HospitalInspections.org

Based on the seriousness of the non-compliance identified during the survey and the effect and the protential effect on patient outcome, the facility failed to substantially comply with the condition.

This condition is not met as evidence by:

Review of facility policy "Cardiac Monitoring on Medical Surgical Units and Stepdown Unit," dated February, 2020, revealed, "Procedure: I. General Guidelines: ... F. The NA (nursing assistant)/PCT (patient care technician) will: ... 2. The NA/PCT will change batteries daily at 7:00 AM on Phillips monitors. ... G. The Nurse will: ... 3. Apply/reapply monitor within 10 minutes of patient arrival to unit. ..."

Review of MR1 revealed a physician order dated December 13, 2020 at 3:48 AM, "Cardiac Monitor."

Review of MR1 Telemonitor Log revealed Tele tracking monitor log revealed 12/13/2020 11:21:35 MCK leads off - leadset unplugged. This alert continued until 12:20:44 when the alert Tele Battery Low was initiated. At 12:30:44, the telepack stopped working, battery depleted.
Further review of MR1 "Rapid Response Team Note," dated December 13, 2020 at 1:26 PM, revealed, "Condition type: A (Arrest). Reason for Call: Cardiovascular: Cardiopulmonary arrest. Diagnosis/Recommendations: Respiratory: Aspiration Cardiovascular: Cardiopulmonary arrest. Disposition: Died after failed resuscitation. ..."
Review of statement from EMP6 revealed, "I assisted the patient to a stretcher to go down for a CT scan. The patient arrived back on the unit at 11:30AM. I checked on the patient after (MR1) arrived at about 11;45 AM, he was sleeping so I left him on the stretcher. Lunch trays came up around 12:30, so I assisted the patient to bed. ... I put the monitor back on the patient. ... After the code, I came in to do postmortem care and realized the monitor was on the body, but the batteries were dead.
Interview with EMP1 on December 17, 2020, at 9:45 am, revealed, "When the patient returned from a CT scan, the monitor was not re-applied for 45 minutes. When it was re-applied, the batteries were dead. ... (EMP6) did not verify that the monitor was working when it was re-applied."


These following standard was cited to show a systemic nature of non-complaince:


482.23(b)(3); Nursing Services (A-0395)

Based on review of facility documentation, medical record review (MR) and interview with staff (EMP), it was determined the facility failed to ensure inpatient monitoring was performed as ordered for the delivery of patient care services and to ensure Registered Nurse (RN) supervision of staff and patients was provided per standards of practice for one of one medical record reviewed (MR1).

Based on review of facility documents, medical record review (MR), and interview with staff (EMP), it was determined the facility failed to ensure inpatient monitoring was performed as ordered for the delivery of patient care services and to ensure Registered Nurse (RN) supervision of staff and patients was provided per standards of practice for one of one medical record reviewed (MR1).

Findings include:

Review of facility policy "Cardiac Monitoring on Medical Surgical Units and Stepdown Unit," dated February, 2020, revealed, "Procedure: I. General Guidelines: ... F. The NA (nursing assistant/PCT (patient care technician) will: ... 2. The NA/PCT will change batteries daily at 7:00 AM on Phillips monitors. ... G. The Nurse will: ... 3. Apply/reapply monitor within 10 minutes of patient arrival to unit. ..."

Review of MR1 revealed a physician order dated December 13, 2020 at 3:48 AM, "Cardiac Monitor."

Review of MR1 Telemonitor Log revealed Tele tracking monitor log revealed 12/13/2020 11:21:35 MCK leads off - leadset unplugged. This alert continued until 12:20:44 when the alert Tele Battery Low was initiated. At 12:30:44, the telepack stopped working, battery depleted.
Further review of MR1 "Rapid Response Team Note," dated December 13, 2020 at 1:26 PM, revealed, "Condition type: A (Arrest). Reason for Call: Cardiovascular: Cardiopulmonary arrest. Diagnosis/Recommendations: Respiratory: Aspiration Cardiovascular: Cardiopulmonary arrest. Disposition: Died after failed resuscitation. ..."
Review of statement from EMP6 revealed, "I assisted the patient to a stretcher to go down for a CT scan. The patient arrived back on the unit at 11:30AM. I checked on the patient after (MR1) arrived at about 11;45 AM, he was sleeping so I left him on the stretcher. Lunch trays came up around 12:30, so I assisted the patient to bed. ... I put the monitor back on the patient. ... After the code, I came in to do postmortem care and realized the monitor was on the body, but the batteries were dead.
Interview with EMP1 on December 17, 2020, at 9:45 am, revealed, "When the patient returned from a CT scan, the monitor was not re-applied for 45 minutes. When it was re-applied, the batteries were dead. ... (EMP6) did not verify that the monitor was working when it was re-applied."