South Florida Baptist Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36678 Based on record review, interviews, policy review, and observation it was determined the hospital failed to ensure life saving measures were activated in a timely manner for one patient (#1) during a heart attack, resulting in the death of Patient #1, and the hospital failed to ensure continuous cardiac telemetry monitoring for 75 patients on cardiac telemetry monitoring. Refer to A0144 Patient Rights, Care in a Safe Setting. The facility provided an Immediate Jeopardy removal plan on 07/10/2025. The immediacy was determined to be removed 5:08 PM on 07/10/2025. The actions included: 1. Immediate Containment: Safety Tip- Provider notification of changes cardiac condition 2. Immediate Containment: Team Resources review/Peer Review 3. Review and Revise SFBH- NUR-124 STEMI Alert policy 4. Educate all inpatient nursing units on revised STEMI alert process, chain of command and STEMI case study 5. Review and Revise the STEMI Activation process 6. New hire education (RNs) r/t STEMI Alert policy and the STEMI Activation process 7. CMU Responsibilities attestation 8. Central Monitoring Unit break coverage The signatures and education were reviewed and interviews conducted with 13 nurses to verify education received.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 36678 Based on record review, observation, interviews, and policy review the hospital failed to oversee the effectiveness of process improvement for ensuring the safety of patients on continuous telemetry monitoring, resulting in death for Patient #1, after a similar occurrence in April 2025. Refer to A0286. The facility provided an Immediate Jeopardy removal plan on 07/10/2025. The immediacy was determined to be removed 5:08 PM on 07/10/2025. The actions included: 1. Immediate Containment: Safety Tip- Provider notification of changes cardiac condition 2. Immediate Containment: Team Resources review/Peer Review 3. Review and Revise SFBH- NUR-124 STEMI Alert policy 4. Educate all inpatient nursing units on revised STEMI alert process, chain of command and STEMI case study 5. Review and Revise the STEMI Activation process 6. New hire education (RNs) r/t STEMI Alert policy and the STEMI Activation process 7. CMU Responsibilities attestation 8. Central Monitoring Unit break coverage The signatures and education were reviewed and interviews conducted with 13 nurses to verify education received.”

“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: 36678 The facility failed to ensure all patients on telemetry were continuously monitored and failed to ensure the staff were aware of the STEMI (ST elevation myocardial infarction,a severe type of heart attack characterized by a complete blockage of a coronary artery, leading to significant oxygen deprivation and potential damage to the heart muscle) process. Failure to inform staff of the STEMI process was associated with the death of Patient #1. Refer to A0396. The facility provided an Immediate Jeopardy removal plan on 07/10/2025. The immediacy was determined to be removed 5:08 PM on 07/10/2025. The actions included: 1. Immediate Containment: Safety Tip- Provider notification of changes cardiac condition 2. Immediate Containment: Team Resources review/Peer Review 3. Review and Revise SFBH- NUR-124 STEMI Alert policy 4. Educate all inpatient nursing units on revised STEMI alert process, chain of command and STEMI case study 5. Review and Revise the STEMI Activation process 6. New hire education (RNs) r/t STEMI Alert policy and the STEMI Activation process 7. CMU Responsibilities attestation 8. Central Monitoring Unit break coverage The signatures and education were reviewed and interviews conducted with 13 nurses to verify education received.”

“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: 36678 Based on record review, interviews, policy review, and observation, the hospital failed to ensure: 1. a change in rhythm and notify a cardiologist for 1(patient #1) of 2 sampled, resulting in the death, and 2. the cardiac telemetry monitors were continuously monitored for 75 of 146 patients on continuous telemetry monitoring. Findings included: 1. Review of Patient #1 medical record revealed he came to the hospital ED (Emergency Department) on 06/15/2025 for a chief complaint of shortness of breath for a week. He had a past medical history of CHF (congestive heart failure), cardiac stent, atrial fibrillation (A-fib), and pericardiectomy (open heart surgery to remove part of the sac surrounding the heart). While Patient #1 was in the ED, cardiac enzymes (Troponins-a biomarker to assess and detect heart muscle damage), were obtained, and were: 10:13 AM 773, 12:45 1285, 3:08 PM 2636. Patient #1 was started on a heparin drip (heparin is a blood thinner) and admitted to the PCU (progressive care unit) on cardiac telemetry monitoring, with plans to perform a cardiac catheter the next morning. At 2:38 AM on 06/16/2025 the RN (registered nurse) noted ST elevation (an upward deviation of the ST segment indicating myocardial ischemia-a heart attack where a coronary artery is completely blocked) on the cardiac monitor. The RN obtained an ECG (electrocardiogram-a test that measures the heart’s electrical activity) and confirmed there was ST elevation. The RN then called the on-call APRN (Advanced Practice Registered Nurse). APRN notified the hospitalist who was in the ED at the time. The hospitalist gave an order to continue the current treatment plan. At 03:12 AM the monitor technician called to report the ST elevation. There was no further action documented until 03:39 AM when the RN noted Patient #1 was lethargic and had a change of rhythm. CPR (cardiopulmonary resuscitation) was started. At 03:48 AM, ROSC (return of spontaneous circulation) was achieved. Patient #1 continued to have rhythm changes with loss of his pulse 2 more times. The on-call interventional cardiologist was paged for a STEMI (ST elevated MI-myocardial infarction-heart attack). At 04:43 AM, Patient #1 was then taken to the Catheter Lab on a Lucas device (a device that provides automated chest compressions during CPR). An Impella was placed (Impella is a ventricular assist device that helps the heart pump blood), and a cardiac catheterization was performed. The interventional cardiologist found a thrombus (blood clot) in the LAD (left anterior descending) artery with stenosis (constriction) of the middle LAD and total occlusion (blockage) of the distal LAD. The interventional cardiologist proceeded with PCI (percutaneous coronary intervention) with balloon angioplasty (a procedure to open the vessels). Patient #1 was placed on full life support and transported by air to [another hospital] and expired 2 days later. During a telephone interview on 07/09/2025 at 4:25 PM, Staff C, RN stated she notified the charge nurse first to see who to call. Staff C, RN then called the APRN . The APRN said she was looking at the EKG, and she would call back. The APRN spoke to Staff A, MD and acknowledged they were seeing the same thing, and to continue the current treatment plan on heparin with plans to cath (cardiac catheterization) the next morning. Patient #1 was complaining of back pain 3 out of 10. He had a history of back surgeries. She said when she saw the ST elevation she checked on him and he was asymptomatic. Staff C, RN got the EKG and called the provider. He coded (respirations and pulse stopped) about an hour after that happened. Staff C, RN stated she did not notify anyone else; she said she notified the charge nurse and the hospitalist. She updated the charge nurse on what the hospitalist said. Staff C. RN said she was not aware of the policy for STEMI at all and that is why she notified the charge nurse. During a telephone interview on 07/09/2025 at 7:39 PM, Staff E, CNC (charge nurse) stated the patient came in a with a non-STEMI and cardiology was aware. Staff C told me and the on-call cardiologist answering center about the ST elevation. Staff C did not speak to the cardiologist; she spoke to Staff A, MD. Staff A, MD called cardiology, it was doctor to doctor communication. Patient #1 was stable; he never complained of chest pain. The plan was medication and monitor. Patient #1 just changed very quickly and drastically. During a telephone interview on 07/09/2025 at 6:30 PM, Staff B, APRN stated she did not speak to a cardiologist. The nurse called and said the MT (Monitor Technician) called and noticed some ST elevation. They woke Patient #1 up to do a 12 lead EKG. Patient #1 came in with elevated troponins and was placed on a heparin drip. They spoke to the cardiologist when he was in the ED, he was aware of the troponins and wanted him on a heparin drip and to take aspirin with plans to do a catheterization in the morning. The patient was asymptomatic. Staff B, APRN stated she printed out the EKG. Patient #1 went from a left bundle block (a heart condition where electrical signals are delayed or blocked as they travel through the heart’s conduction system, specifically the right or left bundle branches) to a right bundle block. He was asymptomatic. Vital signs were stable. Staff B, APRN said she called Staff A, MD who is her supervisor. Staff A, MD reviewed the EKG and his labs and said we can keep doing what we are doing, because he is on heparin, aspirin and is having a cardiac cath in the morning. Staff B, APRN said she does not think Staff A, MD spoke to cardiology. About an hour later Patient #1 coded. The floor will usually call the cardiologist and send the 12-lead to the cardiologist. Cardiology then tells them whether to do a STEMI alert. During a telephone interview on 07/10/2025 at 8:35 AM, Staff A, MD stated she did not call a cardiologist. Staff B,APRN was notified. Staff A, MD then said she was admitting other patients and talking to the ED physician about them when Staff B, APRN brought 2 EKGs to her. The first was A-fib with RVR (rapid ventricular response). The second was left heart block. No EKG was obtained between the first and second. The second EKG showed right incomplete bundle branch block. Patient #1 was on a heparin drip and was stable and sleeping. It could indicate PE (pulmonary embolus) or LAD ischemia. He had a cardiac cath scheduled in the morning. While she was on her way upstairs to see the first patient who was admitted, the code was called. The LAD was blocked with a thrombus. He should have went to cath lab from the ED. He might have had a chance. He had a poor chance of survival because of his history. His cardiac indicator was 10. He was very, very high risk. He had very advanced cardiac disease. During an interview on 07/10/2025 at 11:14 AM, Staff J, cardiologist stated he was not complaining of chest pain, he was hemodynamically stable, no ST changes, and he received Eliquis the night before, and that made him very high risk for any invasive procedure unless it is emergent. Staff J, cardiologist said he would expect to be notified if there were changes in their cardiac rhythm. He said he also expects that when telemetry is ordered, it is continuously monitored. During an interview on 07/10/25 at 3:20 PM, the supervisor of risk management stated the patient came in on June 15th with for shortness of breath. He was admitted for non-STEMI. He went to a tele unit; PCU (progressive care unit). His outside cardiologist had been consulted. They did serial troponins on him, which were not good; over 700, 1500, 2000 something. His cardiologist was aware of the troponins and that the patient was on Eliquis. The plan was to take him to cath the next morning. His vital signs were stable. He was on room air and doing ok. At 2:30 AM when the nurse was charting she notice he had ST elevations. He was supposed to have another EKG in the morning, so she just went ahead and did the EKG. When she saw it, her interpretation was that it was a STEMI. She was concerned but is a newer nurse. At this point she had not received a call from CMU, and she was upset about that. She talked to the charge who told her to call the hospitalist. Staff B, APRN, looked up the EKGs; one from June 15th and the new one. She was not comfortable with it, so she called Staff A, MD who said he was already on heparin and he was getting a cath in the morning. That was the plan. The patient was not symptomatic. The vital signs were normal. He was still having ST elevations. Then he coded at 3:40 something. By this time, CMU (central monitoring room) had called. It was around 3:10 AM and Staff C was very short with the MT because Staff C already knew about the ST elevation. Staff A, MD came up for the code. After ROSC they did another EKG and it read STEMI. The AOD (Adminstrator on Duty) was there because of the code, and she had a call out to the on call interventional cardiologist. He came in to take Patient #1 to the cath lab, and then he coded again. The problem was that he had changes in the cardiac rhythm and EKG, and he had a cardiologist, but that cardiologist was not consulted to make the decision on Patient #1’s care, resulting in a potential delay. He did not meet criteria for the STEMI alert because the old policy did not specify the criteria for a STEMI alert. It was not written in the policy that they should call cardiology. The executive review really did feel that this was something the physician did exercise control over. The cardiologist said he would like to have been notified. He said he does not know if he would have taken the patient to the cath lab or not, but he would have liked to have been able to make that decision. He said he is the specialist, and he should have been consulted. Even though the patient was asymptomatic, the staff were not even aware of the STEMI process. Review of the Policy, STEMI Alert, dated 7/23, revealed no specific instructions when ST elevation is identified without chest pain. However, the following was found in the policy: For an admitted patient with new or worsening onset of chest pain or other anginal equivalent, obtain a stat EKG and initiate a rapid response by dialing 66. The rapid response team will respond and the AOD (administrator on duty) and/or ICU RN will review the EKG and notify the STEMI MD on call for interpretation of the EKG. If the EKG has been interpreted as a STEMI, alert the rapid response team or designee by calling 66 and activate STEMI alert. When STEMI alert is activated the hospital operator will put out one STEMI alert page that goes to the individuals listed below: AOD, ICU charge (Intesive Care Unit Charge Nurse), interventional services lab, IR on call team, interventional services manager, ICU manager, ED medical director, ED nurse manager, education codes pager, Education Manager, pharmacy. 