HospitalInspections.org

This condition is not met as evidenced by:
Based on a review of facility documentation, medical records (MR), and staff interview(s) (EMP) it was determined the facility failed to supervise the patient's care to ensure the patient's cardiac status was being monitored at all times for one of 20 medical records reviewed (MR1), and the facility failed to ensure frequent assessments for cardiac rhythms were completed in accordance with facility policy for 11 of 20 medical records reviewed (MR5, MR6, MR7, MR8, MR8, MR9, MR10, MR11, MR12, MR13, MR14).

It was determined that the facility failed to supervise and ensure the patients's care to ensure the patient's cardiac status was being monitored at all times for one of 20 and frequent assessments for cardiac assessment for cardiac rhythms in accordance with facilty policy for 11 of 20 medical records.
It was determined that the facility failed to ensure that the facility staff adhered to the policies and procedures of the hospital for cardiac monitoring alarm response in one of one medical records (MR1).

Cross reference
482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient.
482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital.

Based on a review of Facility documentation, medical records (MR), and staff interview(s) (EMP) it was determined the facility failed to supervise the patient's care to ensure the patient's cardiac status was being monitored at all times for 1 of 20 medical records reviewed (MR1), and the facility failed to ensure frequent assessments for cardiac rhythms were completed in accordance with facility policy for 11 of 20 medical records reviewed (MR5, MR6, MR7, MR8, MR8, MR9, MR10, MR11, MR12, MR13, MR14).

On March 13, 2024, a review of the facility's Protocol for Patient Management, last reviewed February 23, 2023, revealed, "In consideration of the Joint commission 2015 National Patient Safety Goal (NPSG), Excela Health has created this policy in order to facilitate appropriate alarm management and decrease instances of alarm fatigue and alarm nuisance. ...ALARM RESPONSE. Patient care staff must respond to alarms immediately. ...Patient care staff identifies the reason for the alarm the reason for the alarm, corrects the issue or notifies the appropriate individual when patient monitoring issues arise that are outside the clinicians' scope of practice, ,,, DOCUMENTATION in EMR: All assessment and reassessment findings, Interpretation of the rhythm strips on admission, every 8 hours, and as needed. Alarms are functional, Any changes made to alarms, Any changes inpatient's vital signs or cardiac rhythm...".

On March 13, 2024, a review of MR1 revealed the patient was a 74-year old admitted, via the Emergency Department on 2/21/24 with increased shortness of breath. The patient was recently diagnosed 2/14/24 with COVID-19 infection. The patient was at a Skilled Nursing Facility recovering from a broken arm and has a past medical history Hypertension, Hyperlipidemia, and alcoholism. The patient arrived on the nursing unit at 19:43. The initial cardiac rhythm at 19:43 is documented as Normal Sinus Rhythm. At 20:28, the charge nurse and primary nurse were notified that the patient was off the monitor. At 20:48 the patient was found on the floor when staff went to check a lead off monitor alarm. The patient's intravenous line was pulled out and monitors were disconnected and the patient was not responsive but had a faint pulse, a code blue was called. Cardiac life-support was initiated and the patient had a return of spontaneous circulation. The patient was intubated and transferred to the ICU for further care. On 2/22/2024 neurology consult states patient with severe anoxic brain injury. 2/23/2024 the patient's prognosis discussed with family and family made patient comfort measure only and patient was removed from ventilatory support. The patient was prounced deceased at 17:45 on 2/23/2024.


A review of MR5, revealed a 92 year old admitted, via the Emergency Department with a recent fall, left shoulder pain and a left humerus fracture. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 11, 2024, 23:43 until March 13, 2024 at 0:07.

A review of MR6, revealed a 82 year old admitted, via the Emergency Department with a recent diagnosis of weakness and Atrial Fib. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 11, 2024, 23:50 until March 12, 2024 at 23:37.


A review of MR7, revealed a 72 year old admitted, via the Emergency Department with a recent diagnosis of difficulty breathing. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 08:22 until March 12, 2024 at 22:10.


A review of MR8, revealed a 72 year old admitted, via the Emergency Department with a recent diagnosis of shortness of breath. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 07:57 until March 12, 2024 at 23:53.

A review of MR9, revealed a 80 year old admitted, via the Emergency Department with a recent diagnosis of altered mental status. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 11, 2024, 23:55 until March 12, 2024 at 23:41.

A review of MR10, revealed a 85 year old admitted, via the Emergency Department with a recent diagnosis of confusion. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 11, 2024, 21:00 until March 12, 2024 at 23:15.


A review of MR11, revealed a 55 year old admitted, via the Emergency Department with a recent diagnosis of cough, difficulty breathing. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 08:52 until March 12, 2024 at 22:06.


A review of MR12, revealed a 49 year old admitted, via the Emergency Department with a recent diagnosis of hallucinations, difficulty urinating. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 09:04 until March 12, 2024 at 22:16.


A review of MR13, revealed a 81 year old admitted, via the Emergency Department with a recent diagnosis of weakness. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 09:45 until March 12, 2024 at 22:23.

A review of MR14, revealed a 78 year old admitted, via the Emergency Department with a recent diagnosis of chest pain, Atrial Fib. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 09:49 until March 12, 2024 at 21:42.


Interview with EMP5 at 15:00 on March 13, 2024, confirmed there was no documentation of cardiac telemetry rhythms as per facility policy.

Based on a review of facility documentation, medical record (MR), and staff interview (EMP), it was determined the facility failed to ensure staff adhered to the policies and procedures of the hospital for cardiac monitoring alarm response in one of one medical records (MR1).

Findings include:

On March 13, 2024, a review, of the facility's Protocol for Patient Management, last reviewed February 23, 2023, revealed, "In consideration of the Joint commission 2015 National Patient Safety Goal (NPSG), Excela Health has created this policy in order to facilitate appropriate alarm management and decrease instances of alarm fatigue and alarm nuisance. ...ALARM RESPONSE. Patient care staff must respond to alarms immediately. ...Patient care staff identifies the reason for the alarm the reason for the alarm, corrects the issue or notifies the appropriate individual when patient monitoring issues arise that are outside the clinicians' scope of practice, ,,, DOCUMENTATION in EMR: All assessment and reassessment findings, Interpretation of the rhythm strips on admission, every 8 hours, and as needed. Alarms are functional, Any changes made to alarms, Any changes inpatient's vital signs or cardiac rhythm...".

On March 13, 2024, a review of MR1 revealed the patient was a 74-year old admitted, via the Emergency Department on 2/21/24 with increased shortness of breath. The patient was recently diagnosed 2/14/24 with COVID-19 infection. The patient was at a Skilled Nursing Facility recovering from a broken arm and has a past medical history Hypertension,.Hyperlipidemia, and alcoholism. The patient arrived on the nursing unit at 19:43. The initial cardiac rhythm at 19:43 is documented as Normal Sinus Rhythm. At 20:28, the charge nurse and primary nurse were notified that the patient was off the monitor. At 20:48 the patient was found on the floor when staff went to check a lead off monitor alarm. The patient's intravenous line was pulled out and monitors were disconnected and the patient was not responsive but had a faint pulse, a code blue was called. Cardiac life-support was initiated and the patient had a return of spontaneous circulation. The patient was intubated and transferred to the ICU for further care. On 2/22/2024 neurology consult states patient with severe anoxic brain injury. 2/23/2024 the patient's prognosis discussed with family and family made patient comfort measure only and patient was removed from ventilatory support. The patient was prounced deceased at 17:45 on 2/23/2024.


Interview with EMP5, on March 13, 2024, at 14:20, confirmed the above findings.