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Based on policy, medical record and facility document review and staff interview it was determined the facility failed to maintain and demonstrate evidence of the Quality Assessment and Performance Improvement (QAPI) program.


1. Patient #3 was found unresponsive, pulseless and without respirations 06/24/12 at 1:40 p.m. The patient was on telemetry monitoring. On 6/24/12 at 5:37 a.m. a telemetry strip was printed that showed the patient was in sinus tachycardia(ST) with premature atrial contractions (PACS) and a heart rate of 110 beats per minute. At 10:12 a.m. a telemetry strip was printed that indicated the patient was in ST with PACS and a heart rate of 122 beats per minute. At 1:39 p.m. a telemetry strip was printed and the rhythm was not distinguishable nor was the heart rate able to be determined. There was no documentation of a telemetry strip or notification to the nurse caring for the patient by the telemetry technician regarding a change in cardiac rhythm. There was no documentation on the telemetry monitoring shift report and patient log of any change in the patient's rhythm or notification to the nurse caring for the patient. On 6/24/12 at 1:40 p.m. a code blue was called and the patient was pronounced on 6/24/12 at 1:50 p.m. Refer to A0285.

2. Review of current patient #5's medical record revealed the patient was admitted to the telemetry unit 10/2/12. There was no documented telemetry strip for admission or on 10/3/12 in the medical record according to facility policy.


3. On 10/5/12 at 1:45 p.m. an interview was conducted with the Director of Quality Control and meeting minutes were requested for the last 3 quarters and evidence of tracking and trending for pressure wounds, medication errors, falls, infection control and other facility chosen projects . The Director of Quality Control was unable to provide the requested documents. She indicated they were protected by the Patient Safety Work Product. She said the last meeting was conducted in January 2012. The Quality Assessment Performance Improvement (QAPI) program could not be reviewed to determine that there was a hospital-wide QAPI program in place and if identified adverse events had been addressed.

4. On 10/5/12 at approximately 4:00 p.m. an interview with the Risk Manager was conducted. She indicated a Root Cause Analysis (RCA) was completed by the risk manager for patient #3. The RCA was initiated on 6/25/12 with an end date of 7/3/12. The investigation included identification of the problem/cause, which was lack of observation by the monitor technician of all the telemetry monitors. The RCA failed to determine if the alarms were on at the time of the incident. The documentation noted the monitor tech stated he was overwhelmed and unable to watch all the monitors. The Risk Manager could not produce any evidence of these areas being investigated. She could not produce evidence of the action plan to educate staff was implemented. There was no evidence of monitoring to ensure a reoccurrence of the event did not occur.

5. There was no evidence of tracking and trending of infection control, pressure wounds, medication errors or other quality indicators chosen by the facility for the QAPI processes to promote patient safety and

The cumulative effect of the facility's failure to maintained and provide evidence that a QAPI program was in effect and an adverse incident was fully investigated, correction action implemented and monitoring resulted in the determination that the Condition of Participation for Quality Assessment Performance Improvement 42 CFR 482.21 is not in compliance.

Based on record and document review and staff interview is was determined the hospital failed to investigate, analyze, monitor and track quality indicators for an adverse event that resulted in a patient's death. operations. This practice does not ensure or promote patient safety.

Findings include:

Review of the facility's policy "Telemetry-Initiating, Monitoring and Discontinuing" Policy No. N3-C-18 revised 4/12 revealed a rhythm strip is obtained by the monitor tech and placed in the patient's medical record on admission. The monitor tech is to run a strip and print/interpret strips upon initiation of telemetry, rhythm changes, interruption and reapplication of telemetry and every 6 hours on a 12-6-12-6 schedule and upon termination of telemetry. The monitor tech will notify the primary nurse for rhythm changes and notification will be documented on the telemetry strip. The monitor tech is to keep the floor charge nurse and charge Intensive Care Unit (ICU) nurse aware of any significant telemetry changes. Current telemetry strips will be available to physicians in the ICU nursing station at the monitor tech area. Previous 24-hour rhythm strips will be delivered to appropriate nursing units by 6:00 a.m.

Patient #3 was admitted to the telemetry unit 6/16/12 at 8:52 am. On 6/16/12 there was no evidence of a telemetry strip being printed and placed in the medical record on admission or at 6:00 p.m. On 6/19/12 there was no evidence of a telemetry strip being printed and placed in the medical record at 6:00 p.m. On 6/20/12 there was no evidence of a telemetry strip being printed and placed in the medical record at 12:00 p.m.

On 6/24/12 at 5:37 a.m. a telemetry strip was printed that showed the patient was in sinus tachycardia(ST) with premature atrial contractions (PACS) and a heart rate of 110 beats per minute. At 10:12 a.m. a telemetry strip was printed that indicated the patient was in ST with PACS and a heart rate of 122 beats per minute. At 1:39 p.m. a telemetry strip was printed and the rhythm was not distinguishable nor was the heart rate able to be determined.

There was no documentation on the telemetry monitoring shift report or patient log indicating the nurse had been notified of the change in rhythm by the telemetry technician.

On 6/24/12 at 1:40 p.m. a code blue was called and cardiopulmonary resuscitation (CPR) was started. The code was terminated at 1:50 p.m. and the patient was pronounced.