2. During an observation on 07/09/2025 at 10:15 AM, in the CMU (central monitoring unit) was one MT (monitor tech) with a trainee present. There were 2 monitor stations. Staff H, MT was sitting in front of the 4-screen station nearest to the door. The second 4 screen monitoring station toward the back of the room, had no one monitoring it. There was still no one monitoring the station when the surveyor exited the room at 10:21 AM, a total of 6 minutes. During an interview while observing at 10:18 AM, Staff H, MT stated the other MT was in the rest room. The DON was present during the observation and interview. During an interview on 07/09/2025 at 10:21 AM, Staff H, MT stated he is monitoring 38 to 39 patients. We watch for each other during bathroom breaks; it’s always been that way. It would be difficult to get someone to come in and cover every time one has to go to the bathroom because he is on a diuretic and in the bathroom frequently. During an interview on 07/09/2025 at 10:25 AM, Staff G, MT said they cover each other for bathroom breaks. They have never designated anyone for the bathroom. The number varies. He has 40 patients he is monitoring today; the max is in the 40’s. All alarms are shown on both screens and there is a notification for alarms that displays on both stations. For ST elevation, we call the nurse, document and notify the charge nurse. Then it goes on the call log. During an interview on 07/09/2025 at 10:34 AM, the Staff I, Nurse Manager stated the monitor techs cover themselves. If it is more than a quick run to the bathroom then they have been told to call the charge nurse, assistant nurse manager or herself. Lunch is scheduled with someone covering. They can see the other one’s alarms. The census has been low. If it were high, then they are expected to call for coverage. She agreed, monitoring 76 patients is not ok. They should be calling for relief. There was a delay from CMU and the nurse found it within a few minutes. That monitor tech was put on investigative leave with a written warning. They are to call the nurse immediately, and the charge nurse. They should be giving each other report before taking their bathroom break. During an interview on 07/09/2025 at 1:37 PM, the DON (Director of Nursing) said ideally, someone would be sitting there to cover, but the bathroom is right there. The DON said she is comfortable with it because any arrythmias would show up on the other tech’s screen. He can see it.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 36678 Based on record review, facility documents, observation, interviews and policy review, the hospital failed to ensure appropriate measures were implemented in order to prevent a second serious safety event involving a telemetry patient (Patient #1) for 1 of 1corrective action plans. Findings included: Review of Patient #1 medical record revealed he came to the hospital ED (Emergency Department) on 06/15/2025 for a chief complaint of shortness of breath for a week. He had a past medical history of CHF (congestive heart failure), cardiac stent, atrial fibrillation (A-fib), and pericardiectomy (open heart surgery to remove part of the sac surrounding the heart). While Patient #1 was in the ED, cardiac enzymes (Troponins-a biomarker to assess and detect heart muscle damage), were obtained, and were: 10:13 AM 773, 12:45 1285, 3:08 PM 2636. Patient #1 was started on a heparin drip (heparin is a blood thinner) and admitted to the PCU (progressive care unit) on cardiac telemetry monitoring, with plans to perform a cardiac catheter the next morning. At 2:38 AM on 06/16/2025 the RN (registered nurse) noted ST elevation (an upward deviation of the ST segment indicating myocardial ischemia-a heart attack where a coronary artery is completely blocked) on the cardiac monitor. The RN obtained an ECG (electrocardiogram-a test that measures the heart’s electrical activity) and confirmed there was ST elevation. The RN then called the on-call APRN (Advanced Practice Registered Nurse). APRN notified the hospitalist who was in the ED at the time. The hospitalist gave an order to continue the current treatment plan. At 03:12 AM the monitor technician called to report the ST elevation. There was no further action documented until 03:39 AM when the RN noted Patient #1 was lethargic and had a change of rhythm. CPR (cardiopulmonary resuscitation) was started. At 03:48 AM, ROSC (return of spontaneous circulation) was achieved. Patient #1 continued to have rhythm changes with loss of his pulse 2 more times. The on-call interventional cardiologist was paged for a STEMI (ST elevated MI-myocardial infarction-heart attack). At 04:43 AM, Patient #1 was then taken to the Catheter Lab on a Lucas device (a device that provides automated chest compressions during CPR). An Impella was placed (Impella is a ventricular assist device that helps the heart pump blood), and a cardiac catheterization was performed. The interventional cardiologist found a thrombus (blood clot) in the LAD (left anterior descending) artery with stenosis (constriction) of the middle LAD and total occlusion (blockage) of the distal LAD. The interventional cardiologist proceeded with PCI (percutaneous coronary intervention) with balloon angioplasty (a procedure to open the vessels). Patient #1 was placed on full life support and transported by air to [another hospital] and expired 2 days later. During an observation on 07/09/2025 at 10:15 AM, in the CMU (central monitoring unit) was one MT (monitor tech) with a trainee present. There were 2 monitor stations. Staff H, MT was sitting in front of the 4-screen station nearest to the door. The second 4 screen monitoring station toward the back of the room, had no one monitoring it. There was still no one monitoring the station when the surveyor exited the room at 10:21 AM, a total of 6 minutes. During an interview while observing at 10:18 AM, Staff H, MT stated the other MT was in the rest room. The DON was present during the observation and interview. During an interview on 07/09/2025 at 10:21 AM, Staff H, MT stated he is monitoring 38 to 39 patients. We watch for each other during bathroom breaks; it’s always been that way. It would be difficult to get someone to come in and cover every time one has to go to the bathroom because he is on a diuretic and in the bathroom frequently. During an interview on 07/09/2025 at 10:25 AM, Staff G, MT said they cover each other for bathroom breaks. They have never designated anyone for the bathroom. The number varies. He has 40 patients he is monitoring today; the max is in the 40’s. All alarms are shown on both screens and there is a notification for alarms that displays on both stations. For ST elevation, we call the nurse, document and notify the charge nurse. Then it goes on the call log. During an interview on 07/09/2025 at 10:34 AM, the Staff I, Nurse Manager stated the monitor techs cover themselves. If it’s more than a quick run to the bathroom then they have been told to call the charge nurse, assistant nurse manager or herself. Lunch is scheduled with someone covering. They can see the other one’s alarms. The census has been low. If it were high, then they are expected to call for coverage. She agreed, monitoring 76 patients is not ok. They should be calling for relief. There was a delay from CMU and the nurse found it within a few minutes. That monitor tech was put on investigative leave with a written warning. They are to call the nurse immediately, and the charge nurse. They should be giving each other report before taking their bathroom break. During an interview on 07/09/2025 at 1:37 PM, the DON (Director of Nursing) said ideally, someone would be sitting there to cover, but the bathroom is right there. The DON said she is comfortable with it because any arrythmias would show up on the other tech’s screen. He can see it. During a telephone interview on 07/09/2025 at 4:25 PM, Staff C, RN stated she notified the charge nurse nurse first to see who to call. Staff C, RN then called the APRN . The APRN said she was looking at the EKG, and she would call back. The APRN spoke to Staff A, MD and acknowledged they were seeing the same thing, and to continue the current treatment plan on heparin with plans to cath (cardiac catheterization) the next morning. Patient #1 was complaining of back pain 3 out of 10. He had a history of back surgeries. She said when she saw the ST elevation she checked on him and he was asymptomatic. Staff C, RN got the EKG and called the provider. He coded (respirations and pulse stopped) about an hour after that happened. Staff C, RN stated she did not notify anyone else; she said she notified the charge nurse and the hospitalist. She updated the charge nurse on what the hospitalist said. Staff C. RN said she was not aware of the policy for STEMI at all and that is why she notified the charge nurse. During a telephone interview on 07/09/2025 at 7:39 PM, Staff E, CNC (charge nurse) stated the patient came in a with a non-STEMI and cardiology was aware. Staff C told me and the on-call cardiologist answering center about the ST elevation. Staff C did not speak to the cardiologist; she spoke to Staff A, MD. Staff A, MD called cardiology, it was doctor to doctor communication. Patient #1 was stable; he never complained of chest pain. The plan was medication and monitor. Patient #1 just changed very quickly and drastically. During a telephone interview on 07/09/2025 at 6:30 PM, Staff B, APRN stated she did not speak to a cardiologist. The nurse called and said the MT (Monitor Technician) called and noticed some ST elevation. They woke Patient #1 up to do a 12 lead EKG. Patient #1 came in with elevated troponins and was placed on a heparin drip. They spoke to the cardiologist when he was in the ED, he was aware of the troponins and wanted him on a heparin drip and to take aspirin with plans to do a catheterization in the morning. The patient was asymptomatic. Staff B, APRN stated she printed out the EKG. Patient #1 went from a left bundle block (a heart condition where electrical signals are delayed or blocked as they travel through the heart’s conduction system, specifically the right or left bundle branches) to a right bundle block. He was asymptomatic. Vital signs were stable. Staff B, APRN said she called Staff A, MD who is her supervisor. Staff A, MD reviewed the EKG and his labs and said we can keep doing what we are doing, because he is on heparin, aspirin and is having a cardiac cath in the morning. Staff B, APRN said she doesn’t think Staff A, MD spoke to cardiology. About an hour later Patient #1 coded. The floor will usually call the cardiologist and send the 12-lead to the cardiologist. Cardiology then tells them whether to do a STEMI alert. During a telephone interview on 07/10/2025 at 8:35 AM, Staff A, MD stated she did not call a cardiologist. Staff B,APRN was notified. Staff A, MD then said she was admitting other patients and talking to the ED physician about them when Staff B, APRN brought 2 EKGs to her. The first was A-fib with RVR (rapid ventricular response). The second was left heart block. No EKG was obtained between the first and second. The second EKG showed right incomplete bundle branch block. Patient #1 was on a heparin drip and was stable and sleeping. It could indicate PE (pulmonary embolus) or LAD ischemia. He had a cardiac cath scheduled in the morning. While she was on her way upstairs to see the first patient who was admitted, the code was called. The LAD was blocked with a thrombus. He should have went to cath lab from the ED. He might have had a chance. He had a poor chance of survival because of his history. His cardiac indicator was 10. He was very, very high risk. He had very advanced cardiac disease. During an interview on 07/10/2025 at 11:14 AM, Staff J, cardiologist stated he was not complaining of chest pain, he was hemodynamically stable, no ST changes, and he received Eliquis the night