HCA Florida hospital cited after patient death

CMS placed an HCA Florida hospital in immediate jeopardy between late August and mid-September after a patient died because he was moved to the wrong room and employees couldn't find him.

On Aug. 24, a patient entered the emergency department at 3 p.m. in Hudson, Fla.-based Bayonet Point Hospital because of a positive COVID-19 test, a cough and increased weakness, according to a CMS report. He had Type 2 diabetes, hypertension, hypothyroid, a pacemaker and a cholecystectomy. On arrival, his vital signs were stable. 

At 9:25 p.m., registration put the wrong room number in the electronic bed assignment system. About an hour later, the patient had a fever but a nurse was unable to contact the on-call physician. Two hours later, a code blue was called after a nurse "went into the patient's room to administer medication and noted the patient lying across the bed, mouth open with the nasal cannula out of his nose," according to the report.

She began chest compressions, but said "he was down for 20 minutes before CPR started." He was declared dead Aug. 25 at 12 a.m. 

An immediate jeopardy began Aug. 24 because of issues related to patient rights, care in a safe setting, quality assurance and performance improvement, quality improvement activities, nursing services, and staffing and delivery of care. 

A monitor technician who was watching 55 patients' cardiac telemetry signs said this patient was supposed to be in 2 West, and when his monitor detected a ventricular fibrillation, she scrambled to find him.

"I called the nurse on the floor [2 West] and she said the patient wasn't there yet. I didn't know what to do at that time," the technician said. "It didn't seem reasonable to call a Code Blue to an empty room."

The technician called the nursing unit twice, and was twice told he was not there, and she called the ED three times, with the first two calls going unanswered.

Interviews with multiple staff members reveal more struggles to contact coworkers and varying interpretations of the hospital's telemetry monitoring policy. CMS said Bayonet Point "failed to ensure that patients on telemetry were provided life saving measures in the event of a fatal cardiac arrhythmia in 1 of 3 patients reviewed for cardiac telemetry services, and failed to provide continuous telemetry monitoring for 2 of 3 patients reviewed."

Staff shortages have been a problem at the hospital that's already facing scrutiny from Florida lawmakers because of reports of unsanitary and unsafe conditions that are compromising care. 

"Night shift is extremely short; the staff is talking about how unsafe it is and are refusing to pick up extra shifts," a charge nurse said in a Sept. 11 interview with CMS. "The last 45 days have been horrible with staffing; we are back to charge RNs taking assignments along with acting as unit secretary for the unit."

In response to the patient death and the immediate jeopardy notice, Bayonet Point developed and provided an education plan for its staff to clarify lethal cardiac rhythm escalation and the process for moving a patient in the monitoring system.

ED staff were instructed to refer to patients with their names rather than room numbers when speaking with monitor technicians. The hospital also further defined employees' roles and expectations when talking with monitor techs and working with the computerized charting system. 

A collaborative group composed of quality, patient safety, and nursing teams reassembled the Telemetry Performance Improvement Team, which analyzes events, identifies trends and develops action plans to resolve potential problems. Telemetry audits will be randomly performed five times a week, and a monitor technician telemetry escalation observation audit was added.

CMS removed the immediate jeopardy notice Sept. 15, and follow-up, on-site surveys have confirmed the hospital is complying with its removal plan. 

Editor's note: HCA Healthcare did not respond to requests for comment. Becker's will update the story if more information becomes available.

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