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Based on observation, interview, record review, and policy review, the hospital failed to ensure that staff followed the cardiac (heart) monitoring and pulse oximetry (the percentage of oxygen in the bloodstream, a normal reading would be 95 to 100 percent) policies and procedures and provided consistent cardiac and pulse oximetry monitoring for one current patient (#16) and one discharged patient (#31) who was monitored by telemetry (remote observation of a person's heart rhythm and rate, using signals that are transmitted from the patient to a computer screen).

These deficient practices resulted in the hospital's non-compliance with the specific requirements found under 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census was 22.

The severity and cumulative effect of these practices had the potential to place all patients who required telemetry and monitored oxygen levels at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 08/05/20, the hospital provided an immediate action plan to remove the IJ when they implemented the following:
- An audit was immediately conducted of all current patients that required telemetry and monitored oxygen levels. Documentation compliance was validated and proper function of the central monitor system was visually confirmed.
- An audit process that validated continued compliance would be achieved.
- A process for all audits that would be sent to the State Agency for verification.
- A process that reported and documented audit results to the Quality Assurance and Performance Improvement (QAPI) Committee.
- The current procedure was reviewed with the Telemetry Tech and Charge Nurse that identified opportunities for improvement.
- The Telemetry and Pulse Oximetry policies and procedures were reviewed and revised.
- On-site education of the revised Telemetry and Pulse Oximetry policies and procedures was immediately initiated with all employees. Education would continue until 100% compliance was reached.
- A process for nursing documentation and compliance audits was developed for patients on telemetry and monitored oxygen levels. Documentation would occur every two hours and would indicate the patient's connectivity had been verified.
- A password-protected electronic lock was immediately placed on the central monitor system that could only be unlocked by the Director of Plant Operations and the Chief Executive Officer (CEO).
- A system was developed that ensured employee competencies were completed for all staff who were assigned as telemetry monitors prior to an assigned shift.

Refer to A-0395 for further details.

Based on observation, interview, record review, and policy review, the hospital failed to ensure that staff followed the cardiac (heart) monitoring and pulse oximetry (the percentage of oxygen in the bloodstream, a normal reading would be 95 to 100 percent) policies and procedures and provided consistent cardiac and pulse oximetry monitoring for one current patient (#16) and one discharged patient (#31) who was monitored by telemetry (remote observation of a person's heart rhythm and rate, using signals that are transmitted from the patient to a computer screen). The hospital also failed to consistently identify and implement interventions that prevented skin breakdown for one current patient (#3) out of two current patients reviewed that were identified as being at risk for skin breakdown which resulted in Patient #3 developing a hospital-acquired Stage 2 pressure injury (a shallow opening in the skin with red or pink tissue, or may present as a fluid filled blister) to the right buttock.

The lack of adequate evaluation and supervision of patient care and safety needs had the potential to affect all patients at the hospital in a negative way. The hospital census was 22.

Findings included:

1. Review of the hospital's policy titled, "Respiratory Care: Pulse Oximetry," reviewed 09/2013, showed the following:
- Pulse oximetry was used to determine the patient's blood oxygen saturation (oxygen saturation in the blood), by measuring the absorption of two selected wavelengths of light with a pulse oximeter (a machine that monitors the percentage of oxygen in the bloodstream, a normal reading would be 95 to 100 percent).
- Telemetry units would be used when both telemetry and continuous oximetry was ordered to assure safe monitoring at the monitor tech station.
- If a monitor was to be used continuously, alarms would be at 90% or as ordered by the physician.
- The monitor tech would be informed of the alarm settings and the alarm volume would be checked to ensure it was at an adequate level.
- Continuous monitors would be checked every four hours for proper function and saturation levels and recorded in the respiratory care notes or patient progress notes.

Review of the hospital's policy titled, "Telemetry: Cardiac Monitoring," reviewed 06/2010, showed the following:
- The purpose of telemetry was to provide safe monitoring of a patient's heart rhythm.
- The central monitoring nurses station would be programmed to record.
- Rhythm strips would be documented when cardiac monitoring began, every four hours, and when any dysrhythmias (abnormal heart beat) or changes in rhythm were noted.
- Rhythm strips with patient identification data would be printed at central monitoring every four hours while cardiac monitors were in place.

Review of the physician's orders and History and Physical (H&P) for discharged Patient #31, dated 02/14/20, showed an order for telemetry. Patient #31 was a 69-year-old female admitted to the hospital for acute hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system), due to a stroke (occurs if the flow of oxygen-rich blood cannot reach a portion of the brain), on mechanical ventilator (a machine that supports breathing) status post tracheostomy (an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs). Admitted for ventilator weaning.

