Encompass Health Rehabilitation Hospital of Panama

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45827 Based on observation, staff interview, interview with the offsite contracted cardiac monitoring company, record review and policy review, the hospital failed to protect and promote patient rights for safe and effective cardiac monitoring for 9 of 9 sampled patients (Deceased Patient #1, and 8 current patients receiving remote cardiac monitoring services #2, #4, #5, #6, #9, #10, #11, #13). Cardiac monitoring services were performed remotely via telemetry by a contracted company. The hospital had no onsite cardiac monitors, and hospital staff were dependent on notifications from the telemetry contractor regarding dysrhythmias (abnormal heart rhythms) and services being offline. On 1/21/2025, Patient #1 experienced a life threatening cardiac dysrhythmia requiring cardiopulmonary resuscitation. The contracted telemetry monitoring company failed to notify the hospital of the change in cardiac rhythm during the event and later reported that the telemetry was offline at the time. Interviews with 5 of 9 hospital staff reported prior issues with telemetry going offline which was more prevalent in certain patient rooms (Staff B, C, E, the Chief Nursing Officer and the Quality and Risk Management Director). The hospital had 8 current patients with orders for remote telemetry monitoring. Cross Reference A0286. The cumulative effect of the failures resulted in a determination of Immediate Jeopardy at the Condition of Patient Rights. The hospital Chief Executive Officer and Quality and Risk Management Director were notified of Immediate Jeopardy on 02/21/2025 at 4:58 PM. Immediate Jeopardy began on 01/21/2025, the death date for Patient #1. The hospital submitted an acceptable Immediate Jeopardy removal plan and the state agency removed the Immediate Jeopardy on 02/21/2025 at 7:30 PM. The removal plan included the following immediate actions to remove the Immediate Jeopardy, and the on-site survey of 02/21/2025 found: 1. The hospital terminated the cardiac telemetry monitoring contract with the telemetry provider. Telemetry services will be deferred until further notice. Providers at Encompass Health and Rehabilitation Hospital of Panama City were notified that telemetry services have been discontinued indefinitely. The hospital will not admit any patients requiring telemetry services. On 02/21/2025, the survey team verified this via interview with the Quality and Risk Management Director. 2. The hospital immediately identified patients on telemetry and notified the medical team (physicians, advanced practice providers) of the urgent need for evaluation. After medical evaluation, seven patients’ telemetry services were discontinued and remained in the facility. One patient was transferred to the acute care hospital. On 02/21/2025, the survey team verified this via review of patient orders for the 8 current telemetry patients, verifying the patient transfer and via interview with the Quality and Risk Management Director. 3. The charge nurse or designated leader confirmed all telemetry discontinuation orders have been placed and carried out. Any patient requiring transfer will be tracked until safely admitted to the acute care hospital. Leadership was notified when the process was complete. On 02/21/2025, the survey team verified this via review of patient orders, interview with the Nurse Manager, and interview with the Quality and Risk Management Director. The findings include: Cross Reference A0144: Based on observation, staff interview, interview with the contracted cardiac monitoring company, clinical record review and policy review, the hospital failed to ensure patient rights of care in a safe setting for 9 of 9 sampled patients who had physician orders for continuous cardiac monitoring (Patient #1, deceased, and current patients #2, #4, #5, #6, #9, #10, #11, #13). On 1/21/2025, Patient #1 died after a cardiac event resulting in dysrhythmia and cardiopulmonary resuscitation. The contracted telemetry monitoring company failed to notify the hospital of the change in cardiac rhythm during the event and later reported that the telemetry was offline at the time. Interviews with 5 of 9 hospital staff reported issues with telemetry going offline, more prevalent in certain patient rooms, off and on for the past 2 years (Staff B, C, E, the Chief Nursing Officer and the Quality and Risk Management Director). The hospital had 8 current patients receiving telemetry monitoring.”

