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Based on observation, interview, record review and policy review, the facility failed to provide consistent staff oversight of cardiac telemetry monitors/alarms (a screen-type monitor that receives the transmissions of signals from one electronic unit to another by radio waves using a device that provides real time measurement of a patient's cardiac rhythm and rate) for two patients (#10 and #18) of two patients reviewed with telemetry orders. The facility also failed to ensure a nursing assessment and reassessment were completed for three patients (#7, #13, and #16) of nine patients reviewed according to facility policy. Facility census was 11.

Findings included:

1. The Facility failed to provide a policy addressing Telemetry (a screen-type monitor that receives the transmissions of signals from one electronic unit to another by radio waves using a device that provides real time measurement of a patient's cardiac rhythm and rate).

Review of policy titled "Advanced Care Unit: Admission, Discharge and Transfer Criteria" showed:
- Purpose was to ensure appropriate intensity of services of a patient in accordance with the available resources.
- The location of the advance care beds are located in rooms 106, 107, and 109. Each of these rooms has telemetry monitoring reported at the central nurses station.
- The staffing ratio for these patients will be no greater than one to six, depending on the acuity (the level of severity of an illness) for each patient.

Observation on 04/10/18 at 10:45 AM showed:
- Rooms 106, 107 and 109 are located on the medical/surgical unit.
- Rooms 106 and 107 housed the only patients located on that unit at the time of the observation.
- Patient #10 was in room 106 and he required telemetry. The telemetry monitor kept alarming and the Registered Nurse (RN) would have to get up and leave the desk to check on the patient.
-There was no one watching the monitor when the RN was attending to other patients or performing other duties.

During an Interview on 04/10/18 at 11:00 AM Staff L, RN, stated:
- No one was ever scheduled to watch the telemetry monitor.
- When she was busy with other patients there was no one watching the telemetry monitor.
- Management would not allow staff to make any changes to the telemetry alarm parameters.
- She had heard of Alarm Fatigue (patient safety concern when nurses become overwhelmed and desensitized to alarms that are constantly going off).
- Patient #10 was on telemetry and his activity level would make the alarm sound when there was no issue with his cardiac rhythm.
- She would occasionally not respond to the alarm because she was use to it alarming when there was no problem.

Observation on 04/11/18 at 10:30 AM showed:
-Patient #18 had been admitted on 04/10/18 at 9:56 PM and she was placed on a telemetry monitor.
- Staff S, RN, was responsible for the patients on the unit.
- Staff S was an RN that had not performed direct patient care for six years.

During an interview on 04/11/18 at 10:40 AM Staff S, RN stated that she was not that familiar with telemetry.

During an interview 04/11/18 at 3:30 PM, Staff B, Chief Nursing Officer (CNO), stated that patients on cardiac telemetry should have staff that provided consistent oversight of cardiac telemetry. The facility did not have the staff to provide consistent oversight of cardiac telemetry.

2. Review of the facility's policy titled, "Initial Patient Assessment & Reassessment," revised 04/2015, showed that:
- A complete assessment shall include physical, psychological, pain management, spiritual needs, cognitive level, fall risk/dementia, and discharge preparedness/planning needs;
- All data collected shall be recorded in the nursing assessment record and shall be available to all those disciplines involved in the care of the patient;
- Assessments/Reassessments will be defined on an ongoing basis meeting unit policy at a minimum, and adjusted to more frequently occurring basis based on patient status changes; and
-Registered Nurses perform assessments and reassessments in compliance with state licensure laws, applicable regulations or certification, and perform assessment activities within their specific scope of practice.

Review of Patient #7's History and Physical (H&P) dated 04/04/18, showed he was a 71 year old male admitted to the facility on 04/04/18. He was admitted for aggressive behavior. He had an history of Diabetes (disease that resulted in too much sugar in blood,) Hypertension (HTN, high blood pressure,) and Myocardial Infarction

Review of Patient #7's Electronic Medical Record (EMR) nursing assessments from 04/04/18 through 04/11/18, showed no nursing assessments for 04/10/18 day shift (7:00 AM through 7:00 PM) or night shift (7:00 PM through 7:00 AM). No assessment was documented for a complete day.

Review of Patient #7's paper chart showed no nursing assessment for 04/10/18 day shift or night shift.

During an interview 04/11/18 at 10:20 AM, Staff K, RN, stated that:
- She was responsible for Patient #7 on 04/10/18 on day shift;
- She did not have time to complete a nursing assessment on the patient;
- She told Staff D, RN, to complete the nursing assessment; and
- Nursing should have completed a nursing assessment every shift.

During a telephone interview 04/11/18 at 7:00 PM, Staff D, RN, stated that:
- He relieved Staff K and was responsible for Patient #7 on 04/10/18 night shift;
- He did not document a nursing assessment for the patient; and
- He was new to the unit, and was unfamiliar with the nursing charting.

Review of Patient #13's H&P dated 03/21/18, showed she was an 81 year old female admitted to the facility on 03/21/18. She was admitted for altered mental status. She had a history of HTN, Cerebrovascular accident (CVA, stroke), and was wheelchair bound (unable to walk, used only a wheelchair).

Review of Patient #13's EMR nursing assessments from 03/21/18 through 04/11/18, showed no nursing assessments for 03/27/18 day shift.

Review of patient #13's paper chart showed no nursing assessment for 03/27/18 day shift.

During an interview 04/11/18 at 1:15 PM, Staff K, RN, stated that:
- She was responsible for Patient #13 on 03/27/18 on day shift,
- She did not perform or document a nursing assessment on 03/27/18; and
- She should have performed a nursing assessment because the patient had a skin wound that needed to be assessed.

