Kaiser Foundation Hosp So Sacramento

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 46237 Based on interview, and document review, the hospital failed to ensure policies and procedures designed to ensure safe, quality care for patients undergoing surgical interventions were adhered to for one (PT 1) of 30 sampled patients as evidenced by: 1. PT 1 was taken into the operating room (OR), sedated (given medication to reduce anxiety) and then PT 1’s surgery was cancelled when it was discovered the required personnel for the surgery was not available. 2. PT 1’s surgery cancellation was a near miss (an event or situation that could have resulted in harm but was caught in time and there was no patient harm) and it was not reported in a timely manner according to facility policy and procedure. These failures caused PT 1 anxiety due to a delayed surgery date for her lower back condition and the need to rearrage plans for post surgical care. Findings: 1. During an electronic medical record (EMR) review on 6/30/26 at 11:30 a.m. with the OR manager (ORM) and Quality Registered Nurse (QRN), PT 1’s EMR was reviewed. PT1’s history and physical, dated 5/6/26, indicated PT 1 was admitted on 5/6/26 for lower back surgery, a revision of “L 4/5 [lumbar, lower back, vertebrae 4 and 5] laminectomy [part or all of the bony arch of the vertebrae is removed], fusion and instrumentation [permanently joins two or more vertebrae],” which was scheduled for five hours of OR time by Surgeon 1 (S 1). PT 1’s anesthesia record, dated 5/6/26, indicated PT 1 entered the OR at 9:10 a.m., received sedation medication, and exited the OR at 9:48 a.m. A pre-op note, dated 5/6/26, at 9:46 a.m., by S1, indicated, “During time out [critical safety pause to ensure all required elements of the surgery are in place] no neuro monitoring in room [intraoperative neuromonitoring technologist - IONM - a person who safeguards a patient’s nervous system during complex surgeries by using specialized equipment to monitor nerve pathways in real time and immediately alert the surgeon to potential risks], nobody in OR confirmed they had arrived ...safest to proceed with IONM ...decision made to postpone to another day.” During a concurrent interview and document review on 6/30/26 at 11:30 a.m. with the ORM, PT 1’s SNAP board (a section of the EMR used by surgical services to list any special items needed for each patient’s surgery), dated 5/6/26, was reviewed. The SNAP board indicated, “Neuro Monitoring: yes.” The ORM stated the circulating nurse (a registered nurse who manages the overall environment and workflow of the OR) should check the SNAP board for every assigned surgical case to ensure all requested items and personnel are present and accounted for prior to bringing the patient into the OR. The ORM stated, “If something is missing from the request list on the SNAP board, the patient should not be taken to the OR until all requested items are present.” During an interview on 7/1/26 at 8:50 a.m. with S 1, S 1 stated neuromonitoring was requested for PT 1’s surgery and a neuromonitoring technologist had been confirmed by the facility. S 1 stated that during the time out it was discovered the neuromonitoring technologist was not present in the facility. The company that provides the technologist made a scheduling error and there was not another technologist available at the time. S 1 stated this was discussed with the patient and family in the recovery room who agreed to reschedule the surgery when a neuromonitoring technologist would be available. During an interview on 7/1/26 at 1 p.m. with the OR registered nurse (ORRN 1), ORRN 1 confirmed he was the assigned circulating nurse for PT 1 on 5/6/26. ORRN 1 stated PT 1’s surgery was scheduled to have neuromonitoring present for the procedure. ORRN 1 stated that S 1’s preference card (details all the specific items the surgeon requests for a specific surgical procedure) for PT 1’s surgery indicated neuromonitoring needed. ORRN 1 confirmed the neuromonitoring request was listed on the SNAP board for PT 1. ORRN 1 stated he assumed the neuromonitoring technologist was present at the facility. It was discovered that the neuromonitoring technologist was not present when S 1 started the time out in the OR. ORRN 1 called the front desk and confirmed there was no technologist available for PT 1’s surgery. ORRN 1 acknowledged he should have confirmed the technologist was present prior to bringing PT 1 into the OR. During a phone interview on 7/1/26 at 4:13 p.m., PT 1 stated she was very upset when her surgery was cancelled after being prepared and brought into the OR. She found it hard to reschedule her surgery, which caused anxiety because she needed to rearrange post-surgical home care and pet care plans. During a record review of the