before, and that made him very high risk for any invasive procedure unless it’s emergent. Staff J, cardiologist said he would expect to be notified if there were changes in their cardiac rhythm. He said he expects that when telemetry is ordered, it is continuously monitored. During an interview on 07/10/25 at 3:20 PM, the supervisor of risk management stated the patient came in on June 15th with for shortness of breath. He was admitted for non-STEMI. He went to a tele unit; PCU (progressive care unit). His outside cardiologist had been consulted. They did serial troponins on him, which were not good; over 700, 1500, 2000 something. His cardiologist was aware of the troponins and that the patient was on Eliquis. The plan was to take him to cath the next morning. His vital signs were stable. He was on room air and doing ok. At 2:30 AM when the nurse was charting she notice he had ST elevations. He was supposed to have another EKG in the morning, so she just went ahead and did the EKG. When she saw it, her interpretation was that it was a STEMI. She was concerned but is a newer nurse. At this point she had not received a call from CMU, and she was upset about that. She talked to the charge nurse who told her to call the hospitalist. Staff B, APRN, looked up the EKGs; one from June 15th and the new one. She was not comfortable with it, so she called Staff A, MD who said he was already on heparin and he was getting a cath in the morning. That was the plan. The patient was not symptomatic. The vital signs were normal. He was still having ST elevations. Then he coded at 3:40 something. By this time, CMU (central monitoring room) had called. It was around 3:10 AM and Staff C was very short with the MT because Staff C already knew about the ST elevation. Staff A, MD came up for the code. After ROSC they did another EKG and it read STEMI. The AOD was there because of the code, and she had a call out to the on call interventional cardiologist. He came in to take Patient #1 to the cath lab, and then he coded again. The problem was that he had changes in the cardiac rhythm and EKG, and he had a cardiologist, but that cardiologist was not consulted to make the decision on Patient #1’s care, resulting in a potential delay. He didn’t meet criteria for the STEMI alert because the old policy did not specify the criteria for a STEMI alert. It was not written in the policy that they should call cardiology. The executive review really did feel that this was something the physician did exercise control over. The cardiologist said he would like to have been notified. He said he doesn’t know if he would have taken the patient to the cath lab or not, but he would have liked to have been able to make that decision. He said he is the specialist, and he should have been consulted. Even though the patient was asymptomatic, the staff were not even aware of the STEMI process. Review of Sentinel Events Policy last revised 05/2024 states: Comprehensive Systematic Analysis - A process for identifying the most basic or causal factor or factors that underlie variation in performance, including the occurrence of a sentinel event or serious occurrence. The response to the event includes: a. Formalized team response that stabilizes the patient, discloses the event to the patient and/or patient representative, and provides support for the patient representative and family as well as team members involved in the event b. Notification of hospital leadership c. Immediate investigation d. Completion of a comprehensive systematic analysis for identifying the causal and contributory factors e Corrective actions derived from the identified causal and contributing factors that eliminate or control system hazards or vulnerabilities and result in sustainable improvement overtime f. Timeline for implementation of corrective actions g. Systemic improvement Comprehensive Systematic Analysis investigations are conducted within the Patient Safety Evaluation System (PSES) for the purpose of reporting to the PSO. Documents generated by these investigations are considered Patient Safety Work Product (PSWP) unless individually designated otherwise. Review of the Policy, STEMI Alert, dated 7/23, revealed no specific instructions when ST elevation is identified without chest pain. However, the following was found in the policy: For an admitted patient with new or worsening onset of chest pain or other anginal equivalent, obtain a stat EKG and initiate a rapid response by dialing 66. The rapid response team will respond and the AOD (Administrator on Duty) and/or ICU RN will review the EKG and notify the STEMI MD on call for interpretation of the EKG. If the EKG has been interpreted as a STEMI, alert the rapid response team or designee by calling 66 and activate STEMI alert. When STEMI alert is activated the hospital operator will put out one STEMI alert page that goes to the individuals listed below: AOD, ICU charge (Intesive Care Unit Charge Nurse), interventional services lab, IR on call team, interventional services manager, ICU manager, ED medical director, ED nurse manager, education codes pager, Education Manager, pharmacy.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 36678 Based on review of medical record, interviews, and policy reviews, the hospital failed to ensure the Medical Staff recognized and responded to a change of condition that required emergent action for 1 (Patient #1) of 2 patients sampled for mortality. Findings included: Review of Patient #1 medical record revealed he came to the hospital ED (Emergency Department) on 06/15/2025 for a chief complaint of shortness of breath for a week. He had a past medical history of CHF (congestive heart failure), cardiac stent, atrial fibrillation (A-fib), and pericardiectomy (open heart surgery to remove part of the sac surrounding the heart). While Patient #1 was in the ED, cardiac enzymes (Troponins-a biomarker to assess and detect heart muscle damage), were obtained, and were: 10:13 AM 773, 12:45 1285, 3:08 PM 2636. Patient #1 was started on a heparin drip (heparin is a blood thinner) and admitted to the PCU (progressive care unit) on cardiac telemetry monitoring, with plans to perform a cardiac catheter the next morning. At 2:38 AM on 06/16/2025 the RN (registered nurse) noted ST elevation (an upward deviation of the ST segment indicating myocardial ischemia-a heart attack where a coronary artery is completely blocked) on the cardiac monitor. The RN obtained an ECG (electrocardiogram-a test that measures the heart’s electrical activity) and confirmed there was ST elevation. The RN then called the on-call APRN (Advanced Practice Registered Nurse). APRN notified the hospitalist who was in the ED at the time. The hospitalist gave an order to continue the current treatment plan. At 03:12 AM the monitor technician called to report the ST elevation. There was no further action documented until 03:39 AM when the RN noted Patient #1 was lethargic and had a change of rhythm. CPR (cardiopulmonary resuscitation) was started. At 03:48 AM, ROSC (return of spontaneous circulation) was achieved. Patient #1 continued to have rhythm changes with loss of his pulse 2 more times. The on-call interventional cardiologist was paged for a STEMI (ST elevated MI-myocardial infarction-heart attack). At 04:43 AM, Patient #1 was then taken to the Catheter Lab on a Lucas device (a device that provides automated chest compressions during CPR). An Impella was placed (Impella is a ventricular assist device that helps the heart pump blood), and a cardiac catheterization was performed. The interventional cardiologist found a thrombus (blood clot) in the LAD (left anterior descending) artery with stenosis (constriction) of the middle LAD and total occlusion (blockage) of the distal LAD. The interventional cardiologist proceeded with PCI (percutaneous coronary intervention) with balloon angioplasty (a procedure to open the vessels). Patient #1 was placed on full life support and transported by air to [another hospital] and expired 2 days later. During a telephone interview on 07/09/2025 at 4:25 PM, Staff C, RN stated she notified the charge nurse first to see who to call. Staff C, RN then called the APRN . The APRN said she was looking at the EKG, and she would call back. The APRN spoke to Staff A, MD and acknowledged they were seeing the same thing, and to continue the current treatment plan on heparin with plans to cath (cardiac catheterization) the next morning. Patient #1 was complaining of back pain 3 out of 10. He had a history of back surgeries. She said when she saw the ST elevation she checked on him and he was asymptomatic. Staff C, RN got the EKG and called the provider. He coded (respirations and pulse stopped) about an hour after that happened. Staff C, RN stated she did not notify anyone else; she said she notified the charge nurse and the hospitalist. She updated the charge nurse on what the hospitalist said. Staff C. RN said she was not aware of the policy for STEMI at all and that is why she notified the charge nurse. During a telephone interview on 07/09/2025 at 7:39 PM, Staff E, CNC (charge nurse) stated the patient came in a with a non-STEMI and cardiology was aware. Staff C told me and the on-call cardiologist answering center about the ST elevation. Staff C did not speak to the cardiologist; she spoke to Staff A, MD. Staff A, MD called cardiology, it was doctor to doctor communication. Patient #1 was stable; he never complained of chest pain. The plan was medication and monitor. Patient #1 just changed very quickly and drastically. During a telephone interview on 07/09/2025 at 6:30 PM, Staff B, APRN stated she did not speak to a cardiologist. The nurse called and said the MT (Monitor Technician) called and noticed some ST elevation. They woke Patient #1 up to do a 12 lead EKG. Patient #1 came in with elevated troponins and was placed on a heparin drip. They spoke to the cardiologist when he was in the ED, he was aware of the troponins and wanted him on a heparin drip and to take aspirin with plans to do a catheterization in the morning. The patient was asymptomatic. Staff B, APRN stated she printed out the EKG. Patient #1 went from a left bundle block (a heart condition where electrical signals are delayed or blocked as they travel through the heart’s conduction system, specifically the right or left bundle branches) to a right bundle block. He was asymptomatic. Vital signs were stable. Staff B, APRN said she called Staff A, MD who is her supervisor. Staff A, MD reviewed the EKG and his labs and said we can keep doing what we are doing, because he is on heparin, aspirin and is having a cardiac cath in the morning. Staff B, APRN said she doesn’t think Staff A, MD spoke to cardiology. About an hour later Patient #1 coded. The floor will usually call the cardiologist and send the 12-lead to the cardiologist. Cardiology then tells them whether to do a STEMI alert. During a telephone interview on 07/10/2025 at 8:35 AM, Staff A, MD stated she did not call a cardiologist. Staff B,APRN was notified. Staff A, MD then said she was admitting other patients and talking to the ED physician about them when Staff B, APRN brought 2 EKGs to her. The first was A-fib with RVR (rapid ventricular response). The second was left heart block. No EKG was obtained between the first and second. The second EKG showed right incomplete bundle branch block. Patient #1 was on a heparin drip and was stable and sleeping. It could indicate PE (pulmonary embolus) or LAD ischemia. He had a cardiac cath scheduled in the morning. While she was on her way upstairs to see the first patient who was admitted, the code was called. The LAD was blocked with a thrombus. He should have went to cath lab from the ED. He might have had a chance. He had a poor chance of survival because of his history. His cardiac indicator was 10. He was very, very high risk. He had very advanced cardiac disease. During an interview on 07/10/2025 at 11:14 AM, Staff J, cardiologist stated he was not complaining of chest pain, he was hemodynamically stable, no ST changes, and he received Eliquis the night before, and that made him very high risk for any invasive procedure unless it’s emergent. Staff J, cardiologist said he would expect to be notified if there were changes in their cardiac rhythm. He said he expects that when telemetry is ordered, it is continuously monitored. During an interview on 07/10/25 at 3:20 PM, the supervisor of risk management stated the patient came in on June 15th with for shortness of breath. He was admitted for non-STEMI. He went to a tele unit; PCU (progressive care unit). His outside cardiologist had been consulted. They did serial troponins on him, which were not good; over 700, 1500, 2000 something. His cardiologist was aware of the troponins and that the patient was on Eliquis. The plan was to take him to cath the next morning. His vital signs were stable. He was on room air and doing ok. At 2:30 AM when the nurse was charting she notice he had ST elevations. He was supposed to have another EKG in the morning, so she just went ahead and did the EKG. When she saw it, her interpretation was that it was a STEMI. She was concerned but is a newer nurse. At this point she had not received a call from CMU, and she was upset about that. She talked to the charge nurse who told her to call