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Based on review of policy, review of medical records, and interviews with staff, the facility staff delayed printing and documenting telemetry strips to show telemetry monitoring on patients with telemetry orders for 2 of 4 telemetry patients reviewed (Patient #28 and Patient #1).

The findings include:

Review of policy titled "Nursing Telemetry ECG (Electrocardiogram) Monitoring" with effective date of 04/12/2024 revealed "Policy: Telemetry and Hardwired monitoring will be initiated and maintained per provider order. Summary: This policy provides guidelines for Telemetry and Hardwired monitoring to assess patients for dysrhythmias on a continuous timeframe, or emergency situation.... Documentation/Interpretation: A. Record/print a telemetry monitor strip: 1. Upon admission to the unit. 2. At least every shift. 3. Any time there is a change in rhythm or patient's condition...."

1. Review of Patient #28's medical record revealed a 57-year-old female admitted on 07/22/2025 for nonfunctioning nephrostomy tube (tube inserted into the kidney for drainage). Past medical history for Patient #28 was significant for Hydronephrosis (enlargement of the kidneys), AAA repair (abdominal aortic aneurysm repair), Diabetes, and bilateral Nephrostomy tubes. Patient #28 was transferred to the patient care floor on 07/23/2025 at 1340 with telemetry orders. Review revealed no documentation of telemetry strips in Patient #28's medical record after transfer from the ED. Review revealed documentation of the "telemetry box on" at 2137, approximately 8 hours later.

Interview on 07/25/2025 at 1140 with Manager of Operations #1 revealed Patient #28 arrived on patient care floor at 1340. Patient #28's telemetry box was documented as placed on the patient at 2137. Review revealed there was no telemetry strip placed on the record for review prior to that time. Interview revealed policy was not followed.

2. Review of the medical record of Patient #1 revealed a 35-year-old female presented to the ER (Emergency Room) on 09/28/2024 at 1615 with pleuritic pain (sharp, stabbing pain in the chest that worsened with coughing, breathing or sneezing) with diagnosis of pulmonary embolism (blood clot in the lungs). Patient #28's past medical history includes liver transplant secondary to alcoholic hepatitis (liver disease related to drinking alcohol) on immunosuppression (medicines that suppressed the immune system to prevent rejection of the new organ), recent fibular fracture (leg bone break) and bipolar (disease of mania and depression episodes). Patient #1 was transferred to the patient care floor on 09/28/2024 at 2311 with telemetry orders. Review of the first telemetry strip placed on Patient #1's chart was dated 09/29/2024 at 0324, approximately 4 hours after admission. Review revealed the first documentation of the "telemetry box on" was 09/29/2024 at 0749, approximately 8 hours after admission.

Interview on 07/23/2025 at 1600 with Nurse Manager #2 revealed Patient #1's first telemetry strip was reviewed at 0324, several hours after admission. Interview revealed there was a delay in placing the telemetry box on Patient #1 and documentation of the telemetry strip. Interview revealed policy was not followed.

NC00201433, NC00232347, NC00230113, NC00230387, NC00226879, NC00230233, NC00225885, NC00228798, NC00231179, NC00220721, and NC00228917