facility’s and procedure (P&P) titled, “Administrative Directives within Peri-Operative Services,” dated 4/8/26, the P&P indicated, “The Peri-Operative nurse [specialized in caring for patients before, during and after surgery]plans for the care of the patient using the standards for patient care. Information from the type of procedures, physician preference cards, history and physicals, and previous nursing assessments are used to formulate an individualized care plan ... Physician Preference cards are used to identify the needed supplies and equipment for each procedure. The Preference Card is to be reviewed prior to the surgical case.” 2. During an interview on 6/30/26 at 11:30 a.m. with the Director of Accreditation, Regulatory and Licensing (Dir ARL), the Dir ARL stated an Electronic Responsible Reporting Form (ERRF-the facility’s event reporting system) was not entered into the system for the cancelled surgery of 5/6/26. Dir ARL stated this was an elective (not an emergency) case and there was no harm to PT 1, so an ERRF did not need to be put into the system at the time of service. During an interview on 7/1/26 at 1 p.m. with ORRN 1, ORRN 1 stated an electronic event report was not submitted following the cancellation of PT 1’s surgery, since this was not considered a near miss, and there was no harm to the patient. ORRN 1 acknowledged that if they had not checked to make sure the neuromonitoring technologist was missing, PT 1 would have gone through all the steps to get ready for surgery, such as receiving anesthesia and being placed on a surgical table. During an interview with the ORM on 7/2/26 at 8 a.m., the ORM stated he called PT 1 on 5/7/26 to apologize for the cancellation. The ORM went on to state that he did not enter an ERRF regarding PT 1’s cancellation. During a review of the facility’s P&P titled, “Responsible Reporting of Medical Errors, Adverse Events, and Near Misses,” dated 10/1/24, the P&P indicated, “Every patient has the right to care that is safe, effective, and reliable. It is the responsibility of every leader, employee, and physician to continue to build safer systems to ensure patient safety ...Report all medical errors, adverse events and near misses so that systems and processes can be improved to prevent future events ...Definitions - For Purposes of this Policy ...Near Miss: Any event that did not result in patient injury (either by chance, through timely intervention, or due to robustness of the patient) OR the event or error did not reach the patient ...The employee, physician or contracted staff who witnessed, discovered, or is most familiar with the event will complete an ERRF as soon as feasible.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50121 Based on interview and record review, the hospital failed to ensure the protection of patient rights when: 1. Nine of 23 sampled patients (Patients 3, 4, 5, 14, 23, 24, 26, 27, and 28) with Medicare benefits (a federal health insurance program) did not receive, within the required timeframes, the “Important Message from Medicare” notice informing them of their rights as patients to appeal a hospital’s decision to discharge and express concerns about completeness their care (refer to A-0117), and 2. Two of 5 (Patients 9 and 25) sampled patients who were in restraints (physical devices used to limit a patient’s movement or behavior for medical purposes to prevent injury or harm) did not have documentation of restraint use included in their plan of care (refer to A-0166). These failures had the potential for patients and providers not to effectively communicate about patients’ care putting patients at risk for harm and care not consistent with their wishes. The cumulative effects of these failures resulted in the inability of the hospital to comply with the statutory mandated Condition of Participation for Patient Rights.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50121 Based on interview and record review, the facility failed to inform patients of their rights as Medicare beneficiaries (federal health insurance program) to appeal hospital discharge when: 1. Two of 23 patients with Medicare benefits (Patient 3 and Patient 24) did not receive the “Important Message from Medicare” (IMM- an appeal process where you can dispute a hospital’s decision to discharge from the hospital) within two days of admission, and 2. Seven of 23 Medicare patients (Patients 4, 5, 14, 23, 26, 27, and 28) did not receive IMM within two days of discharge. These failures resulted in Medicare beneficiaries not receiving timely information of their rights as hospital in-patients and their right to appeal hospital discharge and had the potential to result in delay in reporting their concerns about the quality and completeness of their care while hospitalized. Findings: 