Mount Sinai Medical Center of Florida, Inc.

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33162 Based on observations, interviews, and review of records, the hospital failed to follow its own policies and procedures pertaining to (1) telemetry monitoring to ensure nursing staff were made aware of telemetry changes timely, including of lethal arrhythmias and asystole, for 1 of 5 Sampled Patients [Patient #1] for telemetry monitoring, culminating in that patient’s death and (2) Monitor Technician training for 6 of 7 Monitor Technicians (Staff A, C, D, E, F and G). The findings included: The hospital’s Policy and Procedure titled Telemetry Monitoring, 1.29.001, last revised 3/25/2025 documents, “Monitor Technician is responsible for: a. Continuously observe and analyze cardiac rhythms for multiple patients. b. Identify and document normal and abnormal heart rhythms, dysrhythmias, and ST segment changes. c. Promptly notify nurse, charge nurse, or the rapid response team of critical arrhythmias or changes in patient condition. d. Monitor telemetry alarms and ensure timely escalation of actionable alarms as described in Alarms Management policy. e. Follow hospital policy for telemetry alarm response and documentation....;” “RNs and monitor technicians must have successfully completed a course in ECG [electrocardiogram] arrhythmia interpretation, with a 100% passing rate of the ECG challenge exam initially and annually;” and under Telemetry Monitoring Alarm Escalation, for Alarm Classification: Crisis(High Priority), “Life threatening audible alarms includes arrhythmias such as: - Asystole [heart stops beating] - Ventricular tachycardia [irregular heartbeat that starts in the lower chambers of the heart and can be life-threatening] - Ventricular Fibrillation [life-threatening arrhythmia that causes lower chambers of the heart to quiver instead of pump blood] - Ventricular Bradycardia [slow ventricular heart rate, usually defined as less than 50 beats per minute] - If patient is off monitor or leads off for an unknown reason. - Respiratory [rate]>30-<10 Alarm - Apnea [not breathing] Alarm - SPO2 [peripheral oxygen saturation] Alarm less than 85% Color Code Visible: Red Tele Monitoring Alarm Escalation: Crisis(High Priority) --> The monitor tech (MT) will call the primary nurse (RN) or Patient Care Tech (PCT) immediately to check on the patient --> RN or PCT will have 1 minute to respond --> If the RN or PCT does not respond, the MT will call the charge nurse. --> If the charge nurse does not respond in one minute, the MT will call a Rapid Response for assistance;” and for Alarm Classification: Medium Priority or Warning, “An audible alarm for conditions such as noninvasive blood pressure and/or change in rhythm such as: - Pause 3 second or greater - 4 or more Premature Ventricular Contraction (PVC’s) in a row - Bigeminy - Trigeminy - Couplets - SPO2 Alarm less than 90% Color Code Visible: Yellow Tele Monitoring Alarm Escalation: Medium priority -->MT will calls Primary Nurse or PCT immediately. --> If NO response within two-minutes MT will call Charge Nurse --> If NO response within two- minutes call RRT [Rapid Response Team];” and for Alarm Classification: Low Priority Alarm or Technical Alarm, “Audible alert that is displayed as ST segment change in rhythm Visible trigger by the monitoring device: low battery. Color Code Visible: Blue Tele Monitoring Alarm Escalation: Low Priority -->MT calls Primary Nurse or PCT [Patient Care Technician] immediately --> If NO response within three - minutes MT will call Charge Nurse --> If NO response within two- minutes call RRT [Rapid Response Team] and “All calls pertaining to patient communication must be done with SNS [SafeNSound, software system that logs messages and calls].” [Brackets added for clarifications.] 1) Review of the medical record for Patient #1 reveals he was admitted to the hospital’s 7-Main unit on 03/15/2026 with fever and rapid heart rate for treatment of suspected systemic infection and had orders for cardiac telemetry monitoring. Further review of the record reveals a Code Blue was called for Patient #1 on 3/21/2026 at 4:08 AM and his initial cardiac rhythm at 4:10 AM was asystole (no electrical activity in the heart), a critical condition that leads to death within minutes if not treated promptly. Advanced Care Life Support was Initiated and resuscitation efforts continued until 4:24 AM but were unsuccessful and his death was declared at 4:36 AM. Review of Patient #1’s Telemetry records, including rhythm interpretations added by the Monitor Technicians, reveals the following: at 3:45 AM Patient #1 was in normal sinus rhythm; at 3:46:26 (hours:minutes:seconds) Patient #1 was in sinus tachycardia with a rate of 120; between 3:46 AM and 3:53 AM multiple rhythm strips showed sinus tachycardia with rates of 113 to 136; at 3:55 AM he had a 14-beat run of V-tach which triggers a loud, high priority and visible red alarm; at 3:56 AM and 3:57 AM his heart rate was 50 to 52 except for a 9 second pause, which would trigger an audible medium priority and visible yellow alarm; at 3:58 AM Junctional rhythm (indicating failure of the heart’s primary natural pacemaker) with depressed ST segment (which often indicates heart muscle damage); at 3:59 AM Junctional rhythm and Bigeminy PVCs, which would trigger an audible medium priority and visible yellow alarm; at 4:00 AM a heart rate of 17 to 36; from 4:01 AM to 4:04 AM a heart rate of 25 to 42; and a 5 second pause at 4:05 AM. Review of the Central Monitoring Unit video footage from an overhead camera on 03/21/2026 beginning at 3:40 AM revealed the following: At 3:40 AM the Monitor Technician (MT), Staff A who was responsible for telemetry monitoring on the 7-Main unit, where Patient #1 was located, was seated at his station (defined herein as a bank of four monitors surrounded by raised barriers) leaned back in his chair with his arms under a red blanket wrapped around him. At 3:41 AM, the Monitor Technician, Staff B seated next to him at the station for 4-Main was scrolling on a lighted screen device in front of her, sometimes looking up at the monitors in front of her and donned headphones for communicating with nursing staff by 3:56 AM. Staff B was not seen to look at Staff A or to his monitors. Staff A remained in the same position with his arms under the blanket until 4:01 AM, despite Patient #1’s lethal rhythm changes including medium and high-level alarms with visual and auditory cues. Staff A was not seen to respond to alarms for Patient #1’s tachycardia, the high-level alarm for V-tach (ventricular tachycardia, a life-threatening rhythm). During this time, the Lead Technician, Staff C, was observed to use a computer and printer directly behind Staff A beginning at 3:57 AM until giving Staff A some papers at 4:01 AM after he started moving around, without visible efforts to arouse him or direct his attention to the alarm or intervening to notify nursing herself to preserve life. From 4:03 AM to 04:04 AM Staff A seemed immobile as facing the right-hand screens in front of him, then leaned forward at 04:05 AM, and at 04:06 AM used the headset from the wall next to him. Twenty minutes elapsed between Patient #1’s initial rhythm change to sinus tachycardia at 3:46 AM and Staff A’s notification to the nurse, after several progressively worsening changes, at 4:06 AM. By the time the nurse reached the patient at 4:07 AM, the patient was pulseless. Resuscitative efforts were unsuccessful and Patient #1 expired. During a tour of the Central Monitoring Unit (CMU, which includes centralized telemetry monitoring) on 04/13/2026 at 4:48 PM, the Director of Special Programs (which include CMU) reported each Monitor Technician can watch up to 38 patients, that this is the limit that was decided upon since the CMU opened on 03/28/2023, and that she is considering getting an 11 PM to 7 AM MT and an 11 AM to 3 PM MT to cover breaks. Video review of the CMU on 04/12/2026 beginning at 1:00 AM and review of Q2H (Every 2-hour) Telemetry Checks for the morning of 4/12/26 revealed the following: The Lead Tech covered 61 patients with telemetry orders on the 7-Main and 4-Main units, all of whom were considered high acuity, from 2:05 AM to 3:07 AM while both MTs assigned to those areas were absent; MTs for the 8-Main and 5-Tower units covered each other’s breaks as well as their own assignments resulting in a workload of 49 patients to one MT from 2:04 AM until at least 2:54 AM and from 3:15 AM to 4:05 AM; MTs for the 7-Tower and 6-Tower units covered each other’s breaks as well as their own assignments resulting in a workload of 57 patients to one MT from at least 2:05 AM until 3:11 AM and from at least 3:32 AM to at least 4:31 AM; and one MT covered 43 pts for the 5-Main, 6-Blum, and 7-Blum units from at least 1:00 AM to at least 5:04 AM (the time reviewed). During an interview on 04/16/2026 at 12:24 PM, the Patient Safety Director and Cardiac Program Director reported their high acuity units are 7-Main, for postoperative cardiac surgery, neurosurgery patients and stroke overflow; 4-Main, a cardiac unit with stepdown beds that takes patients post PCIs (percutaneous coronary interventions); and 7-Tower, where open heart patients go after they leave the ICU as well as overflow patients post PCIs. 2) During an interview on 04/13/2026 at 4:48 PM the Director of Special Programs stated