HospitalInspections.org

Based on policy review, medical record review, staff interview, personnel file review, hospital investigation report review, and Late medication report review, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights and an organized nursing service to ensure the safety of patients.

The findings include:

1. The hospital failed to ensure care in a safe setting by failing to ensure hospital telemetry monitor technician notified the nurse of a change in telemetry monitoring status of a patient per the facility policy for 1 of 1 patients with a change in cardiac rhythm (Patient #17).

~ cross refer to 482.13 Patient Rights' Condition: Tag 0115.


2. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care.

~ cross refer to 482.23 Nursing Services Condition: Tag 0385.

Based on review of hospital policy, job descriptions, closed medical record review, staff interview and observation, the hospital failed to promote and protect patients' rights by failing to ensure a safe setting for patient care.

Findings include:

The hospital failed to ensure care in a safe setting by failing to ensure hospital telemetry monitor technician notified the nurse of a change in telemetry monitoring status of a patient per the facility policy for 1 of 1 patients with a change in cardiac rhythm (Patient #17).

~ cross refer to 482.13(c)(2) Patient Rights' Standard: Tag 0144.

Based on review of review of hospital policy, job descriptions, closed medical record review, staff interview and observation, the hospital failed to ensure care in a safe setting by failing to ensure a telemetry monitor technician notified a licensed nurse of a change in telemetry monitoring status of a patient per the facility policy for 1 of 1 patients sampled with a change in cardiac rhythm (Patient #17).

The findings include:

Review of the hospital's policy, "Telemetry Policy", effective 07/11/2011, revealed, "PURPOSE : To provide guidelines for cardiac monitoring and nursing care of the patient requiring telemetry monitoring in a non-ICU unit and documenting telemetry information in the medical record. ...I. Communication: ...MT (monitor technician)-to-Nurse Troubleshooting: Notify nurse for situations such as but not limited to leads off, low battery, and rhythm changes. If nurse is not available or does not respond within 5 minutes, notify resource/charge nurse. If resource/charge nurse is not available or does not respond within 5 minutes, notify patient care manager if on duty or the nursing supervisor if the manager is not on duty. ...II. Monitoring Practices - Monitor Technician Role: ...Record continuous strips from telemetry monitor or defibrillator during: Codes, Critical Situations...Notify primary nurse for changes in patient's usual heart rate/rhythm. ...V. Nursing Care- Temporary Interruption of Telemetry: ... Notify MT that patient is being temporarily removed from telemetry...Remove telemetry electrodes as described above. Confirm with MT that patient's rhythm is transmitting...".

Review of the hospital's job description for a Registered Nurse, revised 11/2011, revealed, "...Job Summary: Plans and implements professional nursing care for patients in accordance with hospital policies. ... Major Job Functions: 1. Assesses the patient and identifies patient needs. ...3. Plans, organizes, implements and evaluates patient care. ...".

Review of the hospital's job description for a monitor technician, revised 11/2011, revealed, "Major Job Functions : ...10. Assumes responsibility for maintaining and monitoring cardiac rhythms and alerting assigned nurse of any arrhythmia or change in EKG pattern (rate, rhythm, configuration)...".

Closed record review of Patient #17 revealed a 68 year-old female admitted 12/08/2011 with altered mental status, congestive heart failure, atrial fibrillation and a history of seizure disorders, schizophrenia, anemia, obesity, chronic debility, pulmonary hypertension and Alzheimer dementia. Record review revealed the patient was admitted to the medical telemetry monitored unit of the hospital. Record review revealed an order dated 12/08/2011 at 0620 for soft wrist restraints and an order dated 12/09/2011 at 1010, 12/10/2011 at 1100 and 12/11/2011 at 1100 for a vest restraint. Further record review revealed a cardiac rhythm strip dated for Patient #17, on 12/12/2011 at 0000. Review of the rhythm strip revealed, "Atrial Fib (fibrillation) controlled" electronically printed on the bottom of the strip. Record review revealed the next rhythm strip dated 12/12/2011 at 0033 was electronically printed with "Asystole" (rhythm where the heart is not beating and life cannot be sustained). Record review revealed no rhythm strips from 12/12/2011 at 0000 until 12/12/2011 at 0033 (33 minutes). Record review revealed nursing documentation by RN (Registered Nurse) #1 dated 12/12/2011 at 0213, "At 0034 monitor Tech (Monitor Tech #1) alerted staff of EKG change. Noted patient not breathing nor responding. Called Code immediately and initiated CPR. At 0038 (Physician's Name), Rapid response team, Primary Nurse, supportive staff and family at the bedside. ...0000 @ V/S (vital signs) Pulse-77, resp (respirations) - 20, BP- 105/70 and 02 (oxygen) 94%. MD pronounced patient at 0048. No pulse, no respirations, no blood pressure". Review of the physician's final summary, dictated 12/14/2011 at 1825 revealed, "...The patient succumbed to PEA (pulseless electrical activity) and a code blue was done on 12/12/2011 at 1250 with CPR, which could not revive the patient and the patient was pronounced expired at 1250 a.m. on 12/12/2011...".

