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Based on interview and record review, the facility failed to ensure:

1. Data was being collected and analyzed after changing the dialysis contract due to previous delays that had been identified, resulting in the potential for delayed treatments to go unidentified and uncorrected; and,

2. Data was being collected and analyzed after developing and implementing a protocol that allowed registered nurses (RNs) to override physicians and take patients off of telemetry (cardiac monitoring) to be transported throughout the facility based on written criteria. There was no data being collected to determine the consistency and appropriateness in use of the protocol. This failed practice resulted in the potential for unsafe transporting practices to go unnoticed and uncorrected.


Findings:

1. An interview was conducted with the Director of the Call Center for dialysis (DCC) on March 15, 2016, at 12:34 p.m. The DCC stated the dialysis agency prioritized stat orders first. He stated if there is a delay in treatment, the nurses generated a form to report the delay. He stated the reports from the nurses were generated when they "thought" there was a delay, and the delay would be investigated. The DCC stated the only delayed treatment he was aware of were the ones reported by the nurses. He stated there was no system in place to collect data on the timeliness of dialysis treatment, and he did not know how the contracted services was performing.

An interview was conducted with the Accreditation and Regulatory Manager (ARM) on March 15, 2016, at 1:45 p.m. The ARM stated a stat dialysis order had to be started within two hours from the time it was received by the contracted agency and routine dialysis order had to be started within six hours from the time it was received by the contracted agency.

2. The facility policy titled, "Protocol, Transport of Monitored Patients," with an approval date of February 8, 2016, was reviewed.

According to the protocol, patients with a physician's order for telemetry monitoring could be transported off of their unit, without an RN and without telemetry monitoring in place, if they were not experiencing signs and symptoms that included the following (to be assessed and determined by the nurse):

- Active chest pain;

- Positive cardiac markers (lab values indicating damage to the heart muscle). There was no indication of which cardiac markers or reference ranges would be used to determine whether the markers were positive or not (CPK, CK-MB, Myoglobin, Troponin, a combination, or all of these);

-ST elevation or depression (an elevated [raised] or depressed [lowered] section of the ST segment indicating lack of bloodflow and oxygen to the heart seen on an electrocardiogram [EKG]);

- Arrhythmia changes; and,

-Acute EKG changes.

The policy indicated the RN would be the one to determine if the patient was experiencing any of the above signs/symptoms, and decide whether it was safe for the patient to be transported without a nurse and without telemetry monitoring.

During a concurrent interview with the managers and the nursing director of the telemetry units on March 15, 2016, at 10:40 a.m., the managers stated there was no data being collected to determine whether the nurses were making appropriate decisions in determining which patients could be taken off of telemetry and transported without cardiac monitoring and a nurse. They stated there was no data being collected to track the appropriateness or consistency in implementation of the protocol.

Based on observation, interview, and record review, the Chief Nursing Officer (CNO) failed to ensure registered nurses (RNs) were providing safe and effective care to patients when:

1. The CNO authored and implemented a policy titled, "Protocol:Transport of Monitored Patients," throughout the telemetry (heart monitoring) units. The policy included criteria that enabled the nurses to override a physician's order for telemetry monitoring, and allow telemetry patients to be transported throughout the facility without a nurse and without cardiac monitoring;

2. The RNs responsible for overriding physician's orders and transferring telemetry patients without a nurse or a cardiac monitor were trained and competent in the knowledge and skills required to carry out the protocol; and,

3. No data was collected or analyzed after the new policy titled, "Protocol: Transport of Monitored Patients," was implemented, to determine compliance with the protocol, consistency in it's implementation, and safety of the patients who were selected to be transported without a nurse and a cardiac monitor (A283).

This failed practice resulted in the potential for unrecognized and untreated arrythmias, cardiac arrest, and death.

Findings:

1. According to the California Nurse Practice Act, Business and Professions Code, Chapter 6, Article 2, Section 2725, the practice of nursing is defined as:

Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures; and,

According to Section 2726, the Nursing Practice Act confers no authority upon nurses to practice medicine.

The facility policy titled, "Protocol: Transport of Monitored Patients," was reviewed. According to the document, the policy was authored/revised by the CNO, and approved by the governing board on February 8, 2016. The policy indicated patients with orders written by the physician to have cardiac monitoring while in the hospital could be taken off of telemetry (cardiac monitor), and be transported throughout the facility for tests/procedures without the telemetry monitoring and without a nurse, if they met certain criteria as determined by the nurse.

The policy included the following criteria:

-Active chest pain;

-Positive cardiac markers (not specifically defined) (lab values indicating damage to the heart muscle). There was no indication of which cardiac markers or reference ranges would be used to determine whether the markers were positive or not (CPK, CK-MB, Myoglobin, Troponin, a combination, or all of these);

-ST elevation or depression (an elevated [raised] or depressed [lowered] section of the ST segment indicating lack of bloodflow and oxygen to the heart seen on an electrocardiogram [EKG]);

-Arrhythmia changes (not specifically defined); and,

-Acute EKG changes (not specifically defined).

2. During a tour of the telemetry units on March 14, 2015, between 10:30 a.m., and 4:30 p.m., each unit had a clipboard hanging in or near the nurse's station with forms titled, "Radiology Patient Log," for documentation of the patients who were going, or had gone, to the radiology department for testing that day.

The logs included Patients 10, 11, 12, 14, 17, 23, 30, 31, and 32.

a. The record for patient 10 was reviewed. Patient 10, a 79 year old male, was admitted to the facility on March 12, 2016, with diagnoses that included cerebrovascular disease (stroke).

The admitting orders, written by the physician on March 12, 2016, at 4 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 1, indicated on March 14, 2016, at 3:45 p.m., Patient 10 was, "Taken off the unit at this time by transporter to nuclear medicine for kidney ultrasound. Patient is off telemetry monitor because patient is stable, he is sinus rhythm with first degree AVB (atrial ventricular block), has has no arrhymias, is also a DNR (do not resuscitate). Patient meets criteria for being off unit without nurse escort as per protocol."

