HospitalInspections.org

This condition is not met as evidenced by:

Based on the systemic nature of the standard-level deficiency related to Patient Rights the facility staff failed to substantially comply with this condition.

Findings:

The following standard was cited and showed a systemic nature of non-compliance with regards to Patient Rights as follows:

482.13(c)(2)
The information reviewed during the survey provided evidence that the facility failed to ensure patients were provided continuous telemetry monitoring for 36 of 36 patients requiring physician ordered telemetry monitoring.

Based on review of facility documents, staff interview (EMP), observations, and medical records reviewed, it was determined the facility failed to ensure patients were provided continuous telemetry monitoring for 36 of 36 patients requiring physician ordered telemetry monitoring.

Review on July 15, 2019, of the facility's "Telemetry Guidelines' policy, no review date, revealed "Policy 1. Monitors will be attended at all times by a licensed person who has successfully completed a dysrhythmia course ... 4. All RN's and LPN's are responsible for watching the monitors and acting on alarms in an appropriate manner. This includes replacing batteries and checking lead placement. It is unacceptable to have a flat line on any patient due to battery replacement. 5. All RN's and LPN's are responsible for making sure the monitor has paper in it and replacing when necessary. ... 7. All rhythms must be viewed by the assigned nurse at least every 2 hours and rhythm changes must be documented and reported [as appropriate] to a physician. ..."

Review on July 15, 2019, of facility "Department of CV Telemetry Scope of Patient Care Services," dated August 24, 2018, revealed "I. Scope of Service a. Types of Patients Served: i. Cardiovascular Telemetry unit provides care for adult and geriatric patients who are in need of continuous heart monitoring. ...c. Typical Services, Treatments, Procedures, and Activities Performed: i. Assessment and care of the patients admitted to Cardiovascular Telemetry Unit. ...V. Department Goals and Objectives: a. To provide excellent inpatient care that is comprehensive and sensitive to the patient's social, emotional and physical needs and results in positive quality care, clinical outcomes and patient experience. ..."

Review on July 15, 2019, of the facility's "Department of Progressive Care Unit Scope of Patient Care Services" policy, dated May 30, 2017, revealed "Department Director: I. Scope of Service a. Types of Patients Served; The Progressive Care unit for adult and geriatric patients, trauma patients and those patients with a diagnosis of Cerebral Vascular Accident, all who are in need of continuous heart monitoring. ..."

An observation tour of the Cardiovascular Telemetry Unit was completed on July 15, 2019, at approximately 9:50 AM. It was observed by the survey team there was no dedicated staff continuously observing the telemetry monitors.

An observation tour of the Progressive Care Unit was completed on July 15, 2019, at approximately 11:00 AM. It was observed by the survey team there was no dedicated staff continuously observing the telemetry monitors.

Review on July 15, 2019, of the facility provided list of patient units with continuous telemetry monitoring revealed the Intensive Care Units, the Cardiovascular Telemetry Unit, and the Progressive care unit provided continuous telemetry monitoring. The following patient care units had patients ordered continuous telemetry monitoring:

Cardiovascular Telemetry Unit: had 23 patients with all 23 patients requiring physician ordered continuous telemetry monitoring.

Progressive Care Unit: had 15 Patients with 13 patients requiring physician ordered continuous telemetry monitoring.

Interview on July 15, 2019, at approximately 10:30 AM, with EMP3 revealed there are no trained dedicated staff to continuously observe the telemetry monitors. EMP3 revealed the nurses assigned to the patients are responsible for observing the telemetry monitors. EMP3 revealed nurses on the intensive care units have a maximum of two patients per nurse. EMP3 revealed nurses on the Cardiovascular Telemetry Unit and Progressive Care Unit have a maximum of five patients per nurse.

This condition is not met as evidenced by:

Based on the systemic nature of the standard-level deficiency related to Nursing Services the facility staff failed to substantially comply with this condition.

Findings:

The following standard was cited and showed a systemic nature of non-compliance with regards to Nursing Services as follows:

482.23(b)(3)
The information reviewed during the survey provided evidence that the facility failed to obtain vital signs, complete a reassessment, and notify the physician on a patient with a change in heart rhythm for three of four applicable medical records reviewed (MR1, MR6, and MR12).

Based on review of facility documents, observations, staff interview (EMP), and review of medical records it was determined the facility failed to obtain vital signs, complete a reassessment, and notify the physician on a patient with a change in heart rhythm for three of four applicable medical records reviewed (MR1, MR6, and MR12).

