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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 six current (#15, #14, #13, #17, #18, and #34) and for seven discharged (#44, #26, #27, #28, #23, #24, and #25) patients of 13 sampled patients reviewed with telemetry orders.
- Develop a telemetry monitoring policy that gave direction on whose responsibility it is to watch the monitors.
- Prevent development of pressure sores (injury to the skin, over a bony prominence, caused from pressure) for two (#29 and #33) of six patients reviewed with pressure sores.
- Turn and reposition two patients with a high risk for development of pressure sores, resulting in the development of a pressure sores, for two (#29 and #33) of six patients reviewed for pressure sores.
- Follow physician's treatment orders for a facility-acquired pressure sore on one (#29) of six patients reviewed for pressure sores.
These failures had the potential to affect all patients admitted with a cardiac diagnosis or any patient at risk for development of, or existing, pressure sores. As of 01/25/18, the facility identified 185 patients on telemetry, and 13 patients with facility-acquired pressure sores. The facility census was 500.

The severity and cumulative effect of these systemic failures resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.





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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 six current (#15, #14, #13, #17, #18, and #34) and for seven discharged (#44, #26, #27, #28, #23, #24, and #25) patients of 13 sampled patients reviewed with telemetry orders.
- Develop a telemetry monitoring policy that gave direction on whose responsibility it is to watch the monitors.
- Prevent development of pressure sores (injury to the skin, over a bony prominence, caused from pressure) for two (#29 and #33) of six patients reviewed with pressure sores.
- Turn and reposition two patients with a high risk for development of pressure sores, resulting in the development of a pressure sores, for two (#29 and #33) of six patients reviewed for pressure sores.
- Follow physician's treatment orders for a facility-acquired pressure sore on one (#29) of six patients reviewed for pressure sores.
These failures had the potential to affect all patients admitted with a cardiac diagnosis or any patient at risk for development of, or existing, pressure sores. As of 01/25/18, the facility identified 185 patients on telemetry, and 13 patients with facility-acquired pressure sores. The facility census was 500.

Findings included:

1. Review of the facility's policy titled, "Cardiac Monitoring," revised 02/16, showed:
- The Registered Nurse (RN) certified in dysrhythmia interpretation (knowledge to tell what cardiac activity the patient is having) at the Health Center will be responsible for the interpretation and documentation of rhythm strips on monitored patients.
- All Patients monitored by telemetry will have a rhythm strip documented a minimum of one time per shift.
- Team Leaders (Nurse educated on dysrhythmia interpretation) will identify the rhythm and record this data on the telemetry sheet along with their signature and the date/time that it was interpreted. Interpreted telemetry sheet should be placed in the paper lite chart.
- The arrhythmia computer will be reviewed at least every four hours for alarm history and event recall in areas where history computers are available.
- Any significant changes will be mounted and interpreted as above and appropriate documentation made in the electronic health record.
- Physicians will be notified of significant changes.
- Rhythm strips will be recorded on admission and/transfer to a monitored area.
- The cardiac telemetry monitors are set with default settings. All red monitor alarms will be left on at all times. The Charge Nurse or patient Team Leader may adjust setting parameters as patient condition requires.
The policy failed to give direction on whose responsibility it is to watch the monitors.

2. Observation and concurrent interviews on 01/23/18 at 9:40 AM, on the Burn Unit, no staff responded to several telemetry alarms for approximately five minutes. After another five minutes passed, Staff F, Charge Nurse came out of a patient's room. No one responded to the alarms until she returned. Staff F stated:
- She was responsible for watching the monitors.
- She had one patient assignment.
- When she was busy with patients the RN's were responsible for watching their own monitors.
- The Burn Unit is an adult only, nine bed unit with four ICU (Intensive Care Unit) beds and one Triage.
- She was not sure what the policy actually stated, but referred me to Staff G, Educator.

During an interview 01/23/18 at 10:00 AM, Staff G, stated:
- The facility did not have dedicated staff continuously watching the telemetry and answering alarms.
- It was the Charge Nurse's responsibility and if she had patients then the RN's were responsible for their own patients' monitoring.
- In 2016 there was staff education concerning alarm fatigue and how to set parameters to prevent unnecessary alarms.
- There had been no further education on alarm fatigue since 2016.

During an interview on 01/24/18 at 9:00 AM Staff M, RN Burn Unit stated:
- She did not know what the policy was for telemetry monitoring.
- If an alarm sounded she would check the monitor and enter the patient's room.
- One time a shift the Charge Nurse will print out a strip for the paper chart.

