HCA Florida Citrus Hospital

Based on interview, review of medical records, policy and procedure, and the Board of Trustee Minutes, the hospital failed to maintain and demonstrate an affective functioning Governing Body to ensure all patients were free from neglect, and were provided nursing services as ordered by the physician.

1. The hospital's Governing Body failed to ensure cardiopulmonary resuscitation (CPR) was initiated per the hospital policy and standard of care. The Governing Body failed to ensure staff understanding the expectations about the implementation of CPR. The hospital's Governing Body failed to fully develop and initiate a plan of correction to ensure patients' rights were honored and CPR was initiated when a patient was found unresponsive and absent of vital signs.

2. The hospital's Governing Body failure to ensure physicians' orders were followed for Cardiac Telemetry for patients who are at risk of fatal arrhythmias. Without proper monitoring this could result in a delay in treatment and possibly death. These systemic failures constitute an immediate jeopardy situation. Refer to A129 - Patient Rights, A145 - Patient Rights - Free from neglect, A283 - Quality Assessment and Program Improvement, and A385 - Nursing Services.

On 08/17/2019 at 4:55 p.m., the Administrator was informed of the ongoing IJ situation which began on 06/09/2019.

Based on interviews, observations, policy and procedure, and medical record reviews, the hospital failed to prevent the neglect of 1 of 6 sampled patients, Patient #1. The nursing staff failed to initiate cardiopulmonary resuscitation (CPR) for Patient #1, who had a full code status with wishes to be resuscitated, when found unresponsive and absent of vital signs. These systemic failures constitute an immediate jeopardy situation. Refer to A129 - Patient Rights and A145 - Patient Rights - Free from neglect.

On 08/17/2019 at 4:55 p.m., the Administrator was informed of the IJ situation which began on 06/09/2019.

Based on interviews, policy and procedure, and medical record reviews, the hospital failed to ensure cardiopulmonary resuscitation (CPR) was initiated for a patient (Patient #1) when found unresponsive and absent of vital signs. The patient did not survive. Ongoing failure to follow physicians' orders for Cardiac monitoring to ensure patients with the possibility of suffering a fatal cardiac arrhythmia which could result in delay of treatment and possibly death, (Patients #2, #3, and #4). The QA program failed to prevent neglect and ensure safety of patients. These systemic failures constitute an immediate jeopardy situation. Refer to A129 - Patient Rights, A145 - Patient Rights - Free from neglect, A283 - Quality Assessment and Improvement Program, and A385 - Nursing Services.

On 08/17/2019 at 4:55 p.m., the Administrator was informed of the ongoing IJ situation which began on 06/09/2019. The cumulative deficits place the patients at risk for not having their needs met resulting in the Condition of Participation being out of compliance.

Based on interviews, medical record review, and policy and procedure review the facility failed to ensure the patient needs were met for initiating cardiopulmonary resuscitation (CPR) when a patient was found unresponsive and absent of vital signs. The patient had a full code status, and did not survive, Patient #1. The facility failed to follow physicians' orders for cardiac monitoring for 1 of 4 patients, Patient #1, #2, #3, and #4, Patient #1 did not survive. These multiple systemic failures constitute an ongoing immediate jeopardy situation. Refer to A392, Staff and Delivery of Care.

On 08/17/2019 at 4:55 p.m., the Administrator was informed of the ongoing IJ situation which began 06/09/2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, medical record review, observations, and policy and procedure review the facility failed to ensure patients' needs were met for not initiating cardiopulmonary resuscitation (CPR) when a patient was found unresponsive, absent of vital signs, and had a full code status for 1 of 3 sampled patients, Patient #1. The facility failed to ensure patients' needs were met, and to follow the physicians' orders for continuous telemetry cardiac monitoring for 4 of 6 patients, Patients #1, #2, #3, and #4. Patient #1 did not survive. Additionally, the facility's failure to initiate the Telemetry alert for patients to be checked and or evaluated when the cardiac leads have been identified to be off the patient greater than 5 minutes.

The findings included:

1. Medical record review for Patient #1 the patient revealed admission on 05/15/2019. Diagnosis during admission included Acute Kidney Injury, Elevated Cardiac Enzymes, Cardiac Arrythmias (irregular heart beat), Fluid Retention, Hypertension, Right Iliac Artery Aneurysm (arteries that branch off of the abdominal aorta in the pelvic area) repair dated 05/31/2019, Peripheral Edema (accumulation of fluid causing swelling), and Rhabdomyolysis (death of muscle fibers that release their contents into the bloodstream).

Review of the physician's orders dated 05/15/2019 revealed Medical Telemetry Medical Surgical monitored. Advance directives: Full Code Status.

Review of the Electrocardiogram reveal: Sinus rhythm (normal heart beat) with a first degree atrioventricular block (greater than 0.20 seconds on electrocardiography), right bundle branch block (a delay or blockage of the electrical impulses to the right side of the bottom chambers of the heart), marked T wave abnormality (disease entity of the heart).

Review of the nursing progress notes dated 06/09/2019 revealed expiration at 5:47 a.m., called/pronounced deceased .

During an interview on 08/15/2019 at 10:29 a.m. the Director of Patient Safety, (DPS) stated, the nursing supervisor, Staff Q, RN (Registered Nurse) informed me Patient #1 had been pronounced dead on 06/09/2019 with no CPR initiated and he was a full code. In review of the telemetry monitoring strips for Patient #1, it was conducted immediately on 06/09/2019, it was found there was no monitoring during this period, there were no strips to provide a strip reading because he was not on the monitor, it was indicated the patient had been off of telemetry starting at 5:26 a.m. A telephone call was placed to the floor at 5:26 a.m. to the patient care technician to check the leads. The Monitor Technician (MT) turned away from the monitors to another set of monitors that were alarming and noted at 5:45 a.m. Patient #1 was still off of the monitor. She contacted the patient's primary nurse and after that a Rapid Response was called. When interviewing the primary care nurse, she stated she called a Rapid Response instead of a Code Blue, she knew she should have initiated a Code Blue, but Staff O, RN CCU (Cardiac Care Unit)/Rapid Response Team Leader responded almost immediately as Staff O was on the same floor as Patient #1. Staff O, RN stated the patient was dead and she thought resuscitation would be futile. The primary care nurse stated I have never been in a code, I just trusted the CCU nurse when I called the Rapid Response. Documentation was requested related to the cardiac monitoring for Patient #1 for cardiac strips for 6/9/19 from 5:26 a.m. to 5:45 a.m. The DPS stated, there is no documentation to provide, Patient #1 was completely off the monitor.

During a telephone interview on 08/15/2019 at 2:33 p.m. Staff O, RN she stated, I have worked at the hospital a long time and I am the Critical Care Unit Night Charge Nurse. As the Critical Care Nurse, I am the team leader of any rapid responses that is called. This is to ensure the patients are rapidly assessed by a more seasoned critical care nurse that has the critical thinking skills to rapidly assess the patient and get them the level of care that they require. The Rapid Response team is the Critical Care charge nurse, respiratory therapists, the bedside nurse, the charge nurse from the unit the patient is on, and the nursing supervisor on nights. The goal is to stabilize the patient and prevent further deterioration in the patient's condition. We have protocols. If we get to a rapid response and note that the patient is asystolic (without heart beat) or apneic (without respirations) we initiate a code blue and then the emergency room physician will respond. I did respond to the rapid response for Patient #1 on 06/09/2019 at 05:45 AM, when I entered the room the patient had some mottling in his lower legs, his pupils were fixed and dilated, he had no pulse and no spontaneous respirations. I did not call because I knew he was gone for 20 minutes or more based on his mottling on his legs. I knew he was gone. I knew it was futile. I should have called a code blue but given his condition I just knew it was futile. He did not have rigor mortis, but his skin temperature was cool and then I found out that he had been with no rhythm for 20 minutes and I did not call a code. I knew he was a full code. In hindsight, I should have called the code blue, started CPR and let the emergency room Physician determine the next steps. I know that I did not follow the hospital policy to call a code blue I just knew he was dead, and it was futile. I knew the patient was a full code, but he was in such bad shape. I did the wrong thing, I know that. My role in codes is to respond to them and act as team leader until the ER (emergency room ) physician gets to the bedside. Once the physician arrives, he is the team leader and directs the staff in what to do. I cannot pronounce without a physician present. I don't call the patient deceased , the physician does.

During an interview on 08/15/2019 at 5:45 PM the Chief Medical Officer stated, No patient should be off telemetry indefinitely without the physician being notified and a resolution being found. Whether that resolution is to discontinue the order for telemetry or another intervention. I was not aware of this and honestly, I don't really think that anyone knew it was happening until today. It wasn't something that anyone has brought out during this process. I'm not sure if the monitor technicians have been included in brainstorming barriers in telemetry monitoring. They may have told us the barriers such as this well before you discovered this. We should have been auditing, we could have prevented all of this.

During an interview on 08/18/2019 at 6:13 PM the Administrative Nursing Supervisor stated, I was the Supervisor on 06/09/2019 when Patient #1 expired. I was busy when the Rapid Response was called. I wasn't able to respond immediately. I arrived about five minutes later. I was not aware the patient had been a full code, if I had I would have started the code and allowed the ER Physician to determine when to terminate resuscitation efforts. My role in a Rapid Response is to assist if needed. The CCU Nurse is the team leader. If a staff calls a Rapid Response and we arrive to find that it should be a Code Blue, we initiate a code. I did not make the determination to not start CPR. I trust that the CCU nurses understand their role and responsibilities in providing care to patients that are a full code. It is our responsibility to perform CPR until the ER Physician arrives, and he will stop efforts if he determines efforts are futile. The patient did not have any indications of rigor mortis that I am aware of. Honestly, I had no idea he was a full code.

2. Medical record review for Patient #2 revealed the patient was admitted on [DATE]. Diagnosis during admission included: Acute [DIAGNOSES REDACTED], Chronic Respiratory Failure, Pulmonary Emboli, Deep Vein Thrombosis, Obstructive Sleep Apnea, Severe [DIAGNOSES REDACTED] status post valvuloplasty, Hypertension, [DIAGNOSES REDACTED], and Atrial Fibrillation. The patient had a full code status.

During an observation on 08/15/2019 at 10:56 AM with the Registered Nurse (RN)/Director of the Centralized Cardiac Monitoring Station, Patient #2's cardiac telemetry monitoring screen showed a flat line, monitor in standby mode.

During an interview on 08/15/2019 at 10:56 AM when this surveyor asked Staff E, Monitor Technician (MT) why the patient was on standby, she stated that the patient had been in Nuclear Medicine having a HIDA (Hepatobiliary Iminodiacetic Acid) Scan and was off of cardiac monitoring. She had called the unit five minutes ago and he was back on the floor but would be returning to X-ray. At 11:04 AM the MT confirmed the patient was back from nuclear medicine. She spoke to the nurse who verified the patient was present in his room and the MT then requested to have the patient be placed back on the cardiac monitor. At 11:05 AM the Cardiac Rhythm was then observed on the telemetry screen.

During an Interview on 08/15/2015 at 11:08 AM with the Staff A, RN, Director, she stated, I don't know if they are able to receive the telemetry signal in Nuclear Medicine. I'm not sure if Patient #2 has an order to be off telemetry for anything. We do need orders for a patient to be off telemetry for showers or testing.

During an interview on 08/15/2019 at 3:55 PM Staff R, RN stated, I was the person who placed Patient #2 back on the monitor at about 11:05 AM after receiving a call from the Telemetry Technician. I had to replace the green lead, that is why it was not showing up on the monitor. The other leads were on and the telemetry box was on the patient. I can't remember exactly what time he got back here, I wasn't near the desk.

Review of the Transport Log for PCU (Progressive Care Unit) revealed there was no entry for the date and time Patient #2 was transported to Nuclear Medicine or when he returned to the floor.

Review of the Patients Ticket to ride had no time of when the patient left the unit and no time of the patient's returned to the unit documented.

Review of the Transport Log for Patient #2 revealed The Transport Job request was requested on 08/15/2019 at 06:35 AM by Nuclear Medicine. On 08/15/2019 at 07:10 AM the transport job was assigned to the Transporter at 07:10 AM the transport job was accepted by the Transporter at 07:31 AM. The transport job was started by the Transporter at 7:37 AM on 08/15/2019 the transport job was completed.

Review of the Nursing Documentation on 08/15/2019 at 10:07 AM revealed a nursing assessment was completed by the RN and vital signs were documented at 10:08 AM. At 10:38 AM the patient was examined by the physician.

During an interview on 08/17/2019 at 09:15 AM the Director of Diagnostic Imaging stated, We are capable of monitoring patients while they are in Nuclear Medicine. We wanted to make sure we could do this to determine if that was why Patient #2 was not seen by the monitor technicians. We verified yesterday, with another patient, to make sure it was not part of the problem for Patient #2. We verified patients are visible for telemetry within Nuclear Medicine for cardiac monitoring. Patient #2 was transported to Nuclear Medicine beginning at 7:31 AM when he was picked up from his room. He entered the Department at 7:37 AM. He was transported back to his room at 10:07 AM by the Nuclear Technician. It is my understanding Patient #2 was not on cardiac monitoring during this time. The Director of Diagnostic stated he had not been involved in the plan of correction as this is not his department. It was not an identifiable concern in my department. I only found out yesterday and got involved yesterday evening to determine if patients are able to be viewed on monitor while in this area.

During an interview on 08/17/2019 at 9:25 AM Staff A, RN (Registered Nurse)/Director CCU (Cardiac Care Unit) stated, Patient #2 was going to nuclear medicine and he was not on cardiac telemetry starting at 7:10 AM. The Transport Log was reviewed regarding the entry made by the Transporter. The RN/Director CCU verified the transport log indicated the transport job was assigned to the Transporter at 7:10 AM, and the transport log indicated the transport job started at 7:31 AM, and the patient arrived in Nuclear Medicine at 07:37 AM on 08/15/2019. She

verified the nursing documentation indicated the Patient had arrived back to his room at 10:07 AM and the Telemetry Technician was not notified as per the hospital policy. She verified the patient was not placed back on the monitor until it was requested by the monitor technician during the surveyor interview with the technician. Patients are able to be monitored while they are in Nuclear Medicine. We verified that yesterday. I probably would have discovered that our nurses were not following physicians' orders for cardiac monitoring if I had done daily audits. I might have realized this before today and as an organization we would have fixed it. I see the pattern you are showing me, it's another problem we have that we didn't know about but should have if we had been doing audits.

Review of the cardiac monitoring history record for Patient #2 revealed at 7:00 AM the patient was on cardiac telemetry, at 7:10 AM the patient was off of cardiac telemetry. The record revealed the patient remained off of cardiac monitoring until 11:05 AM, (4 hours). Patient had a full code status. There was no indication that a telemetry alert was called to check on the patient since the patient had been off the telemetry monitor for greater than 5 minutes as stated in the facility's policy.

3. Review of the medical record for Patient #3 revealed the patient was admitted to the facility on [DATE]. Diagnosis included: Acute Pancreatitis, Hypokalemia, Hyponatremia, [DIAGNOSES REDACTED], Syndrome of Inappropriate Diuretic Hormone (SIADH), Hypertension, and [DIAGNOSES REDACTED]. Patient had a Full Code Status.

During an observation conducted on 08/15/2019 at 11:10 AM with Staff A, Director of the Centralized Cardiac Monitoring Station. Patient #3 was observed to have a flat line and the screen showed stand by.

During an interview on 08/15/2019 at 11:10 AM Staff B, MT stated, Patient #3 is off the telemetry monitor because she is confused and pulling off her leads. The nurse is aware.

An observation was conducted on 08/15/2019 at 4:11 PM during a tour of the monitor telemetry room. In attendance was the Chief Medical Officer, the Director of CCU/ PCU and the Monitor Technicians. Patient #3 was observed to have a flat line and showed stand by. The Director of Patient Safety entered the area and verified Patient #3 was observed off the monitor. Staff B, Monitor Technician stated, Patient #3 has been off the telemetry cardiac monitoring since at least 8:00 PM last night. She stated the patient did have an order for cardiac telemetry and verified that there was not an order to discontinue the Cardiac Monitoring.

Review of the Patient #3's cardiac monitoring history with Staff B, MT revealed the last time the patient was on cardiac telemetry was on 08/13/2019 at 8:00 PM. A review of the Daily Rate and Rhythms logs indicated Patient #3 was placed on Cardiac Telemetry at 5:35 PM on 08/10/2019 and continued on telemetry until approximately 2:00 AM on 08/10/2019. Starting at 04:00 AM on 08/11/2019 until 08/13/2019 at 2:00 PM she was documented on the telemetry logs as confused and was not being monitored. Starting at 10:00 PM on 08/13/2019 until 4:00 PM on 08/15/2019 the log documented confused with no telemetry monitoring occurring. There was no indication that a telemetry alert was called to check on the patient since the patient had been off the telemetry monitor for greater than 5 minutes as stated in the facility's policy.

During an interview on 08/15/2019 at 4:11 PM Staff, B MT stated, Patient #3 has been off the cardiac monitor since at least 8:00 PM last night. She pulled up the patient's telemetry screen and found that the patient had been off the cardiac monitor for over 24 hours. It is documented the nurse said she was confused and pulling the monitor off. I don't know if she has an order to be discontinued from telemetry, but I can look. The MT pulled up the patient's and verified that the patient had orders for telemetry monitoring that started on 08/10/2019. She verified there was no order to discontinue the telemetry. Review of Patient #3's telemetry documentation at 4:25 PM dated 08/15/2019 starting at 7:00 AM every two hours the MT documented confused with no telemetry. The MT stated, I did not call the nurse today because I got in report that the nurse okayed her to be off the monitor. I should have called and confirmed that. I document every time I call the nurses for any changes in the patient's rhythms and document if they are off the monitor and who I called. I only call the nurse and if I can't get the nurse, I call the Charge Nurse. If I can't get them, I will call a telemetry alert. The Medical Director, the Patient Safety Officer, Staff A, CCU/Monitor Tech Director re-entered the area and confirmed there was no visible ECG (Electrocardiograph) tracing, that the documentation on the Rates and Rhythm logs indicated confused, and the telemetry event log had no entry related to Patient #3. It was also confirmed there was an order present in the chart for telemetry monitoring and there was no order to discontinue monitoring. A review of the Telemetry Event log did not indicate that the Monitor Technician called the Nurse or that there were any alerts called for Patient #3.