Findings include:

Review on July 15, 2019, of facility "Department of CV Telemetry Scope of Patient Care Services," dated August 24, 2018, revealed "I. Scope of Service a. Types of Patients Served: i. Cardiovascular Telemetry unit provides care for adult and geriatric patients who are in need of continuous heart monitoring. ...c. Typical Services, Treatments, Procedures, and Activities Performed: i. Assessment and care of the patients admitted to Cardiovascular Telemetry Unit. ...V. Department Goals and Objectives: a. To provide excellent inpatient care that is comprehensive and sensitive to the patient's social, emotional and physical needs and results in positive quality care, clinical outcomes and patient experience. ..."

Review on July 15, 2019, of facility policy, "Patient Assessment, Reassessment and Plan of Care" effective date July 14, 1997, revealed "Purpose .... The assessment of the care and/or treatment needs of the patient will be continuously monitored throughout the patient's hospitalization. 2. An individualized, interdisciplinary plan of care will be written for all patients through the assessment and reassessment process performed by all members of the health care team as appropriate to the patient's condition. Scope All RN's and LPN's Guidelines ...iv. Specific to Medical Surgical Units and Telemetry Units Vital Signs are to be taken: a. a minimum of every 12 hours b. as condition warrants ...2. Re-Assessment a. Pertinent reassessment information will be documented in the medical record to enhance an integrated delivery of care. The scope and intensity of any further assessments are determined by the patient's diagnosis, care setting, the care the patient is seeking, the patient's consent to treatment and his/her response to previous care rendered. b. A reassessment shall be documented by the involved members of the health care team for the following: i. Any significant change in the patient's diagnosis and/or condition ... 3. Plan of Care ...d. Those disciplines consulting in the care shall contribute to the plan as appropriate to the patient's assessed needs. ... "

Review on July 15, 2019, of the facility's "Department of Progressive Care Unit Scope of Patient Care Services" policy, dated May 30, 2017, revealed "Department Director: I. Scope of Service a. Types of Patients Served; The Progressive Care unit for adult and geriatric patients, trauma patients and those patients with a diagnosis of Cerebral Vascular Accident, all who are in need of continuous heart monitoring. ..."

Review on July 15, 2019, of the facility's "Telemetry Guidelines" policy, no review date, revealed "Policy 1. Monitors will be attended at all times by a licensed person who has successfully completed a dysrhythmia course ... 4. All RN's and LPN's are responsible for watching the monitors and acting on alarms in an appropriate manner. This includes replacing batteries and checking lead placement. It is unacceptable to have a flat line on any patient due to battery replacement. 5. All RN's and LPN's are responsible for making sure the monitor has paper in it and replacing when necessary. ... 7. All rhythms must be viewed by the assigned nurse at least every 2 hours and rhythm changes must be documented and reported [as appropriate] to a physician. ..."

Observation on July 15, 2019, at 9:57 AM revealed the cardiac monitors on CV telemetry unmonitored and no staff directly observing these cardiac monitors.

Observation on July 15, 2019, at 9:57 AM revealed the following heart rhythms displayed on the cardiac monitor for these patients:
MR1 - Premature Ventricular Contractions (PVC's) greater than 10 per minute;
MR3 - Irregular heart rate of 40 beats per minute;
MR13 - Irregular heart beat of bigeminy (an irregular heart rhythm where the heart skips a beat);
MR14 - Monitor alarming patient was having PVC's; and,
MR15 - Atrial fibrillation (an irregular heart rhythm).

Interview with EMP2 on July 15, 2019, at the time of the observation confirmed these patient's cardiac rhythms.

Observation on July 15, 2019, at 10:07 AM revealed the cardiac monitors on CV telemetry unmonitored and no staff directly observing these cardiac monitors.

Observation on July 15, 2019, at 10:07 AM revealed the following heart rhythms displayed on the cardiac monitor for these patients:
MR1 - PVC's greater than 10 per minute; and
MR3 - Irregular heart rate of 40 beats per minute.

Interview with EMP2 on July 15, 2019, at the time of the observation confirmed these patient's cardiac rhythms.

Review on July 15, 2019, of MR1 revealed patient was admitted to CV Tele on July 13, 2019 at 23:36 PM. Level of Care Telemetry. Documentation on July 15, 2019 at 02:14 AM revealed Rhythm v-tach [Ventricular tachycardia-a type of regular, fast heart rate that arises from improper electrical activity in the ventricles of the heart and may be dangerous] 3 beat. There was no documentation a reassessment or vital signs were completed at that time. There was no documentation the physician was notified.

