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UPMC PRESBYTERIAN SHADYSIDE
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on a review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure that appropriate monitoring of a patient on a cardiac monitor was done as required for one of one medical record reviewed (MR1).
Findings include:
Review of facility policy, "Cardiac and Physiologic Monitoring (ECG, invasive arterial pressures, pulmonary arterial pressures, pulse oximetry, transporting monitored patients, transfer to ICU). ... Monitoring is the responsibility of trained personnel who have successfully completed the UPMC Basic Arrhythmia Course of challenge exam in rhythm recognition and/or hemodynamic monitoring where applicable. ..."
1) Event Description - At approximately 10:55 AM when responding to an IV pump alarm the patient was found to have agonal respirations. A condition C was immediately upgraded to a condition A. Following to condition it was noted that the patient had been off monitor since 10:02 AM. The patient was transferred to the ICU and later in the day CTB (ceased to breathe).
2) During interview with EMP5, March 31, 2017 at approximately 1:30 PM, it was revealed that reviewing the monitor print-out, the alarm on the monitor had been initiated during that time.
3) An interview with EMP4, March 30 2017, confirmed that the facility failed to appropriate monitoring a patient on a cardiac monitor. "The patient was refusing telemetry for a while, the physician ordered it again. After I put the monitor on the patient I ran a rhythm strip and put it on his chart. Sometime later, a colleague said there was an alarm in the patient's room. The IV had a respiratory monitor on, if the patient stops breathing, the alarm sounds. The patient was found the patient in a critical state. The telemetry alarm was not alarming. The lead wire was disconnected from the box. Pam the nurse that was with me also did not hear the alarm sound. I had four patients that day, that is normal for days. I am not sure how many patients had monitors that day. Maintenance is the only people that can adjust the monitor. They have a code to change them."