Telephone interview 12/15/2011 at 1250 with monitor technician (MT#1) revealed she was assigned duties as the MT on 12/12/2011 for the 3 South unit. The interview revealed on 12/12/2011 at 0010 she paged the nursing assistant (NA #1) assigned to patient #17. The interview revealed she paged her because it appeared her telemetry leads were off. The interview revealed the page came back as "OT" meaning NA#1 had not responded to the page. The interview revealed the paging system automatically notified the MT after 3 to 5 minutes when the page was not responded to. The interview revealed she heard NA#1 in the "nursery" area talking. The interview revealed she verbally told NA#1 to go and check the leads on Patient #17 and NA #1 told her "No". The interview revealed MT #1 asked her why she would not go and put the leads back on patient #17 and NA #1 told her the patient had been "agitated pulling off the monitor". The interview revealed MT #1 told her the patient had been on telemetry her "whole shift". MT #1 stated that NA #1 had never before told her she would not respond to check on a patient on telemetry. The interview revealed MT #1 heard NA #1 ask NA #2 to help in Patient #17's room. The interview revealed she knew the patient's son was in the room but did not remember who told her. Interview revealed she knew the NA's were in patient #17's room bathing the patient. The interview revealed it was no more than 10 minutes from the first page until both NA's were in the room bathing patient. The interview revealed she called into patient #17's room to ask the NA what they were doing with the patient. She stated NA #1 told her they had just "hooked" the patient back on the monitor. MT #1 asked what the patient was doing and was told that the patient was sleeping. The interview revealed MT #1 knew that patient had been agitated earlier and was concerned the patient was sleeping now. The interview revealed she thought the patient was in the heart rhythm Asystole. She stated she called the nursing station for the charge nurse (RN #1). Stated RN #1 immediately answered the phone and she told her to check on patient #17 because the NA said the patient was sleeping and she (MT #1) thought she saw Asystole on the heart monitor. The interview revealed it was approximately 10 minutes from the first page (0010) before NA #1 got into patient #17's room and approximately another 10 minutes that the patient was finished being bathed. The interview revealed she called RN #1 at 0033. The interview revealed she had concern about NA #1 not properly putting the leads on patients. She stated she had spoken to the nurse manager (NM) and he had shown NA #1 how to correctly place the leads. The interview revealed she had not spoken to any one about NA #1 not improving since then. The interview revealed she had written a statement about concerns about NA #1 the morning of 12/12/2011. The interview revealed she had not stated her written concerns correctly. Her concern was NA #1 did not properly place the monitor leads on the patient and she did not have concerns with NA #1 not responding to pages.

Telephone interview on 12/15/2011 at 1320 revealed RN #1 was assigned as charge nurse on 12/12/2011 for the 3 South unit. The interview revealed she did not have a patient assignment on 12/12/2011, she had only charge nurse duties. The interview revealed on 12/12/2011 she was coming out of a patient room and noted the light on outside patient #17's door. The interview revealed the hospital had a "no pass policy" which meant when you saw a light on you went to see why the light was on. Interview revealed she went to patient #17's room and NA #1 and NA #2 were in the room bathing the patient and questioned why the light was on and was told MT #1 had called in the room and told them it looked like the patient's (telemetry) lead was not on. She told them to put the leads back on. Stated she noted the patient was breathing. Stated she left, went into another patient room and then went to the nursing station. Stated MT #1 called the station and told her to check the leads on "22" (patient # 17) that it looked like the rhythm "could be" Asystole. The interview revealed she immediately went to patient # 17's room, the son was in the room behind a chair and the patient did not appear to be breathing or responsive so she called a"code". The interview revealed she thought MT #1 said the leads were not on properly and it "looked like Asystole". The interview revealed the maximum time between when she first saw the NA's in the room bathing the patient and receiving the phone call from MT #1 was 15-20 minutes.
The interview revealed she talked to the NM at the end of shift about NA #1 telling MT #1 "no" that the patient had been taking her leads off. The interview revealed when the patient was being bathed and the leads were off the patient NA #1 should have told MT # 1. The interview revealed she was aware of concerns regarding NA's not placing the leads correctly on patients. There was no specific NA and was "Hit/miss". The interview revealed she was aware of the NM responding to this concern. The interview revealed one time the NM showed the NA how to place the leads correctly and the NA did return demonstration of correct placement. The interview revealed she was not aware of any further concerns. The interview revealed no staff had voiced any further concerns to her. The interview revealed the name of the NA that the NM had worked with was NA #1.