3. Observation on 01/23/18 at 9:30 AM of 6 B Medical/Telemetry Unit, showed several telemetry alarms were sounding and no one responded and no one was watching the monitors for approximately six minutes. This was a 32 bed unit and the current census was 31 with 15 patients on telemetry.

During an interview on 01/23/18, at 2:00 PM, Staff KK, RN Educator for 6 B Medical/Telemetry Unit stated:
- The Charge Nurse and Primary RN were responsible for the telemetry alarms.
- The Charge Nurse should review and post the automatic print outs from the monitor every eight hours.
- The Charge Nurse did take a patient assignment.
- Patient ratio (how many patients per RN) for this floor was one RN for four patients.

4. During an interview on 01/24/18, at 8:50 AM, Staff L, RN 6 D Neuro/Trauma Unit (patient care area for patients that have brain, nerve or nervous system damage) stated:
- She was allowed to adjust alarm settings based on her patient's normal activity to include making arrhythmia alarms show red on the monitor should they occur. By them showing red on the monitor they should be looked at first.
- Every morning the Charge Nurse printed the monitor strips.
- Every four hours the Charge Nurse should review alarms and document cardiac activity.
- The Charge Nurse sometimes would only review alarms at the end of the 12 hour shift.

5. During an interview on 01/24/18, at 10:30 AM, Staff C, RN Charge Nurse Medical ICU stated it was his and the RNs responsibility to ensure the alarms were monitored, reviewed and documented.

6. During an interview on 01/24/18 at 11:10 Staff E, RN Charge Nurse on 4 E Neuro ICU stated she and all RNs were responsible for monitoring, reviewing and documenting all alarms.

7. Observation and concurrent chart review on 01/25/18 at 11:00 AM:
- Patient #34 received IV (in the vein) medication Cardizem 10 milligrams (mg-unit of measure) per hour and was receiving a onetime IV dose of Lopressor (medication to treat a faster than normal heart rate) 5 mg.
- The RN administering the medication had to call out to the nursing station to ask someone to look at the patient's cardiac rhythm and to let her know what the patient's heart rate was as she did not have a monitor in the room. She checked the heart rate manually at the wrist.
- After the RN gave the medication, she called the nursing station again and asked them to watch the patient's telemetry monitor for any changes to her rhythm.
- Monitor strips reviewed were done on 1/20/18 at 10:00 PM; 1/21/18 at 10:00 PM; 1/22/18 at 6:00 AM, 2:00 PM, and 10:00 PM; 1/23/18 at 6:00 AM, 2:00 PM and 10:00 PM; 1/24/18 at 6:00 AM, 2:00 PM, 4:30 PM, 9:36 PM, 9:54 PM, 10:18 PM, and 11:30 PM; 01/25/18 at 6:00 AM. Strips were not monitored every shift per policy.
- Record review showed a Physician order for continuous cardiac monitoring related to diagnosis and medications.

8. Chart review for patients (#13 6 B Medical, #17 6 D Neuro, and #18 Burn Unit) showed Physician's orders for continuous cardiac monitoring related to diagnosis and medications.

9. Observation and concurrent interview on 01/23/18 at 2:50 PM, on the 4 C unit, Staff Y, Nurse Manager, stated the following:
- The telemetry monitors at the nurses' station were not being monitored when the surveyor arrived at the unit.
- The 4 C unit, an all adult medical telemetry unit, had two monitoring screens at the nursing station and screens at both ends of the hallway. The unit's capacity was 30, with a current census of 28.
- Patient #15's telemetry readout showed a sticker indicating he was on a cardiac drug called Cardizem.
- The charge nurse was the main person responsible for monitoring the telemetry alarms.
- If an alarm sounded, and the charge nurse was not available, the nearest nurse should silence the alarm, contact the nurse assigned to the patient, and communicate the reason for the alarm.
- Alarms continued to sound until shut off. Alarms can be manually turned off.
- Alarm parameters are typically set from 40 to 140 (lowest heart rate to highest heart rate acceptable), with a four second maximum for absence of a heart beat (asystole). These parameters can be changed per nursing judgment.

During an interview on 01/23/18 at 3:20 PM, Staff H, Chief Nursing Officer (CNO), stated the following:
- The charge nurse was responsible for overseeing the monitors, with the unit manager's oversight.
- When the charge nurse had a patient load, telemetry oversight was still her responsibility.
- The process was consistent throughout the hospital, with exception of the intensive care units, and emergency departments (ED).
- Patients receiving cardiac medications IV should be continuously monitored for change in heart rate and/or rhythm.
- The CNO expected telemetry to be monitored by someone.