the hospitalist. Staff B, APRN, looked up the EKGs; one from June 15th and the new one. She was not comfortable with it, so she called Staff A, MD who said he was already on heparin and he was getting a cath in the morning. That was the plan. The patient was not symptomatic. The vital signs were normal. He was still having ST elevations. Then he coded at 3:40 something. By this time, CMU (central monitoring room) had called. It was around 3:10 AM and Staff C was very short with the MT because Staff C already knew about the ST elevation. Staff A, MD came up for the code. After ROSC they did another EKG and it read STEMI. The AOD was there because of the code, and she had a call out to the on call interventional cardiologist. He came in to take Patient #1 to the cath lab, and then he coded again. The problem was that he had changes in the cardiac rhythm and EKG, and he had a cardiologist, but that cardiologist was not consulted to make the decision on Patient #1’s care, resulting in a potential delay. He did not meet criteria for the STEMI alert because the old policy did not specify the criteria for a STEMI alert. It was not written in the policy that they should call cardiology. The executive review really did feel that this was something the physician did exercise control over. The cardiologist said he would like to have been notified. He said he does not know if he would have taken the patient to the cath lab or not, but he would have liked to have been able to make that decision. He said he is the specialist, and he should have been consulted. Even though the patient was asymptomatic, the staff were not even aware of the STEMI process. Review of the Policy, STEMI Alert, dated 7/23, revealed no specific instructions when ST elevation is identified without chest pain. However, the following was found in the policy: For an admitted patient with new or worsening onset of chest pain or other anginal equivalent, obtain a stat EKG and initiate a rapid response by dialing 66. The rapid response team will respond and the AOD (administrator on duty) and/or ICU RN will review the EKG and notify the STEMI MD on call for interpretation of the EKG. If the EKG has been interpreted as a STEMI, alert the rapid response team or designee by calling 66 and activate STEMI alert. When STEMI alert is activated the hospital operator will put out one STEMI alert page that goes to the individuals listed below: AOD, ICU charge (Intensive Care Unit Charge Nurse), interventional services lab, IR on call team, interventional services manager, ICU manager, ED medical director, ED nurse manager, education codes pager, Education Manager, pharmacy.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 36678 Based on observation, interviews and record reciew, the facility failed to ensure: 1. staff continuously monitored cardiac rhythms of hospitalized patients on telemetry in 76 of 110 patients and 2. failed to ensure nurses providing care to patients adhered to the policies and procedures related to changes in cardiac rhythms 1 (#1) of 1 patient reviewed for adverse events. Findings included: Review of the policy Cardiac Monitoring (Telemetry) Initiation, and Discontinuation (Adult), Last reviewed 1/2024 stated ... PURPOSE: 1. To provide patients with cardiac telemetry monitoring when ordered by the provider. 2. To establish guidelines, including indications and clinical criteria, to evaluate the need for continued telemetry. 3. To record cardiac electrical activity for diagnostic or documentation purposes. 4. To identify and treat various dysrhythmias. . . Emergency Response: 1. Monitor Tech (MT) notifies nurse when a change in patient’s rhythm is identified. 2. Telemetry skill validated nurse assesses the patient immediately. 3. If patient is symptomatic, notify the provider regarding the patient’s condition. 4. Initiate Rapid Response or Code Blue as patient condition dictates. 1.On 7/9/25 at 10:15 AM the CMU (central monitoring unit) was observed. There was one MT (monitor tech) with a trainee present. There were 2 monitor stations. MT H was sitting in front of the 4-screen station nearest to the door. The second 4 screen monitoring station toward the back of the room, had no one monitoring it. MT H was interviewed during the observation at 10:18 AM. He stated the other MT was in the rest room. The DON was present during the observation. There was still no one monitoring the station when the surveyor exited the room for an interview with MT H at 10:21 AM, a total of 6 minutes. During an interview on 07/09/2025 at 10:21 AM with Monitor Technician (MT) H, he said he is monitoring 38 to 39 patients. Watch for each other during bathroom breaks. It’s always been that way. It would be difficult to get someone to come in and cover every time he has to go to the bathroom because he is on a diuretic and in the bathroom frequently. If it’s a STEMI call a nurse or charge nurse. If it’s lethal, call code blue. During an interview with MT G at 10:25 AM on 07/09/2025, he said they cover each other for bathroom breaks. They have never designated anyone for the bathroom. The number varies. He has 40 patients he is monitoring today. The max is in the 40’s. All alarms are shown on both screens. There is a notification for alarms that are displayed on both stations. For ST elevation, call the nurse. Document it. Also, notify the charge nurse. It goes on the call log and in the patient chart. The side by the door normally watches less than 40. During an interview with Nurse Manager I on 07/09/2025 at 10:34 AM, she stated the MT’s cover themselves. If it is more than a quick run to the bathroom then they have been told to call the charge nurse, assistant nurse manager or herself. Lunch is scheduled with someone covering. They can see the other one’s alarms. The census has been low. If it were high, then they are expected to call for coverage. She agreed, 76 patients to watch is not ok. They should be calling for relief. There was a delay from CMU. The nurse found it within a few minutes. That monitor tech was put on investigative leave with a written warning. She said she did not know it was new. They are to call the nurse immediately, and the charge nurse. Within 5 minutes they should be laying eyes on the patient. They have to document it in the chart. They should be giving each other a report before taking their bathroom break. The Director of Nursing (DON) was interviewed on 7/9/25 at 1:37 PM. The DON said she saw it. Ideally, someone would be sitting there to cover, but the bathroom is right there. They might be 5 minutes. The DON said she is comfortable with it because any arrythmias would show up on the other tech’s screen. He can see it. 2.Review of the Policy, STEMI Alert, dated 7/23, revealed no specific instructions when ST elevation is identified without chest pain. However, the following was found in the policy: ... For an admitted patient with new or worsening onset of chest pain or other anginal equivalent, obtain a stat EKG and initiate a rapid response by dialing 66...The rapid response team will respond and the AOD (administrator on duty) and/or ICU RN will review the EKG and notify the STEMI MD on call for interpretation of the EKG ...If the EKG has been interpreted as a STEMI, alert the rapid response team or designee by calling 66 and activate STEMI alert ...When STEMI alert is activated the hospital operator will put out one STEMI alert page that goes to the individuals listed below: AOD, ICU charge nurse, interventional services lab, IR on call team, interventional services manager, ICU manager, ED medical director, ED nurse manager, education codes pager, Education Manager, pharmacy. Review of Patient #1’s medical record revealed he came to the hospital ED (Emergency Department) on 06/15/2025 for a chief complaint of shortness of breath for a week. He had a past medical history of CHF (congestive heart failure), cardiac stent, atrial fibrillation (A-fib), and pericardiectomy (open heart surgery to remove part of the sac surrounding the heart). While Patient #1 was in the ED, cardiac enzymes (Troponins-a biomarker to assess and detect heart muscle damage), were obtained, and were: 10:13 AM - 773, 12:45 - 1285, 3:08 PM - 2636. Patient #1 started on a heparin drip (heparin is a blood thinner) and was admitted to the PCU (Progressive Care Unit) on cardiac telemetry monitoring, with plans to perform a cardiac catheter the next morning. On 06/16/2025 at 2:38 AM the RN (Registered Nurse) noted ST elevation (an upward deviation of the ST segment indicating myocardial ischemia-a heart attack where a coronary artery is completely blocked) on the cardiac monitor. The RN obtained an ECG (electrocardiogram-a test that measures the heart’s electrical activity) and confirmed there was ST elevation. The RN then called the on-call APRN (Advanced Practice Registered Nurse). APRN notified the hospitalist who was in the ED at the time. The hospitalist gave an order to continue the current treatment plan. At 03:12 AM the monitor technician called to report the ST elevation. There was no further action documented until 03:39 AM when the RN noted Patient #1 was lethargic and had a change of rhythm. CPR (cardiopulmonary resuscitation) was started. At 03:48 AM, ROSC (return of spontaneous circulation) was achieved. Patient #1 continued to have rhythm changes with loss of his pulse 2 more times. The on-call interventional cardiologist was paged for a STEMI (ST elevated MI-myocardial infarction-heart attack). At 04:43 AM, Patient #1 was then taken to the Catheter Lab on a Lucas device (a device that provides automated chest compressions during CPR). An Impeller was placed (Impella is a ventricular assist device that helps the heart pump blood), and a cardiac catheterization was performed. The interventional cardiologist found a thrombus (blood clot) in the LAD (left anterior descending) artery with stenosis (constriction) of the middle LAD and total occlusion (blockage) of the distal LAD. The interventional cardiologist proceeded with PCI (percutaneous coronary intervention) with balloon angioplasty (a procedure to open the vessels). Patient #1 was placed on full life support and transported by air to [another hospital] and expired 2 days later. RN C was interviewed by telephone at 4:25 PM on 7/9/25 regarding Patient #1. RN C said she notified the charge nurse first, to see who to call. RN C then called the hospitalist on-call, APRN B. APRN B said she was looking at the EKG, and she would call back. APRN B spoke to Dr. A, MD and acknowledged they were seeing the same thing, and to continue the current treatment plan on heparin with plans to cath (cardiac catheter) the next morning. He was complaining of back pain 3 out of 10. He had a history of back surgeries. When she saw the ST elevation she checked on him. He was asymptomatic. RN C got the EKG and called the provider. He coded (respirations and pulse stopped) about an hour after that happened. RN C confirmed she did not notify anyone else; she said she notified the charge nurse and the hospitalist. She updated the charge nurse on what the hospitalist said. RN C said she was not aware of the policy for STEMI at all and that is why she notified the charge nurse. On 7/9/25 at 4:45 PM a telephone interview was conducted with MD F, Cardiologist on-call regarding Patient #1. The main reason why they called was for the ST elevation. From the time they called about the ST elevation to the time we did the cath was a couple hours. As far as STEMI guidelines go, it was within time. From STEMI it was within the 90 minutes. It did not carry over to the STEMI timeframe because he coded. He was not admitted to us. I was called in because it was a STEMI and a code. Looking back, he was admitted around 5 pm. The ICU and ED physician reviewed the case at that point. Dr A, MD called us about the ST changes after the code. He had high troponins to start with, and pulmonary edema and was treated with heparin. From the time we were activated, it was within time. We put the Impella first because he already coded. He became hemodynamically stable and was transferred to another hospital. There weren’t any cardiology notes, probably because he was admitted late in the afternoon that day. Maybe the cardiology consult should have been stat (immediate). On 7/9/25 at 7:39 PM a telephone interview was conducted with charge nurse, RN E. The patient came with non-STEMI. Cardiology was aware. RN E, charge nursesaid RN C told him and the on-call cardiologist answering center about the ST elevation. RN C did not speak to the cardiologist. She spoke to Dr A, MD. Dr A, MD called cardiology and Dr Saadi answered. It was doctor to doctor communication. Patient #1 was stable. He never complained of chest pain. The plan was medication and monitor. He just changed very quickly and drastically. We have an app called Air Strip that gives more of a point of view of the leads. It’s ICU (intensive care unit) view. The monitor technician (MT) only has telemetry view, and it did not capture it right away. The MT called when they saw it. APRN B was interviewed at 6:30 AM on 7/10/25 by telephone. APRN B said she did not speak to a cardiologist. The nurse called and said the MT called and noticed some ST elevation. They woke Patient #1 up to do a 12 lead EKG. He came in with elevated