Telephone interview with NA #2 on 12/15/2011 at 1620 revealed she had assisted NA #1 with bathing patient #17 on 12/12/2011. The interview revealed she was asked by NA #1 to help her change a soiled diaper on patient #17 on 12/12/2011. Stated she went with NA #1 into the room and patient #17's son was in the room. Interview revealed NA #2 had worked with patient #17 earlier in the week and knew she would be combative and kicking. Interview revealed she stayed at the foot of the bed while NA #1 explained to patient #17 that they were going to clean and change her soiled diaper. Interview revealed patient #17 had her gown on and she could not see if the patient had all the telemetry leads on. Interview revealed the patient told them to "leave " her alone and was not cooperative. Interview revealed the son told the patient the NA's wanted to change her diaper. Interview revealed the patient calmed down and they changed her diaper. Stated NA#1 turned patient on her back and was cleaning the "Peri" (front of groin area) area. Stated she asked had the nurse given something to the patient and no one responded. Stated the patient was turned to her side and patient was continuing to have an active bowel movement. Interview revealed the patient was pushing the stool out and she told NA #1 they "might as well wait" until she finished her bowel movement before continuing to clean her. Interview revealed this took about 2 minutes. She watched her "grimace and grunt about five times" while the patient had the bowel movement. Interview revealed they cleaned the patient after the stool. Stated they had to change her draw sheet and pad under the patient and put a clean diaper back on. Interview revealed the patient looked like she was "drifting" off to sleep. She asked a second time had the nurse given the patient something and the son responded the nurse had given patient #17 a "Sweet tasting medicine". Interview revealed when she asked earlier had the patient been given anything she did observe the patient was breathing because she was flat on her back. Interview revealed NA #1 was checking that the telemetry leads were connected. Interview revealed she saw the red and brown leads on and when the gown was up she saw the black and white lead on. Interview revealed she was not sure but did see NA #1 touching the green lead and did not know if she reattached it or just touched it. Interview revealed as soon as she saw NA #1 touch the green lead MT #1 called into the room and asked what were they doing with the patient. NA #1 told MT #1 they bathed the patient and had put the leads back on. MT #1 asked what was the patient doing and NA #1 told her the patient was resting sleeping. Interview revealed almost immediately RN #1 the charge nurse came to the door and asked what was going on. RN #1 said to call a code. Interview revealed RN #3 was standing in the hall and told her to check the patient's pulse. Interview revealed she checked the patient's radial pulse and it was in the "50's" and the patient was warm. Interview revealed she could not tell if the patient was breathing while she taking her pulse but thought she was still.

Telephone interview with LPN #1 on 12/16/2011 at approximately 0900 revealed she was the primary care nurse assigned patient #17 on 12/12/2011. Interview revealed she was taking her break and when she stepped back onto the floor she heard the code called. Interview revealed she went into the room at the same time as RN #1. Interview revealed she heard RN #1 say call a code. Interview revealed she thought the secretary called the code. Interview revealed she started assisting with putting the back board under the patient. Interview reveals she did not remember all the staff in the room but she saw NA #1 and NA #2 both at the bedside one on each side of the patient. She saw NA #2 with the patient's arm in her hand and she heard NA #1 say "I feel a pulse". Interview revealed she reached for the patient's arm and a member of the rapid response team asked her to move. Interview revealed she did not remember if the patient was breathing because the patient was a "heavy lady" and her focus was on getting the back board under the patient for time she was in the room.

Based on review of hospital policy, job descriptions, closed medical record review, staff interview, Late medication report review and observation, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care.