During an interview on 08/15/2019 at 4:48 PM Staff G, RN stated, I am the nurse who is taking care of Patient #3. She refused the telemetry monitor today, she says she doesn't need it. I got in report she has been refusing to wear it. I did not call the doctor to let him know, I thought he already knew. He has not been in yet to see the patient or I haven't seen him in here to see her. I did not get an order to discontinue the telemetry, and no one from telemetry has called me to ask why she was not on the monitor today. I do think I should have called and gotten the order to discontinue the monitoring before now. I know the Monitor Technicians will call me or a telemetry alert if the patient is off the monitor for longer than five minutes. The telemetry technician did not call any telemetry alerts on the patient today. I think I probably should have called the doctor, but I really thought he knew. There is no nurse's note that states the doctor was notified. I really never thought to look until we looked at it when you asked to see it.

During an interview on 08/15/2019 at 5:05 PM Staff S, Registered Nurse/Charge Nurse stated, The only note in Patient #3's chart indicating the patient was confused and pulling off telemetry is on 08/10/2019 at 11:50 PM by nursing. It does not state that the physician was notified. She acknowledged the physician's notes for 08/11/2019 -08/14/2019 does not indicate he was aware the patient was removing her telemetry and was not on cardiac monitoring per the physician's order. There were no nurses' notes indicating the physician was called and notified that the patient was off the monitor. We should have documented that the doctor was notified and any recommendations. We should have requested an order to discontinue telemetry or have the physician give us alternatives to making sure the telemetry was on. Patient #3 wore the telemetry rarely. I have not received any calls today from the telemetry technicians about her being off the monitor. She is very confused and always pulling the telemetry off, and we should have done a nursing note to indicate that.

4. Review of Patient #4's medical record revealed the patient was admitted on [DATE]. Diagnosis during admission included: Cervical Cancer with lung metastasis and frontal area of the brain, Metabolic [DIAGNOSES REDACTED], Hypercalcemia, Acute Pre-renal Azotemia, Chronic Malnutrition, Hypokalemia.

Review of the physician's orders revealed Full Code status and an order for cardiac monitoring.

On observation on 08/15/2019 at 4:30 PM showed a flat line for Patient #4.

During an interview on 08/15/2019 at 4:30 PM Staff B, MT stated, Patient #4 is not on cardiac telemetry. She is going to be a hospice patient. Staff B, MT reviewed the physician's orders and verified the patient had an order to be on cardiac monitoring, the patient was a Full Code, and there were no orders from Hospice. When Staff B was asked the last telemetry time for the patient she stated, The patient had been off the telemetry monitor since 1:48 PM until 4:30 PM on 08/15/2019.

During an interview on 08/15/2019 at 05:30 PM Staff H, RN stated, Patient #4 had been off the telemetry for several hours, I can't be sure exactly when. The patient is trying to decide if she wants to be a Do Not Resuscitate. I probably should have gotten an order from the physician to discontinue the monitoring.

Review of the Performance Management Plan Position: RN revealed under Decision Making: Identifies issues, problems and opportunities - Recognizes issues, problems or opportunities and determines whether action is needed. Gathers information - identifies the need for and collects information to better understand issues, problems and opportunities. Chooses appropriate action - Formulates clear decision criteria; evaluates options by considering implications and consequences; chooses an effective option. Commits to action - Implements decisions or initiates action within a reasonable time. Quality - Provision of Care: Ensures patient's physical, emotional and rehabilitation needs are met. Accurately documents the administration of care in the patient record in a timely manner. Coordinate the patient's care and identified needs with other services and departments throughout the hospital. Physician Communication & Coordination: Receives, interprets and implements physician orders accurately and in a courteous manner.

Review of the policy titled, Advance Directives with an Effective Date of 10/30/15 and a review date of 11/22/2017 revealed: Purpose: 2. To provide guidelines for implementation of patient rights regarding Advance Directives. Policy: 1. When patient designates advanced directive, Citrus Memorial Hospital honors the same in accordance with law and regulation, and the hospital's capabilities.

Review of the policy titled, Cardiac Telemetry Monitoring: Reference Number: WFD.PC.023, Approval date: 02/25/2019 Definitions: Telemetry alert- an alert that is initiated from the personnel in the monitoring station for immediate care team response to check on the patient whose cardiac monitoring can be visualized but may be in poor quality or at risk of losing visualization but may be in poor quality or at risk of losing visualization (low battery, lead off, etc.) The individuals to respond to the alert are the members of the care team for the location called in the alert. Policy: E. Personnel in the role of monitor technicians will be responsible for monitoring cardiac telemetry, running documentation strips, and communicating to the nurse changes in patient's rhythm and when patients are off monitor. F. If the patient rhythm is still transmitting to the central station but the monitor indicates battery low or lead off the monitoring technician must notify the nurse. If there is no response, the situation is not responded to or if it is not resolved in 5 minutes a telemetry Alert will be called. G. If the patient rhythm is not transmitting to the central Station the monitoring personnel will call for immediate resolution by calling a Rapid Response to the patient room and bed. II. Monitor Technician Responsibilities: E. Sudden loss of monitoring for a patient: The monitor technician should call a Rapid Response to the room/bed location of the patient. 2. The monitor technician will record the notification on the telemetry Event Log. H. Documentation: 1. The Monitor Technician will maintain a daily event log to record telemetry events, calls placed to the care team, and alerts or codes initiated from the monitoring station. III. Nursing Responsibilities: Telemetry verification is conducted as part of the cardiac assessment. Verification of monitoring, timely patient assessment and intervention based on identified abnormal cardiac rhythms, and documentation regarding patient's rhythm and any changes in cardiac rhythm. IV. Transporting patients with cardiac telemetry monitoring: A. All patients transported between departments will be provided the same level of care during the transport. When a monitored patient is transported off the nursing unit the procedure below ensures continual cardiac monitoring. 1. The monitor technician is notified when a patient leaves the nursing unit. 2. The telemetry monitoring device may not be removed without a physician order. 3. The monitor technician is notified when the patient returns to the nursing unit. B. B. Transporting patients with telemetry suspended: 1. A physician order must be present to remove patient from telemetry. 2. Monitor Technician should be notified that the patient is being transported off the telemetry. The box should be kept the nurse's station 3. The alarms should be placed on suspend or stand by mode until the patient has returned 4. A transporter may not remove the telemetry box. Nursing personnel will remove and reapply the telemetry box. Nursing will verify with the telemetry technician. V. Discontinuing Telemetry: telemetry may be discontinued - A. Only when there is a physician's order to discontinue telemetry, or when a discharge order has been received. The facility failed to ensure that their policy and procedure was followed as evidenced by the personnel in the telemetry monitoring station failing to initiate a telemetry alert for the immediate care team response team members to check on/evaluate patient #1 when it was determined the patient's leads were off at 5:25 a.m. to 5:45 a.m., 20 minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, medical record reviews, observations, and plan of correction review the facility failed to ensure an effective and acceptable plan of correction was developed or fully implemented, and failed to measure the success, track the performance, to ensure the actions taken were sustained for a patient who was ordered cardiac monitoring and was not being monitored, found unresponsive and absent of vital signs, with a full code status, who did not have cardiopulmonary resuscitation initiated, the patient did not survive for 1 of 3 sampled patients, Patient #1. The ongoing failure of the quality program to collect data to identify opportunities for improvement and changes to affect improvement in health outcomes, patient safety, and quality for cardiac monitoring resulting in possible serious injury for 4 of 6 sampled patients, Patients #1, #2, #3, and #4.

The findings included;

1. Medical record review for Patient #1 revealed the patient was admitted on [DATE]. Diagnosis during admission to include Acute Kidney injury, Elevated Cardiac Enzymes, Cardiac Arrythmias (irregular heart beat), Fluid Retention, Hypertension, Right Iliac Artery Aneurysm (arteries that branch off of the abdominal aorta in the pelvic area) repair dated 05/31/2019, Peripheral Edema (accumulation of fluid causing swelling), and Rhabdomyolysis (death of muscle fibers that release their contents into the bloodstream).

Review of the physician's orders dated 05/15/2019 revealed Medical Telemetry Medical Surgical monitored. Advance directives: Full Code Status.

Review of the Electrocardiogram reveal: Sinus rhythm (normal heart beat) with a first degree atrioventricular block (greater than 0.20 seconds on electrocardiography), right bundle branch block (a delay or blockage of the electrical impulses to the right side of the bottom chambers of the heart), marked T wave abnormality (disease entity of the heart).

Review of the nursing progress notes dated 06/09/2019 revealed expiration at 5:47 a.m., called deceased .

During an interview on 08/15/2019 at 10:29 a.m. the Director of Patient Safety, (DPS) stated, the nursing supervisor, Staff Q, RN (Registered Nurse) informed me Patient #1 had been pronounced dead on 06/09/2019 with no CPR initiated and he was a full code. In review of the telemetry monitoring strips for Patient #1, it was conducted immediately on 06/09/2019, it was found there was no monitoring during this period, there were no strips to provide a strip reading because he was not on the monitor, it was indicated the patient had been off of telemetry starting at 5:26 a.m. A telephone call was placed to the floor at 5:26 a.m. to the patient care technician to check the leads. The Monitor Technician (MT) turned away from the monitors to another set of monitors that were alarming and noted at 5:45 a.m. Patient #1 was still off of the monitor. She contacted the patient's primary nurse and after that a Rapid Response was called. When interviewing the primary care nurse, she stated she called a Rapid Response instead of a Code Blue, she knew she should have initiated a Code Blue, but Staff O, RN CCU (Cardiac Care Unit)/Rapid Response Team Leader responded almost immediately as Staff O was on the same floor as Patient #1. Staff O, RN stated the patient was dead and she thought resuscitation would be futile. The primary care nurse stated I have never been in a code, I just trusted the CCU nurse when I called the Rapid Response. Documentation was requested related to the cardiac monitoring for Patient #1 for cardiac strips for 6/9/19 from 5:26 a.m. to 5:45 a.m. The DPS stated, there is no documentation to provide, Patient #1 was completely off the monitor.

During a telephone interview on 08/15/2019 at 2:33 p.m. Staff O, RN she stated, I have worked at the hospital a long time and I am the Critical Care Unit Night Charge Nurse. As the Critical Care Nurse, I am the team leader of any rapid responses that is called. This is to ensure the patients are rapidly assessed by a more seasoned critical care nurse that has the critical thinking skills to rapidly assess the patient and get them the level of care that they require. The Rapid Response team is the Critical Care charge nurse, respiratory therapists, the bedside nurse, the charge nurse from the unit the patient is on, and the nursing supervisor on nights. The goal is to stabilize the patient and prevent further deterioration in the patient's condition. We have protocols. If we get to a rapid response and note that the patient is asystolic (without heart beat) or apneic (without respirations) we initiate a code blue and then the emergency room physician will respond. I did respond to the rapid response for Patient #1 on 06/09/2019 at 05:45 AM, when I entered the room the patient had some mottling in his lower legs, his pupils were fixed and dilated, he had no pulse and no spontaneous respirations. I did not call because I knew he was gone for 20 minutes or more based on his mottling on his legs. I knew he was gone. I knew it was futile. I should have called a code blue but given his condition I just knew it was futile. He did not have rigor mortis, but his skin temperature was cool and then I found out that he had been with no rhythm for 20 minutes and I did not call a code. I knew he was a full code. In hindsight, I should have called the code blue, started CPR and let the emergency room Physician determine the next steps. I know that I did not follow the hospital policy to call a code blue I just knew he was dead, and it was futile. I knew the patient was a full code, but he was in such bad shape. I did the wrong thing, I know that. My role in codes is to respond to them and act as team leader until the ER (emergency room ) physician gets to the bedside. Once the physician arrives, he is the team leader and directs the staff in what to do. I cannot pronounce without a physician present. I don't call the patient deceased , the physician does.

During an interview on 08/15/2019 at 5:45 PM the Chief Medical Officer stated, No patient should be off telemetry indefinitely without the physician being notified and a resolution being found. Whether that resolution is to discontinue the order for telemetry or another intervention. I was not aware of this and honestly, I don't really think that anyone knew it was happening until today. It wasn't something that anyone has brought out during this process. I'm not sure if the monitor technicians have been included in brainstorming barriers in telemetry monitoring. They may have told us the barriers such as this well before you discovered this. We should have been auditing, we could have prevented all of this.

During an interview on 08/18/2019 at 6:13 PM the Administrative Nursing Supervisor stated, I was the Supervisor on 06/09/2019 when Patient #1 expired. I was busy when the Rapid Response was called. I wasn't able to respond immediately. I arrived about five minutes later. I was not aware the patient had been a full code, if I had I would have started the code and allowed the ER Physician to determine when to terminate resuscitation efforts. My role in a Rapid Response is to assist if needed. The CCU Nurse is the team leader. If a staff calls a Rapid Response and we arrive to find that it should be a Code Blue, we initiate a code. I did not make the determination to not start CPR. I trust that the CCU nurses understand their role and responsibilities in providing care to patients that are a full code. It is our responsibility to perform CPR until the ER Physician arrives, and he will stop efforts if he determines efforts are futile. The patient did not have any indications of rigor mortis that I am aware of. Honestly, I had no idea he was a full code.

2. Medical record review for Patient #2 revealed the patient was admitted on [DATE]. Diagnosis during admission included: Acute [DIAGNOSES REDACTED], Chronic Respiratory Failure, Pulmonary Emboli, Deep Vein Thrombosis, Obstructive Sleep Apnea, Severe [DIAGNOSES REDACTED] status post valvuloplasty, Hypertension, [DIAGNOSES REDACTED], and Atrial Fibrillation. The patient had a full code status.

During an observation on 08/15/2019 at 10:56 AM with the Registered Nurse (RN)/Director of the Centralized Cardiac Monitoring Station, Patient #2's cardiac telemetry monitoring screen showed a flat line, monitor in standby mode.

During an interview on 08/15/2019 at 10:56 AM when this surveyor asked Staff E, Monitor Technician (MT) why the patient was on standby, she stated that the patient had been in Nuclear Medicine having a HIDA (Hepatobiliary Iminodiacetic Acid) Scan and was off of cardiac monitoring. She had called the unit five minutes ago and he was back on the floor but would be returning to X-ray. At 11:04 AM the MT confirmed the patient was back from nuclear medicine. She spoke to the nurse who verified the patient was present in his room and the MT then requested to have the patient be placed back on the cardiac monitor. At 11:05 AM the Cardiac Rhythm was then observed on the telemetry screen.

During an Interview on 08/15/2015 at 11:08 AM with the Staff A, RN, Director, she stated, I don't know if they are able to receive the telemetry signal in Nuclear Medicine. I'm not sure if Patient #2 has an order to be off telemetry for anything. We do need orders for a patient to be off telemetry for showers or testing.

During an interview on 08/15/2019 at 3:55 PM Staff R, RN stated, I was the person who placed Patient #2 back on the monitor at about 11:05 AM after receiving a call from the Telemetry Technician. I had to replace the green lead, that is why it was not showing up on the monitor. The other leads were on and the telemetry box was on the patient. I can't remember exactly what time he got back here, I wasn't near the desk.

Review of the Transport Log for PCU (Progressive Care Unit) revealed there was no entry for the date and time Patient #2 was transported to Nuclear Medicine or when he returned to the floor.

Review of the Patients Ticket to ride had no time of when the patient left the unit and no time of the patient's returned to the unit documented.

Review of the Transport Log for Patient #2 revealed The Transport Job request was requested on 08/15/2019 at 06:35 AM by Nuclear Medicine. On 08/15/2019 at 07:10 AM the transport job was assigned to the Transporter at 07:10 AM the transport job was accepted by the Transporter at 07:31 AM. The transport job was started by the Transporter at 7:37 AM on 08/15/2019 the transport job was completed.

Review of the Nursing Documentation on 08/15/2019 at 10:07 AM revealed a nursing assessment was completed by the RN and vital signs were documented at 10:08 AM. At 10:38 AM the patient was examined by the physician.

During an interview on 08/17/2019 at 9:15 AM the Director of Diagnostic Imaging stated, We are capable of monitoring patients while they are in Nuclear Medicine. We wanted to make sure we could do this to determine if that was why Patient #2 was not seen by the monitor technicians. We verified yesterday, with another patient, to make sure it was not part of the problem for Patient #2. We verified patients are visible for telemetry within Nuclear Medicine for cardiac monitoring. Patient #2 was transported to Nuclear Medicine beginning at 7:31 AM when he was picked up from his room. He entered the Department at 7:37 AM. He was transported back to his room at 10:07 AM by the Nuclear Technician. It is my understanding Patient #2 was not on cardiac monitoring during this time. The Director of Diagnostic stated he had not been involved in the plan of correction as this is not his department. It was not an identifiable concern in my department. I only found out yesterday and got involved yesterday evening to determine if patients are able to be viewed on monitor while in this area.

During an interview on 08/17/2019 at 9:25 AM Staff A, RN (Registered Nurse)/Director CCU (Cardiac Care Unit) stated, Patient #2 was going to nuclear medicine and he was not on cardiac telemetry starting at 7:10 AM. The Transport Log was reviewed regarding the entry made by the Transporter. The RN/Director CCU verified the transport log indicated the transport job was assigned to the Transporter at 7:10 AM, and the transport log indicated the transport job started at 7:31 AM, and the patient arrived in Nuclear Medicine at 07:37 AM on 08/15/2019. She

verified the nursing documentation indicated the Patient had arrived back to his room at 10:07 AM and the Telemetry Technician was not notified as per the hospital policy. She verified the patient was not placed back on the monitor until it was requested by the monitor technician during the surveyor interview with the technician. Patients are able to be monitored while they are in Nuclear Medicine. We verified that yesterday. I probably would have discovered that our nurses were not following physicians' orders for cardiac monitoring if I had done daily audits. I might have realized this before today and as an organization we would have fixed it. I see the pattern you are showing me, it's another problem we have that we didn't know about but should have if we had been doing audits.

Review of the cardiac monitoring history record for Patient #2 revealed at 7:00 AM the patient was on cardiac telemetry, at 7:10 AM the patient was off of cardiac telemetry. The record revealed the patient remained off of cardiac monitoring until 11:05 AM, (4 hours). Patient had a full code status. There was no indication that a telemetry alert was called to check on the patient since the patient had been off the telemetry monitor for greater than 5 minutes as stated in the facility's policy.

3. Review of the medical record for Patient #3 revealed the patient was admitted to the facility on [DATE]. Diagnosis included: Acute Pancreatitis, Hypokalemia, Hyponatremia, [DIAGNOSES REDACTED], Syndrome of Inappropriate Diuretic Hormone (SIADH), Hypertension, and [DIAGNOSES REDACTED].

During an observation conducted on 08/15/2019 at 11:10 AM with Staff A, Director of the Centralized Cardiac Monitoring Station. Patient #3 was observed to have a flat line and the screen showed stand by.

During an interview on 08/15/2019 at 11:10 AM Staff B, MT stated, Patient #3 is off the telemetry monitor because she is confused and pulling off her leads. The nurse is aware.