During an interview with Registered Nurse (RN) 1 on March 14, 2016, at 4 p.m., RN 1 stated Patient 10 was transported without a nurse to nuclear medicine for a kidney ultrasound. She stated Patient 10 met the criteria for going off the unit without a nurse. According to RN 1, the patient was stable, in normal sinus rhythm with first degree block (an arrythmia), and his rhythm had not changed. The RN stated he was a DNR (Do Not Resuscitate).

The employee file for RN 1 was reviewed on March 15, 2016. There was no evidence in the file RN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

b. The record for Patient 11 was reviewed. Patient 11, a 57 year old male, was admitted to the facility on March 12, 2016, with diagnoses that included pancreatitis (inflammation of the pancreas).

The admitting orders, written by the physician on March 12, 2016, at 1:17 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 1, indicated on March 14, 2016, at 3:55 p.m., Patient 11 was, "Taken off unit to nuclear medicine by transporter for kidney biopsy, he is stable and is sinus rhythm on monitor. Patient has had no arrhythmia's and meets the criteria for going off unit without a nurse escort as per protocol."

During an interview with RN 1 on March 14, 2016, at 4:05 p.m., RN 1 stated Patient 11 was transported without a nurse because he was stable, and had no arrhythmia's. She stated he met the criteria according to policy.

The employee file for RN 1 was reviewed on March 15, 2016. There was no evidence in the file RN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

c. The record for Patient 12 was reviewed. Patient 12, a 37 year old female, was admitted to the facility on March 2, 2016, with diagnoses that included aneurysm (ballooning and weakened area in an artery).

The admitting orders, written by the physician on March 10, 2016, at 1:59 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 2, indicated on March 14, 2016, at 3:58 p.m., Patient 12 was, "Leaving floor in gurney with transporter, patient meets unit protocol to leave without nurse escort. patient is sinus rhythm, in no acute distress, and VSS (vital signs stable)."

During an interview with RN 2 on March 14, 2016, at 4:10 p.m., RN 2 stated Patient 12 was transported without a nurse because he was stable, and had no arrhythmia's. She stated he met the protocol according to policy.

The employee file for RN 2 was reviewed on March 15, 2016. There was no evidence in the file RN 2 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

d. The medical record for Patient 14 was reviewed. Patient 14 was admitted to the facility on March 12, 2016, with diagnoses of syncope (fainting) and a motor vehicle accident with a lumbar 1 (lower back) fracture. Physician order's dated March 12, 2016, at 10:10 p.m., by the emergency department physician and on March 13, 2016, at 1:52 p.m., by the admitting physician, indicated Patient 14 was to be admitted to telemetry (cardiac [heart] monitoring).

On March 14, 2016, at 8:50 a.m., Patient 14 left the unit, was removed from telemetry and direct nursing care to transfer to another department in the facility for a test. Patient 14 returned to the unit at 9:20 a.m.

On March 14, 2016, at 1:50 p.m., Registered Nurse 3 (RN 3) was interviewed. RN 3 was asked if she asked the physician if she could take Patient 14 off of telemetry to transport for a test. She stated, she did not ask the physician. She stated she had assessed the patient and followed the protocol. RN 3 referred to a protocol titled, "Transport of Monitored Patients" last revised and approved on February 8, 2016. She stated the patient's diagnosis is syncope and her assessment was based on, "three normal troponins (a lab value to help determine cardiac injury), labs were all within normal limits, patient had normal sinus rhythm (normal heart rhythm), sats. (saturations of oxygen) were 92-93% (normal range is usually 95 to 100%), physician was aware of that and no oxygen was ordered." Based on the protocol RN 3 stated Patient 14 could be taken off of telemetry to be transported and would not need to go with a registered nurse.

The employee file was reviewed for RN 3 on March 15, 2016. There was no evidence in the file that indicated RN 3 had been inserviced on the protocol, "Transport of Monitored Patients" or demonstrated competency in interpretation of electrocardiograms (EKG) for determining ST segment elevation/depression and EKG changes.

e. The medical record for Patient 17 was reviewed. Patient 17 was admitted to the facility on March 13, 2016, with a diagnosis of chest pain, rule out acute (new onset) coronary syndrome (the patient has symptoms associated with a clogged artery in the heart). Physician order's dated March 13, 2016, at 6:40 p.m., by the emergency department physician and on the same date at 10:41 p.m., by the admitting physician, indicated Patient 17 was to have telemetry monitoring.

A nursing note, dated March 14, 2016, at 7:30 a.m., indicated, "pt alert and oriented x4 (person, place, thing, and event or situation). vs (vital signs) wnl (within normal limits). affebrile. pt is noted ambulatory (able to walk). denies dizziness or light headedness. pt denies chest pain at this time. pt to nuclear med (medicine) for the 1st part of the stress test. denies shortness of breath. denies pain when she deep breath. per pt it's aching and it comes and goes per patient her chest pain is not getting worse. pt went to nuc (nuclear) med with a nurse."

The nursing notes indicated, Patient 17 left the unit and was removed from telemetry to transfer to another department in the facility for a test.

Prior to the patient being taken off telemetry monitoring at 7:30 a.m., there was no assessment documented regarding the cardiac markers, ST elevation/depression, arrhythmia changes, acute EKG changes, or oxygen needs as outlined in the "Transport of Monitored Patients" protocol. According to the documentation, Patient 17 was taken off of telemetry while she was having intermittent chest pain.

At 9:30 a.m., a nursing note indicated (after returning to the unit), "pt (patient) noted c/o (complaint of) of slight chest pain refused medication..." At 11 a.m., the notes indicated Patient 17 was taken off of telemetry monitoring again to leave the unit for a follow-up of the previous test. The patient returned at 12:27 p.m.

On March 14, 2016, at 1:40 p.m., RN 4 was interviewed. RN 4 stated she used the protocol to assess Patient 17 for the ability to take her off of telemetry during transport to another department and they have to be stable. RN 4 stated a nurse went with the patient because there was no transporter (a non-licensed person that transports patients to various areas of the facility) available. RN 4 was asked about the chest pain Patient 17 complained of at 9:30 a.m. RN 4 stated it was not cardiac in nature and the physician was not notified.

