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Based on interview and policy review, the facility failed to take action to measure, analyze and track other aspects of performance that assess processes of care related to cardiac monitoring as a result of an incident involving 1 (SP#1) out of 6 sample patients (SP).

The findings include:

Review of sample patient (SP) #1 Physician Discharge Summary dated 05/08/2019 at 12:24 PM documented Admit Date: 11/19/2018 and Discharge Date: 11/28/2018.

Review of SP#1 Physician Orders dated 11/19/2018 at 4:43 PM documented order for Cardiac Monitoring 48 Hours, as per telemetry algorithm, 11/21/2018, Constant Indicator, Physician Stop.

Review of SP#1 Cardiac Rhythm Flowsheet for the period of 11/19/2018 at 12:00 AM to 11/28/2018 at 11:59 PM did not show evidence of cardiac monitoring for the period of 11/20/2018 at 8:01AM to 11/22/2018 at 5:59AM.

Review of SP#1 Nurse Progress Notes dated 11/21/2018 at 7:30 AM documented patient received without monitor box. Charge Nurse notified.

Review of SP#1 Nurse Progress Notes dated 11/22/2018 at 5:33 AM documented monitor room called due to patient was in asystole at 4:25AM. The patient was assessed immediately and was found pulseless and no breathing. Code Blue called and cardiopulmonary resuscitation started. The team arrived and patient was intubated and all measures according to protocol was done. Patient recovering pulse and blood pressure and transferred to the intensive care unit.

Interview with Registered Nurse-Staff C on 08/28/2019 at 2:54 PM revealed that the physician renews the telemetry order every 48 hours. Stated that if telemetry is no longer needed, the order will be discontinued.

Interview with Director of Quality on 08/29/2019 at 11:14 AM revealed that there are no scanned records of telemetry strips for SP#1 from admission on 11/19/2018 up until the patient coded on 11/22/2018.

Interview with Director of Risk Management on 08/29/2019 at 11:35 AM revealed that there is no documentation of the telemetry strips from the time SP#1 was admitted to the medical floor to the time the patient coded.

Interview with Director of Quality on 09/23/2019 at 1:09 PM revealed there are no specific performance improvement indicators for telemetry monitoring. Stated unless there is a specific incident that occurs, there is no documentation regarding whether the patient was on or off the cardiac monitor prior to the event.

Review of the 2019 Organizational Performance Improvement Evaluation and Plan approved by facility Medical Executive Committee dated January 2018 documented on page 4 of 8, Duties include to assure that appropriate action is taken and the appropriate follow up is carried out when opportunities to improve patient care or services is identified.

Based on interview, record and policy review, the facility nursing services failed to evaluate patient care including assessing (cardiac monitoring) the patient's care needs, and health status as ordered and ensure the nursing care plan is current in documentation of all nursing intervention related to cardiac monitoring for 1 (SP#1) out of 6 sample patients (SP). (Refer to A-0395)

Based on interview, record and policy review, the facility nurses services failed to evaluate patient care including assessing (cardiac monitoring) the patient's care needs, and health status as ordered for 1 (SP#1) out of 6 sample patients (SP).

The findings include:

Review of sample patient (SP) #1 Physician Discharge Summary dated 05/08/2019 at 12:24 PM documented Admit Date: 11/19/2018 and Discharge Date: 11/28/2018.

Review of SP#1 Physician Orders dated 11/19/2018 at 4:43 PM documented order for Cardiac Monitoring 48 Hours, as per telemetry algorithm, 11/21/2018, Constant Indicator, Physician Stop.

Review of SP#1 Cardiac Rhythm Flowsheet for the period of 11/19/2018 at 12:00 AM to 11/28/2018 at 11:59 PM did not show evidence of cardiac monitoring for the period of 11/20/2018 at 8:01 AM to 11/22/2018 at 5:59 AM.

Review of SP#1 Nurse Progress Notes dated 11/21/2018 at 7:30 AM documented patient received without monitor box. Charge Nurse notified.

Review of SP#1 Nurse Progress Notes dated 11/22/2018 at 5:33 AM documented monitor room called due to patient was in asystole at 4:25 AM. The patient was assessed immediately and was found pulseless and no breathing. Code Blue called and cardiopulmonary resuscitation started. The team arrived and patient was intubated and all measures according to protocol was done. Patient recovering pulse and blood pressure and transferred to the intensive care unit.
Interview with the Director of Quality on 08/28/2019 at 12:33PM revealed that the telemetry techs do not currently have a log that documents when call is made to the nurse. The tech will call the nurse to contact the nurse when situation occurs but there is no notation by the tech. The nurse responds. If the phone is not answered, the tech automatically escalates the call to the charge nurse. At the beginning of each shift, the tech documents the initial rhythm. Nursing then reviews the lead and signs the rhythm at the beginning of the shift.