“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: 45827 Based on observation, staff interview, interview with the offsite contracted cardiac monitoring company, record review and policy review, the hospital failed to develop and implement a performance improvement plan to correct identified issues with remote cardiac monitoring services for 9 of 9 sampled patients (Deceased Patient #1, and 8 current patients receiving remote cardiac monitoring services #2, #4, #5, #6, #9, #10, #11, #13). Cardiac monitoring services were performed remotely via telemetry by a contracted company. The hospital had no onsite cardiac monitors, and hospital staff were dependent on notifications from the telemetry contractor regarding dysrhythmias (abnormal heart rhythms) and services being offline. On 1/21/2025, Patient #1 experienced a life threatening cardiac dysrhythmia requiring cardiopulmonary resuscitation. The contracted telemetry monitoring company failed to notify the hospital of the change in cardiac rhythm during the event and later reported that the telemetry was offline at the time. The hospital QAPI committee reviewed the death, but failed to develop immediate corrective actions regarding the contracted cardiac monitoring services. Interviews with 5 of 9 hospital staff reported prior issues with telemetry going offline which was more prevalent in certain patient rooms (Staff B Registered Nurse, Staff C Respiratory Therapist, Staff E Nurse Manager, the Chief Nursing Officer and the Quality and Risk Management Director). The hospital had 8 current patients with orders for remote telemetry monitoring. The cumulative effect of the failures resulted in a determination of Immediate Jeopardy at the Condition of Quality Assessment and Performance Improvement. The hospital Chief Executive Officer and Quality and Risk Management Director were notified of Immediate Jeopardy on 02/21/2025 at 4:58 PM. Immediate Jeopardy began on 01/21/2025, the death date for Patient #1. The hospital submitted an acceptable Immediate Jeopardy removal plan and the state agency removed the Immediate Jeopardy on 02/21/2025 at 7:30 PM. The removal plan included the following immediate actions to remove the Immediate Jeopardy, and the on-site survey of 02/21/2025 found: 1. A QAPI meeting was held on 02/21/2025 beginning at 1739. Members present included: Attending Provider (physician), Nurse Manager, Director of Quality and Risk, Chief Nursing Officer, and Chief Executive Officer. On 02/21/2025, the survey team verified this via review of the QAPI meeting minutes and interview with the Quality and Risk Management Director. 2. The hospital terminated the contract with the contracted telemetry provider. Telemetry services will be deferred until further notice. Providers at Encompass Health and Rehabilitation Hospital of Panama City were notified that telemetry services have been discontinued indefinitely. The hospital will not admit any patients requiring telemetry services. On 02/21/2025, the survey team verified this via interview with the Quality and Risk Management Director. 3. The hospital immediately identified patients on telemetry and notified the medical team (physicians, advanced practice providers) of the urgent need for evaluation. After medical evaluation, seven patients’ telemetry services were discontinued and remained in the facility. One patient was transferred to the acute care hospital. On 02/21/2025, the survey team verified this via review of patient orders, interview with the Nurse Manager, and interview with the Quality and Risk Management Director. The findings include: Cross Reference to A0286: Based on staff interview, interview with the contracted cardiac monitoring company, clinical record review, policy review, contract review, review of corrective actions following an adverse patient event, and observation, the hospital failed to implement preventative measures for 9 of 9 patients ordered to receive telemetry (remote cardiac monitoring) services (Patient #1 deceased, and 8 current patients #2, #4, #5, #6, #9, #10, #11, #13). The hospital contracted with a remote telemetry monitoring company located in another state. On 1/21/2025, Patient #1 died after a cardiac event resulting in dysrhythmia and cardiopulmonary resuscitation. The contracted telemetry monitoring company failed to notify the hospital of the change in cardiac rhythm during the event and later reported that the telemetry was offline at the time. Interviews with 5 of 9 hospital staff reported issues with telemetry going offline, more prevalent in certain patient rooms off and on for the past 2 years (Staff B, C, E, the Chief Nursing Officer and the Quality and Risk Management Director). The hospital QAPI program failed to address identified issues with the remote telemetry services.”