An observation was conducted on 08/15/2019 at 4:11 PM during a tour of the monitor telemetry room. In attendance was the Chief Medical Officer, the Director of CCU/ PCU and the Monitor Technicians. Patient #3 was observed to have a flat line and showed stand by. The Director of Patient Safety entered the area and verified Patient #3 was observed off the monitor. Staff B, Monitor Technician stated, Patient #3 has been off the telemetry cardiac monitoring since at least 8:00 PM last night. She stated the patient did have an order for cardiac telemetry and verified that there was not an order to discontinue the Cardiac Monitoring.

Review of the Patient #3's cardiac monitoring history with Staff B, MT revealed the last time the patient was on cardiac telemetry was on 08/13/2019 at 8:00 PM. A review of the Daily Rate and Rhythms logs indicated Patient #3 was placed on Cardiac Telemetry at 5:35 PM on 08/10/2019 and continued on telemetry until approximately 2:00 AM on 08/10/2019. Starting at 04:00 AM on 08/11/2019 until 08/13/2019 at 2:00 PM she was documented on the telemetry logs as confused and was not being monitored. Starting at 10:00 PM on 08/13/2019 until 4:00 PM on 08/15/2019 the log documented confused with no telemetry monitoring occurring. There was no indication that a telemetry alert was called to check on the patient since the patient had been off the telemetry monitor for greater than 5 minutes as stated in the facility's policy.

During an interview on 08/15/2019 at 4:11 PM Staff, B MT stated, Patient #3 has been off the cardiac monitor since at least 8:00 PM last night. She pulled up the patient's telemetry screen and found that the patient had been off the cardiac monitor for over 24 hours. It is documented the nurse said she was confused and pulling the monitor off. I don't know if she has an order to be discontinued from telemetry, but I can look. The MT pulled up the patient's and verified that the patient had orders for telemetry monitoring that started on 08/10/2019. She verified there was no order to discontinue the telemetry. Review of Patient #3's telemetry documentation at 4:25 PM dated 08/15/2019 starting at 7:00 AM every two hours the MT documented confused with no telemetry. The MT stated, I did not call the nurse today because I got in report that the nurse okayed her to be off the monitor. I should have called and confirmed that. I document every time I call the nurses for any changes in the patient's rhythms and document if they are off the monitor and who I called. I only call the nurse and if I can't get the nurse, I call the Charge Nurse. If I can't get them, I will call a telemetry alert. The Medical Director, the Patient Safety Officer, Staff A, CCU/Monitor Tech Director re-entered the area and confirmed there was no visible ECG (Electrocardiograph) tracing, that the documentation on the Rates and Rhythm logs indicated confused, and the telemetry event log had no entry related to Patient #3. It was also confirmed there was an order present in the chart for telemetry monitoring and there was no order to discontinue monitoring. A review of the Telemetry Event log did not indicate that the Monitor Technician called the Nurse or that there were any alerts called for Patient #3.

During an interview on 08/15/2019 at 4:48 PM Staff G, RN stated, I am the nurse who is taking care of Patient #3. She refused the telemetry monitor today, she says she doesn't need it. I got in report she has been refusing to wear it. I did not call the doctor to let him know, I thought he already knew. He has not been in yet to see the patient or I haven't seen him in here to see her. I did not get an order to discontinue the telemetry, and no one from telemetry has called me to ask why she was not on the monitor today. I do think I should have called and gotten the order to discontinue the monitoring before now. I know the Monitor Technicians will call me or a telemetry alert if the patient is off the monitor for longer than five minutes. The telemetry technician did not call any telemetry alerts on the patient today. I think I probably should have called the doctor, but I really thought he knew. There is no nurse's note that states the doctor was notified. I really never thought to look until we looked at it when you asked to see it.

During an interview on 08/15/2019 at 5:05 PM Staff S, Registered Nurse/Charge Nurse stated, The only note in Patient #3's chart indicating the patient was confused and pulling off telemetry is on 08/10/2019 at 11:50 PM by nursing. It does not state that the physician was notified. She acknowledged the physician's notes for 08/11/2019 -08/14/2019 does not indicate he was aware the patient was removing her telemetry and was not on cardiac monitoring per the physician's order. There were no nurses' notes indicating the physician was called and notified that the patient was off the monitor. We should have documented that the doctor was notified and any recommendations. We should have requested an order to discontinue telemetry or have the physician give us alternatives to making sure the telemetry was on. Patient #3 wore the telemetry rarely. I have not received any calls today from the telemetry technicians about her being off the monitor. She is very confused and always pulling the telemetry off, and we should have done a nursing note to indicate that.

4. Review of Patient #4's medical record revealed the patient was admitted on [DATE]. Diagnosis during admission included: Cervical Cancer with lung metastasis and frontal area of the brain, Metabolic [DIAGNOSES REDACTED], Hypercalcemia, Acute Pre-renal Azotemia, Chronic Malnutrition, Hypokalemia.

Review of the physician's orders revealed Full Code status and an order for cardiac monitoring.

On observation on 08/15/2019 at 4:30 PM showed a flat line for Patient #4.

During an interview on 08/15/2019 at 4:30 PM Staff B, MT stated, Patient #4 is not on cardiac telemetry. She is going to be a hospice patient. Staff B, MT reviewed the physician's orders and verified the patient had an order to be on cardiac monitoring, the patient was a Full Code, and there were no orders from Hospice. When Staff B was asked the last telemetry time for the patient she stated, The patient had been off the telemetry monitor since 1:48 PM until 4:30 PM on 08/15/2019.

During an interview on 08/15/2019 at 05:30 PM Staff H, RN stated, Patient #4 had been off the telemetry for several hours, I can't be sure exactly when. The patient is trying to decide if she wants to be a Do Not Resuscitate. I probably should have gotten an order from the physician to discontinue the monitoring.

Review of the Action Plan (Plan of Correction) revealed: The Action Plan was not dated. The earliest date documented for implementation was 6/10/19.

Process Failure: Communication: Communication to employees not easily accessible/understandable/timely. The Root Cause: Monitor Tech focused on another bank of Telemetry tracings and alerts for 19 minutes before realizing patient (Patient #1) with suspected leads off was not addressed. Action Plan - Error Reduction Strategies: Monitor Technicians (MT) will follow the facility Cardiac Telemetry Monitoring policy regarding timely escalation when a patient's rhythm is not transmitting, whether it is calling Telemetry Alert or Rapid Response. Responsible Person/s: Director of Monitor Techs/Interim CNO (Chief Nursing Officer). Implementation Due Date: 6/14/19. Implementation Completion Date: 6/12/19. Measurement Description: Review of Cardiac Telemetry Monitoring Policy with al Monitor Technicians with signed attestation of understanding. Numerator: Total number of MT staff who have completed the education # needed 12. Denominator: Total number of MT staff required to complete the education # to monitor 12. Expected % of compliance: 100.00%. Monitoring Period: One time event, repeated as needed if telemetry event log shows a breach of the facility policy. Oversight Committee: Patient Safety Committee, MEC (Medical Executive Committee), BOT (Board of Trustees). Error Reduction Type & Strength: Rules/Policies.

Process Failure: Potential failure modes were not identified and/or contingency plans not in place. The Root Cause: Staff cannot visualize more than one bank of monitors easily without having their back turned to one of the banks of monitors. Action Plan - Error Reduction Strategies: Identify another suitable space to relocate the MT room and acquire estimates to accomplish all required to make the change. Until relocation is completed there will always be 3 MTs assigned to the current Telemetry room. This was effective 6/20/19. Responsible Person/s: Plan Operations. Implementation Due Date: 9/30/19. Implementation Completion Date: Pending. Measurement Description: Completion of project. Numerator: NA. Denominator: NA. Expected % of Compliance: Project completion on time or earlier. Monitoring Period: 90 days. Oversight Committee: Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Forcing Function.

Process Failure: Human Factors: Normalized deviance involved. The Root Cause: Perception on the until that the Nursing Techs were capable of addressing suspected leads off. Action Plan - Error Reduction Strategies: Nursing unit will follow the facility Cardiac Telemetry Monitoring policy regarding timely nurses response to MT requests to check a patient for transmission concerns (leads off). Responsible Person/s: Direction 2nd Floor Med/Tele, Interim CNO. Implementation Due Date: 6/21/19. Implementation Completion Date: 6/18/19. Measurement Description: Review of Cardiac Telemetry Monitoring Policy with all 2nd Floor Med/Tele staff, with signed attestation of understanding. Numerator: Total number of 2nd Floor staff who have completed the education # needed 51. Denominator: Total number of 2nd Floor staff required to complete the education # to monitor 51. Expected % of Compliance: 96%. 2 PRN (as needed) staff have not worked since March and 1 staff on Vacation. Monitoring Period: One time event, repeated as needed if telemetry event log shows a breach of the facility policy. Oversight Committee: Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Rules/Policies.

Process Failure: Training and Competency: Orientation/training not completed/inadequate. The Root Cause: ACLS, EKG and Cardiac Monitoring training and completion of test with a passing score was not required as part of the RN competency. Action Plan - Error Reduction Strategies: All RNs currently working in area with monitors or who can be floated to area with monitors, will complete a knowledge assessment for EKG interpretation, as well as, a proctored evaluation of competency. RNs not meeting a passing score of 84% will have 45 days from test date to complete remediation until all completed. The Charge ruse will address all transmission concerns for RNs who have not completed the interpretation course. Responsible Person/s: All Unit Directors/Interim CNO/Market Educators. Implementation Due Date: 12/31/19. Implementation Completion Date: Pending. Measurement Description: Documentation of completion of competency assessment with passing scores in the personnel record for all RNs that meet this error reduction criteria. Numerator: Total number of RNs that completed the EKG knowledge assessment, proctored evaluation and test. Denominator: Total number of RNs required to take the EKG knowledge assessment, proctored evaluation and test. Expected % of Compliance: 90%. Monitoring Period: 6 months. Oversight Committee: Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Standardization/Protocol.

Process Failure: Staffing: Non-contingency staffing plan implemented at time of event. The Root Cause: Once the patient census rose above 90, the facility contingency plan should have been initiated. Action Plan - Error Reduction Strategies: The facility staffing plan of 1 Monitor Tech to 45 patients will be followed at all times. At no time will a MT be responsible for watching more than 45 patients including during medals and breaks. The MT name and # of patients monitoring has been added to the Telemetry Event Log audit purposes. Responsible Person/s: Director of Monitor Techs/Interim CNO/Admin Nursing Supervisors. Implementation Due Date: 6/10/19. Implementation Completion Date: 6/10/19. Measurement Description: Validation of MT daily staffing from the Facility Scheduler Daily Roster showing census and staff scheduled. Numerator: Total MTs that worked per the schedule and census. Denominator: total MTS that are required to work per the census. Expected % of Compliance: 100.00%.

Monitoring Period: 90 days. Oversight Committee: Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Standardization/Protocol.

Process Failure: Organizational Culture: Additional staff performance issue. The Root Cause: The patient was a full code, resuscitation was not imitated (sic). The patient was pronounced by nursing staff and not a physician. Action Plan - Error Reduction Strategies: An attempt will be made to resuscitate all full code patients. Full code patients will be pronounced by a physician. A nurse can only pronounce along with a second nurse, a DNR patient or a withdrawal of life support patient. Responsible Person/s: Director CCU/All Nursing Directors/Interim CNO. Implementation Due Date: 6/10/19. Implementation Completion Date: 7/10/19. Measurement Description: Revision of the facility death pronouncement policy to clearly delineate the components of this error reduction strategy. House-wide education on the policy changes. Numerator: 10 Total nursing staff that completed the policy revision education. 2) Compliance date. Denominator: Total nursing staff required to complete the policy revision education. Expected % of Compliance: 100%. Monitoring Period: 45 days. Oversight Committee: NEC, Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Rules/Policies.

During an interview on 08/16/2019 at 9:35 AM Staff A, RN/Director CCU stated, I am responsible for the monitor technicians and overseeing that they follow the policy and procedure. I haven't been doing audits. I don't think they are completely understanding the seriousness of their job, because I know that they weren't doing it correctly when they were educated. They aren't following the plan and its failed somehow. I gave the forms to the quality coordinator, but I was out, and she had some questions, so they are not complete. I should have checked them every day. I really think we tried to make a good plan to reduce the potential risk and harm to the patients, but I see that we have not. I don't know how much more we could have done. I thought that what we came up with in the Serious Event Analysis was a good plan. I think having the nurses who work with telemetry do an EKG course is a great idea. We had to make the date of completion that far out because of when the classes were starting. I did think that one-time education was enough, but really, I see that it wasn't. I should have been auditing every day. I should have been more proactive. I just didn't realize that once I educated them, they wouldn't continue doing it. The Monitor Technicians were not involved in the event analysis and I hadn't thought to ask or maybe they didn't think to question the nurse's decisions to keep patients off telemetry when they were documenting confused on the logs. I guess we recognized that a problem originated in telemetry, but didn't drill down far enough to discover this, and other potential barriers for cardiac monitoring.

During an interview on 08/15/2019 at 12:15 PM the Director of Patient Safety (DPS) stated, We started education in the area that this occurred, on the second floor medical telemetry floor immediately. Education was started on 6/16/19 and expanded to the entire second floor and was completed on the second floor on 6/22/19. We are having all staff in the hospital go to an ECG interpretation class and knowledge assessment, this will be given to all staff who work with monitors or who can be floated to monitored units. The completion date for that is 12/31/2019, and honestly, I do think it will take that long. There are multiple classes and all of the staff that work in medical telemetry areas already have had this as a part of their competencies. There is a possibility that staff from non-monitored areas can be floated to telemetry areas. I'm not sure how often it happens, but there is a possibility they can be. I'm not sure of exactly how many of the staff have been educated. I just contacted all of the Directors yesterday via e-mail to forward me their education to staff on the Patient pronouncement policy and the Code Blue policy. A request was made for the policy revision of the facility death pronouncement policy to clearly delineate the components of this error reduction strategy and house-wide education on the policy changes. The DPS stated, We have not completed the house-wide education. When asked what policy was being used for staff training the DPS verified the policy used was the prior Death Pronouncement, Post Mortem Care and Nursing Responsibilities, Section Date: 3/16/15. Review Date: 4/2018. Approved 3/16/15. Supersedes: 1/13/14. A request was made for documentation of the audits completed to verify the effectiveness of the plan of correction that was implemented. The DPS stated, There are no audits. The CCU has been out on bereavement leave, and no audits were done.

Review of the Policy and Procedure titled, Death Pronouncement, Post Mortem Care And Nursing Responsibilities Approved 3/16/15 revealed Procedure: Pronouncement: 1. When a patient expires, it is not necessary for a physician to directly view the body. Following the affirmation of death the Nursing Supervisor, Team Leader or Primary Nurse will notify the attending ph

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, medical record reviews, policy and procedure review, and observations the Governing Body failed to implement QAPI efforts in response to systemic identified hospital's failure to ensure an ongoing patient safety plan for identified neglect of Patient #1, who was found unresponsive and absent of vital signs. Patient #1 was a full code status and his rights were not honored to have cardiopulmonary resuscitation initiated, the patient did not survive. The Governing Body failed to ensure a quality improvement plan and patient safety plan was implemented for not following physicians ordered cardiac monitoring for 4 of 6 sampled patients, Patients #1, #2, #3 and #4.

The findings included:

1. Medical record review for Patient #1 revealed admission on 05/15/2019. Diagnosis during admission included Acute Kidney injury, Elevated Cardiac Enzymes, Cardiac Arrythmias (irregular heart beat), Fluid Retention, Hypertension, Right Iliac Artery Aneurysm (arteries that branch off of the abdominal aorta in the pelvic area) repair dated 05/31/2019, Peripheral Edema (accumulation of fluid causing swelling), and Rhabdomyolysis (death of muscle fibers that release their contents into the bloodstream).

Review of the physician's orders dated 05/15/2019 revealed Medical Telemetry Medical Surgical monitored. Advance directives: Full Code Status.

Review of the Electrocardiogram reveal: Sinus rhythm (normal heart beat) with a first degree atrioventricular block (greater than 0.20 seconds on electrocardiography), right bundle branch block (a delay or blockage of the electrical impulses to the right side of the bottom chambers of the heart), marked T wave abnormality (disease entity of the heart).

Review of the nursing progress notes dated 06/09/2019 revealed expiration at 5:47 a.m., called/pronounced deceased .

During an interview on 08/15/2019 at 10:29 a.m. the Director of Patient Safety, (DPS) stated, the nursing supervisor, Staff Q, RN (Registered Nurse) informed me Patient #1 had been pronounced dead on 06/09/2019 with no CPR initiated and he was a full code. In review of the telemetry monitoring strips for Patient #1, it was conducted immediately on 06/09/2019, it was found there was no monitoring during this period, there were no strips to provide a strip reading because he was not on the monitor, it was indicated the patient had been off of telemetry starting at 5:26 a.m. A telephone call was placed to the floor at 5:26 a.m. to the patient care technician to check the leads. The Monitor Technician (MT) turned away from the monitors to another set of monitors that were alarming and noted at 5:45 a.m. Patient #1 was still off of the monitor. She contacted the patient's primary nurse and after that a Rapid Response was called. When interviewing the primary care nurse, she stated she called a Rapid Response instead of a Code Blue, she knew she should have initiated a Code Blue, but Staff O, RN CCU (Cardiac Care Unit)/Rapid Response Team Leader responded almost immediately as Staff O was on the same floor as Patient #1. Staff O, RN stated the patient was dead and she thought resuscitation would be futile. The primary care nurse stated I have never been in a code, I just trusted the CCU nurse when I called the Rapid Response. Documentation was requested related to the cardiac monitoring for Patient #1 for cardiac strips for 6/9/19 from 5:26 a.m. to 5:45 a.m. The DPS stated, there is no documentation to provide, Patient #1 was completely off the monitor.

During a telephone interview on 08/15/2019 at 2:33 p.m. Staff O, RN she stated, I have worked at the hospital a long time and I am the Critical Care Unit Night Charge Nurse. As the Critical Care Nurse, I am the team leader of any rapid responses that is called. This is to ensure the patients are rapidly assessed by a more seasoned critical care nurse that has the critical thinking skills to rapidly assess the patient and get them the level of care that they require. The Rapid Response team is the Critical Care charge nurse, respiratory therapists, the bedside nurse, the charge nurse from the unit the patient is on, and the nursing supervisor on nights. The goal is to stabilize the patient and prevent further deterioration in the patient's condition. We have protocols. If we get to a rapid response and note that the patient is asystolic (without heart beat) or apneic (without respirations) we initiate a code blue and then the emergency room physician will respond. I did respond to the rapid response for Patient #1 on 06/09/2019 at 05:45 AM, when I entered the room the patient had some mottling in his lower legs, his pupils were fixed and dilated, he had no pulse and no spontaneous respirations. I did not call because I knew he was gone for 20 minutes or more based on his mottling on his legs. I knew he was gone. I knew it was futile. I should have called a code blue but given his condition I just knew it was futile. He did not have rigor mortis, but his skin temperature was cool and then I found out that he had been with no rhythm for 20 minutes and I did not call a code. I knew he was a full code. In hindsight, I should have called the code blue, started CPR and let the emergency room Physician determine the next steps. I know that I did not follow the hospital policy to call a code blue I just knew he was dead, and it was futile. I knew the patient was a full code, but he was in such bad shape. I did the wrong thing, I know that. My role in codes is to respond to them and act as team leader until the ER (emergency room ) physician gets to the bedside. Once the physician arrives, he is the team leader and directs the staff in what to do. I cannot pronounce without a physician present. I don't call the patient deceased , the physician does.