On 10/5/12 at 4:00 p.m. the Risk Manager confirmed the above findings.

An interview was conducted 10/5/12 at 2:00 p.m. with Director of the Intensive Care Unit. She was asked if she checks the monitor alarms and how often. She could not supply documentation to show information about checking the monitors. She presented a piece of paper with no dates, just months with check marks. It did not specify what was being monitored on what dates.

On 10/5/12 at 1:4 Quality Control meeting minutes were requested from the Director of Quality. She was not able to provide the requested documentation. The Director of Quality was asked how the adverse incident was being monitored and what trends had they found. She could not provide any documentation. She said she was not allowed to show the surveyor any of the requested information.

An interview with Director of Quality Control and the Risk Manager was conducted 10/5/12 at 4:00 p.m. confirmed the findings.

Based on policy and record review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care related to telemetry monitoring for two (#3, #5) of five sampled patients. This practice does not ensure safe delivery of nursing care and that patient goals are met.

Findings include:

Review of the facility's policy "Telemetry-Initiating, Monitoring and Discontinuing" Policy No. N3-C-18 revised 4/12 revealed a rhythm strip is obtained by the monitor tech and placed in the patient's medical record on admission. The monitor tech is to run a strip and print/interpret strips upon initiation of telemetry, rhythm changes, interruption and reapplication of telemetry and every 6 hours on a 12-6-12-6 schedule and upon termination of telemetry. The monitor tech will notify the primary nurse for rhythm changes and notification will be documented on the telemetry strip. The monitor tech is to keep the floor charge nurse and charge Intensive Care Unit (ICU) nurse aware of any significant telemetry changes. Current telemetry strips will be available to physicians in the ICU nursing station at the monitor tech area. Previous 24-hour rhythm strips will be delivered to appropriate nursing units by 6:00 a.m.

1. Patient #3 was admitted to the telemetry unit 6/16/12 at 8:52 am. On 6/16/12 there was no evidence of a telemetry strip being printed and placed in the medical record on admission or at 6:00 p.m. On 6/19/12 there was no evidence of a telemetry strip being printed and placed in the medical record at 6:00 p.m. On 6/20/12 there was no evidence of a telemetry strip being printed and placed in the medical record at 12:00 p.m.

On 6/24/12 at 5:37 a.m. a telemetry strip was printed that showed the patient was in sinus tachycardia(ST) with premature atrial contractions (PACS) and a heart rate of 110 beats per minute. At 10:12 a.m. a telemetry strip was printed that indicated the patient was in ST with PACS and a heart rate of 122 beats per minute. At 1:39 p.m. a telemetry strip was printed and the rhythm was not distinguishable nor was the heart rate able to be determined.

There was no documentation on the telemetry monitoring shift report or patient log indicating the nurse had been notified of the change in rhythm by the telemetry technician.

On 6/24/12 at 1:40 p.m. a code blue was called and cardiopulmonary resuscitation (CPR) was started. The code was terminated at 1:50 p.m. and the patient was pronounced.

On 10/5/12 at 4:00 p.m. the Risk Manager confirmed the above findings.

2. Patient #5 was admitted to the telemetry unit 10/2/12. A verbal physician's order dated 10/2/12 at 6:00 p.m. instructed for the patient to be placed on telemetry. There was no evidence of a telemetry strip being printed and placed in the medical record on admission. On 10/3/12 there were no documented telemetry strips in the medical record.

An interview was conducted 10/5/12 at 2:15 p.m. with a monitor technician. She was at the nurses' station in front of a large amount of monitors. She indicated she was monitoring 35 patients at the time of the interview. When asked about what she did if one of the monitors showed a change in rhythm, she replied she printed a strip, called the nurse and documented the nurse's name and time they were called. She said if there was no response from the nurse and the rhythm did not change, she call the charge nurse of the unit and the supervisor if necessary. She indicated she was not able to change the volume of the alarms. Each different rhythm had different alarm sounds.

On 10/5/12 at 4:00 p.m. an interview with the Director of the Medical Surgical Unit was conducted. She confirmed the above findings. She stated an admission telemetry strip should be printed and placed in the medical record, the monitor tech should notify the nurse assigned to the patient of changes and it is the responsibility of the monitor tech to print strips and place strips in the medical record before the night shift tech leaves in the morning.

Based on policy and record review and staff interview it was determined the nursing staff failed to develop and kept current a nursing care plan for one (#5) of five telemetry patients. This practice does not ensure patients needs and goals are met.

Findings include:

Patient #5 was admitted to the telemetry unit on 10/2/12 at 6:00 p.m. On 10/2/12 a verbal physician's order instructed the patient was to be placed on telemetry. There was no evidence a care plan had been initiated for the patient for Altered Cardiac Output during the initial admission assessment on 10/2/12.

Review of the facility's policy, "Assessment & Reassessment" #A2-03 reviewed 7/11 revealed the information gathered in the admission assessment is analyzed and patient needs or problems are identified and prioritized according to the physiological and cognitive areas. A Plan of Care will be selected that addresses the patient's prioritized needs.


On 10/5/12 at 4:00 p.m. the Director of Medical Surgical Unit confirmed a patient on telemetry monitoring should have a Altered Cardiac Output care plan.