HospitalInspections.org

Based on record review and interview, the facility failed to ensure documentation of telemetry in the medical record for 2 (#1, 12) of 15 patients whose medical records were reviewed resulting in the potential for unidentified and unmet patient needs. Findings include:

Review of the medical record for Patient #1 on 4/28/2021 at 1147 revealed she was admitted to the cardiac unit from 2/28/2021-4/1/2021. A physician order, dated 2/28/2021, was present for Patient #1 to be placed on telemetry. Review of the nursing admission assessment revealed the area for indicating telemetry use was left blank. Review of nursing notes revealed a lack of documentation regarding telemetry. Review of the nursing flow sheet dated 2/28/2021 revealed documentation identifying the rate and rhythm of Patient #1's heart; however, had no documentation as to if the rhythms were periodically checked, if the patient was on a cardiac monitor, or if the patient was on telemetry.

On 4/28/2021 at 1259, Staff B stated, "There's nothing there that stated (telemetry) occurred."

On 4/28/2021 at 1306, Unit Manager Staff O stated all (cardiac unit) patients were either on the "hard monitor or telemetry box." Either the admitting nurse and/or the nursing assistant were responsible for placing the patient on either the monitor or telemetry. Staff O further stated rhythm strips were required upon admission and every four hours.

Review of cardiac monitoring rhythm strips for Patient #1 revealed the following:
3/2/2021 at 0958 Sinus Tachycardia
3/4/2021 at 0736 Sinus Tachycardia
3/4/2021 at 1958 Sinus Tachycardia
3/5/2021 at 1957 Sinus Tachycardia
3/6/2021 at 1930 Sinus Tachycardia
3/7/2021 at 2057 Sinus Tachycardia
3/8/2021 at 1958 Normal Sinus Rhythm
3/9/2021 at 0758 Normal Sinus Rhythm
3/9/2021 at 2015 Normal Sinus Rhythm
3/10/2021 at 0856 Normal Sinus Rhythm
3/10/2021 at 1938 Sinus Tachycardia
3/11/2021 at 0738 Sinus Tachycardia
3/11/2021 at 2101 Sinus Rhythm
3/12/2021 at 0758 Sinus Tachycardia
3/12/2021 at 2146 Sinus Tachycardia
3/14/2021 at 0030 Sinus Rhythm
3/14/2021 at 2218 Sinus Tachycardia
3/15/2021 at 0722 Sinus Tachycardia
3/15/2021 at 2343 Sinus Tachycardia
3/16/2021 at 0726 Sinus Tachycardia
3/16/2021 at 2315 Sinus Tachycardia
3/17/2021 at 2126 Sinus Rhythm
3/19/2021 at 0049 Sinus Rhythm
3/19/2021 at 2033 Normal Sinus Rhythm
3/20/2021 at 0730 Sinus Tachycardia
3/21/2021 at 2039 Sinus Tachycardia
3/22/2021 at 0843 Sinus Tachycardia
3/22/2021 at 2011 Sinus Tachycardia
3/22/2021 at 2328 Sinus Rhythm
3/23/2021 at 1910 Sinus Tachycardia
3/25/2021 at 0100 Normal Sinus Rhythm
3/25/2021 at 2316 Sinus Tachycardia
3/26/2021 at 1412 Normal Sinus Rhythm
3/26/2021 at 1947 Sinus Rhythm
3/27/2021 at 1906 Sinus Rhythm
3/28/2021 at 1932 Sinus Tachycardia
3/30/2021 at 0038 Sinus Tachycardia
4/1/2021 at 0735 Sinus Tachycardia

Additionally, Patient #1's medical record revealed a medical response team (MRT) was called on 2/28/2021 at 2132 and a Code Blue was called on 2/28/2021 at 2142. No cardiac rhythm strips were obtained during the MRT or during the code.

Review of the medical record for Patient #12 on 4/29/2021 at 1020 revealed he was admitted to the cardiac unit on 4/28/2021 at 1532 and was a current in-patient through the end of survey. Physician orders, dated 4/28/2021, were present for the patient to be on telemetry.

Review of Patient #12's cardiac monitoring strips revealed the following:
4/29/2021 at 0759 Uncontrolled Afib (atrial fibrillation-abnormal heart rhythm)

Facility policy #6119624 titled "Cardiac & Hemodynamic Monitoring at MMC, 070.P021" effective 11/30/2018 states, "An electrocardiogram (ECG) strip will be measured, interpreted, and documented per the following guidelines: A. Critical Care and telemtery departments: A2, A3...ICU (intensive care unit)-On admission, during any newly assigned nurse's initial assessment, with any significant change in rhythm, or patient symptoms..."