“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: 45827 Based on observation, staff interview, interview with the contracted cardiac monitoring company, record review and policy review, the hospital failed to ensure patient rights of care in a safe setting for 9 of 9 sampled patients who had physician orders for continuous cardiac monitoring (Patient #1 deceased, and current patients #2, #4, #5, #6, #9, #10, #11, #13). On 1/21/2025, Patient #1 died after a cardiac event resulting in dysrhythmia (abnormal heart rhythm) and cardiopulmonary resuscitation. The contracted telemetry monitoring company failed to notify the hospital of the change in cardiac rhythm during the event and later reported that the telemetry was offline at the time. Interviews with 5 of 9 hospital staff reported issues with telemetry going offline, more prevalent in certain patient rooms, off and on for the past 2 years (Staff B Registered Nurse, Staff C Respiratory Therapist, Staff E Nurse Manager, the Chief Nursing Officer and the Quality and Risk Management Director). The hospital had 8 current patients receiving telemetry monitoring. Cross Reference A0115. The findings include: Review of Patient #1’s medical record found Patient #1 was admitted on 01/08/2025 with diagnosis that included: Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) (a type of heart attack where there is a partial blockage of a coronary artery, which reduces blood flow to the heart muscle); congestive heart failure (CHF) (a chronic condition where the heart muscle becomes weakened and cannot pump blood efficiently); cardiomyopathy (a group of diseases that affect the heart muscle, making it difficult for the heart to pump blood effectively); ejection fraction (a percentage of the total amount of blood in your heart that is pumped out with each heartbeat) of 10-15% (an ejection fraction below 40 percent means the heart is not pumping enough blood and may be failing). Remote Telemetry (Cardiac Monitoring transmitted to an offsite location) was ordered on 01/12/2025. On 1/21/25 at 4:32 PM, Registered Nurse B found Patient #1 on the bathroom floor without a pulse and immediately initiated a Code Blue (life threatening emergency requiring Cardiopulmonary Resuscitation [CPR]). The Code Blue/Rapid Response summary dated 01/21/25 for Patient #1 documented CPR was initiated at 4:35 PM, Patient #1 defibrillated via shock at 4:40 PM, CPR resumed, and EMS arrived at 4:41 PM. Upon stabilization of patient, Patient #1 was transported via EMS at 4:52 PM to an acute care hospital where he was pronounced deceased. Telemetry strips, dated as received by the hospital on 1/21/2025 at 7:07 PM (after the patient was transferred out), showed that ventricular fibrillation (a life-threatening arrhythmia requiring immediate CPR and electrical shocks) began at 4:30 PM Central time. A review of the hospital investigation revealed on 01/21/2025, Patient #1 was assisted to the bathroom and left unattended. The patient was found on the floor in distress, a Code Blue was initiated with immediate Cardiopulmonary Resuscitation (CPR). Emergency Medical Services (EMS) was notified, and Patient #1 was transferred to a hospital emergency department and died. The facility’s internal investigation revealed Patient #1 was in ventricular fibrillation. No phone call was received by the facility from the telemetry contractor to notify them Patient #1 was in ventricular fibrillation. On 02/19/2025 at approximately 2:46 PM, an interview was conducted with Staff B, a Registered Nurse (RN B) who stated that on 1/21/2025 at 4:30 PM, she walked into Patient #1’s bathroom and found the patient on the floor and non-responsive. RN B called for help and then pushed the Code Blue button. RN B then started CPR at 4:35 PM. Staff A, a Rehabilitation Nurse Technician, entered the bathroom and assisted with CPR and Staff C, a Respiratory Therapist, entered the room with the crash cart. She stated a staff at the nurses’ desk called EMS and the patient was taken to a local hospital. RN B stated she did not recall any communication from the telemetry contractor regarding Patient #1’s condition or problems with telemetry connectivity to [Wi-Fi] during the event. RN B stated she was aware of previous issues with the telemetry contractor not communicating either connectivity issues or changes in patients’ condition. She could not state when or how often this occurs as the facility does not document this. A tour of the hospital was conducted on 02/19/2025 beginning at approximately 10:15 AM. No cardiac telemetry display monitors were observed. The hospital staff were dependent on dysrhythmia and offline notifications from the telemetry contractor. On 02/19/2025 at approximately 10:30 AM, an interview was conducted with the Quality and Risk Management Director (QRMD). The QRMD stated they have problems with the telemetry contractor to include telemetry connectivity and communication regarding patients’ changes in conditions. She stated the facility is looking for another telemetry provider. The QMRD could not state how long they have had problems with the telemetry contractor as there were no call logs to document communication with telemetry contractor regarding issues. On 02/19/2025 at approximately 2:00 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated the facility had connectivity and communication issues with the telemetry contractor. He stated there was no connectivity to telemetry monitors in some of the patient rooms requiring the patients to