HospitalInspections.org

Based on document review and interview, it was determined the Hospital failed to ensure all medical records were complete in 2 of 10 (Pts #2, #3) medical records reviewed for cardiac monitoring.

Findings include:

1. The Hospital policy and procedure titled, "Telemetry" (With a revised date of 4/18/06) was reviewed on 9/30/14. It indicated under, "POLICY: it is the policy of (this Hospital) that each telemetry monitored patient have a telemetry EKG (electrocardiogram) strip on their chart every four (4) hours and prn (as needed), as applicable."

2. The medical record of Pt #2 was reviewed on 9/30/14. It indicated Pt #2 was admitted on 9/12/14 with a diagnosis of Hypernatremia. A physician's order, dated 9/13/14 at 0034, was to "Admit to Telemetry" There were no EKG strips on 9/12 or on 9/16.

3. The medial record of Pt #3 was reviewed on 9/30/14. It indicated Pt #3 was admitted on 9/1/14 with a diagnosis of Diarrhea and Pleural Effusion. A physician's order, dated 9/1/14 at 2226 was to "Admit to Telemetry". There was no baseline, admission, or other strip documented on 9/1/14.

4. During an interview with the Chief Nursing Officer (E-1), it was stated that the practice is to run an EKG strip when the patient is admitted to the unit and then every 4 hours thereafter.