10. Review of the Nursing 2013 Drug Handbook, the medication Cardizem IV required continuous heart monitoring.

11. Review and concurrent interview on the 4 C unit, on 01/24/18 at 9:00 AM, showed the following:
- Staff J, RN, stated that current Patient #15 had a diagnosis of atrial fibrillation (an abnormal heart rhythm characterized by rapid or irregular beating).
- The medication profile, dated 01/24/18, for Patient #15 showed he had received Cardizem IV 5 mg per hour, and it was being titrated (increased/decreased) to control his heart rate.
- Staff J stated that Patient #15 did not receive escalated telemetry monitoring by staff.

12. Review of current Patient #14's History and Physical (H&P) dated 01/11/18, showed the patient was admitted to the 4 D, cardiac/surgical unit on that date with cardiomyopathy (an enlarged, thickened heart muscle which makes it hard to function), and an ejection fraction of 10-15% (the amount of blood that leaves the heart each time it pumps-normal = 50-75%).

Review of the patient's medication profile dated 01/24/18, showed he received Dobutrex 5 micrograms per kilogram per hour IV continuously (increases the cardiac output), starting on 01/11/18.

Record Review of the Nursing 2013 Drug Handbook, the medication Dobutrex IV required continuous heart monitoring.

During an interview on 01/24/18 at 9:30 AM, Staff K, RN assigned to Patient #14, stated that everyone was responsible for monitoring the telemetry alarms, especially if the charge nurse had a patient assignment.

During an interview on 01/25/18 at 10:20 AM, Staff JJ, Pharmacist, stated that patients receiving cardiac drip medications via IV need telemetry monitoring with an Electrocardiagram (EKG-a test that shows the electrical activity of the heart) baseline. Staff JJ stated that Dobutrex had to monitored continuously.

13. Review, on 01/24/18, of event reports reported from 02/01/17 through 01/22/18, showed the following:
- Five events reported that involved telemetry.
- On 03/04/17, discharged Patient #44, never received telemetry monitoring as ordered in the ED.
- On 03/17/17, approximately eight patients (unable to confirm their identities) on the 6 C neurology (stroke) unit were not monitored per policy, and rhythm changes were not documented, or reported on at least four patients.
- On 06/05/17, on the 4 C unit, discharged Patient #26's heart monitor was turned off because it "was beeping too much." The monitor was off for approximately two hours.
- On 09/16/17, on 4 E in the trauma ICU, the bedside nurse for discharged Patient #27 did not receive assistance from the charge nurse as requested twice. The charge nurse silenced the patient's alarm and continued to visit with a friend. The patient had V-tach (potentially life threatening dysrhytmia with a heartrate faster than normal) and was coughing up blood.
- On 11/30/17, in the echocardiography (the use of ultrasound to explore the heart function) department, a technician (tech) removed defibrillation pads from discharged Patient #28's chest so a test could be performed, and they were not replaced. The tech failed to report the removal of the pads to anyone so they could be replaced.

Review of undated facility-provided investigations and action plans for the five events from 02/01/17 through 01/22/18, showed the following:
- Regarding the event on 03/04/17: the ED team received education about bed placement and admission orders.
- Regarding the event on 03/17/17: thirteen nurses and thirteen techs on the 6 C unit received education, on 05/04-05/17 reminding them that all telemetry alarms must be checked every shift and abnormal rates or rhythms must be documented, and physician notified if necessary. Everyone needed to work together to make sure telemetry was on.
- Regarding the event on 06/05/17: the nurse was counseled with expectations.
- Regarding the event on 09/16/17: the charge nurse was removed from the role of charge nurse.
- Regarding the event on 11/30/17: the tech was educated to notify the nurse, and the situation was discussed in a unit huddle.
- Staff failed to identify an opportunity to educate facility-wide on the use of telemetry.

14. Review of undated facility-provided grievances related to telemetry from 01/01/17 through 01/22/18 showed the following:
- On 03/29/17, on the 6 F telemetry unit, discharged Patient #23 had A-fib and was passing out. The heart monitor pads/leads were removed and left off for approximately one and one-half hours.
- On 09/13/17, in the ED, discharged Patient #24's heart monitor/leads were off for approximately one and one-half hours.
- On 09/09/17, in the ED, discharged Patient #25's heart monitor/leads were off for over five hours.
- Staff failed to identify an opportunity to educate facility-wide on the use of telemetry.