Review of discharged Patient #31's medical record and hospital root cause analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) documents showed the following:
- On 02/26/20, Patient #31 was moved from room 101 to room 107.
- She was placed on a bedside monitor which showed the patient's heart rate/rhythm and oxygen saturation level.
- The monitor technician was notified that the patient was hooked up and ready to be admitted into the central monitoring system.
- The monitor technician that day was a Licensed Practical Nurse (LPN) who did not normally work as a monitor technician and was not familiar with the equipment.
- The monitor technician attempted to admit the patient and the patient information did not transfer, therefore, Patient #31's heart rate/rhythm and oxygen saturation level were not present or monitored at the telemetry monitoring station.
- The monitor technician did not notify anyone that Patient #31 was not being monitored at the desk.
- The last documented telemetry strip printed from the central monitoring station with heart rhythm and oxygen saturation level for patient #31 was dated 02/26/20 at 7:14 AM, while she was in room 101.
- No telemetry strips with the patient's heart rhythm and oxygen saturation levels were documented in the medical record according to hospital policy while Patient #31 was in room 107.
- On 02/27/20 at 11:38 AM, Patient #31 was found unresponsive, not breathing, grey in color, and her tracheostomy tube was completely removed from the stoma (hole in the windpipe) and lying in the patient's bed.
- A code was called and the patient was coded without success and time of death was called at 12:33 PM.
- On 02/28/20, an RCA was completed, and a tool was developed where the monitor technician and charge nurse documented the monitor number, patient name, date and time checked of every telemetry patient, at the beginning of every shift .

2. Review of the physician's orders and H&P for current Patient #16, dated 07/28/20, showed an order for telemetry. Patient #16 was a 69-year-old male admitted to the hospital for acute hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system), right sided pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart) and congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues).

Observation on 08/03/20 at 2:45 PM, showed that Patient #16 was lying in his bed. He had a cardiac telemetry box in his hospital gown pocket and the pulse oximetry probe was laying on the bedside table, detached from the patient's finger and telemetry box.

During an interview on 08/03/20 at 2:50 PM, Patient #16 stated that the pulse oximetry probe had been off of his finger since approximately 9:30 AM. He stated that staff removed the probe when he showered and never put it back on.

Observation and concurrent interview on 08/03/20 at 2:53 PM, showed the following:
- Staff C, Telemetry Technician, sat in front of the monitor technician station.
- Staff C was asked by the state surveyor to show Patient #16's oxygen saturation reading on the central monitor.
- Staff C stated that the reading did not show up on the monitor and she was unaware of this.
- Staff C stated that she did not know why the central monitor had not alarmed.
- After further investigation by Staff C, she found that the pulse oximetry alarm had been turned off for Patient #16.
- Staff C stated that the alarms should never be turned off and that was the reason the oxygen saturation monitor had not alarmed for Patient #16.
- Staff C stated that she printed and initialed the telemetry census sheet (document that shows every patient on the unit, room number, monitor number, code status, monitor technician initials, charge nurse initials) at the beginning of the shift.
- Staff C stated that the charge nurse should initial that the information was correct, ideally at the beginning of the shift, but that did not always get done until later because they were busy.

During an interview on 08/03/20 at 3:00 PM, Staff E, Registered Nurse (RN), stated the following:
- She was Patient #16's nurse and she was unaware that he did not have his oxygen saturation probe on his finger since 9:30 AM, and that he should have had it on.
- She did not check that every patient had his or her oxygen saturation probe hooked up properly.
- She remembered they had huddle discussions after the event that occurred on 02/27/20, when a patient died that was not monitored at the telemetry monitoring station, and that it was everyone's job to make sure patients were on telemetry, if ordered.

During an interview on 08/04/20 at 2:00 PM, Staff R, Chief Clinical Officer, stated the following:
- Since the 02/27/20 event and patient death occurred, an RCA was completed and a self-report was sent to the state agency.
- The hospital developed a process where the monitor technician updated a document at the beginning of each shift of all patients on telemetry and had it signed off by the charge nurse.
- The signed sheets had gone to the nurse manager, who no longer worked at the hospital, and Staff R stated she had not looked at them to make sure the process continued to be done correctly and consistently.
- She had not done any audits on the process.
- She was not aware that alarms could be turned off at the telemetry monitoring station and alarms should never be turned off.

During an interview on 08/05/20 at 12:05 PM, Staff B, Chief Executive Officer (CEO), stated the following:
- When telemetry was ordered by a physician, the order included both cardiac and pulse oximetry monitoring.
- If a physician did not want pulse oximetry monitored, a specific order would be written.
- Her expectation of staff was to have oxygen saturation probes and cardiac monitors on patients as ordered and no alarms silenced.
- She had not completed a review of the 02/28/20 RCA until 08/03/20, and she did not realize that it primarily focused on why the event occurred and not on staff training and prevention.
- She should have verified that the RCA was adequate and that education and training was conducted; however, she had not done so.

