HospitalInspections.org

Based on record and policy review, the hospital failed to provide continuous telemetry monitoring, as ordered by the physician, for 2 of 2 telemetry patients out of a sample of 10 patients.


Review of Patient #1 and Patient #2's medical record, on 8/6/13, indicated both patients were ordered for cardiac telemetry (a continuous measure of heart rhythm and rate).

According to the hospital policy titled "Telemetry" approved 1/16/13, a physician order is required to initiate or discontinue cardiac telemetry monitoring.

Surveyor #1, 2 and 3 interviewed Registered Nurse #1 (RN#1) at 1:35 P.M. on 8/5/13. RN #1 said Patient #1 was transported to the Computed Tomography (CT) scan room on 6/29/13 at 18:00. According to RN #1 and review of Patient #1's Physician Orders sheet indicated a physician order to discontinue the cardiac monitoring was not written and Patient #1 was sent without a cardiac monitor. RN #1 said she usually obtained an order to transport a patient without cardiac monitoring. RN #1 said Hospitalist #1 was aware Patient #1 was transported without cardiac monitoring. Patient #1 did not experience any untoward outcome related to the lack of continuous cardiac monitoring.

Review of Patient #2's Ambulance Trip Sheet indicated Patient #2 was transported to the Magnetic Resonance Imaging (MRI) center on 8/2/13 without cardiac monitoring. Review of Patient #2's Physician Orders sheet indicated, a physician order to discontinue the cardiac telemetry was not written. Patient #2 did not experience any untoward outcome related to the lack of continuous cardiac monitoring.

Surveyor #2, and Surveyor #3 interviewed the Vice President of Quality Improvement (VPQI) and Patient Safety on 8/6/13 at 7:45 A.M. The VPQI said the telemetry monitoring system was upgraded in March 2013. The VPQI said a Root Cause Analysis (RCA) was completed on 6/29/13. The Root Cause Analysis Action Plan indicated:
1.) replacement of the new telemetry monitors with an older version until the Hospital is satisfied with the vendor actions to address the Hospital concerns with the upgraded equipment (completed)
2.) determine systems to verify re-connection of a telemetry unit (to be completed 8- 30-13)
3.) establish formal training for the Nursing Assistants about the telemetry monitoring system (to be completed 8-30-13)
4.) establish expectations of a bedside nursing report (to be completed 8-30-13)
5.) to revisit, revise and re-educate telemetry policy and practice (to be completed 9-30-13).