HospitalInspections.org

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to ensure telemetry alarms identifying irregular or abnormal cardiac rhythms on the mobile devices were acknowledged by nursing staff.

A discussion took place with EMP1, EMP2, EMP3 and EMP4 regarding the survey team's concerns related to the Patient Rights on November 29, 2023, at 1250.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (b)(3) Rn Supervision Of Nursing Care
482.23 (b)(6) Supervision Of Contract Staff

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure telemetry alarms identifying irregular or abnormal cardiac rhythms on the mobile devices were acknowledged by nursing staff for one of one medical record reviewed (MR1).

Findings include:

Review on November 29, 2023, of the facility's "Patient Rights And Responsibilities" policy, last approved April 4, 2023, revealed "... Procedure: A ...1. Patient Rights ...(e) Delivery of Care Patients have the right to receive care in a safe environment ..."

Review on November 30, 2023, of the facility's "Vice President, Patient Care Svcs [Services]" job description, last edited April 13, 2023, revealed "Job Summary .... Provides oversight for the assigned respective entity's patient care services leaders, ensuring accountability for network standards ..."

Review on November 30, 2023, of the facility's "Registered Nurse" job description, last edited September 21, 2023, revealed "Job Summary Provides professional nursing care through skillful assessment, diagnosis, outcomes identification, planning, implementation, and evaluation in accordance with facility or department policies and procedures. Directs and manages the care of designated patients. Utilizes effective and appropriate communication styles. Assists in maintaining a safe work environment and maintains clinical and professional competency as appropriate to the population of patients served ..."

Review on November 29. ,2023, of the facility's "Monitoring Cardiac Rhythm (Telemetry / Hardwire) - Patient Care Services" policy, last approved March 23, 2023, revealed "Disclaimer: This policy is meant to be a guideline and is not intended to be the sole source of clinical guidance, nor is it intended to replace sound judgement ...I. Key Points: ...5. RN will have mobile device (where available) in possession at all times, in audible mode, while providing care to patients ...14. Mobile devices: a. Carried by the nurse and must be set on an audible tone - Placing the mobile device (where available) on vibrate is not acceptable. ... 15. An alert will be sent to all mobile devices (where available) for all unsilenced red alarms not addressed within 120 seconds. In the event only one nurse has patients assigned to a mobile device, all nurses on the unit in a patient assignment will carry a mobile device (where available) to respond to unsilenced alarms. Those mobile devices (where available) will receive only unsilenced red alarms. ..."

Interview with EMP4, EMP6, EMP7 and EMP9 on November 29, 2023, revealed the facility utilizes mobile devices and that registered nurses (RN's) and license practical nurses (LPN's) carry these mobile devices. Patients in the nurse's assignment, who require cardiac monitoring, are added to that nurse's mobile device. These mobile devices are designed to notify the nurse when a patient has an irregular or abnormal rhythm by sounding an audible alarm. EMP4, EMP6, EMP7 and EMP9 revealed the facility no longer utilizes monitor observers to watch the cardiac monitors for patients' irregular or abnormal rhythms.

Interview with EMP4 on November 29, 2023, revealed the first notification from the mobile device is considered a Tier 1 notification in which the nurse acknowledges the alarm on the patient, and an assessment of the patient must be completed. EMP4 revealed if the nurse does not acknowledge the first alarm (Tier 1) then the mobile device sends out additional notifications to all RN's and LPN's on the patient care unit who are carrying the mobile devices. These nurses must acknowledge the alarm and complete an assessment of the patient. EMP4 revealed this is considered a Tier 2 notification.

Review of MR1 on November 29, 2023, revealed this patient was admitted to the facility on November 19, 2023, following a fall at home, inability to ambulate and complaint of lower back pain radiating to both legs. MR1 had a history of a pacemaker insertion.

Review on November 29, 2023, of MR1's historical cardiac rhythm strips revealed on November 19, 2023, at 2300 through November 20, 2023, at 0805, revealed this patient's cardiac rhythm was normal sinus rhythm with a rate of 64 to 66 beats per minute (BPM). On November 20, 2023, at 1728, MR1's cardiac rhythm was 35 to 44 BPM and MR1's pacemaker was initiating cardiac rhythm from 1734 to 1800. At 1735 MR1's cardiac rhythm was asystole.

Interview with EMP4 on November 29, 2023, at approximately 1100 confirmed MR1's historical rhythm strips.

