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Based on observation, interview, record review and policy review, the hospital failed to ensure:
- There was continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring and assessment of patients at all times per hospital policy. (A-397)
- All licensed nurses were trained in telemetry monitoring per the hospital's policy. (A-397)
- Cardiac rhythm strips were printed and analyzed, to include measurements of the QRS (a measurement on an EKG tracing that measures the electrical impulse as it travels through the ventricles of the heart), dates, and signature in the medical record per the hospital's policy. (A-397)
- Untrained staff (unit technician) were not utilized for monitoring telemetry patients. (A-397)

These failures had the potential to place all patients at risk for their health and safety.

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census was 15.

Please see the 2567 for additional information.

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44536


Based on observation, interview, record review, and policy review, the hospital failed to follow the standard of practice and provide continuous and competent cardiac monitoring by a trained nurse for all patients on cardiac telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) and failed to document telemetry patient's rhythm strips in the medical record per hospital policy. This failure had the ability to affect all patients on cardiac telemetry, creating the potential for abnormal changes and negative outcomes if the heart rhythm changes were to go unnoticed. The hospital census was 15.

Findings included:

Review of the hospital's policy titled, "Telemetry Monitoring Station," dated 09/2020, showed that:
-The Intensive Care Unit (ICU; a unit where critically ill patients are cared for) Registered Nurse (RN) monitored and responded to central monitor alarms.
- A rhythm strip was printed and documented within the patient's medical record at least every eight hours. The strip included the patient's heart rate, QRS (a measurement on an EKG tracing that measures the electrical impulse as it travels through the ventricles of the heart) width, interpretation of the rhythm with identified abnormalities, and a signature of the nurse who interpreted.
- When a patient on telemetry monitoring was located outside of the ICU, the ICU nurse alerted the patient's primary nurse of any dysrhythmias (abnormal heart beat) and printed a rhythm strip.

Review of the hospital's policy titled, "Scope of Services," dated 09/2020, showed that telemetry monitoring was for the continuous assessment of cardiac conditions, blood pressure and oxygen saturation monitoring. Licensed nursing staff had certification in identifying irregular heartbeats and rhythms for telemetry monitoring.

Review of the hospital's policy titled, "Clinical Alarms," last revised 01/2021, showed that clinical personnel would be educated in the correct equipment use to assure they understood the alarm logic, terminology and controls for each device. Staff had the responsibility to appropriately respond to activated alarms.

Review of the telemetry training of licensed nursing staff assigned to the Medical/Surgical (Med/Surg) units and ICU/PCU units for 07/09/23 through 07/15/23 showed that Staff ZZ, LPN, and Staff AAA, LPN, had not received recent training on dysrhythmias through either in-house training or the prerequisite to obtaining Advanced Cardiac Life Support (ACLS) certification.

Observation on 07/10/23 at 2:20 PM, in the Emergency Department (ED), showed four patients on telemetry monitoring. The telemetry alarm sounded, and no staff were present at the nurse's station to address the alarm. Approximately 20 seconds after the alarm sounded Staff G, RN, walked over from a trauma bay, looked at the telemetry monitor, silenced the alarm and went back to the patient she had been attending to. The RN did not go check on the patient in question and did not inform any other nurse on duty that an alarm had sounded.

Observation on 7/10/23 at 2:35 PM, showed the ICU and the Progressive Care Unit (PCU, a telemetry monitored unit that provides care for adult patients requiring continuous cardiac monitoring) were a combined unit within the hospital and had five patients assigned to telemetry monitoring. The unit was staffed with two RNs and one Licensed Practical Nurse (LPN), who was on her first day of employment and orienting to the unit.

Observation on 7/10/23 at 2:35 PM, in the ICU/PCU, showed the telemetry monitor alarmed for an elevated heart rate (the number of times the heart beats within a certain time period, usually a minute) and atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) for Patient #10. Staff O, LPN, was on her first day of employment and orientation to the unit and was located at the nursing station, but not at the telemetry monitor. Two other RNs (Staff N and P) were located away from the nursing station and not in direct view of the central telemetry monitor.

Observation on 07/11/23 at 9:18 AM, in the ICU/PCU, showed Patients #10, #14 and #51, on telemetry monitoring. When the telemetry alarm sounded, Staff S, Chief Nursing Officer (CNO), looked at the telemetry monitor, pushed a button, and the alarm stopped, no other staff were at the nursing station near the telemetry monitor. The CNO did not go check on the patient and did not inform the nurse on duty that an alarm had sounded.