new Monitor Technicians (MTs) get an arrhythmia booklet when they start work; work with another MT for training; have 90 days to complete “competencies;” that she does 1:1 training with them asking them questions and giving scenarios; and that they can test out of training early if the preceptor or herself says they are ready and the new MT feels confident. Review of Staff A’s personnel file reveals they were hired as a Monitor Technician on 01/26/2026 and completed general orientation to the hospital. However, there is no evidence Staff A completed a course in arrhythmia interpretation. From the night of 3/20/2026 to the morning of 3/21/26 Staff A was responsible for telemetry monitoring for 30 to 31 patients on 7 -Main, a unit for cardiac surgery, neurosurgery, and overflow stroke patients that includes stepdown beds. During an interview on 04/14/2026 at 3:57 PM, the Director of Special Programs showed Staff A’s ECG quiz with a score of 95%, which she stated was proctored by herself. During further interview on 4/15/2026 at 4:25 PM, upon inquiry that Staff A was passed when his ECG test score was 95%, and not 100% as required according to the telemetry policies and procedures, the Director of Special Programs first stated she went over the test and explained it to him and he changed his answer but she forgot to change the grade and then, when questioned as to the significance of the test requirement of 100% to pass if she helps them correct their answers, she then denied helping him and said he changed his own answer. When asked about having Monitor Techs complete an ECG arrythmia course as required per the Telemetry Policy and Procedure, the Director of Special Programs denied the need for an outside course, talked about on-the-job training with other MTs and stated she knows her people, knows if someone is proficient or needs help, and that she is qualified to assess their competence to be on their own. 3) During an observation on 04/16/2026 at 4:15 PM, Monitor Tech, Staff G was observed in the Central Monitoring Unit at a station for units 6B-7B where one of the patient’s rhythms showed abrupt changes between differing rates and waveforms. When asked what was going on with that patient, Staff G expanded the view and selected a section of sinus arrhythmia and said the patient was in sinus arrhythmia. When asked to identify the breakthrough rhythm as pointing to that area, Staff G appeared confused and instead selected another similar section which he correctly identified as sinus arrhythmia with PVCs (premature ventricular contractions). Staff G was unable to identify or explain the breakthrough rhythm and did not ask a peer or the Team Lead, who was present but did not comment. The interview was terminated for patient safety, leaving the Team Lead with Staff G. During an interview on 04/16/2026 at 4:20 PM, Monitor Tech/Team Lead, Staff H stated Staff G has been working here as a Monitor Tech for about 5 months and at present is the newest MT in the room. During an interview on 4/16/2026 at 4:50 PM, Staff G was asked about his training for this job and reported he was given a handout and ECG book when he was hired, that he sat for training with other MTs who explained rhythms to him and how to use the equipment before he took a test after 5 or 6 weeks, described completing competencies with the Director of Special Programs as his reading, understanding, and signing off his part on the left and then her signing off her part, and did not report taking a course in arrhythmias. 4) Review of Staff C’s personnel file reveals she became a Monitor Technician on 4/26/2021 and became a Lead Monitor Technician on 02/20/2026. Although Staff C had yearly evaluations and competencies, no evidence was provided that she successfully completed a course in ECG arrhythmia interpretation as required per the hospital’s policy and procedures. 5) Review of Staff D’s personnel file reveals she was hired as a Monitor Technician on 10/06/2025, completed competencies by 11/17/2025 and had an undated ECG quiz in her file, but no evidence that she successfully completed a course in ECG arrhythmia interpretation. 6) Review of Staff E’s personnel file reveals he was hired as a Monitor Technician on 06/11/2018, became a Lead Monitor Technician on 10/02/2024, and that his most recently completed competencies in 2025 showed he can assess the competencies of others, but no evidence he successfully completed a course in ECG arrhythmia interpretation. 7) Review of Staff F’s personnel file reveals she was hired on 08/08/2023, most recently completed competencies on 08/10/2025, but no evidence she successfully completed a course in ECG arrhythmia interpretation.”