretation was conducted by an RN on the following shifts:

August 27, 2024, day shift (7 a.m. 7 p.m.) 7:32 a.m.;

August 27, 2024, night shift (7 p.m. 7 a.m.) 8:10 p.m.;

September 1, 2024, night shift 8:40 p.m.;

September 3, 2024, day shift 7:31 a.m.;

September 4, 2024, day shift 12:53 p.m.;

September 9, 2024, night shift 11:38 p.m.;

September 10, 2024, day shift 7:02 a.m.;

September 12, 2024, night shift 7:15 p.m.; and

September 15, 2024, day shift 8:34 a.m.

A facility document titled, "Code Blue Sheet," dated September 9, 2024, indicated, "...Time called: 23:40 [11:40 p.m.]...Summary of events Preceding Code/Precipitating Factors: Bradycardia [slow heart rate]...Cardiac Rhythm change...Initial signs of arrest...apnea [absence of breathing]...absence of pulse...unconsciousness...Initial rhythm..."

A facility document titled,"Code Blue Sheet," dated September 16, 2024, indicated,"...Time called: 7:32 a.m...Summary of events Preceding Code/Precipitating Factors: Cardiac Rhythm change...respiratory distress...Hypotension (low blood pressure)...Initial signs of arrest...absence of pulse...unconsciousness...Initial rhythm...PEA..."

4c. A review of Patient 8's medical record was conducted on April 3, 2025, with the RM. A facility document titled, "Patient registration data," reflecting, April 3, 2025, indicated, "Admit: 03/24/2025 [March 24, 2025]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE, UNSP, W HYPOXIA..."

A facility document titled, "History and Physical," dated August 24, 2024, indicated, "...Patient...came to us from [Name of hospital]...for altered level of consciousness...She was treated for desaturation of oxygen...Congestive heart failure...sepsis..."

A facility document titled, "Physician's orders," dated March 24, 2025, indicated, "...Telemetry cardiac monitoring...start 03/24/2025 [March 24, 2025], stop after 3 days...renewable..."

A review of the facility's recorded cardiac rhythm strips was conducted on April 2, 2025, at 8:40 a.m. There was no documented evidence verification of the cardiac rhythm interpretation was conducted by an RN on the following shifts:

March 29, 2025, day shift (7 a.m. 7 p.m.) 8: 31 a.m.;

March 30, 2025, day shift 8:09 a.m.

4d. A review of Patient 9's medical record was conducted on April 3, 2025, with the RM. The facility document titled, "Patient registration data," reflecting, April 3, 2025, was reviewed. The document indicated, "Admit: 03/14/2025 [March 14, 2025]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE, UNSP, W HYPOXIA OR HYPERCAPNIA..."

A facility document titled, "History and Physical, "dated March 14, 2025, indicated, "...Patient...came at the emergency department [Name of hospital] because of difficulty breathing, acute respiratory failure was intubated...past medical history CVA [cerebrovascular accident- refers to a stroke, which is an interruption of blood flow to the brain]...with right sided deficit..."

A facility document titled, "Physician's orders," dated March 14, 2025, indicated, "...Telemetry cardiac monitoring...start 03/14/2025 [March 14, 2025], stop after 3 days...renewable..."

A review of the facility's recorded cardiac rhythm strips was conducted on April 2, 2025, at 11:15 a.m. There was no documented evidence of the RN conducting cardiac rhythm interpretation on the following shifts:

- March 15, 2025, - night shift (7 p.m. - 7 a.m.)- 8:14 p.m.;

- March 17, 2025, - day shift (7 a.m.- 7 p.m.) - 12:44 pm;

- March 24, 2025, - night shift - 8:29 p.m.;

- March 29, 2025, - day shift - 7:14 a.m.; and

- March 30, 2025, - day shift - 8:18 a.m.

An interview was conducted on April 2, 2025, at 2:30 p.m., with the DON. The DON stated her expectation is the RNs should verify the MT's interpretation by signing the cardiac rhythm strip and it was not done for the abovementioned ca