The findings include:

1. The telemetry monitor technician failed to notify the nurse of a change in telemetry monitoring status of a patient per the facility policy.

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

2. The nursing and respiratory therapy staff failed obtain and/or administer medications per the physicians' order.

~cross refer to 482.23 (c)(1) Nursing Services Standard: Tag A0405

Based on review of hospital policy, job descriptions, closed medical record review, staff interview and observation, the telemetry monitor technician failed to notify the nurse of a change in telemetry monitoring status of a patient per the facility policy for 1 of 1 patients with a change in cardiac rhythm (Patient #17).

The findings include:

Review of the hospital's policy, "Telemetry Policy", effective 07/11/2011, revealed, "PURPOSE : To provide guidelines for cardiac monitoring and nursing care of the patient requiring telemetry monitoring in a non-ICU unit and documenting telemetry information in the medical record. ...I. Communication: ...MT (monitor technician)-to-Nurse Troubleshooting : Notify nurse for situations such as but not limited to leads off, low battery, and rhythm changes. If nurse is not available or does not respond within 5 minutes, notify resource/charge nurse. If resource/charge nurse is not available or does not respond within 5 minutes, notify patient care manager if on duty or the nursing supervisor if the manager is not on duty. ...II. Monitoring Practices - Monitor Technician Role: ...Record continuous strips from telemetry monitor or defibrillator during: Codes, Critical Situations...Notify primary nurse for changes in patient's usual heart rate/rhythm. ...V. Nursing Care- Temporary Interruption of Telemetry: ... Notify MT that patient is being temporarily removed from telemetry...Remove telemetry electrodes as described above. Confirm with MT that patient's rhythm is transmitting...".

Review of the hospital's job description for a Registered Nurse, revised 11/2011, revealed, "...Job Summary: Plans and implements professional nursing care for patients in accordance with hospital policies. ... Major Job Functions: 1. Assesses the patient and identifies patient needs. ...3. Plans, organizes, implements and evaluates patient care. ...".

Review of the hospital's job description for a monitor technician, revised 11/2011, revealed, "Major Job Functions : ...10. Assumes responsibility for maintaining and monitoring cardiac rhythms and alerting assigned nurse of any arrhythmia or change in EKG pattern (rate, rhythm, configuration)...".

Closed record review of Patient #17 revealed a 68 year-old female admitted 12/08/2011 with altered mental status, congestive heart failure, atrial fibrillation and a history of seizure disorders, schizophrenia, anemia, obesity, chronic debility, pulmonary hypertension and Alzheimer dementia. Record review revealed the patient was admitted to the medical telemetry monitored unit of the hospital. Record review revealed an order dated 12/08/2011 at 0620 for soft wrist restraints and an order dated 12/09/2011 at 1010, 12/10/2011 at 1100 and 12/11/2011 at 1100 for a vest restraint. Further record review revealed a cardiac rhythm strip dated 12/12/2011 at 0000. Review of the rhythm strip revealed, "Atrial Fib (fibrillation) controlled" electronically printed on the bottom of the strip. Record review revealed the next rhythm strip dated 12/12/2011 at 0033 was electronically printed with "Asystole" (rhythm where the heart is not beating and life cannot be sustained). Record review revealed no rhythm strips from 12/12/2011 at 0000 until 12/12/2011 at 0033 (33 minutes). Record review revealed nursing documentation by RN (Registered Nurse) #1 dated 12/12/2011 at 0213, "At 0034 monitor Tech (Monitor Tech #1) alerted staff of EKG change. Noted patient not breathing nor responding. Called Code immediately and initiated CPR. At 0038 (Physician's Name), Rapid response team, Primary Nurse, supportive staff and family at the bedside. ...0000 @ V/S (vital signs) Pulse-77, resp (respirations) - 20, BP- 105/70 and 02 (oxygen) 94%. MD pronounced patient at 0048. No pulse, no respirations, no blood pressure". Review of the physician's final summary, dictated 12/14/2011 at 1825 revealed, "...The patient succumbed to PEA (pulseless electrical activity) and a code blue was done on 12/12/2011 at 1250 with CPR, which could not revive the patient and the patient was pronounced expired at 1250 a.m. on 12/12/2011...".