The employee file was reviewed for RN 4 on March 15, 2016. There was no evidence in the file that indicated RN 4 had been inserviced on the protocol, "Transport of Monitored Patients" or demonstrated competency in interpretation of electrocardiograms (EKG) for determining ST segment elevation/depression and EKG changes.

f. The medical record for Patient 23 was reviewed. Patient 23 was admitted to the facility on March 12, 2016, with diagnosis of pneumonia. Physician order's dated March 12, 2016, at 6 a.m., indicated Patient 23 was to have telemetry monitoring.

According to the nursing note dated March 14, 2016, at 3:19 p.m., "pt went off unit to Xray (radiology). was transported without RN as patient has been stable in SR (sinus rhythm) and not chest pain." The nursing assessment did not indicate cardiac markers were assessed prior to decision to remove telemetry monitoring at 12:20 p.m. to transport to x-ray department.

On March 14, 2016, at 3:30 p.m., RN 5 was interviewed. RN 5 stated, Patient 23, "could be transported without telemetry, because they (the patient) had been normal sinus rhythm for the past few days, stable and no chest pain."

RN 5's employee file was reviewed on March 15, 2016. There was no evidence in the file that indicated RN 5 had been inserviced on the protocol, "Transport of Monitored Patients" or demonstrated competency in interpretation of electrocardiograms (EKG) for determining ST segment elevation/depression and EKG changes.

g. The record for Patient 30 was reviewed. Patient 30, a 68 year old male, was admitted to the facility on March 11, 2016, with diagnoses that included a history of heart failure, placement of an automatic implantable cardioverter defibrillator (AICD - to automatically shock the heart if it goes into a fatal rhythm), and peripheral vascular disease (narrowing of the blood vessels).

Physician admitting orders, dated March 11, 2016, at 9:03 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes indicated on March 14, 2016, at 8 a.m. and at 12 noon, Patient 30 was in atrial fibrillation (an irregular heart rhythm). According to the record, at 1 p.m., Patient 30 went to the nuclear medicine department for a bone scan. The record did not indicate whether the patient was accompanied by a nurse with telemetry monitoring during the transport.

During an interview with CN 1 on March 14, 2016, at 1:45 p.m., CN 1 stated Patient 30 left the floor and went to the nuclear medicine department without a nurse and without telemetry monitoring. CN 1 stated she determined the patient was safe to go without a nurse and without telemetry monitoring based on the policy.

The employee file for CN 1 was reviewed on March 15, 2016. There was no evidence CN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKGs for determining ST segment and EKG changes;

h. The record for Patient 31 was reviewed. Patient 31, a 52 year old male, was admitted to the facility on March 7, 2016, with diagnoses that included pneumonia, neutropenia (low white blood cell count), and thrombocytopenia (low platelet count).

Physician admitting orders, dated March 7, 2016, at 9:50 p.m., indicated the patient was to be admitted to a telemetry unit with telemetry monitoring.

The nurse's notes, written by RN 10, indicated on March 14, 2016, at 8 a.m., Patient 31 was, "stable to be transported off the unit without a nurse, no active chest pain, no positive cardiac markers, no ST elevation/depression, no arrhythmia changes, no acute EKG changes...no high risk for rapid decompensation."

During an interview with RN 10 on March 14, 2016, at 1:50 p.m., the RN pulled the policy, "Protocol: Transport of Monitored Patients," from his clipboard. RN 10 stated he determined Patient 31 was stable to transport to the radiology department for an ultrasound based on the criteria listed in the policy/protocol.

RN 10 stated he considered cardiac markers to be a Troponin lab value of greater than 1.0 (normal reference range less than or equal to 0.4). RN 10 stated a change in arrhythmia for the purpose of the protocol meant (to him) if the patient had a change in their heart rhythm or arrhythmia since admission (unless they had a high heart rate - if the heart rate was greater than 130 [normal 60-100], he would not allow the patient to be transported unaccompanied and unmonitored). The RN stated he did not perform a 12 lead EKG to determine the presence or absence of ST elevation or depression, or acute EKG changes, but he could change leads on the telemetry monitor and check for those conditions if he needed to.

The employee file for RN 10 was reviewed on March 15, 2016. There was no evidence in the file RN 10 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKGs for determining ST segment and EKG changes.

i. The record for Patient 32 was reviewed on March 14, 2016. Patient 32, a 40 year old female, was admitted to the facility on March 12, 2016, with diagnoses that included congestive heart failure (CHF) and cardiomyopathy (enlarged heart).

Physician admitting orders, dated March 12, 2016, at 10:57 p.m., indicated the patient was to be admitted to the telemetry unit with cardiac monitoring.

The EKG completed in the emergency department (ED) indicated Patient 32 had a left bundle branch block (LBBB - a delay or obstruction in the electrical pattern of the heart, making it harder for the heart to pump blood effectively).

The nurse's notes, written by RN 11, indicated on March 14, 2016, at 9:22 a.m., Patient 32 was transported to the radiology department for an ultrasound guided thoracentesis (removing fluid from the chest cavity). According to the notes, the patient returned and was placed in a telemetry room at 10:54 a.m. (one hour and 22 minutes later). The record did not indicate the patient was accompanied by a nurse with telemetry monitoring during the transport.

During an interview with RN 11 on March 14, 2016, at 2:10 p.m., the RN stated the Patient went to the radiology department for the thoracentesis procedure without a nurse and without telemetry monitoring. RN 11 stated she based her decision to send the patient unaccompanied and unmonitored, on the policy titled, "Protocol:Transport of Monitored Patients." RN 11 stated Patient 32 had stable vital signs (not part of the protocol), no arrhythmias, and was not requiring high level oxygen. RN 11 stated she considered cardiac markers to be CPK, CK-MB, and Troponin, and if any of them were elevated, she would not send the patient without a nurse and a monitor. The RN stated she did not perform a 12 lead EKG to determine the presence or absence of ST elevation or depression, or acute EKG changes, but she could change leads on the telemetry monitor and check for those conditions if she needed to.