Review on November 29, 2023, of the [company name of the mobile device] report revealed MR1's heart rate was 49 BPM at 1722 on November 20, 2023, and bradycardic at 37 BPM at 1726. Further review of the [company name of the mobile device] report revealed EMP17 was notified, through the mobile device, MR1's heart rate was 49 BPM and that EMP17 did not acknowledge this Tier 1 notification. Continued review revealed EMP7, EMP8 and EMP17 were notified at 1726, through the mobile device, MR1's heart rate was bradycardia at 37 BPM and that EMP7, EMP8 and EMP17 did not acknowledge this Tier 2 notification and at 1735 the notification expired.

Interview with EMP4 on November 29, 2023, at approximately 1200 confirmed the above information.

Review on November 29, 2023, of the [company name of the mobile device] report revealed MR1's heart rate was asystole on November 20, 2023, at 1735 and the Tier 1 notification was delivered to EMP17; EMP17 did not acknowledge this notification; Tier 2 notification was delivered to EMP7, EMP8 and EMP17 and these employees did not acknowledge this notification.

Interview with EMP4 on November 29, 2023, at approximately 1215 confirmed the above information.

Interview with EMP7 and EMP8 on November 19, 2023, and EMP17 on November 20, 2023, revealed these employees did not hear the alarm notification on their mobile device indicating MR1's heart rate was 49 BPM; when MR1's heart rate was bradycardia at 37 BPM or when MR1's heart rate registered as asystole.

Review of MR1 on November 29, 2023, revealed nursing documentation dated November 20, 2023, at 1800 indicating MR1's monitor was alarming asystole (no heartbeat); cardiopulmonary resuscitation (CPR) was initiated at 1800; Epinephrine (a medication used to stimulate the heart) was administered at 1812 and 1818. MR1 passed at 1824.

Interview with EMP4 on November 29, 2023, at approximately 1400 confirmed the findings noted above for MR1.

Cross reference
482.13 Condition of Participation: Patient's Rights
482.23 (b)(3) Rn Supervision Of Nursing Care
482.23 (b)(6) Supervision Of Contract Staff

Based on review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to provide telemetry rhythm documentation at least every four hours in two of twelve medical records (MR1 and MR8).

Findings include:

Review on November 30, 2023, of facility policy, "Monitoring Cardiac Rhythm (Telemetry/Hardwire) - Patient Care Services," last review/revision March 2023, revealed "I. Key Points: ... 11. Rhythm description is to be documented at least every 4 hours in the electronic medical record tab associated with rhythms. ... VIII. Documentation: ... 3. Document the rhythm in the EHR every 4 hours."

Review of MR1 on November 30, 2023, revealed a physician order dated November 19, 2023, at 1430 for telemetry monitoring.

Review of MR1 on November 30, 2023, revealed no documentation of telemetry rhythm on November 20, 2023, between 0805 and 1628.

Interview with EMP11 at 1030 on November 30, 2023, confirmed the findings noted above for MR1. EMP11 confirmed the telemetry rhythm is to be documented in the EHR at least every 4 hours.

Review of MR8 on November 30, 2023, revealed a physician order for June 1 through June 7, 2023, for daily telemetry monitoring.
Review of MR8 documentation from June 5, 2023, revealed no telemetry rhythm documentation consecutively between the hours of 1300 and 0300 on June 6, 2023. Continued review of documentation from June 6, 2023, revealed no documentation of telemetry rhythm between 1200 through 1900. Review of documentation from June 7, 2023, revealed no telemetry cardiac rhythm documentation between the hours of 0100 and 0700.

Interview with EMP11 at 1100 on November 30, 2023, confirmed there was no documentation of telemetry rhythm between the above times per policy.

Cross reference
482.13 Patient Rights
482.13 (c)(2) Patient Rights: Care In Safe Setting
482.23 (b)(6) Supervision Of Contract Staff

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure nursing staff received education regarding the audible control of the cardiac rhythm telemetry mobile device for four of four applicable employees (EMP6, EMP7, EMP8 and EMP17) and for six of 12 applicable personnel files reviewed (PF2, PF3, PF4, PF5, PF6 and PF7).

Findings include:

Review on November 30, 2023, of the facility's "Vice President, Patient Care Svcs [Services]" job description, last edited April 13, 2023, revealed "Job Summary .... Provides oversight for the assigned respective entity's patient care services leaders, ensuring accountability for network standards ..."