During an interview on 08/15/2019 at 5:45 PM the Chief Medical Officer stated, No patient should be off telemetry indefinitely without the physician being notified and a resolution being found. Whether that resolution is to discontinue the order for telemetry or another intervention. I was not aware of this and honestly, I don't really think that anyone knew it was happening until today. It wasn't something that anyone has brought out during this process. I'm not sure if the monitor technicians have been included in brainstorming barriers in telemetry monitoring. They may have told us the barriers such as this well before you discovered this. We should have been auditing, we could have prevented all of this.

During an interview on 08/18/2019 at 6:13 PM the Administrative Nursing Supervisor stated, I was the Supervisor on 06/09/2019 when Patient #1 expired. I was busy when the Rapid Response was called. I wasn't able to respond immediately. I arrived about five minutes later. I was not aware the patient had been a full code, if I had I would have started the code and allowed the ER Physician to determine when to terminate resuscitation efforts. My role in a Rapid Response is to assist if needed. The CCU Nurse is the team leader. If a staff calls a Rapid Response and we arrive to find that it should be a Code Blue, we initiate a code. I did not make the determination to not start CPR. I trust that the CCU nurses understand their role and responsibilities in providing care to patients that are a full code. It is our responsibility to perform CPR until the ER Physician arrives, and he will stop efforts if he determines efforts are futile. The patient did not have any indications of rigor mortis that I am aware of. Honestly, I had no idea he was a full code.

2. Medical record review for Patient #2 revealed the patient was admitted on [DATE]. Diagnosis during admission included: Acute [DIAGNOSES REDACTED], Chronic Respiratory Failure, Pulmonary Emboli, Deep Vein Thrombosis, Obstructive Sleep Apnea, Severe [DIAGNOSES REDACTED] status post valvuloplasty, Hypertension, [DIAGNOSES REDACTED], and Atrial Fibrillation. The patient had a full code status.

During an observation on 08/15/2019 at 10:56 AM with the Registered Nurse (RN)/Director of the Centralized Cardiac Monitoring Station, Patient #2's cardiac telemetry monitoring screen showed a flat line, monitor in standby mode.

During an interview on 08/15/2019 at 10:56 AM when this surveyor asked Staff E, Monitor Technician (MT) why the patient was on standby, she stated that the patient had been in Nuclear Medicine having a HIDA (Hepatobiliary Iminodiacetic Acid) Scan and was off of cardiac monitoring. She had called the unit five minutes ago and he was back on the floor but would be returning to X-ray. At 11:04 AM the MT confirmed the patient was back from nuclear medicine. She spoke to the nurse who verified the patient was present in his room and the MT then requested to have the patient be placed back on the cardiac monitor. At 11:05 AM the Cardiac Rhythm was then observed on the telemetry screen.

During an Interview on 08/15/2015 at 11:08 AM with the Staff A, RN, Director, she stated, I don't know if they are able to receive the telemetry signal in Nuclear Medicine. I'm not sure if Patient #2 has an order to be off telemetry for anything. We do need orders for a patient to be off telemetry for showers or testing.

During an interview on 08/15/2019 at 3:55 PM Staff R, RN stated, I was the person who placed Patient #2 back on the monitor at about 11:05 AM after receiving a call from the Telemetry Technician. I had to replace the green lead, that is why it was not showing up on the monitor. The other leads were on and the telemetry box was on the patient. I can't remember exactly what time he got back here, I wasn't near the desk.

Review of the Transport Log for PCU (Progressive Care Unit) revealed there was no entry for the date and time Patient #2 was transported to Nuclear Medicine or when he returned to the floor.

Review of the Patients Ticket to ride had no time of when the patient left the unit and no time of the patient's returned to the unit documented.

Review of the Transport Log for Patient #2 revealed The Transport Job request was requested on 08/15/2019 at 06:35 AM by Nuclear Medicine. On 08/15/2019 at 07:10 AM the transport job was assigned to the Transporter at 07:10 AM the transport job was accepted by the Transporter at 07:31 AM. The transport job was started by the Transporter at 7:37 AM on 08/15/2019 the transport job was completed.

Review of the Nursing Documentation on 08/15/2019 at 10:07 AM revealed a nursing assessment was completed by the RN and vital signs were documented at 10:08 AM. At 10:38 AM the patient was examined by the physician.

During an interview on 08/17/2019 at 09:15 AM the Director of Diagnostic Imaging stated, We are capable of monitoring patients while they are in Nuclear Medicine. We wanted to make sure we could do this to determine if that was why Patient #2 was not seen by the monitor technicians. We verified yesterday, with another patient, to make sure it was not part of the problem for Patient #2. We verified patients are visible for telemetry within Nuclear Medicine for cardiac monitoring. Patient #2 was transported to Nuclear Medicine beginning at 7:31 AM when he was picked up from his room. He entered the Department at 7:37 AM. He was transported back to his room at 10:07 AM by the Nuclear Technician. It is my understanding Patient #2 was not on cardiac monitoring during this time. The Director of Diagnostic stated he had not been involved in the plan of correction as this is not his department. It was not an identifiable concern in my department. I only found out yesterday and got involved yesterday evening to determine if patients are able to be viewed on monitor while in this area.

During an interview on 08/17/2019 at 9:25 AM Staff A, RN (Registered Nurse)/Director CCU (Cardiac Care Unit) stated, Patient #2 was going to nuclear medicine and he was not on cardiac telemetry starting at 7:10 AM. The Transport Log was reviewed regarding the entry made by the Transporter. The RN/Director CCU verified the transport log indicated the transport job was assigned to the Transporter at 7:10 AM, and the transport log indicated the transport job started at 7:31 AM, and the patient arrived in Nuclear Medicine at 07:37 AM on 08/15/2019. She

verified the nursing documentation indicated the Patient had arrived back to his room at 10:07 AM and the Telemetry Technician was not notified as per the hospital policy. She verified the patient was not placed back on the monitor until it was requested by the monitor technician during the surveyor interview with the technician. Patients are able to be monitored while they are in Nuclear Medicine. We verified that yesterday. I probably would have discovered that our nurses were not following physicians' orders for cardiac monitoring if I had done daily audits. I might have realized this before today and as an organization we would have fixed it. I see the pattern you are showing me, it's another problem we have that we didn't know about but should have if we had been doing audits.

Review of the cardiac monitoring history record for Patient #2 revealed at 7:00 AM the patient was on cardiac telemetry, at 7:10 AM the patient was off of cardiac telemetry. The record revealed the patient remained off of cardiac monitoring until 11:05 AM, (4 hours). Patient had a full code status. There was no indication that a telemetry alert was called to check on the patient since the patient had been off the telemetry monitor for greater than 5 minutes as stated in the facility's policy.

3. Review of the medical record for Patient #3 revealed the patient was admitted to the facility on [DATE]. Diagnosis included: Acute Pancreatitis, Hypokalemia, Hyponatremia, [DIAGNOSES REDACTED], Syndrome of Inappropriate Diuretic Hormone (SIADH), Hypertension, and [DIAGNOSES REDACTED].

During an observation conducted on 08/15/2019 at 11:10 AM with Staff A, Director of the Centralized Cardiac Monitoring Station. Patient #3 was observed to have a flat line and the screen showed stand by.

During an interview on 08/15/2019 at 11:10 AM Staff B, MT stated, Patient #3 is off the telemetry monitor because she is confused and pulling off her leads. The nurse is aware.

An observation was conducted on 08/15/2019 at 4:11 PM during a tour of the monitor telemetry room. In attendance was the Chief Medical Officer, the Director of CCU/ PCU and the Monitor Technicians. Patient #3 was observed to have a flat line and showed stand by. The Director of Patient Safety entered the area and verified Patient #3 was observed off the monitor. Staff B, Monitor Technician stated, Patient #3 has been off the telemetry cardiac monitoring since at least 8:00 PM last night. She stated the patient did have an order for cardiac telemetry and verified that there was not an order to discontinue the Cardiac Monitoring.

Review of the Patient #3's cardiac monitoring history with Staff B, MT revealed the last time the patient was on cardiac telemetry was on 08/13/2019 at 8:00 PM. A review of the Daily Rate and Rhythms logs indicated Patient #3 was placed on Cardiac Telemetry at 5:35 PM on 08/10/2019 and continued on telemetry until approximately 2:00 AM on 08/10/2019. Starting at 04:00 AM on 08/11/2019 until 08/13/2019 at 2:00 PM she was documented on the telemetry logs as confused and was not being monitored. Starting at 10:00 PM on 08/13/2019 until 4:00 PM on 08/15/2019 the log documented confused with no telemetry monitoring occurring. There was no indication that a telemetry alert was called to check on the patient since the patient had been off the telemetry monitor for greater than 5 minutes as stated in the facility's policy.

During an interview on 08/15/2019 at 4:11 PM Staff, B MT stated, Patient #3 has been off the cardiac monitor since at least 8:00 PM last night. She pulled up the patient's telemetry screen and found that the patient had been off the cardiac monitor for over 24 hours. It is documented the nurse said she was confused and pulling the monitor off. I don't know if she has an order to be discontinued from telemetry, but I can look. The MT pulled up the patient's and verified that the patient had orders for telemetry monitoring that started on 08/10/2019. She verified there was no order to discontinue the telemetry. Review of Patient #3's telemetry documentation at 4:25 PM dated 08/15/2019 starting at 7:00 AM every two hours the MT documented confused with no telemetry. The MT stated, I did not call the nurse today because I got in report that the nurse okayed her to be off the monitor. I should have called and confirmed that. I document every time I call the nurses for any changes in the patient's rhythms and document if they are off the monitor and who I called. I only call the nurse and if I can't get the nurse, I call the Charge Nurse. If I can't get them, I will call a telemetry alert. The Medical Director, the Patient Safety Officer, Staff A, CCU/Monitor Tech Director re-entered the area and confirmed there was no visible ECG (Electrocardiograph) tracing, that the documentation on the Rates and Rhythm logs indicated confused, and the telemetry event log had no entry related to Patient #3. It was also confirmed there was an order present in the chart for telemetry monitoring and there was no order to discontinue monitoring. A review of the Telemetry Event log did not indicate that the Monitor Technician called the Nurse or that there were any alerts called for Patient #3.

During an interview on 08/15/2019 at 4:48 PM Staff G, RN stated, I am the nurse who is taking care of Patient #3. She refused the telemetry monitor today, she says she doesn't need it. I got in report she has been refusing to wear it. I did not call the doctor to let him know, I thought he already knew. He has not been in yet to see the patient or I haven't seen him in here to see her. I did not get an order to discontinue the telemetry, and no one from telemetry has called me to ask why she was not on the monitor today. I do think I should have called and gotten the order to discontinue the monitoring before now. I know the Monitor Technicians will call me or a telemetry alert if the patient is off the monitor for longer than five minutes. The telemetry technician did not call any telemetry alerts on the patient today. I think I probably should have called the doctor, but I really thought he knew. There is no nurse's note that states the doctor was notified. I really never thought to look until we looked at it when you asked to see it.

During an interview on 08/15/2019 at 5:05 PM Staff S, Registered Nurse/Charge Nurse stated, The only note in Patient #3's chart indicating the patient was confused and pulling off telemetry is on 08/10/2019 at 11:50 PM by nursing. It does not state that the physician was notified. She acknowledged the physician's notes for 08/11/2019 -08/14/2019 does not indicate he was aware the patient was removing her telemetry and was not on cardiac monitoring per the physician's order. There were no nurses' notes indicating the physician was called and notified that the patient was off the monitor. We should have documented that the doctor was notified and any recommendations. We should have requested an order to discontinue telemetry or have the physician give us alternatives to making sure the telemetry was on. Patient #3 wore the telemetry rarely. I have not received any calls today from the telemetry technicians about her being off the monitor. She is very confused and always pulling the telemetry off, and we should have done a nursing note to indicate that.

4. Review of Patient #4's medical record revealed the patient was admitted on [DATE]. Diagnosis during admission included: Cervical Cancer with lung metastasis and frontal area of the brain, Metabolic [DIAGNOSES REDACTED], Hypercalcemia, Acute Pre-renal Azotemia, Chronic Malnutrition, Hypokalemia.

Review of the physician's orders revealed Full Code status and an order for cardiac monitoring.

On observation on 08/15/2019 at 4:30 PM showed a flat line for Patient #4.

During an interview on 08/15/2019 at 4:30 PM Staff B, MT stated, Patient #4 is not on cardiac telemetry. She is going to be a hospice patient. Staff B, MT reviewed the physician's orders and verified the patient had an order to be on cardiac monitoring, the patient was a Full Code, and there were no orders from Hospice. When Staff B was asked the last telemetry time for the patient she stated, The patient had been off the telemetry monitor since 1:48 PM until 4:30 PM on 08/15/2019.

During an interview on 08/15/2019 at 05:30 PM Staff H, RN stated, Patient #4 had been off the telemetry for several hours, I can't be sure exactly when. The patient is trying to decide if she wants to be a Do Not Resuscitate. I probably should have gotten an order from the physician to discontinue the monitoring.

Review of the Action Plan (Plan of Correction) revealed: No date was documented. The earliest date of implementation was 6/10/2019.

Process Failure: Communication: Communication to employees not easily accessible/understandable/timely. The Root Cause: Monitor Tech focused on another bank of Telemetry tracings and alerts for 19 minutes before realizing patient (Patient #1) with suspected leads off was not addressed. Action Plan - Error Reduction Strategies: Monitor Technicians (MT) will follow the facility Cardiac Telemetry Monitoring policy regarding timely escalation when a patient's rhythm is not transmitting, whether it is calling Telemetry Alert or Rapid Response. Responsible Person/s: Director of Monitor Techs/Interim CNO (Chief Nursing Officer). Implementation Due Date: 6/14/19. Implementation Completion Date: 6/12/19. Measurement Description: Review of Cardiac Telemetry Monitoring Policy with al Monitor Technicians with signed attestation of understanding. Numerator: Total number of MT staff who have completed the education # needed 12. Denominator: Total number of MT staff required to complete the education # to monitor 12. Expected % of compliance: 100.00%. Monitoring Period: One time event, repeated as needed if telemetry event log shows a breach of the facility policy. Oversight Committee: Patient Safety Committee, MEC (Medical Executive Committee), BOT (Board of Trustees). Error Reduction Type & Strength: Rules/Policies.

Process Failure: Potential failure modes were not identified and/or contingency plans not in place. The Root Cause: Staff cannot visualize more than one bank of monitors easily without having their back turned to one of the banks of monitors. Action Plan - Error Reduction Strategies: Identify another suitable space to relocate the MT room and acquire estimates to accomplish all required to make the change. Until relocation is completed there will always be 3 MTs assigned to the current Telemetry room. This was effective 6/20/19. Responsible Person/s: Plan Operations. Implementation Due Date: 9/30/19. Implementation Completion Date: Pending. Measurement Description: Completion of project. Numerator: NA. Denominator: NA. Expected % of Compliance: Project completion on time or earlier. Monitoring Period: 90 days. Oversight Committee: Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Forcing Function.

Process Failure: Human Factors: Normalized deviance involved. The Root Cause: Perception on the until that the Nursing Techs were capable of addressing suspected leads off. Action Plan - Error Reduction Strategies: Nursing unit will follow the facility Cardiac Telemetry Monitoring policy regarding timely nurses response to MT requests to check a patient for transmission concerns (leads off). Responsible Person/s: Direction 2nd Floor Med/Tele, Interim CNO. Implementation Due Date: 6/21/19. Implementation Completion Date: 6/18/19. Measurement Description: Review of Cardiac Telemetry Monitoring Policy with all 2nd Floor Med/Tele staff, with signed attestation of understanding. Numerator: Total number of 2nd Floor staff who have completed the education # needed 51. Denominator: Total number of 2nd Floor staff required to complete the education # to monitor 51. Expected % of Compliance: 96%. 2 PRN (as needed) staff have not worked since March and 1 staff on Vacation. Monitoring Period: One time event, repeated as needed if telemetry event log shows a breach of the facility policy. Oversight Committee: Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Rules/Policies.

Process Failure: Training and Competency: Orientation/training not completed/inadequate. The Root Cause: ACLS, EKG and Cardiac Monitoring training and completion of test with a passing score was not required as part of the RN competency. Action Plan - Error Reduction Strategies: All RNs currently working in area with monitors or who can be floated to area with monitors, will complete a knowledge assessment for EKG interpretation, as well as, a proctored evaluation of competency. RNs not meeting a passing score of 84% will have 45 days from test date to complete remediation until all completed. The Charge ruse will address all transmission concerns for RNs who have not completed the interpretation course. Responsible Person/s: All Unit Directors/Interim CNO/Market Educators. Implementation Due Date: 12/31/19. Implementation Completion Date: Pending. Measurement Description: Documentation of completion of competency assessment with passing scores in the personnel record for all RNs that meet this error reduction criteria. Numerator: Total number of RNs that completed the EKG knowledge assessment, proctored evaluation and test. Denominator: Total number of RNs required to take the EKG knowledge assessment, proctored evaluation and test. Expected % of Compliance: 90%. Monitoring Period: 6 months. Oversight Committee: Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Standardization/Protocol.

Process Failure: Staffing: Non-contingency staffing plan implemented at time of event. The Root Cause: Once the patient census rose above 90, the facility contingency plan should have been initiated. Action Plan - Error Reduction Strategies: The facility staffing plan of 1 Monitor Tech to 45 patients will be followed at all times. At no time will a MT be responsible for watching more than 45 patients including during medals and breaks. The MT name and # of patients monitoring has been added to the Telemetry Event Log audit purposes. Responsible Person/s: Director of Monitor Techs/Interim CNO/Admin Nursing Supervisors. Implementation Due Date: 6/10/19. Implementation Completion Date: 6/10/19. Measurement Description: Validation of MT daily staffing from the Facility Scheduler Daily Roster showing census and staff scheduled. Numerator: Total MTs that worked per the schedule and census. Denominator: total MTS that are required to work per the census. Expected % of Compliance: 100.00%.

Monitoring Period: 90 days. Oversight Committee: Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Standardization/Protocol.