The employee file for RN 11 was reviewed on March 15, 2016. There was no evidence in the file RN 11 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKGs for determining ST segment and EKG changes.

j. On March 14, 2016, at 11 a.m., RN 6 was interviewed regarding her knowledge of the new protocol titled, "Transport of Monitored Patients." RN 6 stated the protocol directed the nurses to assess for certain criteria to determine whether the patient could be taken off telemetry and transported to a procedure without a nurse. RN 6 stated the criteria included, medication drips, condition stable, high flow oxygen, change in rhythm, and vital signs stable (She did not mention lab values or cardiac markers). RN 6 stated if these criteria were met, the nurse did not need to call the physician for an order to remove the telemetry. RN 6 further stated, the nurse could make the decision to take a patient off telemetry and transfer to another area in the hospital without a nurse.

The employee file for RN 6 was reviewed on March 15, 2016. There was no evidence in the file that indicated RN 6 had been inserviced on the protocol, "Transport of Monitored Patients" or demonstrated competency in interpretation of electrocardiograms (EKG) for determining ST segment elevation/depression and EKG changes.

During a concurrent interview with nurse managers and nursing directors on March 15, 2016, at 10:40 a.m., Manager 1 stated they were, "so short of nurses," they had to consider every patient on telemetry to see if they met the criteria according to the protocol, as it was difficult to find a nurse to transport every patient.

Staff interviews and record reviews, indicated telemetry patients were regularly being transported throughout the facility without a nurse and without cardiac monitoring, even though there was a physician's order for the patient to be on telemetry monitoring. Staff interviews revealed there was inconsistency in the way the nurses were interpreting and implementing the "Protocol, Transport of Monitiored Patients". There was no evidence of training or competency verification for nurses who were assigned to care for patients where the protocol was in effect.

Based on observation, interview, and record review, the facility failed to ensure:

1. Nursing staff assigned to care for nine sampled patients (Patients 10, 11, 12, 14, 17, 23, 30, 31, and 32) on the telemetry (heart monitoring) unit demonstrated competency in determining whether the patients met criteria to be transported without a nurse and a cardiac monitor, when a new protocol was developed without training the nursing staff and verifying they had the knowledge and skills necessary to implement it, and;

2. Verification of competency and ability to recognize abnormal rhythms for one registered nurse (RN 6) prior to assigning her to care for patients independently on the telemetry unit, when she completed a written examination on arrhythmia recognition, and the examination was not reviewed for accuracy and knowledge.

This failed practice resulted in the potential for the patients to have unrecognized and untreated arrhythmias (abnormal heart rhythm), which had the potential to result in cardiac arrest, and death.

Findings:

1. The facility policy titled, "Protocol, Transport of Monitored Patients," with an approval date of February 8, 2016, was reviewed.

According to the protocol, patients with a physician's order for telemetry monitoring could be transported off of their unit, without an RN and without telemetry monitoring in place, if they were not experiencing signs and symptoms that included the following (to be assessed and determined by the nurse):

- Active chest pain;

- Positive cardiac markers (lab values indicating damage to the heart muscle). There was no indication of which cardiac markers or reference ranges would be used to determine whether the markers were positive or not (CPK, CK-MB, Myoglobin, Troponin, a combination, or all of these);

-ST elevation or depression (an elevated [raised] or depressed [lowered] section of the ST segment indicating lack of bloodflow and oxygen to the heart seen on an electrocardiogram [EKG]);

- Arrhythmia changes; and,

-Acute EKG changes.

The policy indicated the RN would be the one to determine if the patient was experiencing any of the above signs/symptoms, and decide whether it was safe for the patient to be transported without a nurse and without telemetry monitoring.

During a tour of the telemetry units on March 14, 2015, between 10:30 a.m., and 4:30 p.m., each unit had a clipboard hanging in or near the nurse's station with forms titled, "Radiology Patient Log," for documentation of the patients who were going, or had gone, to the radiology department for testing that day.

The logs included Patients 10, 11, 12, 14, 17, 23, 30, 31, and 32.

During an interview with the second floor telemetry charge nurse (CN 1) on March 14, 2016, at 1:35 p.m., CN 1 stated Patients 30, 31, and 32, were transported from her floor earlier in the day without a nurse or a cardiac monitor. She stated a policy was in place that allowed the nurse's to determine whether a telemetry patient could be transported without a nurse and a monitor if they met certain criteria. CN 1 referred to the policy, "Protocol: Transport of Monitored Patients," and stated the criteria, as she understood it, included:

- No continuous intravenous (IV) drip medications to regulate the heart rhythm;

- No need for more than six liters per minute of oxygen;

- No elevated cardiac markers (defined by her as a troponin [laboratory test that measures damage to the heart] value of greater than 1.0 [normal troponin less than or equal to 0.04]); and,

- No change in arrhythmia since admission.

CN 1 stated the nurse should document in the medical record any time their the patient left the floor, and if there was or was not a nurse and/or a cardiac monitor in place during the transport.

a. The record for patient 10 was reviewed. Patient 10, a 79 year old male, was admitted to the facility on March 12, 2016, with diagnoses that included cerebrovascular disease (stroke).

Physician admitting orders dated on March 12, 2016, at 4 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 1, indicated on March 14, 2016, at 3:45 p.m., Patient 10 was, "Taken off the unit at this time by transporter to nuclear medicine for kidney ultrasound. Patient is off telemetry monitor because patient is stable, he is sinus rhythm with first degree AVB (atrial ventricular block), has has no arrhymias, is also a DNR (do not resuscitate). Patient meets criteria for being off unit without nurse escort as per protocol."

During an interview with Registered Nurse (RN) 1 on March 14, 2016, at 4 p.m., RN 1 stated Patient 10 was transported without a nurse to nuclear medicine for a kidney ultrasound. She stated Patient 10 met the criteria for going off the unit without a nurse. According to RN 1, the patient was stable, in normal sinus rhythm with first degree block (an arrythmia), and his rhythm had not changed. The RN stated he was a DNR (Do Not Resuscitate).

The employee file for RN 1 was reviewed on March 15, 2016. There was no evidence in the file RN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

b. The record for Patient 11 was reviewed. Patient 11, a 57 year old male, was admitted to the facility on March 12, 2016, with diagnoses that included pancreatitis (inflammation of the pancreas).