Telephone interview 12/15/2011 at 1250 with monitor technician (MT#1) revealed she was assigned duties as the MT on 12/12/2011 for the 3 South unit. The interview revealed on 12/12/2011 at 0010 she paged the nursing assistant (NA #1) assigned to patient #17. The interview revealed she paged her because it appeared her telemetry leads were off. The interview revealed the page came back as "OT" meaning NA#1 had not responded to the page. The interview revealed the paging system automatically notified the MT after 3 to 5 minutes when the page was not responded to. The interview revealed she heard NA#1 in the "nursery" area talking. The interview revealed she verbally told NA#1 to go and check the leads on Patient #17 and NA #1 told her "No". The interview revealed MT #1 asked her why she would not go and put the leads back on patient #17 and NA #1 told her the patient had been "agitated pulling off the monitor". The interview revealed MT #1 told her the patient had been on telemetry her "whole shift". MT #1 stated that NA #1 had never before told her she would not respond to check on a patient on telemetry. The interview revealed MT #1 heard NA #1 ask NA #2 to help in Patient #17's room. The interview revealed she knew the patient's son was in the room but did not remember who told her. Stated she knew the NA's were in patient #17's room bathing the patient. The interview revealed it was no more than 10 minutes from the first page until both NA's were in the room bathing patient. The interview revealed she called into patient #17's room to ask the NA what they were doing with the patient. She stated NA #1 told her they had just "hooked" the patient back on the monitor. MT #1 asked what the patient was doing and was told that the patient was sleeping. The interview revealed MT #1 knew that patient had been agitated earlier and was concerned the patient was sleeping now. The interview revealed she thought the patient was in the heart rhythm Asystole. She stated she called the nursing station for the charge nurse (RN #1). Stated RN #1 immediately answered the phone and she told her to check on patient #17 because the NA said the patient was sleeping and she (MT #1) thought she saw Asystole on the heart monitor. The interview revealed it was approximately 10 minutes from the first page (0010) before NA #1 got into patient #17's room.. It was approximately another 10 minutes that the patient was finished being bathed. The interview revealed she called RN #1 at 0033. The interview revealed she had concerns about NA #1 not properly putting the leads on patients. She stated she had spoken to the nurse manager (NM) and he had shown NA #1 how to correctly place the leads. The interview revealed she had not spoken to any one about NA #1 not improving since then The interview revealed she had written a statement about concerns about NA #1 the morning of 12/12/2011. The interview revealed she had not stated her written concerns correctly. Her concern was NA #1 did not properly place the monitor leads on the patient and she did not have concerns with NA #1 not responding to pages.

Telephone interview on 12/15/2011 at 1320 revealed RN #1 was assigned as charge nurse on 12/12/2011 for the 3 South unit. The interview revealed she did not have a patient assignment on 12/12/2011, she had only charge nurse duties. The interview revealed on 12/12/2011 she was coming out of a patient room and noted the light on outside patient #17's door. The interview revealed the hospital had a "no pass policy" which meant when you saw a light on you went to see why the light was on. Stated she went to patient #17's room and NA #1 and NA #2 were in the room bathing the patient. She question why the light was on and was told MT #1 had called in the room and told them it looked like the patient's lead was not on. She told them to put the leads back on. Stated she noted the patient was breathing. Stated she left, went into another patient room and then went to the nursing station. Stated MT #1 called the station and told her to check the leads on "22" (patient # 17) that it looked like the rhythm "could be" Asystole. The interview revealed she immediately went to patient # 17's room, the son was in the room behind a chair and the patient did not appear to be breathing or responsive so she called a "code". The interview revealed she thought MT #1 said the leads were not on properly and it "looked like Asystole". The interview revealed the maximum time between when she first saw the NA's in the room bathing the patient and receiving the phone call from MT #1 was 15-20 minutes.
The interview revealed she talked to the NM at the end of shift about NA #1 telling MT #1 "no" that the patient had been taking her leads off. The interview revealed when the patient was being bathed and the leads were off the patient NA #1 should have told MT # 1.
The interview revealed she was aware of concerns regarding NA's not placing the leads correctly on patients. There was no specific NA and was "Hit/miss". The interview revealed she was aware of the NM responding to this concern. The interview revealed one time the NM showed the NA how to place the leads correctly and the NA did return demonstration of correct placement. The interview revealed she was not aware of any further concerns. The interview revealed no staff had voiced any further concerns to her. The interview revealed the name of the NA that the NM had worked with was NA#1.