be moved to different rooms. He further stated the communication concern was related to the telemetry contractor’s responsiveness to changes in the patient’s condition. The CNO also stated there was also an issue with the quality of the telemetry strips. On 02/19/2025 at approximately 2:55 PM, an interview was conducted with Staff E, a Nurse Manager, who stated she was aware of issues with telemetry connectivity. Nurse Manager E further stated she verbally communicated the issue to leadership but could not remember when it was reported and did not have written communication of the report. Nurse Manager E stated when there were issues with telemetry connectivity, the patient was moved to a different room with better connectivity. On 02/20/2025 at approximately 9:55 AM, an interview was conducted with Staff C, Respiratory Therapist (RT C) who stated on 01/21/2025 he spoke with a telemetry contractor employee who could not provide any information on why the telemetry contractor did not report Patient #1 was in ventricular fibrillation or that there were connectivity issues with Patient #1’s telemetry monitor connectivity. RT C stated he was aware some patient rooms have more problematic connectivity issues than others and sometimes they have to move patients to another room for better connectivity. On 02/20/2025 at approximately 10:24 AM, an interview was conducted with the telemetry contractor Vice President of Operations (VPO). When asked for an explanation of the 01/21/2025 event with Patient #1, he stated, “Monitor offline.” He stated (name of the telemetry contractor) will send eight additional Wi-Fi boosters to the facility to improve telemetry connectivity. The VPO stated it was protocol for (name of the telemetry contractor) to communicate with the hospital when having problems with connectivity but he did not know why there was no communication regarding Patient #1. The VPO could not provide records of communication with the hospital because the event happened over a month ago and they do not keep records that long. On 02/20/2025 at approximately 10:54 AM, an additional interview was conducted with the QMRD who stated they do not have a system in place to improve patient cardiac monitoring until the new company was brought in. On 02/21/2025 at approximately 10:34 AM, an additional interview was conducted with the CNO who stated he has worked at the facility about 2 ½ years and during that time there have been issues with telemetry connectivity. The CNO further stated the facility does not track calls from the telemetry contractor or when they are notified of a telemetry monitor being offline and the telemetry contractor does not provide monitors for the facility to see patient telemetry in real time. He stated patient room #108 was a room that he knows has a dead spot. He has not instructed the supervisors not to admit patients to that room as they do not know if a patient will be ordered telemetry prior to being admitted. On 02/21/2025 at approximately 11:41 AM, an additional interview was conducted with the QMRD who stated Patient #1 left with EMS on 01/21/2025 with CPR in progress. The receiving facility notified the family that the patient had died, and the family later notified our Chief Executive Officer the patient had died. On 02/21/205 at approximately 1:00 PM, an additional interview was conducted with RT C who stated the facility has had connectivity issues with the telemetry contractor for at least a year. RT C further stated he receives frequent calls from the telemetry contractor about patients going offline, but no log of the calls is kept. He stated telemetry connectivity issues were more so in patient rooms around the central nurses’ station which were rooms 104, 105, 106, 107, and 108. The hospital provided a list of room locations for all patients receiving telemetry services for each day of the survey. On 02/19/2025, there were patients in both rooms 107 and 108 who were receiving telemetry services and there was a patient in room 107 receiving telemetry services on 02/20/2025 and 02/21/2025. A review of the Remote Telemetry Monitoring policy, revised on 04/09/2022, was conducted. On page 1 it states, “This program will allow patients to be monitored 24-hours a day for a period of time as defined by the physician.” On page 2, under Significant Cardiac Rhythm Disturbance, it states, “In the event of a significant cardiac rhythm disturbance, (name of the telemetry contractor) will call the supervisor phone to inform the staff of the change.” 50447”

“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: 45827 Based on staff interview, interview with the contracted cardiac monitoring company, clinical record review, policy review, contract review, review of corrective actions following an adverse patient event, and observation, the hospital failed to implement preventative measures for 9 of 9 patients ordered to receive telemetry (remote cardiac monitoring) services (Patient #1 deceased, and 8 current patients #2, #4, #5, #6, #9, #10, #11, #13). The hospital contracted with a remote telemetry monitoring company located in another state. On 1/21/2025, Patient #1 died after a cardiac event resulting in dysrhythmia and cardiopulmonary resuscitation. The contracted telemetry monitoring company failed to notify the hospital of the change in cardiac rhythm during the event and later reported that the telemetry was offline at the time. Interviews with 5 of 9 hospital staff reported issues with telemetry going offline, more prevalent