Process Failure: Organizational Culture: Additional staff performance issue. The Root Cause: The patient was a full code, resuscitation was not imitated (sic). The patient was pronounced by nursing staff and not a physician. Action Plan - Error Reduction Strategies: An attempt will be made to resuscitate all full code patients. Full code patients will be pronounced by a physician. A nurse can only pronounce along with a second nurse, a DNR patient or a withdrawal of life support patient. Responsible Person/s: Director CCU/All Nursing Directors/Interim CNO. Implementation Due Date: 6/10/19. Implementation Completion Date: 7/10/19. Measurement Description: Revision of the facility death pronouncement policy to clearly delineate the components of this error reduction strategy. House-wide education on the policy changes. Numerator: 10 Total nursing staff that completed the policy revision education. 2) Compliance date. Denominator: Total nursing staff required to complete the policy revision education. Expected % of Compliance: 100%. Monitoring Period: 45 days. Oversight Committee: NEC, Patient Safety Committee, MEC, BOT. Error Reduction Type & Strength: Rules/Policies.

During an interview on 08/16/2019 at 9:35 AM Staff A, RN/Director CCU stated, I am responsible for the monitor technicians and overseeing that they follow the policy and procedure. I haven't been doing audits. I don't think they are completely understanding the seriousness of their job, because I know that they weren't doing it correctly when they were educated. They aren't following the plan and its failed somehow. I gave the forms to the quality coordinator, but I was out, and she had some questions, so they are not complete. I should have checked them every day. I really think we tried to make a good plan to reduce the potential risk and harm to the patients, but I see that we have not. I don't know how much more we could have done. I thought that what we came up with in the Serious Event Analysis was a good plan. I think having the nurses who work with telemetry do an EKG course is a great idea. We had to make the date of completion that far out because of when the classes were starting. I did think that one-time education was enough, but really, I see that it wasn't. I should have been auditing every day. I should have been more proactive. I just didn't realize that once I educated them, they wouldn't continue doing it. The Monitor Technicians were not involved in the event analysis and I hadn't thought to ask or maybe they didn't think to question the nurse's decisions to keep patients off telemetry when they were documenting confused on the logs. I guess we recognized that a problem originated in telemetry, but didn't drill down far enough to discover this, and other potential barriers for cardiac monitoring.

During an interview on 08/15/2019 at 12:15 PM the Director of Patient Safety (DPS) stated, We started education in the area that this occurred, on the second floor medical telemetry floor immediately. Education was started on 6/1619 and expanded to the entire second floor and was completed on the second floor on 6/22/19. We are having all staff in the hospital go to an ECG interpretation class and knowledge assessment, this will be given to all staff who work with monitors or who can be floated to monitored units. The completion date for that is 12/31/2019, and honestly, I do think it will take that long. There are multiple classes and all of the staff that work in medical telemetry areas already have had this as a part of their competencies. There is a possibility that staff from non-monitored areas can be floated to telemetry areas. I'm not sure how often it happens, but there is a possibility they can be. I'm not sure of exactly how many of the staff have been educated. I just contacted all of the Directors yesterday via e-mail to forward me their education to staff on the Patient pronouncement policy and the Code Blue policy. A request was made for the policy revision of the facility death pronouncement policy to clearly delineate the components of this error reduction strategy and house-wide education on the policy changes. The DPS stated, We have not completed the house-wide education. When asked what policy was being used for staff training the DPS verified the policy used was the prior Death Pronouncement, Post Mortem Care and Nursing Responsibilities, Section Date: 3/16/15. Review Date: 4/2018. Approved 3/16/15. Supersedes: 1/13/14. A request was made for documentation of the audits completed to verify the effectiveness of the plan of correction that was implemented. The DPS stated, There are no audits. The CCU has been out on bereavement leave, and no audits were done.

Review of the Policy and Procedure titled, Death Pronouncement, Post Mortem Care And Nursing Responsibilities Approved 3/16/15 revealed Procedure: Pronouncement: 1. When a patient expires, it is not necessary for a physician to directly view the body. Following the affirmation of death the Nursing Supervisor, Team Leader or Primary Nurse will notify the attending physician (or physician taking call) of the cessation of vital signs and time of death.

Review of the current licensed nursing staff revealed a total of 152 RNs are currently employed at the hospital.

Review o

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, medical record review, and policy and procedure review the facility failed to ensure a patient's rights were exercised for cardiopulmonary resuscitation (CPR) for 1 of 3 patients sampled with a full code status; the patient did not survive, Patient #1.

The findings included:

Medical record review for Patient #1 revealed the patient was admitted on [DATE]. Diagnosis during admission included Acute Kidney Injury, Elevated Cardiac Enzymes, Cardiac Arrythmias, Fluid Retention, Hypertension, Right Iliac Artery Aneurysm repair dated 05/31/2019, Peripheral Edema, and Rhabdomyolysis.

Review of the physician's orders dated 05/15/2019 revealed Medical Telemetry Medical Surgical monitored. Advance directives: Full Code Status.

Review of the Electrocardiogram revealed: Sinus rhythm (normal heart beat) with a first degree atrioventricular block (greater than 0.20 seconds on electrocardiography), right bundle branch block (a delay or blockage of the electrical impulses to the right side of the bottom chambers of the heart), marked T wave abnormality (disease entity of the heart).

Review of the nursing progress notes dated 06/09/2019 revealed expiration at 5:47 a.m., called/pronounced deceased .

During an interview on 08/15/2019 at 10:29 a.m. the Director of Patient Safety, (DPS) stated, the nursing supervisor, Staff Q, RN (Registered Nurse) informed me Patient #1 had been pronounced dead on 06/09/2019 with no CPR initiated and he was a full code. In review of the telemetry monitoring strips for Patient #1, it was conducted immediately on 06/09/2019, it was found there was no monitoring during this period, there were no strips to provide a strip reading because he was not on the monitor, it was indicated the patient had been off of telemetry starting at 5:26 a.m. A telephone call was placed to the floor at 5:26 a.m. to the patient care technician to check the leads. The Monitor Technician (MT) turned away from the monitors to another set of monitors that were alarming and noted at 5:45 a.m. Patient #1 was still off of the monitor. She contacted the patient's primary nurse and after that a Rapid Response was called. When interviewing the primary care nurse, she stated she called a Rapid Response instead of a Code Blue, she knew she should have initiated a Code Blue, but Staff O, RN CCU (Cardiac Care Unit)/Rapid Response Team Leader responded almost immediately as Staff O was on the same floor as was Patient #1. Staff O, RN stated the patient was dead and she thought resuscitation would be futile. The primary care nurse stated I have never been in a code, I just trusted the CCU nurse when I called the Rapid Response. Documentation was requested related to the cardiac monitoring for Patient #1 for cardiac strips for 6/9/19 from 5:26 a.m. to 5:45 a.m. The DPS stated, there is no documentation to provide, Patient #1 was completely off the monitor.

During a telephone interview on 08/15/2019 at 2:33 p.m. Staff O, RN she stated, I have worked at the hospital a long time and I am the Critical Care Unit Night Charge Nurse. As the Critical Care Nurse, I am the team leader of any rapid responses that is called. This is to ensure the patients are rapidly assessed by a more seasoned critical care nurse that has the critical thinking skills to rapidly assess the patient and get them the level of care that they require. The Rapid Response team is the Critical Care charge nurse, respiratory therapists, the bedside nurse, the charge nurse from the unit the patient is on, and the nursing supervisor on nights. The goal is to stabilize the patient and prevent further deterioration in the patient's condition. We have protocols. If we get to a rapid response and note that the patient is asystolic (without heart beat) or apneic (without respirations) we initiate a code blue and then the emergency room physician will respond. I did respond to the rapid response for Patient #1 on 06/09/2019 at 05:45 AM, when I entered the room the patient had some mottling in his lower legs, his pupils were fixed and dilated, he had no pulse and no spontaneous respirations. I did not call because I knew he was gone for 20 minutes or more based on his mottling on his legs. I knew he was gone. I knew it was futile. I should have called a code blue but given his condition I just knew it was futile. He did not have rigor mortis, but his skin temperature was cool and then I found out that he had been with no rhythm for 20 minutes and I did not call a code. I knew he was a full code. In hindsight, I should have called the code blue, started CPR and let the emergency room Physician determine the next steps. I know that I did not follow the hospital policy to call a code blue I just knew he was dead, and it was futile. I knew the patient was a full code, but he was in such bad shape. I did the wrong thing, I know that. My role in codes is to respond to them and act as team leader until the ER (emergency room ) physician gets to the bedside. Once the physician arrives, he is the team leader and directs the staff in what to do. I cannot pronounce without a physician present. I don't call the patient deceased , the physician does.

During an interview on 08/15/2019 at 5:45 PM the Chief Medical Officer stated, No patient should be off telemetry indefinitely without the physician being notified and a resolution being found. Whether that resolution is to discontinue the order for telemetry or another intervention. I was not aware of this and honestly, I don't really think that anyone knew it was happening until today. It wasn't something that anyone has brought out during this process. I'm not sure if the monitor technicians have been included in brainstorming barriers in telemetry monitoring. They may have told us the barriers such as this well before you discovered this.

During an interview on 08/18/2019 at 6:13 PM the Administrative Nursing Supervisor stated, I was the Supervisor on 06/09/2019 when Patient #1 expired. I was busy when the Rapid Response was called. I wasn't able to respond immediately. I arrived about five minutes later. I was not aware the patient had been a full code, if I had I would have started the code and allowed the ER Physician to determine when to terminate resuscitation efforts. My role in a Rapid Response is to assist if needed. The CCU Nurse is the team leader. If a staff calls a Rapid Response and we arrive to find that it should be a Code Blue, we initiate a code. I did not make the determination to not start CPR. I trust that the CCU nurses understand their role and responsibilities in providing care to patients that are a full code. It is our responsibility to perform CPR until the ER Physician arrives, and he will stop efforts if he determines efforts are futile. The patient did not have any indications of rigor mortis that I am aware of. Honestly, I had no idea he was a full code.

Review of the policy titled, Advance Directives with an Effective Date of 10/30/15 and a review date of 11/22/2017 revealed: Purpose: 2. To provide guidelines for implementation of patient rights regarding Advance Directives. Policy: 1. When patient designates advanced directive, Citrus Memorial Hospital honors the same in accordance with law and regulation, and the hospital's capabilities.

Review of the policy titled, Cardiac Telemetry Monitoring: Reference Number: WFD.PC.023, Approval date: 02/25/2019 Definitions: Telemetry alert- an alert that is initiated from the personnel in the monitoring station for immediate care team response to check on the patient whose cardiac monitoring can be visualized but may be in poor quality or at risk of losing visualization but may be in poor quality or at risk of losing visualization (low battery, lead off, etc.) The individuals to respond to the alert are the members of the care team for the location called in the alert. Policy: E. Personnel in the role of monitor technicians will be responsible for monitoring cardiac telemetry, running documentation strips, and communicating to the nurse changes in patient's rhythm and when patients are off monitor. F. If the patient rhythm is still transmitting to the central station but the monitor indicates battery low or lead off the monitoring technician must notify the nurse. If there is no response, the situation is not responded to or if it is not resolved in 5 minutes a telemetry Alert will be called. G. If the patient rhythm is not transmitting to the central Station the monitoring personnel will call for immediate resolution by calling a Rapid Response to the patient room and bed. II. Monitor Technician Responsibilities: E. Sudden loss of monitoring for a patient: The monitor technician should call a Rapid Response to the room/bed location of the patient. 2. The monitor technician will record the notification on the telemetry Event Log. H. Documentation: 1. The Monitor Technician will maintain a daily event log to record telemetry events, calls placed to the care team, and alerts or codes initiated from the monitoring station. III. Nursing Responsibilities: Telemetry verification is conducted as part of the cardiac assessment. Verification of monitoring, timely patient assessment and intervention based on identified abnormal cardiac rhythms, and documentation regarding patient's rhythm and any changes in cardiac rhythm. IV. Transporting patients with cardiac telemetry monitoring: A. All patients transported between departments will be provided the same level of care during the transport. When a monitored patient is transported off the nursing unit the procedure below ensures continual cardiac monitoring. 1. The monitor technician is notified when a patient leaves the nursing unit. 2. The telemetry monitoring device may not be removed without a physician order. 3. The monitor technician is notified when the patient returns to the nursing unit. B. B. Transporting patients with telemetry suspended: 1. A physician order must be present to remove patient from telemetry. 2. Monitor Technician should be notified that the patient is being transported off the telemetry. The box should be kept the nurse's station 3. The alarms should be placed on suspend or stand by mode until the patient has returned 4. A transporter may not remove the telemetry box. Nursing personnel will remove and reapply the telemetry box. Nursing will verify with the telemetry technician. V. Discontinuing Telemetry: telemetry may be discontinued - A. Only when there is a physician's order to discontinue telemetry, or when a discharge order has been received. The facility failed to ensure that their policy and procedure was followed as evidenced by the personnel in the telemetry monitoring station failing to initiate a telemetry alert for the immediate care team response team members to check on/evaluate patient #1 when it was determined the patient's leads were off from 5:25 a.m. to at 5:45 a.m., 20 minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, medical record reviews, observations, and policy and procedure reviews, the facility failed to ensure patients were free from neglect, having their wishes honored for cardiopulmonary resuscitation (CPR) for 1 (Patient #1) of 3 patients sampled with a full code status; the patient did not survive, and failed to follow

physician's orders for cardiac telemetry for 4 of 6 patients sampled for cardiac telemetry, Patients#1, #2, #3, #4.

The findings included:

1. Medical record review for Patient #1 revealed admission 05/15/2019. Diagnosis noted during admission to include Acute Kidney injury, Elevated Cardiac Enzymes, Cardiac Arrythmias (irregular heart beat), Fluid Retention, Hypertension, Right Iliac Artery Aneurysm (arteries that branch off of the abdominal aorta in the pelvic area) repair dated 05/31/2019, Peripheral Edema (accumulation of fluid causing swelling), and Rhabdomyolysis (death of muscle fibers that release their contents into the bloodstream).

Review of the physician's orders dated 05/15/2019 revealed Medical Telemetry Medical Surgical monitored. Advance directives: Full Code Status.

Review of the Electrocardiogram reveal: Sinus rhythm (normal heart beat) with a first degree atrioventricular block (greater than 0.20 seconds on electrocardiography), right bundle branch block (a delay or blockage of the electrical impulses to the right side of the bottom chambers of the heart), marked T wave abnormality (disease entity of the heart).

Review of the nursing progress notes dated 06/09/2019 revealed expiration at 5:47 a.m., called deceased .

During an interview on 08/15/2019 at 10:29 a.m. the Director of Patient Safety, (DPS) stated, the nursing supervisor, Staff Q, RN (Registered Nurse) informed me Patient #1 had been pronounced dead on 06/09/2019 with no CPR initiated and he was a full code. In review of the telemetry monitoring strips for Patient #1, it was conducted immediately on 06/09/2019, it was found there was no monitoring during this period, there were no strips to provide a strip reading because he was not on the monitor, it was indicated the patient had been off of telemetry starting at 5:26 a.m. A telephone call was placed to the floor at 5:26 a.m. to the patient care technician to check the leads. The Monitor Technician (MT) turned away from the monitors to another set of monitors that were alarming and noted at 5:45 a.m. Patient #1 was still off of the monitor. She contacted the patient's primary nurse and after that a Rapid Response was called. When interviewing the primary care nurse, she stated she called a Rapid Response instead of a Code Blue, she knew she should have initiated a Code Blue, but Staff O, RN CCU (Cardiac Care Unit)/Rapid Response Team Leader responded almost immediately as Staff O was on the same floor as Patient #1. Staff O, RN stated the patient was dead and she thought resuscitation would be futile. The primary care nurse stated I have never been in a code, I just trusted the CCU nurse when I called the Rapid Response. Documentation was requested related to the cardiac monitoring for Patient #1 for cardiac strips for 6/9/19 from 5:26 a.m. to 5:45 a.m. The DPS stated, there is no documentation to provide, Patient #1 was completely off the monitor.

During a telephone interview on 08/15/2019 at 2:33 p.m. Staff O, RN she stated, I have worked at the hospital a long time and I am the Critical Care Unit Night Charge Nurse. As the Critical Care Nurse, I am the team leader of any rapid responses that is called. This is to ensure the patients are rapidly assessed by a more seasoned critical care nurse that has the critical thinking skills to rapidly assess the patient and get them the level of care that they require. The Rapid Response team is the Critical Care charge nurse, respiratory therapists, the bedside nurse, the charge nurse from the unit the patient is on, and the nursing supervisor on nights. The goal is to stabilize the patient and prevent further deterioration in the patient's condition. We have protocols. If we get to a rapid response and note that the patient is asystolic (without heart beat) or apneic (without respirations) we initiate a code blue and then the emergency room physician will respond. I did respond to the rapid response for Patient #1 on 06/09/2019 at 05:45 AM, when I entered the room the patient had some mottling in his lower legs, his pupils were fixed and dilated, he had no pulse and no spontaneous respirations. I did not call because I knew he was gone for 20 minutes or more based on his mottling on his legs. I knew he was gone. I knew it was futile. I should have called a code blue but given his condition I just knew it was futile. He did not have rigor mortis, but his skin temperature was cool and then I found out that he had been with no rhythm for 20 minutes and I did not call a code. I knew he was a full code. In hindsight, I should have called the code blue, started CPR and let the emergency room Physician determine the next steps. I know that I did not follow the hospital policy to call a code blue I just knew he was dead, and it was futile. I knew the patient was a full code, but he was in such bad shape. I did the wrong thing, I know that. My role in codes is to respond to them and act as team leader until the ER (emergency room ) physician gets to the bedside. Once the physician arrives, he is the team leader and directs the staff in what to do. I cannot pronounce without a physician present. I don't call the patient deceased , the physician does.

During an interview on 08/15/2019 at 5:45 PM the Chief Medical Officer stated, No patient should be off telemetry indefinitely without the physician being notified and a resolution being found. Whether that resolution is to discontinue the order for telemetry or another intervention. I was not aware of this and honestly, I don't really think that anyone knew it was happening until today. It wasn't something that anyone has brought out during this process. I'm not sure if the monitor technicians have been included in brainstorming barriers in telemetry monitoring. They may have told us the barriers such as this well before you discovered this.

During an interview on 08/18/2019 at 6:13 PM the Administrative Nursing Supervisor stated, I was the Supervisor on 06/09/2019 when Patient #1 expired. I was busy when the Rapid Response was called. I wasn't able to respond immediately. I arrived about five minutes later. I was not aware the patient had been a full code, if I had I would have started the code and allowed the ER Physician to determine when to terminate resuscitation efforts. My role in a Rapid Response is to assist if needed. The CCU Nurse is the team leader. If a staff calls a Rapid Response and we arrive to find that it should be a Code Blue, we initiate a code. I did not make the determination to not start CPR. I trust that the CCU nurses understand their role and responsibilities in providing care to patients that are a full code. It is our responsibility to perform CPR until the ER Physician arrives, and he will stop efforts if he determines efforts are futile. The patient did not have any indications of rigor mortis that I am aware of. Honestly, I had no idea he was a full code.