1. During a review of Patient 3’s History and Physical (H&P), dated 2/11/25, the H&P indicated Patient 3 was admitted to the hospital on 2/11/25 with syncope (sudden, temporary loss of consciousness caused by insufficient blood flow to the brain). The H&P indicated Patient 3’s medical history included alcohol use disorder (pattern of alcohol use that involves problems controlling drinking or continuing to use alcohol even when it causes problems). In a concurrent interview and record review, on 4/16/25, at 1:50 p.m., with Revenue Cycle Manager (RCM), Patient 3’s admission documents were reviewed. RCM stated Patient 3 had admission orders written 2/11/25 and had no record of receipt of IMM until 2/14/25. RCM stated Patient 3 “did not receive IMM within two days of admission as required.” A record review of Patient 24’s H&P, dated 3/13/25, indicated this patient had a diagnosis of dementia (progressive loss of brain functions including memory, language, problem-solving and changes in mood, behavior including increased irritability, agitation, or withdrawal) and arrived at the emergency department for evaluation of an unwitnessed fall. According to the H&P, Patient 24 was not able to provide history, was mumbling and crying. An x-ray was done and noted a broken hip bone. In a concurrent interview and record review, on 4/17/25, at 9:17 a.m., with the Coordination of Care Service Director (CCSD), the CCSD could not locate evidence that Patient 24 was provided with the IMM notice at time of admission. CCSD stated despite being a short admission, an initial IMM notice is required; however, it appeared to be missing. 2. During a review of Patient 4’s H&P, dated 3/3/25, H&P indicated Patient 4 presented to the hospital on 3/3/25 with confusion and disorientation. The H&P indicated Patient 4’s medical history included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), and a previous cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). Patient 4’s medical record (MR) indicated, after a period of observation, Patient 4 was admitted as an in-patient to the hospital on 3/4/25. In a concurrent interview and record review, on 4/16/25, at 2:10 p.m., with CCSD, Patient 4’s MR was reviewed. CCSD stated care coordination staff needed to deliver an additional IMM to Medicare patients within two days of discharge if discharge was greater than two days after receiving the initial message. CCSD confirmed the physician placed an order to discharge Patient 4 on 3/8/25 and stated there was no evidence in the MR that Patient 4 received the IMM within two days of the discharge order as required. During a review of Patient 5’s H&P, dated 3/11/25, the H&P indicated Patient 5 presented to the hospital on 3/11/25 with progressive fatigue and shortness of breath. H&P indicated Patient 5’s medical history included COPD, CHF, and peripheral vascular disease (a slow progressive narrowing of the blood flow to the arms and legs). Patient 5’s MR indicated, after a period of observation, Patient 5 was admitted as an inpatient to the hospital on 3/14/25. In a concurrent interview and record review, on 4/16/25, at 2:10 p.m., with CCSD, Patient 5’s MR was reviewed. CCSD stated the physician placed an order to discharge Patient 5 on 3/25/25 and stated there was no evidence in the MR that Patient 5 received the IMM within two days of the discharge order. During a review of Patient 14’s H&P, dated 2/11/25, the H&P indicated Patient 14 presented to the hospital on 2/11/25 with leg pain after a fall. The H&P indicated Patient 14’s medical history included kidney failure (body organ that filters waste and extra fluid from your blood no longer works). Patient 14’s MR indicated, after a period of observation, Patient 14 was admitted as an inpatient to the hospital on 2/12/25. In a concurrent interview and record review, on 4/16/25, at 2:10 p.m., with CCSD, Patient 14’s MR was reviewed. CCSD stated the physician placed an order to discharge Patient 14 on 2/18/25 and stated there was no evidence in the MR that Patient 14 received the IMM within two days of the discharge order. A record review of Patient 23’s H&P, dated 3/8/25, noted Patient 23 had stomach cancer and was on chemotherapy (medication used to treat cancer)> Patient 23 was evaluated in the emergency department and noted to have an inflamed lower gut and a hole in the stomach. During concurrent record review and interview with Quality Nurse Consultant (QNC), on 4/16/25, at 11:12 a.m., QNC stated the physician discharge order for Patient 23 was written for 3/16/25 at 1:30 p.m. and no follow-up IMM notice was found in Patient 23’s medical records. On 4/17/25 at 9:17 a.m., concurrent interview and record review of Patient 23’s scanned medical documents with CCSD verified the follow-up IMM notice was not