HospitalInspections.org

Based on a tour of the Women's Health unit, facility documents and interview with staff (EMP), it was determined the facility failed to monitor the safety of service and quality of care for telemetry patients on the Women's Health unit.

Findings include:

A tour of the 3 East Women's Health unit on August 9, 2010, at 10:00 AM revealed closed and locked double doors at the entrance to 3 East. Two overhead monitors were located in the hallway. The nursing station was located outside of the locked doors. The nursing station contained a central telemetry monitoring station.

1) An interview was conducted with EMP3 on August 9, 2010, at 10:20 AM. EMP3 confirmed that only the monitor at the rotunda nursing station will alarm. EMP3 stated "The secretary notifies the nurse via overhead paging." EMP3 stated that the secretary is not a monitor technician and was not trained to read the telemetry monitors.

2) An interview was conducted with EMP10, August 9, 2010, at 10:00 AM. EMP10 stated "All staff nurses take annual competencies. The competencies vary from year to year. The unit decides on what to make a competency based on input from the monthly educational council, which is a committee of staff nurses, facilitated by the nurse educator. They meet monthly and build the competencies based on input from the staff. We don't do every skill every year, there are just too many. We target on a cycle basis by what is brought up by education council. EKG strip identification is done every year. The staff are required to pass with an 80%. If the RN does not score at least 80%, they are required to attend the class "Cardiac Rhythms: Interpretation and Treatment. ... We were not aware of any staff concerns regarding telemetry monitoring on the Women's Health unit."

3) An interview was conducted with EMP5 on August 9, 2010, at 10:20 AM. EMP5 stated that "the Women's Health unit does not have a central monitor technician. No one is constantly looking at the monitors and the telemetry alarms cannot be heard if they alarm because the patients and staff are behind locked doors from the central monitor station. Most of the staff are not comfortable taking care of the telemetry patients because they get about one patient per month."

4) An interview was conducted with EMP6 on August 9, 2010, at 10:20 AM. EMP6 stated that they do not "usually take care of a telemetry patient." EMP6 was asked by the surveyor to read a rhythm strip of normal sinus rhythm. EMP6 could not identify the rhythm. EMP6 was unable to "associate" the telemetry box with the monitor.

5) An interview was conducted with EMP8 on August 9, 2010, at 10:20 AM. EMP8 stated that they admit about one telemetry patient per month. EMP8 stated that a nurse may be assigned to one telemetry patient in a six month period. EMP8 also stated that it is very difficult to keep their telemetry skills if they are not using them. EMP8 also stated that the hallway monitor does not alarm. The alarm occurs behind locked closed doors because the post delivery patients are in rooms with their babies and the doors to the area must be locked." EMP8 was not able to "associate" the telemetry box with the monitor.

6) An interview was conducted with EMP9 on August 9, 2010, at 10:20 AM. EMP9 stated, "The staff does not feel comfortable taking care of telemetry patients because they only get a couple telemetry monitored patients per year. The nurses cannot hear the telemetry alarms when they are charting or taking care of their assigned patients and that makes the nurses feel very uneasy."
7) A review on August 9, 2010, of the Women's Health Educational Council meetings for June, July, and August failed to contain any telemetry issues in the minutes.

8) A review of employee personnel files revealed that EMP5, EMP6, EMP8 and EMP9 passed the Cardiac Rhythm Knowledge Assessment test with 80% or above.

Based on a review of facility policy, facility documents, medical records (MR) and interview with staff (EMP), it was determined the facility failed to provide nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available, and failed to recognize and to notify a physician of a significant change in condition for one of ten MR reviewed (MR2).

Findings include:

A review conducted on August 9, 2010, of facility policy "Physician Notification of Changes in Patient's Status" last reviewed December 2010 revealed "1. Nursing staff shall notify a physician of any significant change in patient status."

1) A review on August 9, 2010, of MR2 revealed that the patient had a surgical procedure. Post operatively the patient experienced two syncopal episodes with a drop in blood pressure. MR2 failed to contain documentation that the physician was notified of the significant changes in the vital signs or the syncopal episodes. A physician note at 6:40 AM revealed, "concern for intraabdominal bleeding ..."

2) An interview conducted on August 9, 2010, at 2:30 PM, with EMP2 confirmed that the patient had two syncopal episodes with a drop in blood pressure and the nurse did not notify the physician of the change in the patient's condition.

3) An interview was conducted with EMP3 on August 9, 2010, at 10:20 AM. EMP3 confirmed that only the monitor at the rotunda nursing station will alarm. EMP3 stated "The secretary notifies the nurse via overhead paging."

4) An interview was conducted with EMP10, August 9, 2010, at 10:00 AM. EMP10 stated "All employees take annual competencies. The competencies vary from year to year. The unit decides on what to make a competency based on input from the monthly educational council, which is a committee of staff nurses, facilitated by the nurse educator. They meet monthly and build the competencies based on input from the staff. We don't do every skill every year, there are just too many. We target on a cycle basis by what is brought up by education council. EKG strip identification is done every year. The staff are required to pass with an 80%. If the RN does not score at least 80%, they are required to attend the class "Cardiac Rhythms: Interpretation and Treatment. ... We were not aware of any staff concerns regarding telemetry monitoring on the Women's Health unit."

5) An interview was conducted with EMP5 on August 9, 2010, at 10:20 AM. EMP5 stated that "the Women's Health unit does not have a central monitor technician. No one is constantly looking at the monitors and the telemetry alarms cannot be heard if they alarm because the patients and staff are behind locked doors from the central monitor station. Most of the staff are not comfortable taking care of the telemetry patients because they get about one patient per month."

6) An interview was conducted with EMP6 on August 9, 2010, at 10:20 AM. EMP6 stated that they do not "usually take care of a telemetry patient." EMP6 was asked by the surveyor to read a rhythm strip of normal sinus rhythm. EMP6 could not identify the rhythm. EMP6 was unable to "associate" the telemetry box with the monitor.

7) An interview was conducted with EMP8 on August 9, 2010, at 10:20 AM. EMP8 stated that they "admit about one telemetry patient per month. The hallway monitor does not alarm. The alarm occurs behind locked closed doors because the post delivery patients are in rooms with their babies and the doors to the area must be locked." EMP8 was not able to "associate" the telemetry box with the monitor.

8) An interview was conducted with EMP9 on August 9, 2010, at 10:20 AM. EMP9 stated that "the staff do not feel comfortable taking care of telemetry patients because they only get a couple telemetry monitored patients per year. The nurses cannot hear the telemetry alarms when they are charting or taking care of their assigned patients and that makes the nurses feel very "uneasy."
9) A review on August 9, 2010, of the Women's Health Educational Council meetings for June, July, and August failed to contain any telemetry issues in the minutes.

10) A review of employee personnel files revealed that EMP5, EMP6, EMP8 and EMP9 passed the Cardiac Rhythm Knowledge Assessment test with 80% or above.