troponins and was placed on a heparin drip. They spoke to the cardiologist when he was in the ED, who was aware of the troponins and wanted him on a heparin drip and aspirin with plans to do a cath in the morning. The patient was asymptomatic. APRN B stated she printed out the EKG. Patient #1 went from a left bundle to a right bundle block. He was asymptomatic. Vital signs were stable. APRN B said she called Dr A, MD who is her supervisor. Dr A, MD reviewed the EKG and his labs and said we can keep doing what we are doing, because he is on heparin and aspirin and is having a cardiac cath in the morning. APRN B said she does not think Dr A, MD spoke to cardiology. About an hour later Patient #1 coded. They usually call the cardiologist and send the 12-lead to the cardiologist. Cardiology tells them whether to do a STEMI alert. Dr A, MD was interviewed at 8:35 AM on 7/10/25 by telephone. Dr A, MD confirmed she did not call a cardiologist. The patient was admitted during the day by ED who had a cardiology consult. The patient was on aspirin, Plavix and Eliquis. About 11 AM his troponin was in the 700s. Around 1:00 PM it was inthe1000s, and about 3:00 PM it was 2700. The nurse noted cardiology consulted, cardiac cath in the morning if the patient is stable. APRN B answers the calls. The patient was asymptomatic. Telemetry (monitor) did not notice any changes. The bedside nurse was watching the monitor. After the patient received an albuterol treatment, the nurse noticed a change on the monitor. APRN B was notified. Dr A, MD said she was admitting other patients and talking to the ED physician about them. APRN B brought 2 EKGs to her. The first was A-fib with RVR (rapid ventricular response). The second was left heart block. No EKG was obtained between the first and second. The second EKG showed right incomplete bundle branch block. Patient #1 was on a heparin drip and was stable and sleeping. It could indicate PE (pulmonary embolus) or LAD ischemia. He had a cardiac cath scheduled in the morning. While she was on her way upstairs to see the first patient who was admitted, the code was called. Patient #1 received several doses of Lasix and magnesium. When she arrived he was in Torsades (ventricular tachycardia-rapid irregular ventricular rate). He had QTC prolongation after ROSC, and ST elevation, caused by electrolyte abnormalities. Dr A, MD said she gave him multiple doses of magnesium. The Albuterol treatment and electrolyte imbalance could have caused it. His potassium was 2.9 (normal is 3.5-5.0). He was already on digoxin, heparin, coreg, and aspirin. He was admitted to PCU because he was stable. They continued to provide resuscitation and took the patient to cardiac cath. The LAD was severely occluded and the RCA. The cardiologist wasn’t even able to put the balloon in. Patient #1 had a resected pericardium and had a window done. His anatomy was completely obstructed. This was not acute MI. This was an arrhythmia caused by electrolyte imbalance. He had a large thrombosis in the LAD. Eliquis has a black box warning that discontinuation of Eliquis can cause a thrombus. He hadn’t been feeling well, and there is no way to know if they are taking their medications at home. He was flown out. He did not die here. The LAD was blocked with a thrombus. He should have went to cath lab from the ED. He might have had a chance. It was not ischemia, it was Torsades. He had 5 mg of magnesium, calcium gluconate, atropine, ACLS (advanced cardiac life support) and she escorted him to cardiac cath. He had a poor chance of survival because of his history. His cardiac indicator was 10. He was very, very high risk. He was completely asymptomatic , and vital signs were stable. He had very advanced cardiac disease. They have a new policy to call cardiology directly and not the hospitalist. This is an excellent policy, and it will save lives. The nurse has to call the answering service and wait for answering service to call the on-call, and the on-call to call back. This was 20 minutes wasted. No one called her. She just looked at the EKG. She is in the ED all night. She is available from 6 PM to 6 AM. They choose not to call her. The patient was on maximum therapy. 70% occluded LAD by thrombus, and RCA completely occluded. Right heart block is even more serious than left. The cardiologist put in an Impella and 2 stents. Albuterol can precipitate cardiac arrythmias. He had it 10 minutes prior to the event. She said she does not know why he was on albuterol. At 11:14 AM on 7/10/25 Dr J, cardiologist was interviewed. He was not complaining of chest pain, hemodynamically stable, no ST changes, and he received Eliquis the night before, and that made him very high risk for any invasive procedure unless it is emergent. Dr J, cardiologist said he would expect that cardiology would be notified if there were changes in their cardiac rhythm. He said he also expects that when telemetry is ordered, it is being continuously monitored. On 7/10/25 at 3:20 PM the supervisor of risk was interviewed. The patient came in on June 15th with a cardiac history, 1 stent, CHF, and pericarditis with surgery, and history of ascites. The pericardiectomy surgery resolved the ascites. He came in for shortness of breath. He was admitted for non-STEMI. He went to a tele unit; PCU. His outside cardiologist had been consulted, because he comes here. They did serial troponins on him, which were not good; over 700, 1500, 2000 something. Outside cardiologist was aware of the troponins and that the patient was on Eliquis. The plan was to take him to cath the next morning. His vital signs were stable. He was on room air and doing ok. At 2:30 in the morning when the nurse was charting she pulled up her air strips, and just happened to notice he had ST elevations on his tracings. He was supposed to have another EKG in the morning, so she just went ahead and did the EKG. When she saw it, her interpretation was that it was a STEMI. She was concerned. She is a newer nurse. She was recently out of the critical care internship program. At this point she had not received a call from CMU, and she was upset about that. She talked to the charge nurse who told her to call the hospitalist. Inpatient is supposed to call the nurse practitioner first. APRN B pulled up the patient. She looked up the EKGs; one from June 15th and the new one. She was not comfortable with it, so she called Dr A, MD who said he was already on heparin and he was getting a cath in the morning. That was the plan. The patient was not symptomatic. The vital signs were normal. He was still having ST elevations. Then he coded at 3:40 something. By this time, CMU (central monitoring room) had called. It was around 3:10 AM and RN C was very short with the MT because RN C already knew about the ST elevation. Dr A, MD came up for the code. After ROSC they did another EKG and it read STEMI. The AOD was there because of the code, and she had a call out to Dr F, cardiologist, who came in to take Patient #1 to the cath lab, and then he coded again. It did take a few minutes to get him to the Cath lab because he was really unstable after they coded him. They did the cath and he coded again. Dr F, cardiologist did an Impella and stabilized the patient and sent him to another hospital. The problem was that he had changes in the cardiac rhythm and EKG, and he had a cardiologist, but that cardiologist was not consulted to make the decision on Patient #1’s care, resulting in a potential delay. He did not meet criteria for the STEMI alert because the old policy did not specify the criteria for a STEMI alert. It was not written in the policy that they should call cardiology. The ST elevation started 10 minutes before the nurse found it. Even if CMU had called, it would not have changed who was called. The executive review really did feel that this was something the physician did exercise control over. The cardiologist said he would like to have been notified. He said he does not know if he would have taken the patient to the cath lab or not, but he would have liked to have been able to make that decision. He said he is the specialist, and he should have been consulted. Even though the patient was asymptomatic, the staff were not even aware of the STEMI process.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48190 Based on review of medical records, facility documents, observation, and interviews, the facility failed to ensure the safety of patients on telemetry. The facility failed to ensure that patients on telemetry were continuously monitored in 11 (Emergency room patients) of 119 facility patients. The facility failed to ensure that fatal changes in cardiac rhythms were identified, acted upon in accordance with policies in 1 (Patient #1) of 10 patients reviewed. Refer to A0144, Standard. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Patient #1,and resulted in the determination of Immediate Jeopardy on 03/14/2025. Based on the immediate action of the facility, the findings of Immediate Jeopardy were determined to be removed on 04/10/2025. Verification of the facility’s removal plan was conducted by the survey team on 04/10/2025. Facility immediate actions to remove the Immediate Jeopardy included: Nursing Telemetry Competency: 1. The charge nurse will sign off all telemetry strips until 04/30/2025 or until the team member passes the telemetry interpretation exam. 2. Contracted nurses will be tested upon arrival, if they do not pass the exam, the charge nurse will sign off the telemetry strips until the nurse passes. Off Telemetry Test: 1. Charge nurse verifies patients have off telemetry test orders prior to leaving the unit. 2. Charge nurse to sign off on transport log. Audit Plan for QAPI: 1. As soon as a serious safety event is identified, Risk, Quality, and Patient Safety will huddle and do the following: a. review the event and identify if an immediate action is needed. b. If so, develop an immediate containment plan to include required education, actions and auditing that needs to be in place until the full investigation is completed. c. Identify and include key stakeholders required for the containment plan. 2. Risk Leadership will complete a verification of the medical record and timeline of the Code 15 Event Summary prior to submission. 3. Include a team resource representative in the RCA Meeting. Verification of the immediate actions was confirmed through interviews conducted with floor staff and leadership and thru signatures obtained by 3 of 3 charge nurses currently working validating the understanding of signing off all telemetry strips until 04/30/2025. Observations were also made verifying all ED (Emergency Department) patients on continuous heart monitoring are 100% monitored by a designated qualified employee.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48190 Based on facility documents, policy review, medical record review, and interviews conducted, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, including a complete analysis of an adverse event and the development of an effective plan of correction involving staff failure to recognize and respond to a change in cardiac rhythm. Failure to develop a complete analysis of the adverse event and plan of correction could result in injury or death to other patients in similar situations. Refer to A286, A297 This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Patient #1,and resulted in the determination of Immediate Jeopardy on 03/14/2025. Based on the immediate action of the facility, the findings of Immediate Jeopardy were determined to be removed on 04/10/2025. Verification of the facility’s removal plan was conducted by the survey team on 04/10/2025. Facility immediate actions to remove the Immediate Jeopardy included: Nursing Telemetry Competency: 1. The charge nurse will sign off all telemetry strips until 04/30/2025 or until the team member passes the telemetry interpretation exam. 2. Contracted nurses will be tested upon arrival, if they do not pass the exam, the charge nurse will sign off the telemetry strips until the nurse passes. Off Telemetry Test: 1. Charge nurse verifies patients have off telemetry test orders prior to leaving the unit. 2. Charge nurse to sign off on transport log. Audit Plan for QAPI: 1. As soon as a serious safety event is identified, Risk, Quality, and Patient Safety will huddle and do the following: a. review the event and identify if an immediate action is needed. b. If so, develop an immediate containment plan to include required education, actions and auditing that needs to be in place until the full investigation is completed. c. Identify and include key stakeholders required for the containment plan. 2. Risk Leadership will complete a verification of the medical record and timeline of the adverse event reporting summary prior to submission to the state. 3. Include a team resource representative in the event analysis meeting. Verification of the immediate actions was confirmed through interviews conducted with floor staff and leadership and through signatures obtained by 3 of 3 charge nurses currently working validating the understanding of signing off all telemetry strips until 04/30/2025. Observations were also made verifying all ED patients on continuous heart monitoring are 100% monitored by a designated qualified employee.”