Review of Patient #10's medical record showed she was a 96-year-old female who was admitted on 07/10/23 for atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), rapid ventricular response (RVR, a result of A-fib with a rapid and irregular pumping of blood through the heart) and elevated troponin level (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01) of 0.6193. The record included orders for cardiac monitoring and continuous pulse oximetry. Printed rhythm strips included in the medical record were dated 7/10/23 at 1:35 PM and 8:18 PM; 07/11/23 at 6:38 AM and 7:20 PM; and 7/12/23 at 9:04 AM. The printed rhythm strip from 7/11/23 at 7:20 PM did not identify an interpreted rhythm. The printed rhythm strip from 07/12/23 at 9:04 AM did not include identification of the nurse who interpreted the rhythm or any measurement of QRS or other rhythm components. Other than documentation on these printed rhythms strips and the strip dated 07/10/23 at 1:35 PM, all other printed rhythm strips showed no documentation of measurements, rhythm interpretation or initials of staff who reviewed the printed the rhythm strip. Rhythm strips were not included in the patient's medical record every eight hours.

Review of Patient #14's medical record showed she was a 76-year-old female who was admitted on 07/10/23 for an abscess of the left jaw and a history of cardiac dysrhythmia (abnormal heart beat) and diastolic heart failure (a condition where the lower left chamber of the heart is not able to fill properly with blood during the resting phase, reducing the amount of blood pumped out to the body). Printed rhythm strips included in the medical record were dated 7/10/23 (no time noted); 07/11/23 at 6:37 AM and 11:23 AM. The printed rhythm strip from 07/10/23 showed no documentation of rhythm measurements. The printed rhythm strip from 07/11/23 at 6:37 AM showed no documentation of the rhythm rate or the initials of the staff who reviewed the rhythm strip.

Review of Patient #51's medical record showed she was a 88-year-old female who presented to the ED and was admitted on 07/10/23 with a diagnosis of acute exacerbation of congestive heart failure (CHF; a weakness of the heart that causes it to not pump blood like it should, leading up to a buildup of fluid in the lungs and surround body tissues). The record included orders for constant cardiac monitoring with telemetry. Printed rhythm strips included in the medical record were dated 7/10/23 at 5:01 PM and 5:20 PM, and 07/11/23 at 6:37 AM. The printed rhythm strip from 07/10/23 at 5:01 PM showed no documentation of measurements, rhythm interpretation or initials of staff who reviewed the printed the rhythm strip. The printed rhythm strip from 07/10/23 at 5:20 showed no documentation of the staff who reviewed the printed rhythm strip.

During an interview on 07/10/23 at 2:55 PM, Staff P, RN, stated that the monitor that displayed telemetry patients' heart rhythms and vital signs (body temperature, blood pressure, heart rate, and breathing rate) were monitored by the ICU nurses. No staff were assigned to specifically watch the monitor activity. If a patient had a telemetry event, staff at the nursing desk responded. If nurses were in patient rooms, an audible alarm from the nursing desk was heard from patient rooms and nursing staff responded to the audible alarm. Typical staffing for the unit was two RNs and one Certified Nursing Assistant (CNA) or one RN and one LPN.

During an interview on 07/11/23 at 9:15 AM, Staff CC, ED Technician, stated that the telemetry monitor only alarmed at the nurse's station, but that staff would always know if it alarmed as there was always someone at the desk watching the monitor. When she wasn't doing other assigned duties she would watch the monitors and alert nurse's when it alarmed. She was unsure what the hospital's policy stated about silencing the alarm, or what to do if the ED was busy and all staff had stepped away from the nurse's station.

During an interview on 07/13/23 at 8:55 AM, Staff YY, RN, stated that there was not a dedicated staff member assigned to observe telemetry patients on the monitor located in the Med/Surg unit nursing station. The nurses in the ICU also monitored telemetry patients located on the Med/Surg unit on their telemetry monitors and notified Med/Surg staff if an abnormality was identified with a patient. The telemetry monitors located on Med/Surg and the ICU had an audible alarm that alerted nursing staff of a concerning cardiac rhythm or vital signs outside of programmed parameters. She stated that LPNs were sometimes assigned care of telemetry patients on the Med/Surg Unit.

During interviews on 07/11/23 at 9:30 AM and 12:17 PM, Staff DD, Director of Critical Care, stated every patient in the ICU was on telemetry. She expected staff to check on the patient if they silenced the telemetry alarm. There was no designated staff member to watch the telemetry monitors on any unit and that it was the nurse's responsibility to watch the monitors and address alarms. Only nurses, not technicians, were trained on the telemetry monitors. It was the nurse's responsibility to print telemetry strips for the medical record.

During an interview on 07/13/23 at 10:35 AM, Staff S, CNO, stated nursing staff were directed in the hospital's policy to print rhythm strips on telemetry patients at least every eight hours and include them in the patient's medical record. She expected that licensed staff assigned care of a telemetry patient had received training in arrhythmia identification and she was not aware that there were LPNs who had not received arrhythmia training.