in certain patient rooms off and on for the past 2 years (Staff B Registered Nurse, Staff C Respiratory Therapist, Staff E Nurse Manager, the Chief Nursing Officer and the Quality and Risk Management Director). The hospital QAPI program failed to address identified issues with the remote telemetry services. Cross Reference A0115 and A0263. The findings include: A review of the hospital investigation following the death of Patient #1 on 01/21/2025 found that Patient #1 was assisted to the bathroom and left unattended. The patient was found on the floor in distress and a Code Blue (emergency response) was initiated with immediate Cardiopulmonary Resuscitation (CPR). Emergency Medical Services (EMS) was notified, and Patient #1 was transferred to a hospital emergency department where he was pronounced deceased. The hospital’s internal investigation revealed Patient #1 was in ventricular fibrillation (a life-threatening arrhythmia requiring immediate CPR and electrical shocks). No phone call was received by the hospital from the contracted telemetry monitoring company to notify them Patient #1 was in ventricular fibrillation. Telemetry strips, dated as received by the hospital on 1/21/2025 at 7:07 PM (after the patient was transferred out), showed that ventricular fibrillation (a life-threatening arrhythmia requiring immediate CPR and electrical shocks) began at 4:30 PM central time. The investigation included an analysis which stated the hospital was working with the contracted telemetry service provider regarding lack of notification of patients’ arrythmias and notification process failure may have caused a delay in care. The investigation also included the plan of correction for telemetry concerns, which stated the hospital was working with the contracted telemetry provider to obtain a copy of analysis and performance improvement plan/corrective action plan. No further corrective actions were indicated. A tour of the hospital was conducted on 02/19/2025 beginning at approximately 10:15 AM. No cardiac telemetry display monitors were observed within the hospital. On 02/19/2025 at approximately 10:30 AM, an interview was conducted with the Quality and Risk Management Director (QRMD). The QRMD stated they have problems with the contracted telemetry monitoring company to include telemetry connectivity [to Wi-Fi] and communication regarding patients’ changes in conditions. She stated the facility was looking for another telemetry provider. The QMRD could not state how long they have had problems with the contracted telemetry company as there were no call logs to document communication with the company regarding issues. On 02/19/2025 at approximately 2:00 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated the hospital has connectivity and communication issues with the contracted telemetry company. He stated there were connectivity problems in some of the patient rooms requiring the patient to be moved to a different room. He further stated the communication concern was related to the contracted telemetry company’s responsiveness to changes in the patient’s condition. The CNO also stated there was also an issue with the quality of the telemetry strips. On 02/19/2025 at approximately 2:46 PM, an interview was conducted with Staff B, a Registered Nurse (RN B) who stated that on 1/21/2025 at 4:30 PM, she walked into Patient #1’s bathroom and found the patient on the floor and non-responsive. RN B called for help and then pushed the Code Blue button. RN B then started CPR at 4:35 PM. Staff A, a Rehabilitation Nurse Technician, entered the bathroom and assisted with CPR and Staff C, Respiratory Therapist, entered the room with the crash cart. RN B stated a staff at the nurses’ desk called EMS and the patient was taken to a local acute care hospital. RN B stated she did not recall any communication from the telemetry contractor notifying them of Patient #1’s condition or problems with telemetry connectivity during the event. RN B stated she was aware of previous issues with the telemetry contractor failing to communicate connectivity issues and/or changes in patients’ condition. RN B could not state when or how often this occurs as the hospital does not track this. On 02/19/2025 at approximately 2:55 PM, an interview was conducted with Staff E, a Nurse Manager, who stated she was aware of issues with telemetry connectivity. Nurse Manager E further stated she verbally communicated the issue to leadership but could not remember when it was reported and did not have written communication of the report. Nurse Manager E stated when there were issues with telemetry connectivity, the patient was moved to a different room with better connectivity. On 02/20/2025 at approximately 9:55 AM, an interview was conducted with Staff C, Respiratory Therapist (RT C) who reported on 01/21/2025 at 4:52 PM he spoke with a telemetry contractor employee who could not provide any information on why the telemetry contractor did not report Patient #1 was in ventricular fibrillation or that there were connectivity issues with Patient #1’s telemetry monitor connectivity. RT C stated he was aware some patient rooms have more problematic connectivity issues than others and sometimes they have to move patients to another room for better connectivity. On 02/20/2025 at approximately 10:24 AM, an interview was conducted with the Vice President of Operations (VPO) from the telemetry contractor. When asked for an explanation of the 01/21/2025 event with Patient #1, he stated, “Monitor