“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: 48190 Based on of medical record review, facility documents, facility policies and interviews conducted, the facility failed to provide immediate nursing care to a patient with a change in cardiac rhythm on the telemetry monitoring for 1 (Patient #1) of 10 patients sampled. Failure to provide immediate nursing care for Patient #1 resulted in death. The hospital actions resulted in an Immediate Jeopardy starting on 03/19/2025. The Immediate Jeopardy was removed on 04/10/2025, the day of exit. Refer to tag 395. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Patient #1,and resulted in the determination of Immediate Jeopardy on 03/14/2025. Based on the immediate action of the facility, the findings of Immediate Jeopardy were determined to be removed on 04/10/2025. Verification of the facility’s removal plan was conducted by the survey team on 04/10/2025. Facility immediate actions to remove the Immediate Jeopardy included: Nursing Telemetry Competency: 1. The charge nurse will sign off all telemetry strips until 04/30/2025 or until the team member passes the telemetry interpretation exam. 2. Contracted nurses will be tested upon arrival, if they do not pass the exam, the charge nurse will sign off the telemetry strips until the nurse passes. Off Telemetry Test: 1. Charge nurse verifies patients have off telemetry test orders prior to leaving the unit. 2. Charge nurse to sign off on transport log. Audit Plan for QAPI: 1. As soon as a serious safety event is identified, Risk, Quality, and Patient Safety will huddle and do the following: a. review the event and identify if an immediate action is needed. b. If so, develop an immediate containment plan to include required education, actions and auditing that needs to be in place until the full investigation is completed. c. Identify and include key stakeholders required for the containment plan. 2. Risk Leadership will complete a verification of the medical record and timeline of the Code 15 Event Summary prior to submission. 3. Include a team resource representative in the RCA Meeting. Verification of the immediate actions was confirmed thru interviews conducted with floor staff and leadership and thru signatures obtained by 3 of 3 charge nurses currently working validating the understanding of signing off all telemetry strips until 04/30/2025. Observations were also made verifying all ED patients on continuous heart monitoring are 100% monitored by a designated qualified employee.”

“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: 48190 Based on observation, interviews, record review, facility documents and policy review, the facility failed to: 1. Provide a safe setting for 1 (Patient #1) of 10 patients sampled. 2. Provide a safe setting for patients on telemetry in the Emergency Department in 11 of 107 Patients The facility’s actions contributed to the death of Patient #1, and put patients in the Emergency Department at risk of potential harm which resulted in Immediate Jeopardy. Findings included: 1. Review of Patient #1’s medical record revealed on 03/14/2025 the patient was admitted to the hospital for a gangrene/necrotic (dead or dying tissue) on the left 5th toe. Upon admission the patient had an order for continuous telemetry monitoring (a technique used to track heart activity) for 48 hours. The telemetry order expired on 3/16/25 and the nursing staff was alerted to renew the order but failed to follow through. The patient remained on the cardiac telemetry monitor. On 3/19/25 at 1:23pm the Telemetry Monitor Technologist informed Staff A, RN (Registered Nurse) the patient developed a significant ST depression (A ST depression can be a sign of underlying condition that can lead to lethal rhythm disturbances). Staff A, RN failed to document and notify the physician of the ST depression. During shift change, Staff A, RN reported to Staff G, RN but failed to mention the ST depression. Staff D, RN signed the night shift telemetry strip (a printout of the cardiac rhythm) and failed to identify the ST depression. On 03/20/2025 at 9:20 PM, Patient #1 reported complaints of jaw pain and acetaminophen (over the counter pain medication) was given. At 10:20 PM, Patient #1 complained of 7/10 jaw pain (0 to 10 pain scale where 10 in the most pain). Staff B, APRN (Advanced Practice Registered Nurse) was made aware of jaw pain and drop in blood pressure (70/48). Staff B, APRN ordered CT of the Head (a diagnostic imaging procedure that uses X-rays to create detailed images of the brain, skull, and other structures within the head) STAT (immediately; without delay). At 1:00 AM, the patient was taken off the continuous telemetry monitor and transported to Radiology by a transporter. After the CT of the head, the transporter was assisting the patient back onto the stretcher from the CT machine, the patient became diaphoretic, stated “I do not feel well” and started vomiting. At 1:13 AM, a rapid response (a program designed to intervene swiftly when a patient’s condition deteriorates, often before a major medical emergency like cardiac arrest or respiratory failure occurs) was initiated then at 1:18 AM, a code blue (cardiac arrest) was called. Patient expired on 03/20/2025 at 2:15 AM. Review of telemetry event log dated 3/19/2025, reveals no cardiac event noted for Patient #1. Review of cardiac rhythm strip dated 03/19/2025 at 1:23 PM, revealed Sinus Rhythm (the normal, regular pattern of electrical activity in the heart that starts in the sinus node, the heart’s natural pacemaker) with a ST depression (ST segment depression typically indicates that a person has an underlying condition that affects the heart. The condition may be relatively benign or potentially life threatening). Review of the Policy “Cardiac Monitoring (Telemetry), Initiation and Discontinuation” last revised 07/2024, revealed the purpose is “To identify and treat various dysrhythmias “.... Discontinuation of Telemetry Monitoring includes: 1. A provider order is required. 2, Telemetry orders are reviewed every shift by a registered nurse. 3, If the telemetry skill validated RN reviewing the strip or the RN caring for the patient at the time of telemetry order expiration has a rhythm concern, continue telemetry, and review the rhythm concerns with provider to obtain a new order for telemetry monitoring and document why telemetry was not removed in patient record.... Emergency response includes: ... monitor technician notifies the nurse when a change in patient’s rhythm is identified, a skilled validated nurse must assess the patient immediately. Initiate Rapid Response or Code Blue as condition dictates. During an interview on 04/08/2025 at 12:00 PM, Staff C, Nurse Manager stated on 3/19/25 at 1:36 PM the telemetry technician called the nurse regarding a rhythm change. He stated he sent up the strip and recommended an EKG (electrocardiogram is a test that measures the electrical activity of your heart) to confirm. There was no documentation or reassessment noted in the EMR (Electronic Medical Record) regarding a rhythm change, including no follow up with the physician or EKG obtained. During an interview on 04/09/2025 at 2:40 PM, Staff C, Nurse Manager stated the night nurse failed to properly identify the rhythm strip. Staff C, Nurse Manager stated the rhythm strip clearly reveals “sinus rhythm with ST depression”. During an interview on 4/10/15 at 11:30 AM, Staff A, RN stated “I received a call from CMU [Cardiac Monitoring Unit] about a change in rhythm for my patient, I didn’t hear what was said and I just hung up and continued with my other patients. I know I was supposed to act on it, but I was very busy.” During an interview on 04/11/2025 at 1:44 PM, the APRN (Advanced Practice Registeren Nurse) stated the expectation is when a patient is on continuous cardiac monitoring, he/she is being monitored 24/7. If there is a change in the patient rhythm, then I expect monitor tech to notify the bedside RN and the bedside RN to notify us (cardiology). I did not receive a phone call that day regarding Patient #1 having any changes on the monitor. During an interview on 4/14/25 at 3:15 PM Staff D,RN stated I usually review the strips at the beginning of the shift. That day I didn’t have time because his blood pressure started to drop, and he started to complain of right jaw pain. I notified the APRN and she ordered a STAT CT (Computed Tomography scan is an imaging test that uses a series of X-rays and a computer to create detailed images) head. The patient went down to CT then I got a call from the APRN stating I should be down there with the patient. I went down then the patient coded. After the patient expired, I looked at the rhythm strip and signed off sinus rhythm. I didn’t know I had to document the “ST depression” too. During an interview on 04/17/2025 at 5:40PM, Staff H, MT (monitor technician) stated I documented on the strip “SR with ST depression’s”, the nurse that I spoke with was advised to get a 12 lead to confirm and that was pretty much it. It was a very busy shift, and I forgot to put this event on the log, I only wrote it on the telemetry strip. 2. During a tour on 04/09/2025 at 2:33 PM in the ED (Emergency Department), 3-screen telemetry mirror monitors were noted at the red zone (one of two nursing areas) nurse and physician station, next to the charge desk. No one was sitting at the charge desk. There was a PST (Patient Service Technician) sitting at a computer with her back facing the monitors. There was no one else behind the desk during the observation. This was confirmed by the ED Nurse Manager who was interviewed during the observation. ED Nurse Manager said the charge was in the rest room. The PST is a unit clerk, who listens for alerts while the charge is away. The nurse manager disclosed the PST was not telemetry certified. During an interview on 4/9/2025 at 11:25 AM, the ED nurse manager stated the charge watches the telemetry monitors. They are not monitored by the central monitoring unit. They are supposed to be stationary, but they are doing multiple jobs. There is no log of telemetry events. The nurse manager of the ED stated there was no way to track and trend telemetry issues in the ED. During an interview on 4/9/2025 at 12:12 PM, the DON (Director of Nursing) stated central telemetry does not monitor the ED; the charge nurse does. During an observation on 04/09/2025 at 2:38 PM, observation of the mirror monitors next to the charge desk revealed rooms 3, 10, 11, 18, 21, 22, 23 and 24 leads were off. The alarms were activated, and the screens were flashing. No one was at the desk watching the monitors to alert nursing staff to check on their patients. The ED nurse manager was present during the observation. During an observation on 04/09/2025 at 2:46 PM of the red zone station charge desk, no one was sitting at the charge desk, and no one was watching the telemetry monitors. Staff F, PST was on the phone at the charge desk. The nurse manager, who was present during the observation, stated that the charge went to get Tylenol. During an interview on 4/9/25 at 2:47 PM, Staff E, Charge RN (Registered Nurse) stated when she is at her desk she watches the monitors. She had a headache and went to get some Tylenol. She does have to use the restroom. She talks to paramedics when they bring patients in. She does participate in codes, but the resuscitation rooms are right here. Someone relieves her for lunch. “There should be someone watching these monitors. What is realistic and what we do as nurses aren’t the same.” I have to talk to the paramedics. She confirmed she is a resource for nurses. She confirmed there is not a communication log for the telemetry monitors. During an observation on 04/09/25 at 2:59 PM, the charge RN was getting report from paramedics who just brought a patient in. No one was watching the telemetry monitor screens. During an interview on 4/9/25 at 2:55 PM, Staff F, PST (Patient Services Technician) stated she acts as a health unit clerk/coordinator. She answers EMS calls. She answers the phones, prints discharge papers and makes calls for the doctors. She listens for the telemetry alarms. She would call the nurse to check the patient. She is not telemetry certified. She does not watch the monitors. She has other duties to attend to. During an observation on 04/09/25 at 2:59 PM, the charge RN was getting report from paramedics who just brought a patient in. No one was watching the telemetry monitor screens. During an interview on 4/10/25 at 8:37 AM, the Director of Nursing, and the Regional Director of Quality both stated that is not our standard or expectation for our telemetry patients in the ED.