The nursing assessment includes cardiovascular document rhythm once a shift. The nurse always has access to the patient's rhythm. The techs are really good with calling when the pt is disconnected
Interview with Registered Nurse-Staff C on 08/28/2019 at 2:54 PM revealed that the physician renews the telemetry order every 48 hours. Stated that if telemetry is no longer needed, the order will be discontinued.

Interview with Director of Quality on 08/29/2019 at 11:14 AM revealed that there are no scanned records of telemetry strips for SP#1 from admission on 11/19/2018 up until the patient coded on 11/22/2018.

Interview with Director of Risk Management on 08/29/2019 at 11:35 AM revealed that there is no documentation of the telemetry strips from the time SP#1 was admitted to the medical floor to the time the patient coded.

Review of Policy Code Number 400.119, Subject: "Cardiac Monitoring/Telemetry", (dated 09/30/2015), documented I. Types of Cardiac Monitoring: Telemetry is defined as a monitoring system attached to a patient which uses a wireless network to transmit electrocardiogram (ECG) data to a centralized monitor location.
Cardiac monitoring, also referred to as ECG monitoring, is defined as any of the following:
Bedside monitors only (monitored by bedside nurse/physician)
A physician/mid-level provider's order is required to temporarily interrupt remote monitoring or to remove cardiac/telemetry monitoring for any reason.

The facility failed to provide evidence of a physician's order to interrupt remote monitoring or to remove cardiac/telemetry monitoring for any reason for SP#1, and documentation of the telemetry strips.

Based on interview, record and policy review, the facility failed to maintain medical records that is accurate, complete, properly filed, and retained (with cardiac monitoring documentation) for 1 (SP#1) out of 6 sample patients (SP).

The findings include:

Review of sample patient (SP) #1 Physician Discharge Summary dated 05/08/2019 at 12:24 PM documented Admit Date: 11/19/2018 and Discharge Date: 11/28/2018.

Review of SP#1 Physician Orders dated 11/19/2018 at 4:43 PM documented order for Cardiac Monitoring 48 Hours, as per telemetry algorithm, 11/21/2018, Constant Indicator, Physician Stop.

Interview with Staff C on 08/28/2019 at 2:54 PM revealed that the physician renews the telemetry order every 48 hours. Stated that if telemetry is no longer needed, the order will be discontinued.

Interview with Director of Quality on 08/29/2019 at 11:14 AM revealed that there are no scanned records of telemetry strips for SP#1 from admission on 11/19/2018 up until the patient coded on 11/22/2018.

Interview with Director of Risk Management on 08/29/2019 at 11:35 AM revealed that there is no documentation of the telemetry strips from the time SP#1 was admitted to the medical floor to the time the patient coded.

Review of SP#1 Authorization for Release of Confidential Medical Records dated 01/28/2019 documented requests for the following: Other: Telemetry Records.

Interview with Release of Information Supervisor on 09/23/2019 at 1:30PM revealed that there was only one medical record request from the father of SP#1 dated 01/28/2019 that consisted of 107 pages. Stated that the requestor was a walk-in and upon receipt of records the requestor told the Release of Information Specialist that the electrocardiogram (EKG) records were not received. Stated the requestor received all other records except the EKG Reports and the Telemetry Records. Stated that there was no communication provided to the requestor about the incomplete records and the file was closed.

Review of Health Information Management Policy No. MR-RI-1, Section: HIM Release of Information, Subject: "Authorization for Release of Confidential Information", (Last reviewed 04/2017 ) documented I. Record Completion: a. The medical record must be completed prior to release of information whether the record is to be copied or examined. However, it is preferred that the patient's records be released within 10 days of a written request regardless of completion. Therefore, the record should be completed as quickly as possible in order to release it within the 10-day time period. b. If records cannot be completed within the 10-day time period for release, the records should be released along with a statement that the records being produced are "incomplete." c. Should the requested record be unavailable, a status update will be sent to the requestor every fifteen days until the record is located.

The provider failed to follow its policy.