During an interview on 07/13/23 at 10:25 AM, Staff BBB, Physician, stated if telemetry patients experienced certain heart rhythms, he expected the nurse to identify the rhythm and a physician notified immediately for potential orders for treatment. He stated that ventricular tachycardia (V-tach, a type of abnormal heart rhythm, or arrhythmia) required an immediate response. V-tach could be significantly relevant if the patient also experienced adverse symptoms. If nurses were not at the nursing station and in the negative pressure isolation room, they might not hear an audible alarm at the telemetry monitor.

Based on observation, interview, record review and policy review, the hospital failed to follow their policies and ensure all medications were locked in a secure location and all medications were labeled with patient information. (A-502)

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.25 Condition of Participation (CoP): Pharmaceutical Services.

The hospital census was 15.

Based on observation, interview, record review and policy review, the hospital failed to ensure that patient medications were properly secured, labeled with a patient identifier and date opened or use by date in two patient care areas (Intensive Care Unit [ICU, a unit where critically ill patients are cared for] and Surgery) of six patient care areas observed. These failed practices had the potential to cause harm for all patients receiving medications in the hospital. The hospital census was 15.

Findings included:

Review of the hospital's policy titled "Department of Pharmacy. Inventory Control-Medication Security," revised 12/2015, showed that:
- All staff who had access to medications were involved in medication security.
- Medications were stored in a locked area or stored so that unauthorized individuals did not have access to them.
- Medications for return were placed in a secured medication bin in the medication room, medication cart or locked medication drawer.
- Discontinued medications were marked as "Discontinued" and returned to pharmacy as soon as possible.
- Medications delivered to patient care areas and not immediately administered to a patient were placed in a locked medication room or medication cart.
- Medications for surgical cases were kept in a secured location, locked cart or under constant observation.

Review of Patient #23's medical record showed she was a 38-year-old female who was admitted to the ICU, on 07/06/23 and transferred to the medical-surgical (med-surg) unit on 07/07/23. The physician orders included Haloperidol (Haldol, a medication used to treat mental disorders by decreasing excitement of the brain) 4 milligrams (mg) four tablets by mouth twice a day.

Review of Patient #24's medical record showed he was a 54-year-old male, who presented to the Emergency Department (ED) 06/15/23 and was admitted for an allergic reaction. The patient had a history of diabetes. The patient was admitted to the ICU on 06/15/23, and discharged from the hospital on 06/16/23. Physician orders included Lispro (Lantus, long acting blood-glucose-lowering medication) 40 units twice a day.

Review of Patient #25's medical record showed she was a 40-year-old female, who presented to the ED on 06/29/23 for suicidal ideations (thoughts of killing herself) and homicidal ideations (thoughts of killing others). The patient was admitted to the hospital on 06/29/23, and discharged from the hospital on 06/30/23. Physician orders included Desvenlafaxine (Pristiq, medication used to treat depression) 100 mg, two tablets by mouth twice a day.

Observation on 07/11/23 at 12:17 PM, in the ICU, showed 24-one mg tablets of Haldol labeled for Patient #23; one Lispro pen, labeled for Patient #24 and two-50 mg tablets of Desvenlafaxine, labeled for Patient #25 placed in a clear, unsecure container, on the counter beside the medication dispensing system. The observation of unsecured medications occurred more than four days after identified patients were transferred to other units within the hospital or discharged from the hospital.

Observation on 07/11/23 at 12:55 PM, showed an unlocked anesthesia (the use of medicines to prevent pain during surgery and other procedures) supply cart in the endoscopy (a procedure to examine the interior of a hollow organ or cavity of the body with a lighted tube with a camera) suite of the hospital's Surgery Department. The top drawer of the unlocked cart contained a bottle of succinylcholine (medication used by trained medical providers for short-acting muscle paralysis [unable to make voluntary muscle movement]).

During an interview on 07/11/23 at 12:37 PM, Staff DD, Director of Critical Care, stated medications should not be left on the counter, they should be in a locked drawer. All medication was to be labeled with a patient name and dated. All medications that wouldn't fit in the medication dispensing system were to go into locked drawers. The drawers were supposed to have a code to lock and unlock them, the lock did not work.

During an interview on 07/13/23 at 8:50 AM, Staff WW, Pharmacist, stated when a patient had medications that would not fit in the "medication dispensing system", the medications were to go into a drawer, in the slot with the patients room number on it. The drawer was to be locked, however the lock was broken. When medications were returned to the pharmacy, the medication was put in a "Return to Pharmacy bin" and pharmacy would pick them up. Pharmacy made multiple rounds to the units daily to deliver or pick up medication.