present. CCSD stated the follow-up IMM should be given to patients at time of discharge. A record review of Patient 26’s H&P, dated 3/12/25, noted Patient 26 arrived at the emergency department on 3/12/25, at 6:06 a.m., due to a fall and loss of consciousness. This patient had a history of diabetes, (a disorder characterized by difficulty in blood sugar control and poor wound healing), CVA, multiple cancers, and high blood pressure. Patient 26 was diagnosed and treated for a urinary tract infection (bacteria enters the opening to the body’s drainage system for removing urine). A physician discharge order for Patient 26 was written for 3/16/25, at 2:45 p.m. On 4/17/25, at 9:41 a.m., during a concurrent record review of Patient 26’s MR and interview with CCSD, no follow-up IMM notice was found. CCSD stated patients should receive a follow-up IMM notice prior to discharge; however, no IMM can be found for Patient 26. A record review of Patient 27’s discharge summary physician note, dated 3/23/25, indicated Patient 27 had previous tobacco smoking and unhealthy alcohol drinking. Patient 27 reportedly slipped off her wheelchair and fell on her left side. Patient 27 was admitted on 3/18/25 as an in-patient for a hip and leg bone breaks in three or more pieces. On 4/17/25, at 9:17 a.m., during a concurrent record review of Patient 27’s MR and interview with CCSD, the record indicated a physician discharge order was written for 3/23/25, at 1:00 p.m. The CCSD confirmed the record only contained a receipt of the IMM at time of admission on 3/19/25, and there was not a receipt of a follow-up IMM notice given within two days of discharge. CCSD confirmed this notice was required. A record review of Patient 28’s H&P, dated 3/18/25, noted Patient 28 was brought to the emergency department after he was found unconscious. In the emergency department, he was found to have low levels of oxygen and an irregular heartbeat. On 4/17/25, at 9:41 a.m. during concurrent record review of Patient 28’s MR and interview with CCSD, the physician discharge order indicated to discharge patient home on 3/22/25 at 11:30 a.m. CCSD stated there was no follow-up IMM notice in the MR. CCSD stated patients should receive a follow-up IMM notice prior to discharge; however, no IMM can be found for Patient 28. In a review of facility policy and procedure (P&P) titled, “CMS [Center for Medicare Services] Important Message NCAL [Northern California] Regional Policy”, dated 1/8/25, P&P indicated “When a Medicare patient presents at the hospital for inpatient admission, the Admitting Department will provide the patient with a copy of the ‘Important Message’. ...The ‘Important Message’ can be completed at the time of admission or ...if no one is available at the time of admission, the Admitting Staff will continue to try and obtain a signature within 2 calendar days of admission. ...Follow-up copy of the Important Message: If the patient is in the hospital for more than 2 calendar days after receiving the notice, the patient must again be presented with the notice as far as possible but no more than 2 calendar days prior to discharge.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 50121 Based on interview and record review, the facility failed to follow its policy and procedures to initiate and document restraint use (physical devices used to limit a patient’s movement or behavior for medical purposes) in patient care plans for two of five sampled patients in restraints, (Patient 25 and Patient 9). This failure precluded members of the healthcare team from having necessary information on which to base clinical decisions in a timely manner and had potential to put Patient 25 and 9 at risk for errors and harm made by providers who relied on the content of these records for care decisions. Findings: In a review of Patient 25’s History and Physical (H&P), dated 4/7/25, the H&P indicated Patient 25 arrived at the emergency department with altered mental status (confusion), generalized weakness after falling in the bathroom, and unknown head trauma (injury to scalp, skull, or brain caused by an external force). Patient 25 was unable to recall the reason he was brought to the hospital. Patient 25 was admitted to the Intensive Care Unit (ICU). In a review of an ICU RN (Registered Nurse) End-of-Shift Team Note, dated 4/7/25, the Note indicated as day progressed, Patient 25 became more confused, attempting to climb out of bed, and staff was unable to re-direct patient. Review of physician order, dated 4/9/25, indicated mitten restraints ( a glove-like device used to cover the hand to prevent patient’s from dislodging medical equipment) ordered to both hands due to Patient 25 pulling out intravenous (IV) line (tubing inserted to the patient’s in which fluids and medications are administered