15. Review of the facility's policy titled, "Pressure Ulcer Prevention," reviewed 01/2018, showed the following:
- The Braden Scale tool is used to assess the patient's potential risk for skin breakdown. If the patient's score is "18" or less, interventions specific to the patient's needs should be instituted including turning every two hours.
- If the Braden score is "10" or less, possibly more frequently.
- The patient's risk is assessed every shift.
- All dressings and wound treatments have a physician's order.

16. Review of Patient #29's History and Physical (H&P) dated 01/03/18, showed the patient was admitted at 4:37 AM on that date with diabetes (high blood sugar-which can cause poor circulation resulting in pressure sore development), and wounds on both feet. The patient's wound on his left foot, between his little toe and fourth toe, required drainage because it was infected. The patient had no pressure sores on admission.

Review of the patient's admission nursing assessment dated 01/03/18, showed he had a Braden risk score of "12," or a risk for potential skin breakdown.

Review of the patient's turning and repositioning documentation showed he was not turned or repositioned from 3:00 PM through 7:00 PM on 01/03/18, and from 4:00 AM through 10:00 AM on 01/04/18.

During an interview on 01/25/18 at 9:42 AM, Staff V, Charge Nurse, stated that it was the facility's expectation to turn and reposition any patient with a Braden score of "18" or below.

Review of a nursing assessment dated 01/08/18, showed the patient had a Braden score of "12" and he had developed a Stage I (intact skin with non-blanchable redness over a bony prominence) pressure sore on the left gluteal area (buttocks) that measured 1.5 centimeters (cm) by 1.5 cm. The patient was incontinent of urine and bowel at times (this can increase the potential for skin breakdown).

Review of a nursing assessment dated 01/25/18, showed the patient had a Braden score of "18."

Review of physician's orders showed an order to clean the wound on his left foot with soap and water or TheraWorx (a cleansing cloth), pat dry, paint with iodine, and cover with gauze daily.

Observation on 01/25/18 at 9:47 AM, showed the following:
- Patient #29 had been incontinent of stool.
- The pressure sore on his left gluteal actually involved the right gluteal as well, measuring approximately a three to four-inch circumference.
- Staff W, Registered Nurse (RN), changed the dressing on the patient's left foot; however, she failed to cover the area with gauze per the physician's orders.

During an interview on 01/25/18 at 3:10 PM, Staff W stated that she reviewed the physician's orders but did not remember that Patient #29's treatment order for the left foot included a gauze cover. She said she thought it was to be open to the air.

17. Review of Patient #33's H&P dated 01/13/18, showed the patient was admitted to the neurological intensive care unit (specialized in critical care) on that date with a thoracic aorta tear and multiple fractures on her left side.

Review of the patient's Braden score dated 01/13/18, showed a score of "13."

Review of the patient's physicians' orders dated 01/13/18, showed an order to turn the patient every two hours.

Review of the patient's turn documentation from 01/13/18 through 01/18/18, showed the following:
- On 01/13/18, staff failed to turn the patient from 12:00 PM to 6:00 PM, and from 6:00 PM to 11:00 PM.
- On 01/14/18, staff failed to turn the patient from 1:00 AM to 6:00 AM, from 7:00 PM to 10:00 PM, and from 10:00 PM to 2:00 PM on 01/15/18.
- On 01/15/18, staff failed to turn the patient from 3:00 PM to 10:00 PM.
- On 01/16/18, staff failed to turn the patient from 1:00 AM to 4:00 AM, from 4:00 AM to 8:00 AM, and from 1:00 PM to 5:00 PM.
- On 01/17/18, staff failed to turn the patient from 7:00 AM to 11:00 AM, and from 3:00 PM to 2:00 AM on 01/18/18.
- On 01/18/18, staff failed to turn the patient from 3:00 AM to 7:45 AM.

Review of the patient's nursing assessment dated 01/18/18, showed the patient developed a Stage II (partial thickness loss, presenting as a shallow open crater) pressure sore on the coccyx (tailbone) that measured 2.1 cm by 0.5 cm, and a Stage II pressure sore on the right gluteal area that measured 1.0 cm by 3.2 cm.

Observation on 01/25/18 at 1:42 PM, showed the patient had a Stage II pressure sore on the coccyx (appeared as a split, cracked area right in the buttock fold), which measured 2.1 cm by 0.5 cm, and a Stage II pressure sore on the right upper buttocks (gluteal) which measured 0.4 cm by 0.8 cm.




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