2. Medical record review for Patient #2 revealed the patient was admitted on [DATE]. Diagnosis during admission included: Acute [DIAGNOSES REDACTED], Chronic Respiratory Failure, Pulmonary Emboli, Deep Vein Thrombosis, Obstructive Sleep Apnea, Severe [DIAGNOSES REDACTED] status post valvuloplasty, Hypertension, [DIAGNOSES REDACTED], and Atrial Fibrillation. The patient had a full code status.

During an observation on 08/15/2019 at 10:56 AM with the Registered Nurse (RN)/Director of the Centralized Cardiac Monitoring Station, Patient #2's cardiac telemetry monitoring screen showed a flat line, monitor in standby mode.

During an interview on 08/15/2019 at 10:56 AM when asked Staff E, Monitor Technician (MT) why the patient was on standby, she stated that the patient had been in Nuclear Medicine having a HIDA (Hepatobiliary Iminodiacetic Acid) Scan and was off of cardiac monitoring. She had called the unit five minutes ago and he was back on the floor but would be returning to X-ray. At 11:04 AM the MT confirmed the patient was back from nuclear medicine. She spoke to the nurse who verified the patient was present in his room and the MT then requested to have the patient be placed back on the cardiac monitor. At 11:05 AM the Cardiac Rhythm was then observed on the telemetry screen.

During an Interview on 08/15/2015 at 11:08 AM with the Staff A, RN, Director, she stated, I don't know if they are able to receive the telemetry signal in Nuclear Medicine. I'm not sure if Patient #2 has an order to be off telemetry for anything. We do need orders for a patient to be off telemetry for showers or testing.

During an interview on 08/15/2019 at 3:55 PM Staff R, RN stated, I was the person who placed Patient #2 back on the monitor at about 11:05 AM after receiving a call from the Telemetry Technician. I had to replace the green lead, that is why it was not showing up on the monitor. The other leads were on and the telemetry box was on the patient. I can't remember exactly what time he got back here, I wasn't near the desk.

Review of the Transport Log for PCU (Progressive Care Unit) revealed there was no entry for the date and time Patient #2 was transported to Nuclear Medicine or when he returned to the floor.

Review of the Patients Ticket to ride had no time of when the patient left the unit and no time of the patient's returned to the unit documented.

Review of the Transport Log for Patient #2 revealed The Transport Job request was requested on 08/15/2019 at 06:35 AM by Nuclear Medicine. On 08/15/2019 at 07:10 AM the transport job was assigned to the Transporter at 07:10 AM the transport job was accepted by the Transporter at 07:10 AM. The transport job was started by the Transporter at 7:31 AM on 08/15/2019 and the transport job was completed on 08/15/2019 at 7:37 AM.

Review of the Nursing Documentation on 08/15/2019 at 10:07 AM revealed a nursing assessment was completed by the RN and vital signs were documented at 10:08 AM. At 10:38 AM the patient was examined by the physician.

During an interview on 08/17/2019 at 09:15 AM the Director of Diagnostic Imaging stated, We are capable of monitoring patients while they are in Nuclear Medicine. We wanted to make sure we could do this to determine if that was why Patient #2 was not seen by the monitor technicians. We verified yesterday, with another patient, to make sure it was not part of the problem for Patient #2. We verified patients are visible for telemetry within Nuclear Medicine for cardiac monitoring. Patient #2 was transported to Nuclear Medicine beginning at 7:31 AM when he was picked up from his room. He entered the Department at 7:37 AM. He was transported back to his room at 10:07 AM by the Nuclear Technician. It is my understanding Patient #2 was not on cardiac monitoring during this time.

During an interview on 08/17/2019 at 9:25 AM Staff A, RN (Registered Nurse)/Director CCU (Cardiac Care Unit) stated, Patient #2 was going to nuclear medicine and he was not on cardiac telemetry starting at 7:10 AM. The Transport Log was reviewed regarding the entry made by the Transporter. The RN/Director CCU verified the transport log indicated the transport job was assigned to the Transporter at 7:10 AM, and the transport log indicated the transport job started at 7:31 AM, and the patient arrived in Nuclear Medicine at 07:37 AM on 08/15/2019. She

verified the nursing documentation indicated the Patient had arrived back to his room at 10:07 AM and the Telemetry Technician was not notified as per the hospital policy. She verified the patient was not placed back on the monitor until it was requested by the monitor technician during the surveyor interview with the technician. Patients are able to be monitored while they are in Nuclear Medicine. We verified that yesterday. I probably would have discovered that our nurses were not following physicians' orders for cardiac monitoring if I had done daily audits. I might have realized this before today and as an organization we would have fixed it. I see the pattern you are showing me, it's another problem we have that we didn't know about but should have if we had been doing audits.

Review of the cardiac monitoring history record for Patient #2 revealed at 7:00 AM the patient was on cardiac telemetry, at 7:10 AM the patient was off of cardiac telemetry. The record revealed the patient remained off of cardiac monitoring until 11:05 AM, (4 hours). Patient had a full code status. There was no indication that a telemetry alert was called to check on the patient since the patient had been off the telemetry monitor for greater than 5 minutes as stated in the facility's policy.

3. Review of the medical record for Patient #3 revealed the patient was admitted to the facility on [DATE]. Diagnosis included: Acute Pancreatitis, Hypokalemia, Hyponatremia, [DIAGNOSES REDACTED], Syndrome of Inappropriate Diuretic Hormone (SIADH), Hypertension, and [DIAGNOSES REDACTED].

During an observation conducted on 08/15/2019 at 11:10 AM with Staff A, Director of the Centralized Cardiac Monitoring Station. Patient #3 was observed to have a flat line and the screen showed stand by.

During an interview on 08/15/2019 at 11:10 AM Staff B, MT stated, Patient #3 is off the telemetry monitor because she is confused and pulling off her leads. The nurse is aware.

An observation was conducted on 08/15/2019 at 4:11 PM during a tour of the monitor telemetry room. In attendance was the Chief Medical Officer, the Director of CCU/ PCU and the Monitor Technicians. Patient #3 was observed to have a flat line and showed stand by. The Director of Patient Safety entered the area and verified Patient #3 was observed off the monitor. Staff B, Monitor Technician stated, Patient #3 has been off the telemetry cardiac monitoring since at least 8:00 PM last night. She stated the patient did have an order for cardiac telemetry and verified that there was not an order to discontinue the Cardiac Monitoring.

Review of the Patient #3's cardiac monitoring history with Staff B, MT revealed the last time the patient was on cardiac telemetry was on 08/13/2019 at 8:00 PM. A review of the Daily Rate and Rhythms logs indicated Patient #3 was placed on Cardiac Telemetry at 5:35 PM on 08/10/2019 and continued on telemetry until approximately 2:00 AM on 08/10/2019. Starting at 04:00 AM on 08/11/2019 until 08/13/2019 at 2:00 PM she was documented on the telemetry logs as confused and was not being monitored. Starting at 10:00 PM on 08/13/2019 until 4:00 PM on 08/15/2019 the log documented confused with no telemetry monitoring occurring. There was no indication that a telemetry alert was called to check on the patient since the patient had been off the telemetry monitor for greater than 5 minutes as stated in the facility's policy.

During an interview on 08/15/2019 at 4:11 PM Staff, B MT stated, Patient #3 has been off the cardiac monitor since at least 8:00 PM last night. She pulled up the patient's telemetry screen and found that the patient had been off the cardiac monitor for over 24 hours. It is documented the nurse said she was confused and pulling the monitor off. I don't know if she has an order to be discontinued from telemetry, but I can look. The MT pulled up the patient's and verified that the patient had orders for telemetry monitoring that started on 08/10/2019. She verified there was no order to discontinue the telemetry. Review of Patient #3's telemetry documentation at 4:25 PM dated 08/15/2019 starting at 7:00 AM every two hours the MT documented confused with no telemetry. The MT stated, I did not call the nurse today because I got in report that the nurse okayed her to be off the monitor. I should have called and confirmed that. I document every time I call the nurses for any changes in the patient's rhythms and document if they are off the monitor and who I called. I only call the nurse and if I can't get the nurse, I call the Charge Nurse. If I can't get them, I will call a telemetry alert. The Medical Director, the Patient Safety Officer, Staff A, CCU/Monitor Tech Director re-entered the area and confirmed there was no visible ECG (Electrocardiograph) tracing, that the documentation on the Rates and Rhythm logs indicated confused, and the telemetry event log had no entry related to Patient #3. It was also confirmed there was an order present in the chart for telemetry monitoring and there was no order to discontinue monitoring. A review of the Telemetry Event log did not indicate that the Monitor Technician called the Nurse or that there were any alerts called for Patient #3.

During an interview on 08/15/2019 at 4:48 PM Staff G, RN stated, I am the nurse who is taking care of Patient #3. She refused the telemetry monitor today, she says she doesn't need it. I got in report she has been refusing to wear it. I did not call the doctor to let him know, I thought he already knew. He has not been in yet to see the patient or I haven't seen him in here to see her. I did not get an order to discontinue the telemetry, and no one from telemetry has called me to ask why she was not on the monitor today. I do think I should have called and gotten the order to discontinue the monitoring before now. I know the Monitor Technicians will call me or a telemetry alert if the patient is off the monitor for longer than five minutes. The telemetry technician did not call any telemetry alerts on the patient today. I think I probably should have called the doctor, but I really thought he knew. There is no nurse's note that states the doctor was notified. I really never thought to look until we looked at it when you asked to see it.

During an interview on 08/15/2019 at 5:05 PM Staff S, Registered Nurse/Charge Nurse stated, The only note in Patient #3's chart indicating the patient was confused and pulling off telemetry is on 08/10/2019 at 11:50 PM by nursing. It does not state that the physician was notified. She acknowledged the physician's notes for 08/11/2019 -08/14/2019 does not indicate he was aware the patient was removing her telemetry and was not on cardiac monitoring per the physician's order. There were no nurses' notes indicating the physician was called and notified that the patient was off the monitor. We should have documented that the doctor was notified and any recommendations. We should have requested an order to discontinue telemetry or have the physician give us alternatives to making sure the telemetry was on. Patient #3 wore the telemetry rarely. I have not received any calls today from the telemetry technicians about her being off the monitor. She is very confused and always pulling the telemetry off, and we should have done a nursing note to indicate that.

4. Review of Patient #4's medical record revealed the patient was admitted on [DATE]. Diagnosis during admission included: Cervical Cancer with lung metastasis and frontal area of the brain, Metabolic [DIAGNOSES REDACTED], Hypercalcemia, Acute Pre-renal Azotemia, Chronic Malnutrition, Hypokalemia.

Review of the physician's orders revealed Full Code status and an order for cardiac monitoring.

On observation on 08/15/2019 at 4:30 PM showed a flat line for Patient #4.

During an interview on 08/15/2019 at 4:30 PM Staff B, MT stated, Patient #4 is not on cardiac telemetry. She is going to be a hospice patient. Staff B, MT reviewed the physician's orders and verified the patient had an order to be on cardiac monitoring, the patient was a Full Code, and there were no orders from Hospice. When Staff B was asked the last telemetry time for the patient she stated, The patient had been off the telemetry monitor since 1:48 PM until 4:30 PM on 08/15/2019.

During an interview on 08/15/2019 at 05:30 PM Staff H, RN stated, Patient #4 had been off the telemetry for several hours, I can't be sure exactly when. The patient is trying to decide if she wants to be a Do Not Resuscitate. I probably should have gotten an order from the physician to discontinue the monitoring.

Review of the policy titled, Advance Directives with an Effective Date of 10/30/15 and a review date of 11/22/2017 revealed: Purpose: 2. To provide guidelines for implementation of patient rights regarding Advance Directives. Policy: 1. When patient designates advanced directive, Citrus Memorial Hospital honors the same in accordance with law and regulation, and the hospital's capabilities.

Review of the policy titled, Cardiac Telemetry Monitoring: Reference Number: WFD.PC.023, Approval date: 02/25/2019 Definitions: Telemetry alert- an alert that is initiated from the personnel in the monitoring station for immediate care team response to check on the patient whose cardiac monitoring can be visualized but may be in poor quality or at risk of losing visualization but may be in poor quality or at risk of losing visualization (low battery, lead off, etc.) The individuals to respond to the alert are the members of the care team for the location called in the alert. Policy: E. Personnel in the role of monitor technicians will be responsible for monitoring cardiac telemetry, running documentation strips, and communicating to the nurse changes in patient's rhythm and when patients are off monitor. F. If the patient rhythm is still transmitting to the central station but the monitor indicates battery low or lead off the monitoring technician must notify the nurse. If there is no response, the situation is not responded to or if it is not resolved in 5 minutes a telemetry Alert will be called. G. If the patient rhythm is not transmitting to the central Station the monitoring personnel will call for immediate resolution by calling a Rapid Response to the patient room and bed. II. Monitor Technician Responsibilities: E. Sudden loss of monitoring for a patient: The monitor technician should call a Rapid Response to the room/bed location of the patient. 2. The monitor technician will record the notification on the telemetry Event Log. H. Documentation: 1. The Monitor Technician will maintain a daily event log to record telemetry events, calls placed to the care team, and alerts or codes initiated from the monitoring station. III. Nursing Responsibilities: Telemetry verification is conducted as part of the cardiac assessment. Verification of monitoring, timely patient assessment and intervention based on identified abnormal cardiac rhythms, and documentation regarding patient's rhythm and any changes in cardiac rhythm. IV. Transporting patients with cardiac telemetry monitoring: A. All patients transported between departments will be provided the same level of care during the transport. When a monitored patient is transported off the nursing unit the procedure below ensures continual cardiac monitoring. 1. The monitor technician is notified when a patient leaves the nursing unit. 2. The telemetry monitoring device may not be removed without a physician order. 3. The monitor technician is notified when the patient returns to the nursing unit. B. B. Transporting patients with telemetry suspended: 1. A physician order must be present to remove patient from telemetry. 2. Monitor Technician should be notified that the patient is being transported off the telemetry. The box should be kept the nurse's station 3. The alarms should be placed on suspend or stand by mode until the patient has returned 4. A transporter may not remove the telemetry box. Nursing personnel will remove and reapply the telemetry box. Nursing will verify with the telemetry technician. V. Discontinuing Telemetry: telemetry may be discontinued - A. Only when there is a physician's order to discontinue telemetry, or when a discharge order has been received. The facility failed to ensure that their policy and procedure was followed as evidenced by the personnel in the telemetry monitoring station failing to initiate a telemetry alert for the immediate care team response team members to check on/evaluate patient #1 when it was determined the patient's leads were off at 5:25 a.m. to 5:45 a.m., 20 minutes.

Based on Medical record and interviews the facility failed to have nursing notes and other necessary information present in medical record to monitor patient's condition in 1 ( Patient # 9 second admission) of 9 patients reviewed. :

Findings :

Patient # 9 ( second Admission ) on 08/01/2013 for post craniotomy with evacuation of hematoma that was performed at another facility and patient # 9 was readmitted 08/01/2013 to this facility. Review of the demographic history was under patient history with a fall risk of 75.

Review of Patient care policy/procedure for patient fall prevention protocol, Policy number 73, code F. states on page 1 under policy 1. The patient fall prevention protocol is applicable to hospitalized patients. Assessments includes use of modified Morse Fall scale for evaluation of potential fall risk and includes. A. History of falling: immediate or within 6 months ( Patient # 9 had a fall on the previous admission in July 2013 ) or F. mental status. ( Patient # 9 patient currently confused).

Review of policy/procedure for patient assessment and reassessment : Nursing Division , policy number 138-C, code A. Under purpose states that to ensure that all patients receive the appropriate assessment ( including initial/screening and reassessment) provided by qualified individuals within the organizational setting.

Under Policy numbered : 2. At the time of admission, each patient will be seen by the assigned nurse for evaluation of immediate needs.

Under policy numbered : 4. All patients will have an initial comprehensive assessment completed by a registered nurse. includes fall risk and data necessary to assess needs of the patient.

Under policy numbered : 5. As appropriate assessment , determined by the RN ( Registered Nurse) performing the initial assessment , and / or as indicated by initial physician order, other disciplines will be contacted to assess the patient.

Under policy numbered : 9. data collected on initial assessment shall be recorded into the nursing assessment record, and shall be available to all those disciplines involved in the care of the patient.

Under policy numbered: 11. Admission time frame for the Neurology- Telemetry Unit ( NTU) is to be initiated with in 30 minutes of arrival to the floor and completed with in 12 hours.

Review of initial assessment for patient # 9 second admission was not completed with in the 12 hours specified in the Policy numbered 138-C, Code A. as above shows. ( No initial nursing assessment was ever completed for patient # 9 second admission )

There is no documentation of second fall on the second admission in the nursing notes.

On 08/06/2013 at 10:06 AM an interview with staff # A bedside nurse at 10:06 has sitter at bedside due to falls. Had fallen twice in the facility, after the first admission had fallen and sent to another facility for evaluation. On return to this facility had a second fall. There should be a fall sign on the door and now there is a sitter at all times with patient. Patient is also with in site of nurses station.

Based on observation, record reviews, and interviews, the facility failed for 2 of 3 patients (# 5, # 6) to follow accepted infection control practices during blood specimen collection procedure and in the cleaning of equipment in the Emergency Department.

Findings:

1.) A tour and observation of the Emergency Department was conducted on 11/28/2012 at 11:04 AM with the Emergency Department Manager. Two staff persons were observed in the hallway, one was an Environmental Services Worker (EVS) floor tech and the other was a Paramedic at 11:18 AM. The Paramedic was observed actively cleaning a patient bed. During the observation, the Paramedic was observed utilizing a blue reusable cloth which was used to clean both the mattress and the pillow without changing the clothes between tasks (bed mattress to pillow). The Paramedic was dressed in scrubs with no personal protective measures observed.

An interview was conducted with the Emergency Department Manager, EVS floor tech and Paramedic at 11:21 AM specific to the process of cleaning the bedding. The EVS floor tech confirmed along with the Emergency Department Manager at that time different cleaning cloths would be utilized depending on who would be cleaning the bedding. It was also confirmed a changing of the cloths would be completed so that the mattress and the pillow would not be cleaned utilizing the same cloth.

An interview was conducted with the Environmental Services Director at 11:52 AM where the policies and procedures for the terminal or standard cleaning of beds in the Emergency Department were requested. A follow-up interview on 11/18/2012 at 12:14 PM confirmed the standard practice is for the EVS workers assigned to the Emergency Department are the persons who would generally be responsible for the cleaning. It was confirmed in this situation, a Paramedic volunteered to assist in the cleaning of the equipment when observed completing the process inappropriately.