Telephone interview with NA #2 on 12/15/2011 at 1620 revealed she had assisted NA #1 with bathing patient #17 on 12/12/2011. The interview revealed she was asked by NA #1 to help her change a soiled diaper on patient #17 on 12/12/2011. Stated she went with NA #1 into the room and patient #17's son was in the room. Interview revealed NA #2 had worked with patient #17 earlier in the week and knew she would be combative and kicking. Interview revealed she stayed at the foot of the bed while NA #1 explained to patient #17 that they were going to clean and change her soiled diaper. Interview revealed patient #17 had her gown on and she could not see if the patient had all the telemetry leads on. Interview revealed the patient told them to "leave" her alone and was not cooperative. Interview revealed the son told the patient the NA's wanted to change her diaper. Interview revealed the patient calmed down and they changed her diaper. Stated NA#1 turned patient on her back and was cleaning the "Peri" (front of groin area) area. Stated she asked had the nurse given something to the patient and no one responded. Stated the patient was turned to her side and patient was continuing to have an active bowel movement. Interview revealed the patient was pushing the stool out and she told NA #1 they "might as well wait" until she finished her bowel movement before continuing to clean her. Interview revealed this took about 2 minutes. She watched her "grimace and grunt about five times" while the patient had the bowel movement. Interview revealed they cleaned the patient after the stool. Stated they had to change her draw sheet and pad under the patient and put a clean diaper back on. Interview revealed the patient looked like she was "drifting" off to sleep. She asked a second time had the nurse given the patient something and the son responded the nurse had given patient #17 a "Sweet tasting medicine". Interview revealed when she asked earlier had the patient been given anything she did observe the patient was breathing because she was flat on her back. Interview revealed NA #1 was checking that the telemetry leads were connected. Interview revealed she saw the red and brown leads on and when the gown was up she saw the black and white lead on. Interview revealed she was not sure but did see NA #1 touching the green lead and did not know if she reattached it or just touched it. Interview revealed as soon as she saw NA #1 touch the green lead MT #1 called into the room and asked what were they doing with the patient. NA #1 told MT #1 they bathed the patient and had put the leads back on. MT #1 asked what was the patient doing and NA #1 told her the patient was sleeping. Interview revealed almost immediately RN #1 the charge nurse came to the door and asked what was going on. RN #1 said to call a code. Interview revealed RN #3 was standing in the hall and told her to check the patient's pulse. Interview revealed she checked the patient's radial pulse and it was in the "50's" and the patient was warm. Interview revealed she could not tell if the patient was breathing while she taking her pulse but thought she was still.

Telephone interview with LPN #1 on 12/16/2011 at approximately 0900 revealed she was the primary care nurse assigned patient #17 on 12/12/2011. Interview revealed she was taking her break and when she stepped back onto the floor she heard the code called. Interview revealed she went into the room at the same time as RN #1. Interview revealed she heard RN #1 say call a code. Interview revealed she thought the secretary called the code. Interview revealed she started assisting with putting the back board under the patient. Interview reveals she did not remember all the staff in the room but she saw NA #1 and NA #2 both at the bedside one on each side of the patient. She saw NA #2 with the patient's arm in her hand and she heard NA #1 say "I feel a pulse". Interview revealed she reached for the patient's arm and a member of the rapid response team asked her to move. Interview revealed she did not remember if the patient was breathing because the patient was a "heavy lady" and her focus was on getting the back board under the patient for time she was in the room.

Telephone interview with RN #2 on 12/16/2011 at 0950 revealed she was a staff nurse on the unit 12/12/2011. Interview revealed she was not sure of the time on 12/12/2011 but around 0100 RN #1 running into the nursery room where the crash cart is stored. Interview revealed RN #1 told her to call a code and she used the desk phone to call a code. Interview revealed within 30 seconds she then went to patient #17's room. Interview revealed NA # 1 was standing in the doorway of the room. Interview revealed a nurse was with the patient and there were 3 to 4 people already in the room. Interview revealed she immediately took the patient's blood sugar. Interview revealed she was not sure if she beat the crash cart in the room. Interview revealed the patient's blood sugar results were 119. The interview revealed she did not look at the patient's chest and could not say if the patient was breathing when she was doing the blood sugar. The interview revealed it was about 30 minutes before the code when MT #1 called into the desk asking for LPN #1 (Patient #17's primary nurse) and she told her that LPN #1 had gone on break.