to patient via their blood vessels) and dressings (gauze material to cover up wounds and/or IV lines). On 4/17/25, at 8:56 a.m., during concurrent interview and record review of Patient 25’s care plan records, the Quality Nurse Consultant (QNC) was unable to locate documentation for use of restraints in Patient 25’s care plan records. QNC confirmed restraint usage was not documented in the care plan and should be according to policy and procedure. In a review of Patient 9’s H&P physician progress record, dated 2/2/25, H&P indicated Patient 9 was injured in a boating accident resulting in a cervical-7 fracture (broken neck bone) and a subarachnoid hemorrhage (a brain injury associated with bleeding in the spaces between the brain and the tissue surrounding the brain). On 2/2/25, a physician’s order was written for right wrist soft limb restraint (a cuff and strap device used to restrict the movement of the patient’s arm) due to pulling at IV line and pulling at dressings. On 4/17/25, at 8:56 a.m., during concurrent interview and record review of Patient 9’s care plan records with QNC, QNC was unable to locate documentation for use of restraints in Patient 9’s care plan records. QNC confirmed restraint usage was not documented in the care plan and should be according to policy and procedure. A review of the facility policy and procedure (P&P) titled, “Restraints NCAL [Northern California] Regional Policy,” dated 12/6/23, indicated, “Documentation Requirements: When restraint is used, there must be documentation in the patient’s medical record of the following:... The use of a restraint shall be reflected in the patient’s plan of care or treatment plan ...””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45882 Based on interview and record review, the hospital failed to ensure an organized nursing service that provided safe patient care for one of 20 sampled patients (Patient 1) when: A. Staff failed to follow a policy and procedure for the continuous maintenance and monitoring of audible clinical alarms when the continuous pulse oximetry (SPO2T, a method of detecting and monitoring oxygenation, used to detect sudden changes in a patients clinical status and is useful for early detection low oxygen levels) audible alarm was turned off (silenced) for Patient 1, and staff did not respond to Patient 1’s drop in oxygen level for 43 minutes. Refer to A0398. This failure resulted in a delay in care and treatment, which subsequently resulted in Patient 1’s death. The cumulative effects of this problem resulted in the inability of the hospital to comply with the statutorily mandated Condition of Participation for Nursing Services.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45882 Based on interview, record review, and facility policy and procedure review, the hospital failed to ensure staff followed a policy and procedure for the continous maintenance and monitoring of clinical alarms when the continuous pulse oximetry (SPO2T, a method of detecting and monitoring oxygenation, used to detect sudden changes in a patients clinical status and is useful for early detection low oxygen levels) audible alarm was turned off (silenced) for one of 20 sampled patients (Patient 1), and staff did not respond to Patient 1’s drop in oxygen level for 43 minutes. This failure resulted in a delay in care and treatment, which subsequently resulted in Patient 1’s death. Findings: During a review of Patient 1’s clinical record titled, “History and Physical” (H&P), dated 10/5/2024, the H&P indicated Patient 1 was admitted to the hospital due to shock (critical condition brought on by the sudden drop in blood flow), chronic respiratory failure (history of breathing difficulty), pneumonia (an infection in the lungs), and encephalopathy (disturbance in brain function). During a review of Patient 1’s clinical record titled, “Orders”, dated 10/07/2024, at 11:05 a.m., the physician order indicated, “MEASURE CONTINUOUS PULSE OXIMETRY [SPO2T].” During a review of Patient 1’s pulse oximetry clinical log, dated 10/10/2024, at 9:35 p.m. and 10 seconds, the clinical log indicated, “Patient transferred from 2108,” which meant Patient 1 was transferred from the Intensive Care Unit to the 4 South Medical Telemetry Unit. During a review of Patient 1’s pulse oximetry clinical log, dated 10/10/2024, at 9:35 p.m. and 13 seconds, the clinical log indicated, “SpO2T - [audible] Alarms ON.” During a review of Patient 1’s pulse oximetry clinical log, dated 10/10/2024, at 9:44 p.m. and 51 seconds, the clinical log indicated, “SpO2T - Alarms from On to Off [silenced].” During a review of Patient 1’s “Strip Report,” dated 10/10/2024, the Strip Report indicated a continuous recording of Patient 1’s heart rate, heart rhythm, and oxygen level (SPO2T). The first recording of