HospitalInspections.org

Based on a review of facility documents and medical record (MR11), and staff interviews (EMP), it was determined that facility staff failed to maintain a safe environment for the patient's condition.

Findings include:

Review of nursing policy and procedure titled "Cardiac Monitoring" part IV. Procedure: B...."The US/MT will monitor each patient's cardiac rhythm at the central monitoring station. They will respond immediately to alarms....." This policy was not followed as evidenced by a review of MR11 on November 10, 2019 revealing a flow sheet dated October 17, 2019 at 1:26 p.m. showing the patient's O2 sat reading at 77% with tachycardia at 109 beats per minute (bpm). The flow sheet continues for 23 minutes and reflects decreasing trend in O2 sat and heart rate. 1:45 p.m. flow sheets reflects a final O2 reading of 31% with a heart rate of 75bpm, the following 3 minutes show no O2 reading with a final heart rate of 28bpm. No evidence exists that staff informed nursing staff or medical staff of alarming vital signs.

Review of Standard Work Instructions: Telemetry Alarm Escalation Standard Work, last updated 10/21/2019 states...."3 If unable to reach the primary RN after 1 attempt, the Monitor Tech will call the unit charge nurse to check on the patient. 4 Unit charge nurse will check on the patient who is alarming and notify the monitor tech if any issues are noted. 5 Charge nurse communicates with patient's bedside nurse regarding patient status. No evidence exists that personnel responded or intervened to the alarms of patient distress.

An interview with EMP1 on November 9, 2019 at 3:00 p.m. revealed the monitor tech was unable to respond immediately to alarming telemetry monitor due to lack of availability of the nurse. It was revealed a nurse aid was sent to the patient's room however, no information was given to the care providers in the room about alarming O2 saturation or heart rates and, no visible monitors were located in the patient's room

Interview with EMP2 on November 10, 2019 at 10:00 a.m. EMP2 confirmed that monitor techs and aids have the ability to document in the medical record however, the medical record contained no notes about notification of the patient's condition to medical personnel.

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Based on review of electronic medical record (EMR) and interview with employee (EMP) it was determined the facility failed to ensure that pertinent information related to the patient's decreasing O2 saturation and cardiac function was documented for one of one medical record reviewed (MR11).

Findings include:

Review of MR11 revealed a flow sheet dated October 17, 2019 at 1:26 p.m. showing the patient's O2 sat reading at 77% with tachycardia at 109 beats per minute (bpm). The flow sheet continues for 23 minutes and reflects decreasing trend in O2 sat and heart rate. 1:45 p.m. flow sheets reflects a final O2 reading of 31% with a heart rate of 75bpm, the following 3 minutes show no O2 reading with a final heart rate of 28bpm. The medical record contained no documentation of any assessment of alarming vital signs. The EMR contained no documentation that medical staff recognized or acted upon the decline in the patient's condition immediately nor patient response.

An interview with EMP2 on November 10, 2019 at 10:00 a.m. confirmed monitor techs and aids can chart in the EMR and no documentation of any notification of the patient's declining medical condition was present.

An interview with EMP3 on November 12, 2019 at 2:00 p.m. confirmed no additional information was available and the EMR contained no evidence of any intervention or response of the aforementioned events.

Based on review of medical record (MR) and interview with employee (EMP) it was determined the facility failed to ensure that pertinent information related to the patient's decreasing O2 saturation and cardiac function was documented for one of one medical record reviewed (MR11).

Findings include:

Review of MR11 revealed a flow sheet dated October 17, 2019 at 1:26 p.m. showing the patient's O2 sat reading at 77% with tachycardia at 109 beats per minute (bpm). The flow sheet continues for 23 minutes and reflects decreasing trend in O2 sat and heart rate. 1:45 p.m. flow sheets reflects a final O2 reading of 31% with a heart rate of 75bpm, the following 3 minutes show no O2 reading with a final heart rate of 28bpm. No nursing or staff documentation of the aforementioned monitoring, assessments, or intervention was seen in the patient's medical record.

An interview with EMP1 on November 9, 2019 at 3:00 p.m. revealed the monitor tech was unable to respond immediately to alarming telemetry monitor due to lack of availability of the nurse. It was revealed a nurse aid was sent to the patient's room however, no information was given to the care providers in the room about alarming O2 saturation or heart rates and, no visible monitors were located in the patient's room. No evidence of monitoring of the patient's declining medical condition was documented in the electronic medical record (EMR).

An interview with EMP3 on November 12, 2019 at 2:00 p.m. EMP3 confirmed this was the entire medical record and no additional information was available. No evidence of monitoring of the aforementioned events was present in the electronic medical record (EMR)