3. Review of the hospital's policy titled, "Pressure Ulcer (injury to the skin and/or underlying tissue, usually over a bony area) Prevention Strategies," reviewed 06/2015, showed the following:
- A Braden Scale Risk Assessment tool (an assessment tool for predicting the risk of pressure sores)was used to assess the level of risk for the development of pressure ulcers. A score of 18 or lower was considered to be at risk.
- Patients should be repositioned at least every 2 hours, even while on special beds, and documentation would be maintained in the medical record.
- A comprehensive skin and wound assessment would be completed for all patients on admission as well as an ongoing daily basis using the Braden Scale skin assessment.
- Patients who had been identified as at-risk for skin breakdown or who had an existing wound would have a comprehensive care plan developed and updated as indicated.

Review of the H&P for current Patient #3, dated 07/18/20, showed the patient was a 67-year-old male admitted for acute respiratory failure that needed weaned from mechanical ventilation (assistance with breathing by mechanical means) and a tracheostomy. He was also admitted with malnutrition and required continued enteral nutrition (tube feeding) therapy.

Review of the admission assessment for Patient #3, dated 07/18/20, showed that the patient had no pressure injuries on admission.

Review of the skin assessments for Patient #3, dated 07/18/20 and 08/04/20, showed Braden Scale scores of 14 and 13 respectively, both which indicated that the patient was at-risk for skin breakdown.

Review of the physician orders for Patient #3, showed that on 07/22/20, an order was placed for skin breakdown prevention, which included the patient be turned and repositioned every two hours and his heels floated. On 07/24/20, an order was placed for calcium alginate (a highly absorbent wound dressing) to be applied to the patient's Stage 2 pressure injury of the right buttock.

Review of the care plans for Patient #3 showed that on 08/04/20, no comprehensive care plan had been developed to address his risk for skin breakdown.

Review of the activity flow sheet for Patient #3 on 08/04/20, showed the following:
- 07/19/20, no documented turns for 7 hours;
- 07/20/20, no documented turns for 8 hours;
- 07/21/20, no documented turns for 5 hours;
- 07/22/20, no documented turnsfor 8 hours;
- 07/23/20, no documented turns for 8 hours;
- 07/24/20, no documented turns for 8 hours; and
- 07/26/20, no documented turns for 6 hours.

Observations on 08/04/20 at 10:00 AM and 1:00 PM, and on 08/05/20 at 9:40 AM and 12:30 PM, showed Patient #3 lied on his back in bed and his heels were not floated.

During an interview on 08/04/20 at 11:00 AM, Staff L, LPN and Wound Nurse, stated the following:
- The wound care team should see every patient within 48-hours of admission.
- Patient #3 was first seen by the wound care team on 07/22/20, four days after admission.
- The wound care team had a delay with Patient #3's assessment because he had been admitted on a Saturday.
- He was placed on skin breakdown prevention orders once the wound care team assessed him.
- He developed an open wound on his right buttock that she considered to have been avoidable.
- There was an uptick in hospital acquired pressure injuries in July.
- Skin concerns should be addressed swiftly by nursing staff, but sometimes they just waited for the wound care team.
- Heels should be floated with pillows or wedge cushions.

During an interview on 08/05/20 at 11:30 AM, Staff U, RN, stated the following:
- Everyone on the long-term acute care (LTAC) side gets consulted by the wound care team within 48-hours of admission.
- There were six hospital acquired pressure injuries in July, which she believed was higher than normal for them.
- Previous data on hospital acquired pressure injuries were undetermined as the person that was previously responsible for this information was no longer employed and the data could not be located.
- She was working to build a quality assurance process around wound management and tracking.
- Nursing assessments were not always completed accurately and timely.
- A care plan should always be developed when a patient was identified as at-risk for skin breakdown.
- Patients identified as at-risk for skin breakdown should always be turned and repositioned at least every two hours.
- Documentation for patients that were turned and repositioned should have occurred in the activity flow sheet; however, they did not have a good audit system in place.

During an interview on 08/05/20 at 12:05 PM, Staff B, CEO, stated the following:
- In July, the number of hospital acquired pressure injuries increased from previous months.
- They utilized a contracted wound company, Wound Care Plus, for some of their wound care needs.
- She noted a disconnect between their in-house wound care team and the contracted wound team, which had caused confusion.
- Nursing staff relied too heavily on the wound care teams for the care and treatment of skin issues.
- She had considered termination of the contracted wound care support in favor of complete in-house care for skin management.
- She expected staff would document consistently in the medical record when patients were turned and repositioned.