Patient 1’s SpO2T was at 10:26 p.m. and 8 seconds and indicated 100% (normal oxygen saturation range from 92% to 100%) and the heart rate (HR) was 86 beats per minute (normal heart rate range from 60 to 100 beats per minute). On 10/11/2024 at 2:36 a.m. and 6 seconds, the SpO2T was recorded at 84% and the HR at 90 beats per minute. At 2:54 a.m. and 55 seconds, the SpO2T was recorded at 20% and the HR at 93 beats per minute. At 3:18 a.m. and 45 seconds, the SpO2T was recorded at 24%, the HR at 63 beats per minute, and a note indicating “...RN notified.” At 3:19 a.m. and 19 seconds, the SpO2T was recorded at 18% and the HR at 22 beats per minute, which was 43 minutes from the initial recording of Patient 1’s drop in SpO2T at 2:36 a.m. and 6 seconds. During a review of Patient 1’s clinical record titled, “IP [inpatient] Nursing,” dated 10/11/2024, at 4:02 a.m., Registered Nurse (RN) 1 indicated, “Late entry or 0319 [3:19 a.m.] ...monitor tech [Name], called me to check on this patient for low HR. Upon entering room, patient was unresponsive and high flow O2 (oxygen) in patients hand ...attempts to stimulate patient were ineffective. Patient had a very weak heart rate and overhead [paged] RRT [rapid response team, a team that responds to situations in a hospital when patients need immediate care]...heart rate was 37 at 0322 [3:22 a.m.].” During a review of Patient 1’s clinical record titled, “Rapid Response Team Activation,” dated 10/11/2024, at 4:47 a.m., the clinical record indicated, “Responded to overhead. Patient unresponsive, on High Flow Nasal Cannula [oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 60 liters per minute], No respirations, No pulse. Asystole [no heart beat] on monitor. Partial code status [medical directive that indicates what resuscitation procedures can be performed for a patient]. Medical Doctor [name] arrived to bedside. Will pronounce patient [legal time of death] at time of Rapid Response Team call”. During a review of Patient 1’s clinical record titled, “Death Summary,” dated 10/11/2024, at 12:26 p.m., the clinical record indicated, “[Patient 1] had acute desats [decrease in blood oxygen levels] and bradycardia [decrease in heart rate] resulting in cardiac arrest [heart suddenly stops beating]. She had elected against chest compressions [the act of pushing down on the center of a person’s chest with your hands to help blood flow and restore breathing], or shocks [the delivery of electrical current to the heart to restore electrical activity]. Her time of death 3:27 a.m.” During a phone interview on 12/3/2024, at 12 p.m., with Monitor Tech (MT) 1, MT 1 stated she was assigned to the centralized monitor station for all patients on cardiac and pulse oximetry monitors. MT 1 confirmed Patient 1 was on continuous pulse oximetry as well as cardiac monitoring. MT 1 stated she did not see or hear any changes in Patient 1’s pleth (a visual indicator on a monitor of a patient’s blood flow and pulse, which may be used to measure oxygen saturation). MT 1 stated, “[On 10/11/24] Around 3:20 [a.m.], [Patient 1’s] heart rate started dropping and the alarm sounded ...[Name of nurse] was nearby ...asked him to check the patient.” MT 1 further stated, “If I don’t see or hear alarms ...I can’t escalate”. MT 1 stated, “All alarms were default to always be on ...we don’t turn off or change alarms.” During a phone interview on 12/3/2024, at 2:10 p.m., with RN 2, RN 2 stated, on 10/11/2024, during the incident with Patient 1, she was assigned as charge nurse on 4 South. RN 2 stated she was in the hallway and glanced up at one of the monitor screens and observed Patient 1’s heart rate in the 30’s and dropping. RN 2 stated she responded by going to Patient’s 1 room, and found staff present, medical treatment was provided according to physician orders and facility policy. RN 2 stated Patient 1 was pronounced dead by the MD. RN 2 stated, “After the incident, I wanted to look at [Patient 1] monitor history and noticed the [pulse oximetry] alarm was turned off.” RN 2 stated the facility policy was to never turn off alarms. During an interview on 12/4/2024, at 9:18 a.m., with Nurse Manager (NM) 1, NM 1 stated she was the manager for the monitor technicians. NM 1 stated staff should not turn off clinical alarms, and Patient 1’s pulse oximetry monitor alarm should not have been turned off. During an interview on 12/4/2024, at 1:38 p.m., with NM 2, the facility policy and procedure (P&P) titled, “Clinical Alarms,” dated 5/2/2023 was reviewed. NM 2 stated, “The expectation was for staff to follow facility policy, [Patient 1’s] pulse oximetry monitor alarm should not have been turned off.” Review of the facility P&P titled, “Clinical Alarms,” dated 5/2/2023, indicated, “Pulse Oximeter Alarm: 5.7.3 Staff shall not “turn off” these alarms”.”