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48190 Based on medical record review, facility documents, facility policies, and interviews conducted, the facility failed to identify opportunities for improvement and develop an effective plan of correction for an adverse event involving staff failure to recognize and respond to a change in cardiac rhythm and without prompt intervention to seek effective preventive measures to protect in 1 of 1 QAPI program. Findings included: Review of Patient #1’s medical record revealed on 03/14/2025 the patient was admitted to the hospital for a gangrene/necrotic (dead or dying tissue) on the left 5th toe. Upon admission the patient had an order for continuous telemetry monitoring (a technique used to track heart activity) for 48 hours. The telemetry order expired on 3/16/25 and the nursing staff was alerted to renew the order but failed to follow through. The patient remained on the cardiac telemetry monitor. On 3/19/25 at 1:23pm the Telemetry Monitor Technologist informed Staff A, RN the patient developed a significant ST depression (A ST depression can be a sign of underlying condition that can lead to lethal rhythm disturbances). Staff A, RN failed to document and notify the physician of the ST depression. During shift change, Staff A, RN reported to Staff G, RN but failed to mention the ST depression. Staff D, RN signed the night shift telemetry strip (a printout of the cardiac rhythm) and failed to identify the ST depression. On 03/20/2025 at 9:20 PM, Patient #1 reported complaints of jaw pain and acetaminophen (over the counter pain medication) was given. At 10:20 PM, Patient #1 complained of 7/10 jaw pain (0 to 10 pain scale where 10 in the most pain). Staff B, APRN (Advanced Practice Registered Nurse) was made aware of jaw pain and drop in blood pressure (70/48). Staff B, APRN ordered CT of the Head (a diagnostic imaging procedure that uses X-rays to create detailed images of the brain, skull, and other structures within the head) STAT (immediately). At 1:00 AM, the patient was taken off the continuous telemetry monitor and transported to Radiology by a transporter. After the CT of the head, the transporter was assisting the patient back onto the stretcher from the CT machine, the patient became diaphoretic (sweating), stated “I do not feel well” and started vomiting. At 1:13 AM, a rapid response (a program designed to intervene swiftly when a patient’s condition deteriorates, often before a major medical emergency like cardiac arrest or respiratory failure occurs) was initiated then at 1:18 AM, a code blue (cardiac arrest) was called. Patient expired on 03/20/2025 at 2:15 AM. Review of cardiac rhythm strip dated 03/19/2025 at 1:23PM, the strip revealed Sinus Rhythm (the normal, regular pattern of electrical activity in the heart that starts in the sinus node, the heart’s natural pacemaker) with a ST depression (ST segment depression typically indicates that a person has an underlying condition that affects the heart. The condition may be relatively benign or potentially life threatening) Review of telemetry event log dated 3/19/2025, reveals no cardiac event noted for Patient #1. Review of facility event investigation completed on 04/03/2025 revealed the root cause is failure to acknowledge and response to rhythm change. Review of facility improvement plan revealed actions taken did not include recognizing or education for cardiac rhythm changes. Review of facility policy, Sentinel [Adverse] Events, last revision 5/2024, revealed: upon identification of a sentinel event or possible sentinel event, an analysis is conducted to understand the causes of the event, and when appropriate, to make changes in systems and processes to reduce the probability of a future event. A sentinel event is a patient safety event, not primarily related to the natural course of the patient’s illness or underlying condition, that reaches a patient and results in any of the following: a. death..... A review of the Risk Management Plan, last reviewed 1/2023, revealed the following: Purpose- The plan promotes the development of processes that identify, prevent, and mitigate organizational risks. Scope and Implementation- a. Audit reports and review findings are analyzed and tracked to identify operational deficiencies and potential areas or risk. B. Based on site visit audits and reviews, leadership identifies corrective action plan options to revise operational deficiencies and mitigate risks. Monitors the Effectiveness of the Action Taken- Action plans incorporate specific measures to demonstrate effectiveness of actions. On-going Activities- To meet plan objectives leadership focuses on: 1. Proactively reviewing operations and near-misses to identify opportunities for process improvement. 2. Investigating and trending adverse events to assess and determine how similar events might be averted and to control the loss related to the adverse outcome. A. Events are analyzed using the following criteria: frequency of occurrence, severity of occurrence, intense analysis, and corrective actions to improve care and services and environmental condition During an interview on 04/08/25 at 2:30 PM, Staff G, Manager of Quality stated “We have not started anything yet. We are waiting for the RCA [Root Cause Analysis] to be completed.” During an interview on 4/9/2025 at 11:25 AM, the ED (Emergency Department) Nurse Manager stated the charge watches the telemetry monitors. They are not monitored by the central monitoring unit. They are supposed to be stationary, but they are doing multiple jobs. There is no log of telemetry events. The nurse manager of the ED stated there was no way to track and trend telemetry issues in the ED. During an interview on 04/09/2025 at 2:47 PM, Staff E,Charge RN (Registered Nurse) stated when she is at her desk she watches the monitors. “There should be someone watching these monitors. What is realistic and what we do as nurses aren’t the same. I have to talk to the paramedics. I am a resource for nurses. There is not a communication log for the telemetry monitors.” During an interview on 4/9/25 at 2:55 PM, Staff F, PST (Patient Safety Attendant) stated she acts as a HUC (health unit clerk/coordinator). “I answer EMS calls, answer the phones, print discharge papers and makes calls for the doctors. I listen for the telemetry alarms. I would call the nurse to check the patient. I am not telemetry certified. I do not watch the monitors.” During an interview on 04/09/2025 at approximately 3:00 PM, Staff I/Regional Quality Director stated she recognized the risk manager did not complete a thorough investigation regarding Patient #1.”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 48190 Based on record review, facility documents and interviews, the facility failed to maintain an effective QAPI (Quality Assurance Program Improvement) program related to telemetry events, resulting in a multi system failure for one (#1) out of 10 sampled patients. The hospital failed to ensure tracking of telemetry events and failed to ensure appropriate and effective documentation, resulting in a death for one patient and patients on telemetry were continuously monitored in 11 (Emergency room patients) of 119 facility patients. Findings included: Review of Patient #1 ’ s medical record revealed on 03/14/2025 the patient was admitted to the hospital for a gangrene/necrotic (dead or dying tissue) on the left 5th toe. Upon admission the patient had an order for continuous telemetry monitoring (a technique used to track heart activity) for 48hours. The telemetry order expired on 3/16/25 and the nursing staff was alerted to renew the order but failed to follow through. The patient remained on the cardiac telemetry monitor. On 3/19/25 at 1:23pm the Telemetry Monitor Technologist informed, Staff A, RN the patient developed a significant ST depression (A ST depression can be a sign of underlying condition that can lead to lethal rhythm disturbances). Staff A, RN failed to document and notify the physician of the ST depression. During shift change, Staff A, RN reported to Staff G, RN but failed to mention the ST depression. Staff D, RN signed the night shift telemetry strip (a printout of the cardiac rhythm) and failed to identify the ST depression. On 03/20/2025 at 9:20 PM, Patient #1 reported complaints of jaw pain and Tylenol given. At 10:20 PM, Patient complains of 7/10 jaw pain. Staff B, APRN (Advanced Practice Registered Nurse) was made aware of jaw pain and drop in blood pressure (70/48). Staff B, APRN ordered CT of the Head (a diagnostic imaging procedure that uses X-rays to create detailed images of the brain, skull, and other structures within the head) STAT (immediately; without delay). At 1:00 AM, the patient was taken off the continuous telemetry monitor and transported to Radiology by a transporter. After the CT of the head, the transporter was assisting the patient back onto the stretcher from the CT machine, the patient became diaphoretic, stated “I do not feel well” and started vomiting. At 1:13 AM, a rapid response (a program designed to intervene swiftly when a patient’s condition deteriorates, often before a major medical emergency like cardiac arrest or respiratory failure occurs) was initiated then at 1:18 AM, a code blue (cardiac arrest) was called. Patient expired on 03/20/2025 at 2:15 AM. Review of cardiac rhythm strip dated 03/19/2025 at 1:23pm, the strip revealed Sinus Rhythm (the normal, regular pattern of electrical activity in the heart that starts in the sinus node, the heart’s natural pacemaker). with a ST depression (ST segment depression typically indicates that a person has an underlying condition that affects the heart. The condition may be relatively benign or potentially life threatening) Review of telemetry event log dated 3/19/2025, reveals no cardiac event noted for Patient #1. Review of the RCA (Root Cause Analysis) revealed it was completed on 4/3/2025. No participates documented and the identified cause was failure to acknowledge and response to rhythm change. Review of facility improvement plan revealed actions taken did not include recognizing or education for cardiac rhythm changes. A review of the Risk Management Plan, last reviewed 1/2023, revealed the following: Purpose. The plan promotes the development of processes that identify, prevent, and mitigate organizational risks. Scope and Implementation a. Audit reports and review findings are analyzed and tracked to identify operational deficiencies and potential areas or risk. b.Based on site visit audits and reviews, leadership identifies corrective action plan options to revise operational deficiencies and mitigate risks. 