The admitting orders, written by the physician on March 12, 2016, at 1:17 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 1, indicated on March 14, 2016, at 3:55 p.m., Patient 11 was, "Taken off unit to nuclear medicine by transporter for kidney biopsy, he is stable and is sinus rhythm on monitor. Patient has had no arrhythmia's and meets the criteria for going off unit without a nurse escort as per protocol."

During an interview with RN 1 on March 14, 2016, at 4:05 p.m., RN 1 stated Patient 11 was transported without a nurse because he was stable, and had no arrhythmia's. She stated he met the criteria according to policy.

The employee file for RN 1 was reviewed on March 15, 2016. There was no evidence in the file RN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

c. The record for Patient 12 was reviewed. Patient 12, a 37 year old female, was admitted to the facility on March 2, 2016, with diagnoses that included aneurysm (ballooning and weakened area in an artery).

The admitting orders, written by the physician on March 10, 2016, at 1:59 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 2, indicated on March 14, 2016, at 3:58 p.m., Patient 12 was, "Leaving floor in gurney with transporter, patient meets unit protocol to leave without nurse escort. patient is sinus rhythm, in no acute distress, and VSS (vital signs stable)."

During an interview with RN 2 on March 14, 2016, at 4:10 p.m., RN 2 stated Patient 12 was transported without a nurse because he was stable, and had no arrhythmia's. She stated he met the protocol according to policy.

The employee file for RN 2 was reviewed on March 15, 2016. There was no evidence in the file RN 2 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

d. The medical record for Patient 14 was reviewed. Patient 14 was admitted to the facility on March 12, 2016, with diagnoses of syncope (fainting) and a motor vehicle accident with a lumbar 1 (lower back) fracture. Physician order's dated March 12, 2016, at 10:10 p.m., by the emergency department physician and on March 13, 2016, at 1:52 p.m., by the admitting physician, indicated Patient 14 was to be admitted to telemetry (cardiac [heart] monitoring).

On March 14, 2016, at 8:50 a.m., Patient 14 left the unit, was removed from telemetry and direct nursing care to transfer to another department in the facility for a test. Patient 14 returned to the unit at 9:20 a.m.

On March 14, 2016, at 1:50 p.m., Registered Nurse 3 (RN 3) was interviewed. RN 3 was asked if she asked the physician if she could take Patient 14 off of telemetry to transport for a test. She stated, she did not ask the physician. She stated she had assessed the patient and followed the protocol. RN 3 referred to a protocol titled, "Transport of Monitored Patients" last revised and approved on February 8, 2016. She stated the patient's diagnosis is syncope and her assessment was based on, "three normal troponins (a lab value to help determine cardiac injury), labs were all within normal limits, patient had normal sinus rhythm (normal heart rhythm), sats. (saturations of oxygen) were 92-93% (normal range is usually 95 to 100%), physician was aware of that and no oxygen was ordered." Based on the protocol RN 3 stated Patient 14 could be taken off of telemetry to be transported and would not need to go with a registered nurse.

The employee file was reviewed for RN 3 on March 15, 2016. There was no evidence in the file that indicated RN 3 had been inserviced on the protocol, "Transport of Monitored Patients" or demonstrated competency in interpretation of electrocardiograms (EKG) for determining ST segment elevation/depression and EKG changes.

e. The medical record for Patient 17 was reviewed. Patient 17 was admitted to the facility on March 13, 2016, with a diagnosis of chest pain, rule out acute (new onset) coronary syndrome (when a patient has symptoms associated with a clogged artery in the heart). Physician order's dated March 13, 2016, at 6:40 p.m., by the emergency department physician and on the same date at 10:41 p.m., by the admitting physician, indicated Patient 17 was to have telemetry monitoring.

A nursing note, dated March 14, 2016, at 7:30 a.m., indicated, "pt alert and oriented x4 (person, place, thing, and event or situation). vs (vital signs) wnl (within normal limits). affebrile. pt is noted ambulatory (able to walk). denies dizziness or light headedness. pt denies chest pain at this time. pt to nuclear med (medicine) for the 1st part of the stress test. denies shortness of breath. denies pain when she deep breath. per pt it's aching and it comes and goes per patient her chest pain is not getting worse. pt went to nuc (nuclear) med with a nurse."

On March 14, 2016, at 7:30 a.m., the nursing notes indicated, Patient 17 left the unit and was removed from telemetry to transfer to another department in the facility for a test.

Prior to the patient being taken off telemetry monitoring at 7:30 a.m., there was no assessment documented regarding the cardiac markers, ST elevation/depression, arrhythmia changes, acute EKG changes, or oxygen needs as outlined in the "Transport of Monitored Patients" protocol. According to the documentation, Patient 17 was taken off of telemetry while she was having intermittent chest pain.

At 9:30 a.m., a nursing note indicated (after returning to the unit), "pt (patient) noted c/o (complaint of) of slight chest pain refused medication..." At 11 a.m., after experiencing chest pain, Patient 17 was taken off of telemetry monitoring again to leave the unit for a follow-up of the previous test. The patient returned at 12:27 p.m.

On March 14, 2016, at 1:40 p.m., RN 4 was interviewed. RN 4 stated she used the protocol to assess Patient 17 for the ability to take her off of telemetry during transport to another department and they have to be stable. RN 4 stated a nurse went with the patient because there was no transporter (a non-licensed person that transports patients to various areas of the facility) available. RN 4 was asked about the chest pain Patient 17 complained of at 9:30 a.m. RN 4 stated it was not cardiac in nature and the physician was not notified.

The employee file for RN 4 was reviewed on March 15, 2016. There was no evidence in the file that indicated RN 4 had been inserviced on the protocol, "Transport of Monitored Patients" or demonstrated competency in interpretation of electrocardiograms (EKG) for determining ST segment elevation/depression and EKG changes.

f. The medical record for Patient 23 was reviewed. Patient 23 was admitted to the facility on March 12, 2016, with diagnosis of pneumonia. Physician order's dated March 12, 2016, at 6 a.m., indicated Patient 23 was to have telemetry monitoring.