Review on November 30, 2023, of the facility's "Registered Nurse" job description, last edited September 21, 2023, revealed "Job Summary Provides professional nursing care through skillful assessment, diagnosis, outcomes identification, planning, implementation, and evaluation in accordance with facility or department policies and procedures. Directs and manages the care of designated patients. Utilizes effective and appropriate communication styles. Assists in maintaining a safe work environment and maintains clinical and professional competency as appropriate to the population of patients served ..."

Review on November 29. ,2023, of the facility's "Monitoring Cardiac Rhythm (Telemetry / Hardwire) - Patient Care Services" policy, last approved March 23, 2023, revealed "Disclaimer: This policy is meant to be a guideline and is not intended to be the sole source of clinical guidance, nor is it intended to replace sound judgement ...I. Key Points: ...5. RN will have mobile device (where available) in possession at all times, in audible mode, while providing care to patients ...14. Mobile devices: a. Carried by the nurse and must be set on an audible tone - Placing the mobile device (where available) on vibrate is not acceptable. ... 15. An alert will be sent out to all mobile devices (where available) for all unsilenced red alarms not addressed within 120 seconds. In the event only one nurse has patients assigned to a mobile device, all nurses on the unit in a patient assignment will carry a mobile device (where available) to respond to unsilenced red alarms. Those mobile devices (where available) will receive only unsilenced red alarms. ..."

Review of MR1 on November 29, 2023, revealed this patient was admitted to the facility on November 19, 2023, following a fall at home, inability to ambulate and complaint of lower back pain radiating to both legs. MR1 had a history of a pacemaker insertion.

Review on November 29, 2023, of the [company name of the mobile device] report revealed MR1's heart rate was 49 BPM at 1722 on November 20, 2023, and bradycardic at 37 BPM at 1726. Further review of the [company name of the mobile device] report revealed EMP17 was notified, through the mobile device, MR1's heart rate was 49 BPM and that EMP17 did not acknowledge this Tier 1 notification. Continued review revealed EMP7, EMP8 and EMP17 were notified at 1726, through the mobile device, MR1's heart rate was bradycardia at 37 BPM and that EMP7, EMP8 and EMP17 did not acknowledge this Tier 2 notification and at 1735 the notification expired.

Review on November 29, 2023, of the [company name of the mobile device] report revealed MR1's heart rate was asystole on November 20, 2023, at 1735 and the Tier 1 notification was delivered to EMP17; EMP17 did not acknowledge this notification; Tier 2 notification was delivered to EMP7, EMP8 and EMP17 and these employees did not acknowledge this notification.

Interview with EMP4 on November 29, 2023, at approximately 1215 confirmed the above information.

Interview with EMP7 and EMP8 on November 19, 2023, and EMP17 on November 20, 2023, revealed these employees did not hear the alarm notification on their mobile device indicating MR1's heart rate was 49 BPM; when MR1's heart rate was bradycardia at 37 BPM or when MR1's heart rate registered as asystole.

Interview with EMP7 and EMP8 on November 29, 2023, and with EMP17 on November 30, 2023, confirmed the above information. Further interview with EMP7, EMP8 and EMP17 revealed they do not check that the volume is in the audible mode when accepting the mobile device at the beginning of the shift.

Review on November 30, 2023, of EMP6, EMP7, EMP8 and EMP17's education files revealed these nursing staff received education on the [company name] mobile cardiac rhythm monitoring device.

There was no documentation in EMP6, EMP7, EMP8 and EMP17's education files indicating the facility provided education to these nursing staff regarding the audible control of the cardiac rhythm telemetry mobile device or that these nursing staff were educated to ensure the mobile device is in the audible mode when accepting the mobile device at the beginning of the shift.

Review on November 30, 2023, of PF2, PF3, PF4, PF5, PF6 and PF7 revealed these nursing staff receive education on the [company name] mobile cardiac rhythm monitoring device.

There was no documentation in PF2, PF3, PF4, PF5, PF6 and PF7's education files indicating the facility provided education to these nursing staff regarding the audible control of the cardiac rhythm telemetry mobile device or that these nursing staff were educated to ensure the mobile device is in the audible mode when accepting the mobile device at the beginning of the shift.

Interview with EMP4 on November 30, 2023, confirmed the above information.

Cross reference
482.13 Condition of Participation: Patient's Rights
482.23 (b)(3) Rn Supervision Of Nursing Care
482.13 (c)(2) Patient Rights: Care In Safe Setting