A review of the policies and procedures revealed in policy #EVS-H-G #2 Cleaning Mattresses: Mattresses are cleaned on a discharge basis with an approved germicide. The mattresses are a special type in which they are constructed using foam rubber for the interior. A removable nylon cover makes up the portion of the mattress that the patient rest on. This cover is impermeable to fluids. The other half of the mattress is made of a tough and durable plastic. All personnel will wear gloves and follow universal precautions regarding personal protective equipment when cleaning or handling mattresses prior to cleaning.

Stretcher type mattresses are cleaned by nursing after patient use and routinely cleaned by Environmental Service staff.

Normal Procedure:

Dust mattress using a disposable dusting cloth.

Wipe down entire outer mattress using an approved germicide.

A review of 6 policies provided by the Environmental Services Director on 11/28/2012, each involving cleaning and disinfecting of patient rooms, equipment and areas, fail to identify how the patient pillow is to be handled, cleaned and sanitized between patient use.

2.) An observation of a patient blood draw was conducted on 11/28/2012 at 11: 45 AM on Patient # 4, Staff # 1. The staff person prepared all venipuncture kits and tubes outside the patient's room. Staff #1 knocked on door before entering room, identified patient's name and date of birth. Staff #1 identified accuracy of ID bracelet. Explained the purpose of the blood draw to the patient. Staff #1 donned on a pair of gloves, applied tourniquet to left upper forearm, cleaned area with alcohol, used a butterfly needle with one attempt, and collected 4 ml of blood in a tube. A small gauze dressing applied over venipuncture site and covered with tape. Staff #1 applied pressure for approximately 2-3 seconds on the left antecubital area. Staff #1 wrote her initial and time of draw on a pre-printed patients name and attached label to the tube. Removed and disposed contaminated gloves. Staff used hand sanitizer in patients ' room and exited room.

Observation on 11/28/2012 at 11:50 AM revealed Staff # 1 failed to wash her hands after removing the contaminated gloves and before leaving Patient # 4 room. Staff # 1 used hand sanitizer from the wall before exiting room. Observed Staff # 1 proceeded to Patient # 5 room to perform another blood draw.

Observation of blood draws on 11/28/2012 at 11:55 AM on Patient # 5. Staff #1 knocked on door before entering room, identified patients ' name and date of birth. Staff identified accuracy of ID bracelet. Explained the purpose of the blood draw to the patient. Staff # 1 donned on a pair of gloves, applied tourniquet to left upper forearm, cleaned area with alcohol, used a butterfly needle with one attempt, and collected 4 ml of blood in a tube. A small gauze dressing is applied and covered with tape. Staff #1 applied pressure for approximately 2-3 seconds on the left antecubital area. Staff #1 wrote her initial and time of draw on a pre-printed patients name and attached label to the tube. Staff #1 removed contaminated gloves and used hand sanitizer from the wall in patients ' room and exited room.

Observation of blood draws on 11/28/2012 at 12:25 PM on Patient # 6 by Staff # 1, Clinical Lab assistant. Staff knocked on door before entering room, identified patients ' name and date of birth. Staff identified accuracy of ID bracelet. Explained the purpose of the blood draw to the patient. Staff # 1 donned on a pair of gloves and applied tourniquet to right upper forearm, cleaned right antecubital area with alcohol, used a butterfly needle with one attempt, and collected 8 ml of blood in 2 tubes. Small gauze dressing applied and covered with tape. Staff # 1 applied pressure for approximately 2-3 seconds on the right antecubital area. Staff # 1 wrote her initial and time of draw on a pre-printed patients name and attached label to each tube. Staff used hand sanitizer from wall and exited room.

Observation on 11/28/2012 at 12:30 PM, Staff # 1 failed to wash her hands after removing the contaminated gloves and before leaving the Patient # 6 room.

Interview with Staff # 1 on 11/28/2012 at 12:32 PM revealed and concurred that she did not wash her hands before leaving Patient # 5 and # 6 rooms and between patients ' blood draw procedure. She stated that she used the hand sanitizer from the wall.

Interview with Staff # 2 on 11/28/2012 at 12:35PM concurred and confirmed through observation and subsequent interview that Staff # 1 failed to wash her hands after removing her contaminated gloves

Review of hospitals policy and procedure on Fundamentals of Standard and Transmission - Based Precautions, Appendix (CDC-2007), Effective Date of July 1, 2010, page 3 of 9 revealed hand washing is cited as the single most important measure to reduce the transmission of infectious agents in healthcare settings. Washing hands as promptly and thoroughly as possible between patient contacts and after contacts with blood-body fluids, secretions and equipment or articles contaminated by them is an important component of infection control and isolation precautions. Gloves must be changed between patient contacts and hands should be washed after gloves are removed. Wearing gloves does not replace the need for hand washing, because gloves may have small inapparent defects or may be torn during use, and hands can become contaminated during removal of gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interviews, the facility failed to ensure to care plan services for 1 of 3 sampled patients (patient #2).

Findings:

A review of the medical record for patient #2 revealed the lack of a care plan developed from an assessment indicating patient specific problem, goals, and interventions. There was no evaluation of interventions documented or reassessments as the patient's status changed. Noted on a kardex care plan was one problem with five interventions and no goals .

Patient # 2 was admitted on [DATE] was identified with a diagnosis of respiratory failure and hypoxia. Patient #2 was admitted to the critical care unit (CCU). There was only one problem identified for care planing. Further review showed that on 01/30/2011 at 7 PM the patient's oxygen saturation was not documented from 7:00 PM to 12 midnight, there are three saturation's notes from 1:00 AM to 6:00 AM but it does not have oxygen saturations noted.

Further review of medical record shows that the patient's blood pressure was decreasing from 1:00 AM to 6:00 AM, and no reassessment was completed to show that there was any plan to correct the blood pressure issue. Review of nurses notes shows that the patient was placed on a bipap, but there is no documentation to determine the reason why the patient was placed on the bipap machine.

Noted in nurses notes that the nurse documented at 4:50 AM that medication was discontinued and the patient's blood pressure was low. Next nurses note shows that at 6:25 AM there was code blue initiated.

Interview with Director of Nursing Operations on 07/24/2012 at 2:30 PM revealed, when looking at nurses notes, that she felt that there should have been more nurses notes specific to vital signs and that there was no report of oxygen saturation in the 70's. and vital signs hourly. Stated that according to policy on patient reassessment that this patient should have reassessment of oxygen saturation completed more frequently due to condition changes, as indicated by the nurses' notes.

Review of policy number 138 implemented on 2/29/2008 and reviewed 02/16/2009, 02/15/2010, 02/11/2011 and 02/20/2012. Subject Patient Assessment and reassessment under number 3 reassessment is done with any change in patients' status, diagnosis, or any condition that necessitates immediate reassessment with notification of physician for changes.

Interview the License Practical Nurse in CCU on 07/25/2012 at 10:15 AM who states that a goal is set every day for the patient, based on needs of the care plan to accomplish that goal for the day. Saturations are checked every hour and reassessment every 4 hours.

Based on observation and interviews, the facility failed to ensure that medications were prepared and administered in accordance with accepted standards of practice.

Findings:

Observation on 07/24/2012 at 9:10 AM of the Registered Nurse preparing and administering two medications. One pill needed to be cut in half, the nurse removed the medication from the package and put it on the pill cutter with her ungloved, hands and moved the pill to cut in half.

Observation on 07/24/2012 at 9:12 AM, in the medication room, the nurse prepared to draw 4 milligrams (mg) or 4 Cubic centimeter (cc) of the medication from two syringes and pulled the medication into one syringe without labeling the syringe. Normal saline flush was placed near the syringe. The nurse then moved away from the unlabeled syringe and two other nurses walked into room. The nurse was away from the unsecured/unlabeled medication. The nurse picked up the medications and went out of the room, to patients room, where again medication was unattended on table in hall.

Interview with Registered Nurse on 07/24/2012 at 5:30 PM who states that yes she had touched the pill, but did not remember that she had left the dilaudid unattended. The nurse stated that she usually labels syringes, but not today, also stated that she knows that the medication in the syringe is less than what is in the saline syringe and that is how she would know that it is the medication syringe.

Based on observations and interviews the facility failed to ensure that both respiratory and oxygen saturation alarms that communicates a problem were turned on in five of nine patients' rooms ( Patient #4, #27, #28, #29 and #30). Based on observation, interview and facility policy, it was confirmed the facility failed to ensure patient linen and other patient related clean equipment and belongings were maintained in a sanitary manner and under sanitary conditions throughout the hospital to prevent the potential for contamination.

Findings:

1. Observation on 07/25/2012 at 3:00 PM in patient # 4's room noted that monitor in room had an alarm off, checked and it was the respiratory alarm. patient admitted for altered mental status, fever and hypoxia.

Observation on 07/26/2012 at 10:35 AM, in patients # 4's room again that respiratory monitor showed alarms off. Check of the rest of Critical Care Unit showed that in room 233 patient # 29, room 235 patient # 28, room 238 patient # 27, alarms off and room 241 patient # 30 had respiratory alarms off on monitor. Room 235 patient # 28 had both respiratory and oxygen saturation alarms off on monitor.

Interview with Interim Manager of Critical care Unit on 07/26/2012 at 10:45 AM shows that this is not her expectations on this unit and that all alarms should be on the monitors.

Interview with Direct care Registered nurse for patient # 4, on 07/26/2012 at 10:45 AM Didn't notice alarms off and now will be part of initial assessment.

Interview with Team Leader on 07/26/2012 at 10:47 AM : that didn't know why alarms off and had not observed them to be off.

Review of policy numbered 251, Patient alarm safety-clinical. Implemented 12/29/2008, and revised 01/18/2012 that policy shows that the hospital will identify and assess critical clinical alarms systems to ensure patient safety is maintained. Under procedure it is noted that alarm settings are activated and appropriately monitored according to the area/unit specific criteria or according to the patients medical condition medical condition/activity level. It is noted that under policy that equipment alarms will remain on at all times unless continuous monitoring is in place.

2. A tour of the nursing units (3 floors) was conducted on 7/26/2012 beginning at 9:40 AM with the facility Director of Housekeeping Services. During the tour, the following observations with the Director of Environmental Services were identified and confirmed:

a.) Medical/Surgical 3rd floor across from room 322, a black multi-level cart with what was determined by staff to be clean linen on the cart uncovered and not on a protective barrier to prevent potential contamination. An Environmental Services worker was interviewed at 9:45 AM, stating she was unaware of the need for a protective barrier under the linens.

b.) Medical/Surgical 3rd floor across from room 302 a linen cart not covered, covering thrown over top of cart.

c.) Pulmonary Care Unit at 9:50 AM, a linen cart not covered, covering thrown over top of cart.

d.) Pulmonary Care Unit at 9:53 AM, a clean linen cart, open and exposed (covering thrown over the top of the cart) with 5 pillows stored on top of the cart.

e.) 4th floor clean utility room (Heart/Catheter) with a clean linen cart, open and exposed (covering thrown over the top of the cart).

f.) 2nd floor clean utility room with clean linen cart, open and exposed (covering thrown over the top of the cart). A second clean linen cart was observed in the clean utility room across from room 200, door propped open with the cart open and exposed (covering thrown over the top of the cart).

g.) 2nd floor multi-level rolling cart in the hallway observed at 10:13 AM, with what was confirmed as clean linen on the cart, uncovered without a barrier to prevent potential contamination.

h.) Critical Care Unit clean utility room observed at 10:21 AM, linen cart open and exposed (covering thrown over the top of the cart).

A review of the facility Policy & Procedure #IC-12 for clean linen handling revealed, Clean linen must be placed on a clean surface. Further interview with the Director of Housekeeping at 11:03 AM revealed the inability to produce a policy specific to how linens should be stored while on the nursing unit, aside from the policy provided of storing on a clean surface. The Director confirmed staff has been instructed in the proper storage of linen.

In addition during the tour conducted on 7/26/2012 beginning at 9:40 AM, multiple areas of concern were identified related to items, identified as ready to use for patient care, stored in the soiled utility rooms. Those areas identified included:

i.) Pulmonary Care Unit: Personal belongings (ready for pick up by patient or family) were found stored in the soiled utility room next to the bins marked for hazardous waste, with the bins not securely covered.

j.) Pulmonary Care Unit: A Hoyer life, respiratory machine both unmarked as soiled or do not use, were found in the soiled utility room.

k.) 4th floor soiled utility room contained 5 full oxygen tanks which would be ready for transport to a patient's room observed at 9:59 AM. A vacuum cleaner was found in the soiled utility room at this time placed partially under a biohazard collection barrel. It was confirmed with the Director of Environmental Services the vacuum had no tag on it identifying it not for use, and would/could be used in a patient or public area.

l.) 2nd floor soiled utility room contained 3 bedside commodes, each with a green clean tag on them. It was later confirmed with the Director of Infection Control on 7/26/2012 at 11:30 AM, the tags should have been removed if they had been previously used by a patient.

An interview was conducted with the facility Director of Infection Control and Director of Environmental Services on 7/26/2012 at 11:25 AM. Through review of policies, it was confirmed the facility failed to identify those items which should not be placed in the soiled utility rooms. Further discussion revealed the confirmation of the items found, which appeared to be clean use items and personal belongings which had been stored in the soiled utility rooms. It was confirmed a contamination risk was present due to the placement of clean use items in the soiled utility rooms.

No further information could be provided.

Based on medical record review and interview, it was confirmed the facility failed to ensure an informed consent was completed thoroughly, providing information specific to the person administering moderate sedation during a procedure for 1 of 31 patients reviewed, Patient #21.

Findings:

A review of the medical record for Patient #21 revealed a surgical procedure involving a tunneled Hemodialysis catheter insertion was scheduled for 2/03/2012. A review of the surgical consent revealed the lack of the name or signature of the person administering the anesthesia, (moderate sedation), with notification of the risks and benefits to the patient prior to the procedure.

Further review of the document revealed the lack of the patient's initial (where requested) regarding the facility policy of Do Not Resuscitate (DNR) during such procedures. The document indicates the DNR or No Code status is void during such procedures. There is no indication the patient was made aware of this. A Physician's Progress note dated 1/29/2012 indicates the resident's DNR and DNI (Do Not Intubate) status.

A review of the facility policy and procedure #C-196 indicates, It is the policy of Citrus Memorial Health System that patients must be given the opportunity to give informed consent. Written verification of informed consent is required prior to the administration of anesthesia or sedation and prior to operative procedures that are performed by a physician or LIP, except in emergency situations. Written verification of the informed consent must be documented on the Surgery/Invasive Procedure Consent form and placed on the patient's chart prior to initiation of anesthesia, sedation or any operative procedures. It is the responsibility of the Anesthesiologists and/or treating physician to provide the patient necessary information for informed consent before hospital personnel obtain consent signatures. This is a non-delegable duty.

An interview was conducted with the facility Risk Manager on 7/26/2012 at 10:35 AM regarding the lack of the informed consent signatures. It was confirmed the signatures had not been documented. No further information could be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital's Quality Assurance Performance Improvement (QAPI) failed to ensure that there was a mechanism in place to monitor medication errors when the designated personnel with password protected access to the system were not available.

Findings:

1.) During review of the grievance log it was noted that on 2/21/12 Patient #2 wrote a letter to the hospital concerning her emergency room (ER) visit on 2/19/12. She stated that she had laryngitis so she wrote her medical history including allergies on paper. She also was wearing a medic alert bracelet indicating her allergies were albuterol and codeine. She stated that she was administered albuterol in the ER by a named physician's assistant. She also stated that on her ER paperwork it indicated that she did not have any allergies. On 2/21/12 an acknowledgement letter went out to the patient informing her that her concerns would be investigated. On 3/2/12 a follow-up letter was sent to the patient informing her of the hospital's findings. The letter stated that the ER physician and ER manager were investigated her concerns.

2.) During review of the grievance log it was noted that on 2/15/12, Patient #3's daughter wrote a letter to the hospital concerning her mother's care in the ER on 2/14/12. The patient advocate wrote a letter on 2/15/12 apologizing for her mother's experience and acknowledging that her concerns would be investigated. On 3/13/12 the daughter received a letter from the hospital revealing that her mother received pain medication within 3 hours and fifty minutes apart from another pain medication. The letter stated that metabolism in the elderly can lead to prolonged sedation.

Review of the ER record for Patient #3 revealed that on 2/14/12 at 3:39 PM the patient arrived to the hospital's ER for abdominal pain and nausea. The patient home medication profile documented in the ER record does not indicate that she is on any medication. The physician documented that the patient had a history of gallbladder removal, appendix removal, and hysterectomy and colon surgery. On 2/14/12 the patient received the following medication:

2/14/12 at 2 PM normal saline per IV to increase hydration.

2/14/12 at 7 PM morphine 2 mg IVP (intravenous push). Response: decreased pain.

2/14/12 at 7 PM Zofran 4 mg IVP. Response: decreased nausea.

2/14/12 at 10:50 PM Dilaudid 1 mg IM (intramuscular). Response: no pain.

2/14/12 at 10:52 PM Maalox and donnatal 40 mg by mouth. Response: no pain.

The nurse documented on 2/15/12 at 12:55 AM attempting to give discharge instructions, patient very sleepy, unable to stand, physician informed. At 1:50 AM the patient was transferred to the 3rd floor for observation. On 2/15/12 at 8:52 AM the patient was discharged in the company of her daughter with the following new prescriptions: Protonix 40 mg once a day, Zofran 4 mg tablets one tablet three times a day and lobrax 5-2.5 mg one capsule three times a day.

Interview with the pharmacist on 4/23/12 at 3:30 PM provided the surveyor additional information concerning Dilaudid dosing. Dilaudid 1.5 mg is equivalent to Morphine 10 mg when given intravenously. When the pharmacist was asked if Patient #3 had an opiate naive response to the Dilaudid, he did not answer. He stated that Dilaudid 1 mg is considered a normal dose. Review of the patient's medication profile revealed that the patient was not on any opiates prior to admission to the hospital. Review of the information concerning Dilaudid dosing provided by the pharmacist revealed that precautions for intramuscular administration: variation absorption and a lag time to peak effect may result from IM use. Geriatric considerations: elderly may be particularly susceptible to the CNS (central nervous system) depressant and constipating effects of narcotics. Initial dosages of the drug should be in the lower end of the usual range. The usual range was documented as 0.8 mg-1 mg intramuscularly for opiate naive patients.