According to the nursing note dated March 14, 2016, at 3:19 p.m., "pt went off unit to Xray (radiology). was transported without RN as patient has been stable in SR (sinus rhythm) and not chest pain."

The nursing note did not indicate cardiac markers were assessed prior to decision to remove telemetry monitoring at 12:20 p.m. to transport to x-ray department.

On March 14, 2016, at 3:30 p.m., RN 5 was interviewed. RN 5 stated, Patient 23, "could be transported without telemetry, because they (the patient) had been normal sinus rhythm for the past few days, stable and no chest pain."

The employee file for RN 5 was reviewed on March 15, 2016. There was no evidence in the file that indicated RN 5 had been inserviced on the protocol, "Transport of Monitored Patients" or demonstrated competency in interpretation of electrocardiograms (EKG) for determining ST segment elevation/depression and EKG changes.

g. The record for Patient 30 was reviewed. Patient 30, a 68 year old male, was admitted to the facility on March 11, 2016, with diagnoses that included a history of heart failure, placement of an automatic implantable cardioverter defibrillator (AICD - to automatically shock the heart if it goes into a fatal rhythm), and peripheral vascular disease (narrowing of the blood vessels).

Physician admitting orders, dated March 11, 2016, at 9:03 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes indicated on March 14, 2016, at 8 a.m. and at 12 noon, Patient 30 was in atrial fibrillation (an irregular heart rhythm). According to the record, at 1 p.m., Patient 30 went to the nuclear medicine department for a bone scan. The record did not indicate the patient was accompanied by a nurse with telemetry monitoring during the transport.

During an interview with CN 1 on March 14, 2016, at 1:45 p.m., CN 1 stated Patient 30 left the floor and went to the nuclear medicine department without a nurse and without telemetry monitoring. CN 1 stated she determined the patient was safe to go without a nurse and without telemetry monitoring based on the policy.

The employee file for CN 1 was reviewed on March 15, 2016. There was no evidence in the file CN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKGs for determining ST segment and EKG changes;

h. The record for Patient 31 was reviewed. Patient 31, a 52 year old male, was admitted to the facility on March 7, 2016, with diagnoses that included pneumonia, neutropenia (low white blood cell count), and thrombocytopenia (low platelet count).

The admitting orders, entered by the physician on March 7, 2016, at 9:50 p.m., indicated the patient was to be admitted to a telemetry unit with telemetry monitoring.

The nurse's notes, written by RN 10, indicated on March 14, 2016, at 8 a.m., Patient 31 was, "stable to be transported off the unit without a nurse, no active chest pain, no positive cardiac markers, no ST elevation/depression, no arrhythmia changes, no acute EKG changes...no high risk for rapid decompensation."

During an interview with RN 10 on March 14, 2016, at 1:50 p.m., the RN pulled the policy, "Protocol: Transport of Monitored Patients," from his clipboard. RN 10 stated he determined Patient 31 was stable to transport to the radiology department for an ultrasound based on the criteria listed in the policy/protocol.

RN 10 stated he considered cardiac markers to be a Troponin lab value of greater than 1.0 (normal reference range less than or equal to 0.4). RN 10 stated a change in arrhythmia for the purpose of the protocol meant (to him) if the patient had a change in their heart rhythm or arrhythmia since admission (unless they had a high heart rate - if the heart rate was greater than 130 [normal 60-100], he would not allow the patient to be transported unaccompanied and unmonitored). The RN stated he did not perform a 12 lead EKG to determine the presence or absence of ST elevation or depression, or acute EKG changes, but he could change leads on the telemetry monitor and check for those conditions if he needed to.

The employee file for RN 10 was reviewed on March 15, 2016. There was no evidence in the file RN 10 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKGs for determining ST segment and EKG changes;

i. The record for Patient 32 was reviewed on March 14, 2016. Patient 32, a 40 year old female, was admitted to the facility on March 12, 2016, with diagnoses that included congestive heart failure (CHF) and cardiomyopathy (enlarged heart).

Physician admitting orders, dated March 12, 2016, at 10:57 p.m., indicated the patient was to be admitted to the telemetry unit with cardiac monitoring.

The EKG completed in the emergency department (ED) indicated Patient 32 had a left bundle branch block (LBBB - a delay or obstruction in the electrical pattern of the heart, making it harder for the heart to pump blood effectively).

The nurse's notes, written by RN 11, indicated on March 14, 2016, at 9:22 a.m., Patient 32 was transported to the radiology department for an ultrasound guided thoracentesis (removing fluid from the chest cavity). According to the notes, the patient returned and was placed in a telemetry room at 10:54 a.m. (one hour and 22 minutes later). The record did not indicate the patient was accompanied by a nurse with telemetry monitoring during the transport.

During an interview with RN 11 on March 14, 2016, at 2:10 p.m., the RN stated the Patient went to the radiology department for the thoracentesis procedure without a nurse and without telemetry monitoring. RN 11 stated she based her decision to send the patient unaccompanied and unmonitored on the policy titled, "Protocol:Transport of Monitored Patients." RN 11 stated Patient 32 had stable vital signs (not part of the protocol), no arrhythmias, and was not requiring high level oxygen. RN 11 stated she considered cardiac markers to be CPK, CK-MB, and Troponin, and if any of them were elevated, she would not send the patient without a nurse and a monitor. The RN stated she did not perform a 12 lead EKG to determine the presence or absence of ST elevation or depression, or acute EKG changes, but she could change leads on the telemetry monitor and check for those conditions if she needed to.

The employee file for RN 11 was reviewed on March 15, 2016. There was no evidence in the file RN 11 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKGs for determining ST segment and EKG changes.

j. On March 14, 2016, at 11 a.m., RN 6 was interviewed regarding her knowledge of the new protocol titled, "Transport of Monitored Patients." RN 6 stated the protocol directed the nurses to assess for certain criteria to determine whether they could be taken off telemetry and transported to a procedure without a nurse. RN 6 stated the criteria included, medication drips, condition stable, high flow oxygen, change in rhythm, and vital signs stable (She did not mention lab values or cardiac markers). RN 6 stated if these criteria were met, the nurse did not need to call the physician for an order to remove the telemetry. RN 6 further stated, the nurse could make the decision to take a patient off telemetry and transfer to another area in the hospital without a nurse.