During an interview on 07/13/23 at 8:40 AM, Staff P, RN, stated all medications that wouldn't fit in the "medication dispensing system" were to go into the locked drawers. The drawers did not lock. The drawers were supposed to have a code to lock and unlock them but, the lock did not work. When a patient was discharged, the medications left were placed in a bin on the counter. The bin was not locked. Pharmacy would make their rounds and pick up the medication out of the bin.

During an interview on 07/13/23 at 8:57 AM, Staff XX, Pharmacy Technician, stated when a patient's medications were taken to the ICU, and the medications would not fit in the "medication dispensing system", the medications were put in a drawer in the slot for the patient's room. The drawer did not lock. All medications should be behind a lock. Medications, that were to be returned to the pharmacy, were placed in a clear plastic "Return to Pharmacy" bin. The bin was not locked and it sat on the counter beside the "medication dispensing system". Pharmacy made multiple rounds a day, Monday through Saturday, to all the units to deliver and pick up medications. The pharmacy was closed on Sunday. If a patient was discharged on Sunday, and medications did not go with the patient, the medications would sit on the counter, beside the "medication dispensing system", and pharmacy would pick them up on Monday.

During an interview on 07/13/23 at 10:40 AM, Staff S, Chief Nursing Officer, stated that she expected nursing staff followed the hospital's pharmacy policies and secured all medications. All hospital staff had resources available to them to prevent unsecured medications. Medications should not have been left on the counter of the nursing stations and nursing staff should have locked up any medications awaiting return to the pharmacy. She expected that every opened medication was labeled with a patient identifier and a use by date, as directed in pharmacy policies.

During an interview on 07/11/23 at 12:56 PM, Staff D, RN, Director of Surgical Services, stated that the anesthesia supply carts were to be locked when not actively utilized by anesthesia personnel for patient care.

Review of the hospital's policy titled "Department of Pharmacy. Medication Distribution - Medication Orders," revised 08/2016, showed that if the medication was not in an automated dispensing cabinet, the medication will contain a label containing the patient's name, room assignment and prescriber's name. The medication should be placed in a zip-lock bag accompanied by the patient label or affixed to a manufacturer's container.

Observation on 07/11/23 at 12:17 PM, in the ICU, showed an opened vial of olanzapine xydis (zyprexa, antipsychotic medication that affects chemicals in the brain) with no patient label placed in a clear, unsecure container, on the counter beside the medication dispensing system.

Observation on 7/10/23 at 3:55 PM, showed a bottle of insulin (medication that regulates the amount of sugar in the blood) with the protective cap removed on the ICU nursing station. The bottle did not have a patient identification label or annotation of the date opened.

During an interview on 07/10/23 at 3:59 PM, Staff N, Registered Nurse (RN), stated she did not know who placed the unlabeled, opened bottle of insulin on the ICU nursing station counter. She thought the bottle was possibly transported to the ICU with a patient recently admitted from the Emergency Department.

During an interview on 07/13/23 at 10:40 AM, Staff S, RN, Chief Nursing Officer, stated she expected that every opened medication was labeled with a patient identifier and a use by date, as directed in pharmacy policies.



44536

Based on observation, interview, and policy review, the hospital failed to maintain a safe environment for patients' food preparation and serving. This applied to all patients. The hospital census was 15.

Findings included:

Review of the hospital document titled "Hair Restraints. Sanitation and infection control", dated 01/2023, showed team members will wear hair restraints regardless of the length of hair or beard at all times in the kitchen. Food team members shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single use articles. Anyone entering the kitchen, must wear the appropriate hair restraints.

Review of the hospital document titled "Disposable gloves. Sanitation and infection control", dated 01/2023, showed hands must be washed before putting on and after removing disposable gloves when working in the kitchen. Disposable gloves must be changed and hands washed when the gloves are dirty or ripped and when moving from one task to another.

Observation, of the kitchen area, on 07/12/23 between 10:15 AM and 11:38 AM, showed the following:
-Staff TT, Cook, and Staff UU, Cook, both prepared the patients' noon meal and neither had the back of their hair covered with a hair net or hair covering,
-Staff TT, Cook, and Staff UU, Cook, both had beards and neither had their beard covered with a hair net or hair covering.
-Staff TT, Cook, had disposable gloves on, picked up a steam table pan, scratched the side of his nose twice, and continued to hold the steam table pan (with his fingers inside the pan) and put food in it. He did not change gloves or wash his hands after he touched his nose.

During an interview on 07/13/23 at 8:45 AM, Staff TT, Cook, stated that all hair was to be covered while in the kitchen preparing food, including beards. If staff touched their face during the preparation of food they were to wash their hands and change their gloves prior to continuing to prepare food.

During an interview on 07/12/23 at 3:10 PM, Staff VV, Interim Dietary Manager, stated all hair and beards should be covered at all times while in the kitchen. Hands should be washed and gloves changed after touching your face.