Telephone interview on 12/16/2011 at 1020 revealed RN #3 was on duty 12/12/2011 in the unit where patient #17 was a patient. Interview revealed she was walking down the hall and saw the door open to patient #17's room. Interview revealed she looked into the room while in the hall and did a "quick assessment". Interview revealed her "quick assessment" consisted of her looking at the patient from the hall. Interview revealed she could see that the patient was not breathing. Interview revealed when looking into the room she saw NA #1 and NA #2 at the bedside. Interview revealed NA #1 was on the right side of the bed and NA #2 was on the left side of the bed. Interview revealed both NA's were looking at the patient. Interview revealed she was not sure if the light outside the room was activated or not. Interview revealed she told the NA's they "had a code". Interview revealed NA #1 tried to shake the patient for a response and NA #2 did not move. Interview revealed RN #1 was in the hall and heard her say this. Interview revealed she went into the room and saw the son in the room after entering the room. Interview revealed she tried to feel for a femoral pulse and could not feel a pulse. Interview revealed the head of the bed was slightly elevated and she did not see any indication of the patient breathing. Interview revealed there was no back board under the patient and a nurse was at the head of the bed suctioning the patient. Interview revealed she did not know where NA #1 and NA #2 were during the code. Interview revealed LPN # 1 checked for a pulse and said she had a pulse. Interview revealed when RN #1 got there with the back board she told her she was "shocked" they (NA #1 and NA #2) were looking at the patient when she first looked into the room. Interview revealed when LPN #1 felt a pulse the patient was not having chest compressions. Interview revealed she thought that 50 percent of the NA's did not recognize when a patient was in trouble. Interview revealed she had talked with the charge nurse about patients calling out for the bathroom and the NA's taking too long and "basic things". Interview revealed she had not talked with anyone about 50 percent of the NA's did not recognize a patient in trouble.

Interview with the Nurse Manager (NM) on 12/16/2011 at 1126 revealed RN #2 and LPN #1 had clarified that both NA's were at the patient's bedside on 12/12/2011.

Second telephone interview on 12/15/2011 at 1705 with RN #1 revealed the first time she went to patient #17's room was when she saw the light above the door was "blinking". The interview revealed she knocked on the door and when she opened the door NA #1 and NA #2 were bathing the patient. The interview revealed the patient had a large bowel movement. The interview revealed when a white light is on it means nursing staff need to assess the patient and when the green light is on it means the telemetry has activated the light.

Interview on 12/20/2011 at 1310 with monitor technician #2 on the medical telemetry unit revealed the rhythm strips are run every four hours. Interview further revealed once a patient is discharged, the patient's profile in the telemetry recording system is deleted after 96 hours. Interview further revealed, "when a lethal rhythm is detected, the printer automatically starts printing the strips". Interview revealed, "if the leads are off, I would call the nursing assistant. If it is a lethal rhythm, I would call the nurse and call the desk".


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Observation during tour of 4 South (a Telemetry Unit) on 12/22/2011 at 1324 revealed a telemetry monitoring room. Observation within the room revealed a Monitor Technician (MT#3) sitting in front of multiple monitor screens displaying patient heart rhythms. Further observation revealed an paging system control unit adjacent and to the right of the monitoring screens. Interview during tour with MT#3 revealed he has the capability of monitoring up to 32 patients at the same time. Interview revealed the MT monitors the patient in Lead II. Interview revealed the monitoring system alarms when a patient's monitor lead(s) has been disconnected or when there has been a change in the patient's heart rhythm. Interview revealed the monitoring system automatically prints rhythm strips when "lethal" changes in heart rhythms are detected (i.e. Asystole, Ventricular Fibrillation or V-Tachycardia, Supraventricular Tachycardia or Bradycardia et al). Interview revealed the system does not print out a rhythm strip when a lead is off. Interview revealed if the monitoring system identifies a "lead off" a message is displayed on the screen and an audible alarm signals. Interview revealed "If a lead comes off, I call the nursing assistant." Interview revealed the MT uses the paging system located adjacent to the monitors to page the nursing assistant (NA) to go check on the patient. Interview revealed the NA has a "5 minute window" to respond to the page. Interview revealed if the NA does not respond within the 5 minute window (delay) the system goes into "overtime" and alarms again then the patient's nurse is paged using the same system. Interview revealed all the nursing assistants and nurses carry pagers. Interview during tour with a Resource Nurse (supervisor) revealed "according to hospital policy, the monitor tech. should page the nurse for leads off, battery changes, and rhythm changes."