The employee file was reviewed for RN 6 on March 15, 2016. There was no evidence in the file that indicated RN 6 had been inserviced on the protocol, "Transport of Monitored Patients" or demonstrated competency in interpretation of electrocardiograms (EKG) for determining ST segment elevation/depression and EKG changes.



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2. On March 14, 2016, at 11 a.m., RN 6 was interviewed. RN 6 stated she had worked on the unit for a couple of years, caring for patients requiring cardiac monitoring and rhythm interpretation.

On March 15, 2016, the employee file for RN 6 revealed, the competency exam to assess knowledge of cardiac rhythm interpretation had not been graded or validated for accuracy.

On March 15, 2016, at 1:05 p.m., the manager of 3 East Medical/Surgical/Telemetry (Manager 1) was interviewed. Manager 1 stated she graded and evaluated the rhythm interpretation tests for her nurses. Manager 1 acknowledged that RN 6's test had not been graded or validated. A computer search was done to determine if RN 6 had done any rhythm interpretation competency online. There was no indication that RN 6 had validated competency to interpret cardiac rhythms.

2. During a tour of the facility on March 14, 2016, at 2:25 p.m., Patient 33 was observed in her bed with her eyes closed. The patient was undergoing a dialysis treatment, with the dialysis machine and the dialysis nurse at her bedside.

A review of Patient 33's record was conducted. Patient 33 was admitted to the facility on March 10, 2016, with diagnoses that included acute (sudden) on chronic kidney failure.

A review of the physician orders for Patient 33 was conducted. The dialysis orders dated March 13, at 00:21 a.m., indicated an initial dialysis treatment was to be started.

The "Acute Hemodialysis Flow Sheet," indicated Patient 33 received dialysis on March 14, 2016, at 2:45 p.m. (14 hours and 24 minutes after the order was written).

The current dialysis contract was provided by the Director of Quality and was reviewed. The dialysis contract did not include expectations of timeliness.

An interview was conducted with the Accreditation and Regulatory Manager (ARM) on March 15, 2016, at 1:45 p.m. The ARM stated a stat dialysis order had to be started within two hours from the time it was received by the contracted agency and routine dialysis order had to be started within six hours from the time it was received by the contracted agency.



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Based on observation, interview, and record review, the governing body failed to ensure dialysis services provided by a contracted agency were performed timely when two of three patients (Patient 4, and 33) experienced a delay receiving their initial dialysis (system where blood is filtered to remove toxins). This failed practice resulted in the potential for harm or death related to build up of harmful toxins.

Findings:

1. During a tour of the facility on March 14, 2016, at 1:40 p.m., Patient 4 was observed in her bed with her eyes closed. The patient was connected to a heart monitor and was receiving oxygen at two liters per minute by nasal cannula.

A review of Patient 4's record was conducted. Patient 4 was admitted to the facility on February 4, 2016, with diagnoses that included diarrhea and end stage renal (kidney) disease. The patient had a history of hypotension (low blood pressure), and was on dialysis.

A review of the physician orders for Patient 4 was conducted. The dialysis orders indicated, "Dialysis Procedure 2/5/16 (17:16 p.m.) Stat."

The "Acute Hemodialysis Flow Sheet," indicated Patient 4 received dialysis on February 5, 2016, at 9:45 p.m. This was 4 hours and 29 minutes after the initial physician's order for stat dialysis was received.

Based on observation, interview, and record review, the Chief Nursing Officer (CNO) failed to ensure registered nurses (RNs) were providing safe and effective care to patients when:

1. The CNO authored and implemented a policy titled, "Protocol:Transport of Monitored Patients," throughout the telemetry (heart monitoring) units. The policy included criteria that enabled the nurses to override a physician's order for telemetry monitoring, and allow telemetry patients to be transported throughout the facility without a nurse and without cardiac monitoring;

2. The RNs responsible for overriding physician's orders and transferring telemetry patients without a nurse or a cardiac monitor were trained and competent in the knowledge and skills required to carry out the protocol; and,

3. No data was collected or analyzed after the new policy titled, "Protocol: Transport of Monitored Patients," was implemented, to determine compliance with the protocol, consistency in it's implementation, and safety of the patients who were selected to be transported without a nurse and a cardiac monitor (A283).

This failed practice resulted in the potential for unrecognized and untreated arrythmias, cardiac arrest, and death.

Findings:

1. According to the California Nurse Practice Act, Business and Professions Code, Chapter 6, Article 2, Section 2725, the practice of nursing is defined as:

Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures; and,

According to Section 2726, the Nursing Practice Act confers no authority upon nurses to practice medicine.

The facility policy titled, "Protocol: Transport of Monitored Patients," was reviewed. According to the document, the policy was authored/revised by the CNO, and approved by the governing board on February 8, 2016. The policy indicated patients with orders written by the physician to have cardiac monitoring while in the hospital could be taken off of telemetry (cardiac monitor), and be transported throughout the facility for tests/procedures without the telemetry monitoring and without a nurse, if they met certain criteria as determined by the nurse.

The policy included the following criteria:

-Active chest pain;

-Positive cardiac markers (not specifically defined) (lab values indicating damage to the heart muscle). There was no indication of which cardiac markers or reference ranges would be used to determine whether the markers were positive or not (CPK, CK-MB, Myoglobin, Troponin, a combination, or all of these);

-ST elevation or depression (an elevated [raised] or depressed [lowered] section of the ST segment indicating lack of bloodflow and oxygen to the heart seen on an electrocardiogram [EKG]);

-Arrhythmia changes (not specifically defined); and,

-Acute EKG changes (not specifically defined).

2. During a tour of the telemetry units on March 14, 2015, between 10:30 a.m., and 4:30 p.m., each unit had a clipboard hanging in or near the nurse's station with forms titled, "Radiology Patient Log," for documentation of the patients who were going, or had gone, to the radiology department for testing that day.

