HospitalInspections.org

Based on review of facility policy, medical records (MR) and staff interview (EMP), it was determined the facility failed to provide ordered cardiac monitoring for one of ten medical records reviewed (MR1).

Findings include:

Review on November 13, 2024, of facility policy "Telemetry Monitoring," last reviewed September 4, 2024, revealed "I. Policy It is the policy of UPMC to provide standardized, consistent care of patients undergoing continuous cardiac rhythm monitoring. When a patient's clinical condition warrants the need for cardiac monitoring, UPMC nursing will utilize the type of monitoring necessary as is detailed in this policy. ... II. The purpose of this policy is to provide the minimal criteria necessary to safely manage patients receiving cardiac rhythm monitoring ... IV. Procedure 1. Monitor Orders and Association a. Monitor Orders & Evaluation 1. A physician and/or the advanced practice provider will assess the need and provide the order for the cardiac rhythm monitoring ... B. Monitor Association 1. Confirm cardiac monitor order 2. Upon admission to the designated area, the patient who is ordered cardiac rhythm monitoring will be connected to the bedside monitor and/or telemetry, as is appropriate to the unit monitoring system ... "

Review of MR1 on November 13, 2024, revealed a physician order dated October 13, 2024, at 1145 for cardiac monitoring.

Review of MR1 on November 13, 2024, revealed there was no documentation of cardiac monitoring from the time of the order on October 13, 2024, at 1145 until the time of cardiac arrest on October 14, 2024, at 0539.

Interview with EMP1 on November 13, 2024, at approximately 0945 confirmed the above findings. EMP1 confirmed the cardiac monitor ordered on October 13, 2024, at 1145 was never initiated for MR1.

Review of facility documents on November 13, 2024, revealed an acceptable action plan was initiated by the facility when the event with MR1 occurred.

Interview with EMP1 on November 13, 2024, at approximately 1400 confirmed the Telemetry Monitoring policy was a system-wide policy. EMP1 confirmed the action plan developed by the facility as a result of the event with MR1 would not be placed into a written policy for staff to follow.