Based on policy and procedure review, Late medication report review, medical record review and staff interviews the nursing and respiratory therapy staff failed to obtain and/or administer medications per the physicians' order in 1 of 1 sampled patients with missed medications. (Patient #5).

The findings include:

Review of hospital policy 207-A, reviewed 08/11 revealed "Medication Administration Policy: Medications are administered per physician order".

Review of hospital; policy 126-A revised 8/18/2011 revealed "Medication Administration check...17. CHARTING A LATE MEDICATION. 1. Respiratory will have a one-hour window prior to the time the medication is scheduled, and a one-hour window after the scheduled time to administer a medication."( minimum 3 hours and maximum 5 hours).

Review of the respiratory "Medications Charted Late" report, revealed the treatments on 11/27/2011 at 2051 was administered late, 11/28/2011 at 0903 was late.

Closed medical record review of patient #5 on 12/21/2011 revealed a 66 year old admitted on 11/25/2011 with a diagnosis of SOB (shortness of breath), COPD (chronic obstructive pulmonary disease), Atrial fibrillation COPD precipitated by acute bronchitis. Record review revealed the patient was discharged on 11/30/2011. Record review revealed admission orders on 11/25/2011 at 0140 for Xenopax nebulizer treatments (to assist the patient in breathing) every 4 hours. Medical record review revealed on 11/27/2011 at 2051 documentation of 5 hours and 38 minutes between medical respiratory treatments (38 minutes beyond the maximum 5 hours). Further record review revealed on 11/28/2011 at 0903 documentation of 5 hours and 43 minutes between medical respiratory treatments (44 minutes beyond the maximum 5 hours). Record review revealed on 11/28/2011 at 1834 documentation of 2 hours and 3 minutes between medical respiratory treatments (57 minutes prior to the minimum of 3 hours).

Interview with the Director of Respiratory care on 12/21/2011 at 1010 revealed the treatments on 11/27 and 11/28/2011 at 2051,0903 and 1834 respectively were not given within the facility policy. The interview revealed the treatments were late or early due to the staff providing care with another patient. The interview confirmed the treatments noted on the Medications Charted Late report were correct in that the treatments were late.

Record review revealed admission orders on 11/25/2011 at 0140 for Low dose insulin regimen for fingerstick blood glucose on a sliding scale of 61-150--0 units; 151-200--1 unit of insulin to be administered ; 201-250--3 units; 251-300--5 units; 301-350--7 units; 351-400 --9 units and greater than 400--11 units, call MD. Record review revealed on 11/25/2011 at 1810, the patient's blood sugar was 173 and there was no documentation of 1 unit of insulin given per the sliding scale physician orders. Record review revealed on 11/28/2011 at 1845 the patient's blood sugar was 226 and there was no documentation of 3 units of insulin given per the sliding scale physician orders. Record review revealed on 11/29/2011 at 1835 the patient's blood sugar was 153 and there was no documentation of 1 unit of insulin given per the sliding scale physician orders. Record review did not reveal why the patient was not administered insulin per the physician's sliding scale order.

Interview on 12/21/2011 at 0930 with administrative nursing staff revealed the 3 units of insulin was not given on 11/28/2011 at 1843 because the nurse misread the results as 96. The interview revealed the patient should have been given 3 units per the physician's order. The interview also confirmed the patient was not given insulin on 11/25/2011 at 1810 and on 11/29/2011 at 1835. The interview revealed the patient should have been administered 1 unit of insulin each on both dates/times.

Record review revealed a physicians' order on 11/29/2011 at 1530 for Lidocaine Viscous (for pain in mouth) 15 cc's rinse and spit "QID PRN" (four times per day as needed). Record review revealed the order to the pharmacy was not sent until 11/30/2011 at 0129 (10 hours after physician's order written). Record review revealed the patient was administered on 11/30/2011 at 0151. Record review did not reveal why the physician's order was not scanned to the pharmacy after being written.

Interview with Clinical Pharmacist #1 on 12/21/2011 at 0840 revealed the turn around time between orders received and medications sent is 12 to 30 minutes. The interview confirmed 10 hours is beyond the hospital standard for a medication to be available after the physician's order is written. Interview revealed the hours for medications ordered as QID is at 0830, 1230,1730 and 2200.

NC00077032, NC00077168, NC00077193, NC00077196, NC00077288, NC00077389, NC00077450, NC00077479