4.) During review of the grievances it was noted that the mother of Patient #4 filed a grievance by telephone on 2/28/12 concerning her son's visit to the emergency room on [DATE]. The mother was upset that the physician wrote a prescription for an antibiotic that her son was allergic to which she had filled at her pharmacy. She was upset because the medication was listed as an allergy on his medical record. The mother received an acknowledgement letter on 2/29/12. She received a conclusion letter on 3/13/12. The letter stated that an investigation of her concerns revealed that the allergy was documented in the medical record and that the physician had ordered a derivative of that medication. An apology for the incident was conveyed to the mother. A courtesy write off of her balance owed to the hospital was also provided to offset the cost of her purchase of medication should could not use.

Interview with the pharmacist and the Risk Manager on 4/23/12 at 12:30 PM revealed that they could not confirm if a medication incident report was generated for these incident as they both did not have password access to the system. The pharmacist who has access to the system was out of state at a conference. The nursing Quality Assurance Manager who has access to the system was out on leave at the time of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure adequate resources that would monitor medication errors when the designated personnel, who has password protected acess to the system, were not available.

Findings:

1.) During review of the grievance log it was noted that on 2/21/12 Patient #2 wrote a letter to the hospital concerning her emergency room (ER) visit on 2/19/12. She stated that she had laryngitis so she wrote her medical history including allergies on paper. She also was wearing a medic alert bracelet indicating her allergies were albuterol and codeine. She stated that she was administered albuterol in the ER by a named physician's assistant. She also stated that on her ER paperwork it indicated that she did not have any allergies. On 2/21/12 an acknowledgement letter went out to the patient informing her that her concerns would be investigated. On 3/2/12 a follow-up letter was sent to the patient informing her of the hospital's findings. The letter stated that the ER physician and ER manager were investigated her concerns.

Interview with the pharmacist on 4/24/12 at 11:15 AM stated that it is up to the nurses to report medication errors.

2.) During review of the grievance log it was noted that on 2/15/12, Patient #3's daughter wrote a letter to the hospital concerning her mother's care in the ER on 2/14/12. The patient advocate wrote a letter on 2/15/12 apologizing for her mother's experience and acknowledging that her concerns would be investigated. On 3/13/12 the daughter received a letter from the hospital revealing that her mother received pain medication within 3 hours and fifty minutes apart from another pain medication. The letter stated that metabolism in the elderly can lead to prolonged sedation.

Review of the ER record for Patient #3 revealed that on 2/14/12 at 3:39 PM the patient arrived to the hospital's ER for abdominal pain and nausea. The patient home medication profile documented in the ER record does not indicate that she is on any medication. The physician documented that the patient had a history of gallbladder removal, appendix removal, and hysterectomy and colon surgery. On 2/14/12 the patient received the following medication:

2/14/12 at 2 PM normal saline per IV to increase hydration.

2/14/12 at 7 PM morphine 2 mg IVP (intravenous push). Response: decreased pain.

2/14/12 at 7 PM Zofran 4 mg IVP. Response: decreased nausea.

2/14/12 at 10:50 PM Dilaudid 1 mg IM (intramuscular). Response: no pain.

2/14/12 at 10:52 PM Maalox and donnatal 40 mg by mouth. Response: no pain.

The nurse documented on 2/15/12 at 12:55 AM attempting to give discharge instructions, patient very sleepy, unable to stand, physician informed. At 1:50 AM the patient was transferred to the 3rd floor for observation. On 2/15/12 at 8:52 AM the patient was discharged in the company of her daughter with the following new prescriptions: Protonix 40 mg once a day, Zofran 4 mg tablets one tablet three times a day and lobrax 5-2.5 mg one capsule three times a day.

Interview with the pharmacist on 4/23/12 at 3:30 PM provided the surveyor additional information concerning Dilaudid dosing. Dilaudid 1.5 mg is equivalent to Morphine 10 mg when given intravenously. When the pharmacist was asked if Patient #3 had an opiate naive response to the Dilaudid, he did not answer. He stated that Dilaudid 1 mg is considered a normal dose. Review of the patient's medication profile revealed that the patient was not on any opiates prior to admission to the hospital. Review of the information concerning Dilaudid dosing provided by the pharmacist revealed that precautions for intramuscular administration: variation absorption and a lag time to peak effect may result from IM use. Geriatric considerations: elderly may be particularly susceptible to the CNS (central nervous system) depressant and constipating effects of narcotics. Initial dosages of the drug should be in the lower end of the usual range. The usual range was documented as 0.8 mg-1 mg intramuscularly for opiate naive patients.

4.) During review of the grievances it was noted that the mother of Patient #4 filed a grievance by telephone on 2/28/12 concerning her son's visit to the emergency room on [DATE]. The mother was upset that the physician wrote a prescription for an antibiotic that her son was allergic to which she had filled at her pharmacy. She was upset because the medication was listed as an allergy on his medical record. The mother received an acknowledgement letter on 2/29/12. She received a conclusion letter on 3/13/12. The letter stated that an investigation of her concerns revealed that the allergy was documented in the medical record and that the physician had ordered a derivative of that medication. An apology for the incident was conveyed to the mother. A courtesy write off of her balance owed to the hospital was also provided to offset the cost of her purchase of medication should could not use.

Interview with the pharmacist and the Risk Manager on 4/23/12 at 12:30 PM revealed that they could not confirm if a medication incident report was generated for these incident as they both did not have password access to the system. The pharmacist who has access to the system was out of state at a conference. The nursing Quality Assurance Manager who has access to the system was out on leave at the time of the survey.

Based on observation, record review and interview the facility failed to ensure that nursing services was provided appropriately during medication administration for 2 of 11 (#1 and #9) sampled patients.

Findings:

Reference A 404: Based on record review, interview and observation, the facility failed to follow the facility's policy and procedure regardin re-assessing 1 of 11 (#1) patients. The facility also failed to ensure the physician properly authenticated physician's verbal orders for 1 of 11 (#9) patients.

Reference A 405: Based on record review and interview the hospital failed to ensure that 1 (#1) of 11 patients reviewed received nursing assessments and a nursing re-assessment prior to discharging the patient from the facility.

Reference A 407: Based on observation and interview the hospital failed to ensure that verbal orders are authenticated by the physician for 1(#9) of 5 patients.

Based on record review, interview and observation, the facility failed to follow the facility's policy and procedure regardin re-assessing 1 of 11 (#1) patients. The facility also failed to ensure the physician properly authenticated physician's verbal orders for 1 of 11 (#9) patients.

Findings:

1. During record review for Patient #1 it was revealed that the patient arrived by ambulance to the hospital's emergency department on 4/4/12 at 1:35 AM with abdominal distention and complaining of leg pain. The patient stated that he had dental work performed the previous day. On 4/4/12 at 1:37 AM it is documented that the patient's vital signs are as follows: blood pressure: 104/53, temperature= 97.9 F, pulse= 111, respirations= 26 and oxygen saturation= 92%. It is documented that the patient was administered the following medication:

4/4/12 at 3:40 AM Benadryl 25 mg IVP (intravenous push). Response: No adverse drug reaction.

4/4/12 at 3:40 AM Reglan 10 mg IVP. Response: No nausea and vomiting.

4/4/12 at 3:40 AM Toradol 30 mg IVP. Response: No pain.

4/4/12 at 3:50 AM Potassium 40 MEQ (miliequivelents) by mouth. Response: No adverse drug reaction.

There are no other vital signs documented in the medical record. The words data erased is written on the area where vital signs are documented. On 4/4/12 at 6:40 AM the patient is discharged in the company of his wife.

Interview with the emergency room (ER) physician on 4/23/12 at 2:46 PM after reviewing the medical record stated that he treated Patient #1 on 4/4/12. He stated that the patient was in liver failure and is awaiting a transplant. He stated that the patient's blood sugar was 600, he had fever and chills and was 1+ jaundice. His liver enzyme tests were also high. He stated that the patient was hyponatremic, hypokalemic and tachycardia. He stated that the patient was given 40 of potassium for his low potassium levels. He stated that the patient had a history of migraines. He stated that in his practice he orders Reglan, toradol and Benadryl to treat migraines. He stated that this cocktail usually relieves the symptoms.

Interview with the spouse of Patient #1 on 4/23/12 at 10 AM she stated that her husband arrived by ambulance to the ER on 4/4/12. She stated that when the hospital discharged her husband from the ER he was lethargic. She stated that she took him to the VA hospital after 6 hours at home and no improvement in his sleepiness.

On 4/26/12 at 4:21 PM the Risk Manager stated that assessments are to be done every hour.

Review of the facility's policy (#1160) titled Standards of Patient Care in the Emergency Department implemented 8/09 on page 4 A. prior to transfer of a patient from the ER revealed Assessment of patient's current status.

2. Observation of medication administration for Patient #9 on 4/24/12 at 10:50 AM by RN #2 revealed that the nurse was at the pyxis machine and obtained Demerol 25 milligrams (mg). He stated that he received a verbal order from the physician. The surveyor then observed the nurse go to the nurse's station write the order on the sheet that had been signed by the physician prior to this order. He then went to the patient's bedside, identified the patient, and explained the medication. The nurse cleaned the IV port with alcohol and slowly administered the medication. The patient was complaining of pain on a scale of 8-9 of 10.

Interview with the Risk Manager (who was present during the medication observation) on 4/24/12 at 11 AM stated that she observed that the nurse wrote the order on a pre-signed order sheet prior to administration.

Interview with the pharmacist on 4/24/12 at 11:15 AM stated that it is up to the nurses to report medication errors.

Based on record review and interview the hospital failed to ensure that 1 (#1) of 11 patients reviewed received nursing assessments and a nursing re-assessment prior to discharging the patient from the facility.

Findings:

During record review for Patient #1 it was revealed that the patient arrived by ambulance to the hospital's emergency department on 4/4/12 at 1:35 AM with abdominal distention and complaining of leg pain. The patient stated that he had dental work performed the previous day. On 4/4/12 at 1:37 AM it is documented that the patient's vital signs are as follows: blood pressure: 104/53, temperature= 97.9 F, pulse= 111, respirations= 26 and oxygen saturation= 92%. It is documented that the patient was administered the following medication:

4/4/12 at 3:40 AM Benadryl 25 mg IVP (intravenous push). Response: No adverse drug reaction.

4/4/12 at 3:40 AM Reglan 10 mg IVP. Response: No nausea and vomiting.

4/4/12 at 3:40 AM Toradol 30 mg IVP. Response: No pain.

4/4/12 at 3:50 AM Potassium 40 MEQ (miliequivelents) by mouth. Response: No adverse drug reaction.

There are no other vital signs documented in the medical record. The words data erased is written on the area where vital signs are documented. On 4/4/12 at 6:40 AM the patient is discharged in the company of his wife.

Interview with the emergency room (ER) physician on 4/23/12 at 2:46 PM after reviewing the medical record stated that he treated Patient #1 on 4/4/12. He stated that the patient was in liver failure and is awaiting a transplant. He stated that the patient's blood sugar was 600, he had fever and chills and was 1+ jaundice. His liver enzyme tests were also high. He stated that the patient was hyponatremic, hypokalemic and tachycardia. He stated that the patient was given 40 of potassium for his low potassium levels. He stated that the patient had a history of migraines. He stated that in his practice he orders Reglan, toradol and Benadryl to treat migraines. He stated that this cocktail usually relieves the symptoms.

Interview with the spouse of Patient #1 on 4/23/12 at 10 AM she stated that her husband arrived by ambulance to the ER on 4/4/12. She stated that when the hospital discharged her husband from the ER he was lethargic. She stated that she took him to the VA hospital after 6 hours at home and no improvement in his sleepiness.

On 4/26/12 at 4:21 PM the Risk Manager stated that assessments are to be done every hour.

Review of the facility's policy (#1160) titled Standards of Patient Care in the Emergency Department implemented 8/09 on page 4 A. prior to transfer of a patient from the ER revealed Assessment of patient's current status.

Based on observation and interview the hospital failed to ensure that verbal orders are authenticated by the physician for 1(#9) of 5 patients.

Findings:

Observation of medication administration for Patient #9 on 4/24/12 at 10:50 AM by RN #2 revealed that the nurse was at the pyxis machine and obtained Demerol 25 milligrams (mg). He stated that he received a verbal order from the physician. The surveyor then observed the nurse go to the nurse's station write the order on the sheet that had been signed by the physician prior to this order. He then went to the patient's bedside, identified the patient, and explained the medication. The nurse cleaned the IV port with alcohol and slowly administered the medication. The patient was complaining of pain on a scale of 8-9 of 10.

Interview with the Risk Manager (who was present during the medication observation) on 4/24/12 at 11 AM stated that she observed that the nurse wrote the order on a pre-signed order sheet prior to administration.

Interview with the pharmacist on 4/24/12 at 11:15 AM stated that it is up to the nurses to report medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital was unable to demonstrate that administration errors and potential adverse drug reactions are immediately reported to the attending physician or the Quality Assurance Performance Improvement (QAPI) committee for 3 of 11 sample patients.

Findings:

1.) During record review for Patient #1 it was revealed that the patient arrived by ambulance to the hospital's emergency department on 4/4/12 at 1:35 AM with abdominal distention and complaining of leg pain. The patient stated that he had dental work performed the previous day. On 4/4/12 at 1:37 AM it is documented that the patient's vital signs are as follows: blood pressure: 104/53, temperature= 97.9 F, pulse= 111, respirations= 26 and oxygen saturation= 92%. It is documented that the patient was administered the following medication:

4/4/12 at 3:40 AM Benadryl 25 mg IVP (intravenous push). Response: No adverse drug reaction.

4/4/12 at 3:40 AM Reglan 10 mg IVP. Response: No nausea and vomiting.

4/4/12 at 3:40 AM Toradol 30 mg IVP. Response: No pain.

4/4/12 at 3:50 AM Potassium 40 MEQ (miliequivelents) by mouth. Response: No adverse drug reaction.

There are no other vital signs documented in the medical record. The words data erased is written on the area where vital signs are documented. On 4/4/12 at 6:40 AM the patient is discharged in the company of his wife.

Interview with the emergency room (ER) physician on 4/23/12 at 2:46 PM after reviewing the medical record stated that he treated Patient #1 on 4/4/12. He stated that the patient was in liver failure and is awaiting a transplant. He stated that the patient's blood sugar was 600, he had fever and chills and was 1+ jaundice. His liver enzyme tests were also high. He stated that the patient was hyponatremic, hypokalemic and tachycardia. He stated that the patient was given 40 of potassium for his low potassium levels. He stated that the patient had a history of migraines. He stated that in his practice he orders Reglan, toradol and Benadryl to treat migraines. He stated that this cocktail usually relieves the symptoms.

2.) During review of the grievance log it was noted that on 2/21/12 Patient #2 wrote a letter to the hospital concerning her ER visit on 2/19/12. She stated that she had laryngitis so she wrote her medical history including allergies on paper. She also was wearing a medic alert bracelet indicating her allergies were albuterol and codeine. She stated that she was administered albuterol in the ER by a named physician's assistant. She also stated that on her ER paperwork indicated that she did not have any allergies. On 2/21/12 an acknowledgement letter went out to the patient informing her that her concerns would be investigated. On 3/2/12 a follow-up letter was sent to the patient informing her of the hospital's findings. The letter stated that the ER physician and ER manager were investigated her concerns.

Interview with the pharmacist on 4/24/12 at 11:15 AM stated that it is up to the nurses to report medication errors.

3.) During review of the grievance log it was noted that on 2/15/12, Patient #3's daughter wrote a letter to the hospital concerning her mother's care in the ER on 2/14/12. The patient advocate wrote a letter on 2/15/12 apologizing for her mother's experience and acknowledging that her concerns would be investigated. On 3/13/12 the daughter received a letter from the hospital revealing that her mother received pain medication within 3 hours and fifty minutes apart from another pain medication. The letter stated that metabolism in the elderly can lead to prolonged sedation.

Review of the ER record for Patient #3 revealed that on 2/14/12 at 3:39 PM the patient arrived to the hospital's ER for abdominal pain and nausea. The patient home medication profile documented in the ER record does not indicate that she is on any medication. The physician documented that the patient had a history of gallbladder removal, appendix removal, and hysterectomy and colon surgery. On 2/14/12 the patient received the following medication:

2/14/12 at 2 PM normal saline per IV to increase hydration.

2/14/12 at 7 PM morphine 2 mg IVP (intravenous push). Response: decreased pain.

2/14/12 at 7 PM Zofran 4 mg IVP. Response: decreased nausea.

2/14/12 at 10:50 PM Dilaudid 1 mg IM (intramuscular). Response: no pain.

2/14/12 at 10:52 PM Maalox and donnatal 40 mg by mouth. Response: no pain.

The nurse documented on 2/15/12 at 12:55 AM attempting to give discharge instructions, patient very sleepy, unable to stand, physician informed. At 1:50 AM the patient was transferred to the 3rd floor for observation. On 2/15/12 at 8:52 AM the patient was discharged in the company of her daughter with the following new prescriptions: Protonix 40 mg once a day, Zofran 4 mg tablets one tablet three times a day and lobrax 5-2.5 mg one capsule three times a day.

Interview with the pharmacist on 4/23/12 at 3:30 PM provided the surveyor additional information concerning Dilaudid dosing. Dilaudid 1.5 mg is equivalent to Morphine 10 mg when given intravenously. When the pharmacist was asked if Patient #3 had an opiate naive response to the Dilaudid, he did not answer. He stated that Dilaudid 1 mg is considered a normal dose. Review of the patient's medication profile revealed that the patient was not on any opiates prior to admission to the hospital. Review of the information concerning Dilaudid dosing provided by the pharmacist revealed that precautions for intramuscular administration: variation absorption and a lag time to peak effect may result from IM use. Geriatric considerations: elderly may be particularly susceptible to the CNS (central nervous system) depressant and constipating effects of narcotics. Initial dosages of the drug should be in the lower end of the usual range. The usual range was documented as 0.8 mg-1 mg intramuscularly for opiate naive patients.

4.) During review of the grievances it was noted that the mother of Patient #4 filed a grievance by telephone on 2/28/12 concerning her son's visit to the emergency room on [DATE]. The mother was upset that the physician wrote a prescription for an antibiotic that her son was allergic to which she had filled at her pharmacy. She was upset because the medication was listed as an allergy on his medical record. The mother received an acknowledgement letter on 2/29/12. She received a conclusion letter on 3/13/12. The letter stated that an investigation of her concerns revealed that the allergy was documented in the medical record and that the physician had ordered a derivative of that medication. An apology for the incident was conveyed to the mother. A courtesy write off of her balance owed to the hospital was also provided to offset the cost of her purchase of medication should could not use.

Interview with the pharmacist and the Risk Manager on 4/23/12 at 12:30 PM revealed that they could not confirm if a medication incident report was generated for this incident as they both did not have password access to the system. The pharmacist who has access to the system was out of state at a conference. The nursing Quality Assurance Manager who has access to the system was out on leave at the time of the survey.