Direct observation of MR1's telemetry monitor with EMP1 on July 15, 2019, at approximately 11:00 AM revealed MR1 had non-sustained V-tach on July 15, 2019 at 01:53 AM, 02:04 AM, and 02:56 AM. The telemetry monitor did not reveal a 3 beat V-tach on July 15, 2019 at 02:14 AM.

Interview on July 15, 2019, at approximately 11:00 AM confirmed MR1's telemetry monitor revealed non-sustained V-tach on July 15, 2019 at 01:53 AM, 02:04 AM, and 02:56 AM. EMP1 confirmed there was no 3 beat V-tach on July 15,2 019 at 02:14 AM on MR1's telemetry monitor.

Continued review on July 15, 2019, of MR1 revealed no documentation of non-sustained v-tach on July 15, 2019 at 01:53 AM, 02:04 AM, and 02:56 AM; no documentation of vital signs or a reassessment was completed at 01:53 AM, 02:04 AM, and 02:56 AM; and no documentation the physician was notified.

Interview on July 15, 2019, with EMP1 confirmed MR1 had no documentation of non-sustained v-tach on July 15, 2019 at 01:53, 02:04 AM, and 02:56 AM and no documentation of vital signs or a reassessment was completed at 01:53, 02:04 AM, and 02:56 AM.

Review of MR6 on July 15, 2019, revealed this patient was admitted to the facility on July 11, 2019, and MR6's admitting diagnosis was chest pain. MR6's physician ordered this patient's level of care as telemetry and ordered continuous cardiac monitoring. MR6's physician assessed this patient and documented this patient's admitting heart rhythm as atrial fibrillation (an irregular heartbeat).

Review of MR6 on July 15, 2019, revealed cardiac rhythm strips dated July 14, 2019, indicating this patient was in atrial flutter (an abnormal heart rhythm) with Premature Ventricular Contractions (PVC's).

Interview with EMP4 on July 15, 2019, revealed MR6's atrial flutter with PVC's was a change in this patient's cardiac rhythm.

There was no documentation in MR6 indicating nursing staff took this patient's vital signs, completed an assessment or notified this patient's physician regarding the change in MR6's cardiac rhythm from atrial fibrillation to atrial flutter with PVC's.

Observation of MR6's cardiac monitor alarming on July 15, 2019, at 10:29 AM and at 10:47 AM. MR6's cardiac monitor indicated this patient was having runs of PVC's.

Interview with EMP4 on July 15, 2019, at the time of the observations confirmed MR6 was having runs of PVC's.

Review of MR6 on July 15, 2019, at 2:15 PM revealed no documentation nursing staff assessed this patient's vital signs, completed an assessment following the runs of PVC's at 10:29 AM and at 10:47 AM or notified the patient's physician regarding MR6's runs of PVC's at 10:29 AM and at 10:47 AM.

Interview with EMP4 on July 15, 2019, at 2:15 PM confirmed there was no documentation nursing staff assessed this patient's vital signs, completed an assessment following the runs of PVC's at 10:29 AM and at 10:47 AM or notified the patient's physician regarding MR6 runs of PVC's at 10:29 AM and at 10:47 AM.

Review of MR12 on July 16, 2019, revealed this patient was admitted to the facility on June 28, 2019, MR12's physician ordered this patient's level of care as telemetry and ordered continuous cardiac monitoring. MR12's physician assessed this patient and documented this patient's admitting heart rhythm as atrial fibrillation.

Review of MR12 on July 16, 2019, revealed a rhythm strip dated July 2, 2019, at 6:33 PM indicating this patient had 14 beats of ventricular fibrillation/tachycardia (considered the most serious cardiac rhythm with potential to cause cardiac arrest).

There was no documentation in MR12 indicating nursing staff took this patient's vital signs, completed an assessment or notified this patient's physician regarding MR12's 14 beats of ventricular fibrillation/tachycardia.

Phone interview with EMP1 on July 18, 2019, at 11:24 AM confirmed there was no documentation nursing staff assessed this patient's vital signs, completed an assessment following the 14 beats of ventricular fibrillation/tachycardia or notified the patient's physician regarding the 14 beats of ventricular fibrillation/tachycardia.