Review of Patient #16's H&P dated 04/03/18, showed he was a 61 year old male admitted to the facility on 04/03/18. He was admitted for Suicidal Ideation (thoughts of killing self). He had a history of HTN, CVA times two, and a closed head injury from motor vehicle accident.

Review of patient #16's EMR nursing assessments from 04/03/18 through 04/11/18, showed no nursing assessments for 04/10/18 night shift.

Review of patient #16's paper chart showed no nursing assessment for 04/10/18 night shift.

During a telephone interview 04/11/18 at 7:05 PM, Staff N, RN, stated that:
- She was responsible for Patient #16 on 04/10/18 night shift for four hours;
- She did not perform a nursing assessment because the patient was sleeping; and
- The nurses were responsible to perform a nursing assessment every shift.

During an interview 04/11/18 at approximately 3:05 PM, Staff F, Geri Psychiatric Director, stated that:
- She had relieved Staff N on 04/10/18 night shift and was responsible for Patient #16;
- She did not perform a nursing assessment on the patient;
- As the Geri Psychiatric Director, she expected every nurse to perform and document a "head to toe" nursing assessment every shift; and
- Performing a nursing assessment every shift was "nursing 101."

During an interview 04/11/18 at 10:30 AM, Staff M, Risk Manager, stated that after review of the EMR and paper chart she did not find any documented nursing assessments for:
- Patient #7 for 04/10/18;
- Patient #13 for 03/27/18 day shift; and
- Patient #16 for 04/10/18 night shift.

During an interview 04/11/18 at 3:30 PM, Staff B, CNO, stated that it was nursing's responsibility to document a nursing assessment every shift.


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Based on observation, interview, record review and policy review, the facility failed to ensure staff took measures to decrease the risk of harm when they did not double check, with another licensed person, the dose of High-Alert medications (medications that bear a heightened risk of causing significant patient harm, also known as High-Risk medication) prior to administration for one of one current patient #10 with an order for insulin (a high alert medication given by injection to control blood glucose levels) and to provide clean paper cups, used for medication administration, for nine out of nine current patients.
These failures to conduct safety precautions to reduce the risk of patient harm from High-Alert medications and reusing dirty paper cups had the potential to cause serious harm to all patients who receive medications. The facility census was 11.

Findings include:

1. Review of the facility policy titled "High Alert Medications", review date of 02/2018 showed the following:
- Purpose is to ensure high-alert medications that bear a heightened risk of causing significant patient harm are used safely and appropriately.
- The facility shall monitor for high-alert medications and will follow the facility's proactive strategies for preventing errors associated with the use of these medications.
- There was a list of drugs and drug categories that have been reviewed and reflect what is utilized at the facility and indicated safeguards to reduce the risk of error.
- Insulin was listed as a high-alert medication with the following safeguards:
- Keep only Regular Insulin Unit 100;
- Restrict access by keeping in the inpatient refrigerator; and
- Double check dose with another nurse.

Review of the H&P for Patient #10 showed:
- He was admitted on 04/08/18 at 10:42 PM with a diagnosis of Congestive Heart Failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should), uncontrolled Diabetes Mellitus Type II (DM, a chronic condition that affects the way the body processes blood sugar), and Dyspnea (shortness of breath or difficult breathing).

Review of the patient's physician orders showed:
- On 04/09/18 at 9:15 AM he was placed on Novolog (a fast acting Insulin), and a medium dose sliding scale insulin protocol (the progressive increase in pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges to approximate daily insulin requirements).
- On 04/10/18 at 7:50 AM a new order was written to change the sliding scale from medium to high dose scale.

Review of the patient's medication administration record (MAR) showed:
- On 04/10/18 at 11:30 AM, Staff L, RN, documented the patient's blood glucose level at 447 (normal glucose range before eating 70 to 130).
- Staff L, RN, gave the patient 15 units of Novolog Insulin per the high dose sliding scale protocol and she did not document that a second licensed person verified the dose with her prior to administration.

Observation on 04/10/18 showed Staff L, RN, drew up insulin into a syringe and administered same medication to patient #10 without verifying the dose with a second licensed person.

During an interview on 04/10/18 at 12:00 PM with Staff L, RN, she stated that she did not get the insulin dose verified. She further described that due to her being the only RN on the unit, without another licensed person available, she never verified any medication dose she gave. She further stated that there was only one staff per shift scheduled and that person had to be an RN.

2. Review of Patient #8's MAR on 04/10/18, showed that Patient #8 was to receive Carbidopa-Levodopa (a medication to control Parkinson's disease, a disorder that affects movement), one tablet by mouth at noon.

Observation on 04/10/18 at 11:30 AM, on the Geri-Psych Unit (a unit focused on treating mental health and psychiatric disorders in older adults), showed the following:
- Staff K, RN, carried two wax-coated cups to Patient #8;
- One cup was labeled with Patient #8's hospital sticker and contained one pill, the other cup was unlabeled and contained water;
- After the medication was administered to Patient #8, Staff K, RN, returned the labeled wax coated cup to the medication room and placed the cup on top of the medication dispensing cabinet; and
- Eight wax coated cups with patient labels, stacked on top of each other sat on the medication dispensing cabinet.

During an interview on 04/10/18 at 11:40 AM, Staff K, RN, stated that the labeled medication cups were reused on each patient until they look dirty.

Observation on 04/10/18 at 2:00 PM on the Geri-Psych unit medication room showed nine labeled medication cups stacked on top of each other.

During an interview 04/11/18 at 3:30 PM, Staff B, CNO, stated that:
- Nursing staff should have not reused the medication cups;
- The reuse of the medication cups causes an infection control issue; and
- With high alert medications, such as insulin, the nurses should verify in real time with another staff member before administration of the drug.



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