4. Monitors the Effectiveness of the Action Taken a.Action plans incorporate specific measures to demonstrate effectiveness of actions. On-going Activities To meet plan objectives leadership focuses on: Proactively reviewing operations and near-misses to identify opportunities for process improvement. Investigating and trending adverse events to assess and determine how similar events might be averted and to control the loss related to the adverse outcome. Events are analyzed using the following criteria: frequency of occurrence, severity of occurrence, intense analysis, and corrective actions to improve care and services and environmental conditions. Review of facility policy, Sentinel [Adverse] Events, last revision 5/2024, revealed: upon identification of a sentinel event or possible sentinel event, an analysis is conducted to understand the causes of the event, and when appropriate, to make changes in systems and processes to reduce the probability of a future event. A sentinel event is a patient safety event, not primarily related to the natural course of the patient ’ s illness or underlying condition, that reaches a patient and results in any of the following: a. death..... Comprehensive Systematic Analysis-A process for identifying the most basic or causal factor or factors that underlie variation in performance, including the occurrence of a sentinel event or serious occurrence. The response to the event includes: Notification of hospital leadership, Immediate , investigation, Completion of a comprehensive systematic analysis for identifying the causal ad contributory factors, Corrective actions derived from the identified causal and contributing factors that eliminate or control system hazards or vulnerabilities and result in sustainable improvement over time, Timeline for implementation of corrective actions and Systemic improvement. Procedure: The team utilizes tools that include but are not limited to: review of the applicable policies and procedures and/or clinical standards provided by the Unit Manager/Team Lead where the event occurred. d. The following may be included in the comprehensive systematic analysis process: III. Analysis to determine the root causes by continuously asking “why” until no additional logical answer can be identified, resulting in identification of root cause (s). Identification of risk reduction strategies and action plans for process improvement through redesign or development of new systems and processes that may improve performance and reduce the risk of future adverse events. During an interview on 04/08/25 at 2:30 PM, Staff G, Manager of Quality stated we have not started anything yet, we are waiting for the RCA (Root Cause Analysis) to be completed. However, we are going to develop and create an interview-based audit to ensure staff can speak (verbalize) the telemetry process. We are going to track, and trend acknowledge of understanding the process through notification and escalation. We are going to initiate new hire orientation training on telemetry. During an interview on 04/09/2025 at 11:25 AM, the ED (Emergency Department) Nurse Manager stated the charge nurse watches the telemetry monitors. They are not monitored by the central monitoring unit. They are supposed to be stationary, but they are doing multiple jobs. There is no log of telemetry events. The nurse manager of the ED confirmed there was no way to track and trend telemetry issues in the ED. During an interview on 04/09/2025 at 2:47 PM, Staff E/Charge RN (Registered Nurse) stated when she is at her desk she watches the monitors. She had a headache and went to get some acetaminophen. She does have to use the restroom. She talks to paramedics when they bring patients in. She does participate in codes, but the resuscitation rooms are right here. Someone relieves her for lunch. “There should be someone watching these monitors. What is realistic and what we do as nurses aren’ t the same. I have to talk to the paramedics. She confirmed she is a resource for nurses. She confirmed there is not a communication log for the telemetry monitors.” During an interview on 04/09/2025 at 2:55 PM, Staff F, PST (Patient Services Technician) stated she acts as a health unit clerk/coordinator. She answers EMS calls, answers the phones, prints discharge papers and makes calls for the doctors. She listens for the telemetry alarms. She would call the nurse to check the patient. She is not telemetry certified. She does not watch the monitors. She has the other duties to attend to.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48190 Based on medical record review, interview, policy review, and observation, the facility failed to 1. Respond to changes in cardiac rhythm and provide immediate nursing care for a patient on telemetry monitoring resulting in the death of 1 Patient (#1) of 10 sampled patients for telemetry, and 2. Ensure cardiac monitors on patients in the ED (Emergency Department) were being observed for 11 patients in the ED of 119 patients in the hospital. Findings included: 1. Review of Patient #1’s medical record revealed on 03/14/2025 the patient was admitted to the hospital for a gangrene/necrotic (dead or dying tissue) on the left 5th toe. Upon admission the patient had an order for continuous telemetry monitoring (a technique used to track heart activity) for 48hours. The telemetry order expired on 3/16/25 and the nursing staff was alerted to renew the order but failed to follow through. The patient remained on the cardiac telemetry monitor. On 3/19/25 at 1:23PM the Telemetry Monitor Technologist informed Staff A, RN (Registered Nurse) the patient developed a significant ST depression (A ST depression can be a sign of underlying condition that can lead to lethal rhythm disturbances). Staff A, RN failed to document and notify the physician of the ST depression. During shift change, Staff A, RN reported to Staff G, RN but failed to mention the ST depression. Staff D, RN signed the night shift telemetry strip (a printout of the cardiac rhythm) and failed to identify the ST depression. On 03/20/2025 at 9:20 PM, Patient #1 reported complaints of jaw pain and Tylenol given. At 10:20 PM, Patient complains of 7/10 jaw pain. Staff B, APRN (Advanced Practice Registered Nurse) was made aware of jaw pain and drop in blood pressure (70/48). Staff B, APRN ordered CT of the Head (a diagnostic imaging procedure that uses X-rays to create detailed images of the brain, skull, and other structures within the head) STAT (immediately). At 1:00 AM, the patient was taken off the continuous telemetry monitor and transported to Radiology by a transporter. After the CT of the head, the transporter was assisting the patient back onto the stretcher from the CT machine, the patient became diaphoretic (sweaty), stated “I do not feel well” and started vomiting. At 1:13 AM, a rapid response (a program designed to intervene swiftly when a patient’s condition deteriorates, often before a major medical emergency like cardiac arrest or respiratory failure occurs) was initiated then at 1:18 AM, a code blue (cardiac arrest) was called. Patient expired on 03/20/2025 at 2:15 AM. During an interview on 04/08/2025 at 12:00PM, Staff C, Nurse Manager stated on 3/19/25 at 1:36PM the telemetry technician called the nurse regarding a rhythm change. Stated he sent up the strip and recommended an EKG to confirm. There was no documentation or reassessment noted in the EMR regarding a rhythm change, including no follow up with the physician or EKG obtained. During an interview on 04/09/2025 at 2:40 PM, Staff C, Nurse Manager stated the night nurse failed to properly identify the rhythm strip. He stated the rhythm strip clearly reveals “sinus rhythm with ST depression”. During an interview on 4/10/15 at 11:30AM, Staff A, RN stated “I received a call from CMU (Cardiac Monitioring Unit) about a change in rhythm for my patient, I didn’t hear what was said and I just hung up and continued with my other patients. I know I was supposed to act on it, but I was very busy.” During an interview on 04/11/2025 at 1:44 PM, Staff, APRN stated the expectation is when a patient is on continuous cardiac monitoring, he/she is being monitored 24/7. If there is a change in the patient rhythm, then “I expect monitor tech to notify the bedside RN and the bedside RN to notify us (cardiology). I did not receive a phone call that day regarding Patient #1 having any changes on the monitor.” During an interview on 4/14/25 at 3:15PM Staff D, RN stated I usually review the strips at the beginning of the shift. That day “I didn’t have time because his blood pressure started to drop, and he started to complain of right jaw pain. I notified the APRN and she ordered a STAT CT head. The patient went down to CT then I got a call from the APRN stating I should be down there with the patient. I went down then the patient coded. After the patient expired, I looked at the rhythm strip and signed off sinus rhythm. I didn’t know I had to document the “ST depression” too.” Review of Assessment/Reassessment of (Adult) Patients policy last revision date 7/2024, the Registered Nurse (RN) assess for signs and symptoms of pain, performs initial assessment, plan of care and reassessments in the medical record. The patient reassessed at regular intervals. Reassessment is triggered by changes in patient ’ s condition or needs and document in the patient ’ s medical records. Review of the Cardiac Monitoring (Telemetry) policy last revision date 7/2024, the RN interprets and evaluates rhythm strip, every shift or more often for changes in patient condition and/or if rhythm, rate changes occur.... Emergency Response: Monitor tech notifies nurse when a change in patient ’ s rhythm is identified. Telemetry skill validated nurse assesses the patient immediately...... 2. During an interview on 04/09/2025 at 11:25 AM, the ED (emergency department) nurse manager stated the charge nurse watches the telemetry monitors. They are not monitored by the central monitoring unit. They are supposed to be stationary, but they are doing multiple jobs. There is no log of telemetry events. The nurse manager of the ED confirmed there was no way to track and trend telemetry issues in the ED. During an interview on 04/09/25 at 12:12 PM, the DON (Director of Nursing) stated the central telemetry does not monitor the ED. The Charge nurse does. Once they are admitted to inpatient, central telemetry monitors them even if they ’ re in the ED. During a tour of the ED on 04/09/2025 at 2:33 PM, 3-screen telemetry mirror monitors were noted at the red zone nurse and physician station, next to the charge desk. No one was sitting at the charge desk. There was a PST (Patient Services Technician) sitting at a computer with her back facing the monitors. There was no one else behind the desk during the observation. This was confirmed by the nurse manager who was interviewed during the observation. She said the Charge nurse was in the rest room. The PST listens for alerts while the charge is away. The nurse manager disclosed the PST was not telemetry certified. During an observation on 04/09/2025 at 2:38 PM, the mirror monitors next to the charge desk revealed rooms 3, 10, 11, 18, 21, 22, 23 and 24 leads were off. The alarms were activated, and the screens were flashing. No one was at the desk watching the monitors to alert nursing staff to check on their patients. The ED nurse manager was present during the observation. During an observation on 04/09/2025 at 2:46 PM, no one was sitting at the charge desk and no one was watching the telemetry monitors. The PST, Staff F was on the phone at the charge desk. The nurse manager, who was present during the observation, said that the charge went to get Tylenol. During an interview at 04/09/2025 at 2:47 PM, Staff E, charge RN stated when she is at her desk she watches the monitors. She has a headache and went to get some acetaminophen. She does have to use the restroom. She talks to paramedics when they bring patients in. She does participate in codes, but the resuscitation rooms are right here. Someone relieves her for lunch. “There should be someone watching these monitors. What is realistic and what we do as nurses aren’t the same. I have to talk to the paramedics. She confirmed she is a resource for nurses. She confirmed there is not a communication log for the telemetry monitors.” During an interview on 04/09/2025 at 2:55 PM, Staff F, PST stated she acts as a health unit clerk/coordinator. She answers EMS (Emergency Medical Services) calls. She answers the phones, prints discharge papers and makes calls for the doctors. She listens for the telemetry alarms. She would call the nurse to check the patient. She is not telemetry certified. She does not watch the monitors. She has the other duties to attend to. During an observation on 04/09/2025 at 2:59 PM, the charge nurse was getting report from paramedics who just brought a patient in. No one was watching the telemetry monitor screens. During an interview on 04/10/25 at 8:37 AM, the DON, and the regional Director of Quality both stated that is not our standard or expectation for our telemetry patients in the ED.”