offline.” He stated (name of telemetry contractor) will send eight additional Wi-Fi boosters to the facility to improve telemetry connectivity. The VPO stated it is protocol for (name of telemetry contractor) to communicate with the hospital when having problems with connectivity but he did not know why there was no communication regarding Patient #1. The VPO could not provide records of communication with the hospital because the event happened over a month ago and they do not keep records that long. On 02/20/2025 at approximately 1:45 PM, an additional interview was conducted with the QRMD who stated they do not have a plan for not receiving the calls from the telemetry contractor. Their plan was to change providers as quickly as possible. The QRMD further stated they had a QAPI meeting on 02/11/2025 at 2:00 PM to discuss the incident on 01/21/2025, but only the patient fall was discussed. There has not been a QAPI meeting regarding telemetry issues. She stated they report events a quarter behind and this event has not yet been officially reported to the governing body as it meets tomorrow, 02/21/2025. She stated unofficially everyone on the governing body was aware of the event but there has not been a formal meeting since the event happened. The QRMD stated a root cause analysis was completed on the 01/21/2025 event but she could not provide the report because of the Patient Safety Organization (PSO) confidentiality rule (protects the privacy of data submitted to a PSO to analyze and learn from patient safety events without fear of repercussions). On 02/21/2025 at approximately 10:34 AM, an additional interview was conducted with the CNO who stated he has worked at the facility about 2 ½ years and during that time there have been issues with telemetry connectivity. The CNO further stated the facility does not track calls from the telemetry contractor or when they are notified of a telemetry monitor being offline and the telemetry contractor does not provide in house monitors for the hospital staff to see patient telemetry in real time. The CNO stated patient room #108 was a room that he knows has a dead spot. He has not instructed the supervisors not to admit patients to that room as they do not know if a patient will be ordered telemetry prior to being admitted. On 02/21/2025 at approximately 11:41 AM, an additional interview was conducted with the QRMD who stated Patient #1 left with EMS on 01/21/2025 with code (CPR) in progress. The receiving facility notified the family that the patient had died, and the family later notified our Chief Executive Officer the patient had died. The QRMD further stated she was communicating with the VPO of the contracted telemetry company via telephone only but began email communication with him starting last week. She did not maintain a log of the phone calls to the VPO. The VPO was supposed to provide an action plan related to the incident which she requested on 01/22/2025. The VPO provided an action plan on 02/19/2025; however, the QRMD did not feel the plan was adequate and did not use it. The hospital initiated discussions on a corrective action plan for telemetry services on 02/19/2025. The QRMD reiterated on 02/11/2025 a quality improvement meeting was held and they did a workflow analysis for the purpose of putting telemetry on patients. They did not discuss services with the contracted telemetry company, the patient incident on 01/21/2025 or their concerns with current telemetry. The QRMD stated there were no quality improvement meeting minutes regarding telemetry to review as they have not had a meeting to discuss telemetry concerns. On 02/21/2025 at approximately 1:00 PM, an additional interview was conducted with RT C who reported the hospital has had connectivity issues with the telemetry contractor for at least a year. RT C further stated he receives frequent calls from the telemetry contractor about patients going offline, but no log of the calls was kept. He stated telemetry connectivity issues were more prevalent in patient rooms around the central nurses’ station which were rooms 104, 105, 106, 107, and 108. The hospital provided a list of room locations for all patients receiving telemetry services for each day of the survey. On 02/19/2025, there were patients in both rooms 107 and 108 with orders for telemetry services and there was a patient in room 107 receiving telemetry services on 02/20/2025 and 02/21/2025. Review of the Remote Telemetry Monitoring policy, revised on 04/09/2022, was conducted. On page 1 it states, “This program will allow patients to be monitored 24-hours a day for a period of time as defined by the physician.” On page 2, under Significant cardiac rhythm disturbance, it states, “In the event of a significant cardiac rhythm disturbance, (name of the telemetry contractor) will call the supervisor phone to inform the staff of the change.” Review of the facility’s contract with (name of the telemetry contractor) for telemetry services found the contract’s effective date was 09/24/2019. On page 2, 3.1 it reads, “At the request of a Participating Hospital, Supplier shall provide cardiac monitoring services, to patients of such Participating Hospitals in accordance with all applicable federal and state laws and regulations and protocols lawfully set forth by participating hospital. All equipment, tools, materials and supplies required to perform the Services shall be selected by the Supplier in its sole discretion, and supplied by the Supplier, at Supplier’s expense.” 50447”