The logs included Patients 10, 11, 12, 14, 17, 23, 30, 31, and 32.

a. The record for patient 10 was reviewed. Patient 10, a 79 year old male, was admitted to the facility on March 12, 2016, with diagnoses that included cerebrovascular disease (stroke).

The admitting orders, written by the physician on March 12, 2016, at 4 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 1, indicated on March 14, 2016, at 3:45 p.m., Patient 10 was, "Taken off the unit at this time by transporter to nuclear medicine for kidney ultrasound. Patient is off telemetry monitor because patient is stable, he is sinus rhythm with first degree AVB (atrial ventricular block), has has no arrhymias, is also a DNR (do not resuscitate). Patient meets criteria for being off unit without nurse escort as per protocol."

During an interview with Registered Nurse (RN) 1 on March 14, 2016, at 4 p.m., RN 1 stated Patient 10 was transported without a nurse to nuclear medicine for a kidney ultrasound. She stated Patient 10 met the criteria for going off the unit without a nurse. According to RN 1, the patient was stable, in normal sinus rhythm with first degree block (an arrythmia), and his rhythm had not changed. The RN stated he was a DNR (Do Not Resuscitate).

The employee file for RN 1 was reviewed on March 15, 2016. There was no evidence in the file RN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

b. The record for Patient 11 was reviewed. Patient 11, a 57 year old male, was admitted to the facility on March 12, 2016, with diagnoses that included pancreatitis (inflammation of the pancreas).

The admitting orders, written by the physician on March 12, 2016, at 1:17 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 1, indicated on March 14, 2016, at 3:55 p.m., Patient 11 was, "Taken off unit to nuclear medicine by transporter for kidney biopsy, he is stable and is sinus rhythm on monitor. Patient has had no arrhythmia's and meets the criteria for going off unit without a nurse escort as per protocol."

During an interview with RN 1 on March 14, 2016, at 4:05 p.m., RN 1 stated Patient 11 was transported without a nurse because he was stable, and had no arrhythmia's. She stated he met the criteria according to policy.

The employee file for RN 1 was reviewed on March 15, 2016. There was no evidence in the file RN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

c. The record for Patient 12 was reviewed. Patient 12, a 37 year old female, was admitted to the facility on March 2, 2016, with diagnoses that included aneurysm (ballooning and weakened area in an artery).

The admitting orders, written by the physician on March 10, 2016, at 1:59 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 2, indicated on March 14, 2016, at 3:58 p.m., Patient 12 was, "Leaving floor in gurney with transporter, patient meets unit protocol to leave without nurse escort. patient is sinus rhythm, in no acute distress, and VSS (vital signs stable)."

During an interview with RN 2 on March 14, 2016, at 4:10 p.m., RN 2 stated Patient 12 was transported without a nurse because he was stable, and had no arrhythmia's. She stated he met the protocol according to policy.

The employee file for RN 2 was reviewed on March 15, 2016. There was no evidence in the file RN 2 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

d. The medical record for Patient 14 was reviewed. Patient 14 was admitted to the facility on March 12, 2016, with diagnoses of syncope (fainting) and a motor vehicle accident with a lumbar 1 (lower back) fracture. Physician order's dated March 12, 2016, at 10:10 p.m., by the emergency department physician and on March 13, 2016, at 1:52 p.m., by the admitting physician, indicated Patient 14 was to be admitted to telemetry (cardiac [heart] monitoring).

On March 14, 2016, at 8:50 a.m., Patient 14 left the unit, was removed from telemetry and direct nursing care to transfer to another department in the facility for a test. Patient 14 returned to the unit

Based on observation, interview, and record review, the facility failed to ensure:

1. Nursing staff assigned to care for nine sampled patients (Patients 10, 11, 12, 14, 17, 23, 30, 31, and 32) on the telemetry (heart monitoring) unit demonstrated competency in determining whether the patients met criteria to be transported without a nurse and a cardiac monitor, when a new protocol was developed without training the nursing staff and verifying they had the knowledge and skills necessary to implement it, and;

2. Verification of competency and ability to recognize abnormal rhythms for one registered nurse (RN 6) prior to assigning her to care for patients independently on the telemetry unit, when she completed a written examination on arrhythmia recognition, and the examination was not reviewed for accuracy and knowledge.

This failed practice resulted in the potential for the patients to have unrecognized and untreated arrhythmias (abnormal heart rhythm), which had the potential to result in cardiac arrest, and death.

Findings:

1. The facility policy titled, "Protocol, Transport of Monitored Patients," with an approval date of February 8, 2016, was reviewed.

According to the protocol, patients with a physician's order for telemetry monitoring could be transported off of their unit, without an RN and without telemetry monitoring in place, if they were not experiencing signs and symptoms that included the following (to be assessed and determined by the nurse):

- Active chest pain;

- Positive cardiac markers (lab values indicating damage to the heart muscle). There was no indication of which cardiac markers or reference ranges would be used to determine whether the markers were positive or not (CPK, CK-MB, Myoglobin, Troponin, a combination, or all of these);

-ST elevation or depression (an elevated [raised] or depressed [lowered] section of the ST segment indicating lack of bloodflow and oxygen to the heart seen on an electrocardiogram [EKG]);

- Arrhythmia changes; and,

-Acute EKG changes.

The policy indicated the RN would be the one to determine if the patient was experiencing any of the above signs/symptoms, and decide whether it was safe for the patient to be transported without a nurse and without telemetry monitoring.

During a tour of the telemetry units on March 14, 2015, between 10:30 a.m., and 4:30 p.m., each unit had a clipboard hanging in or near the nurse's station with forms titled, "Radiology Patient Log," for documentation of the patients who were going, or had gone, to the radiology department for testing that day.

The logs included Patients 10, 11, 12, 14, 17, 23, 30, 31, and 32.

During an interview with the second floor telemetry charge nurse (CN 1) on March 14, 2016, at 1:35 p.m., CN 1 stated Patients 30, 31, and 32, were transported from her floor earlier in the day without a nurse or a cardiac monitor. She stated a policy was in place that allowed the nurse's to determine whether a telemetry patient could be transported without a nurse and a monitor if they met certain criteria. CN 1 referred to the policy, "Protocol: Transport of Monitored Patients," and stated the criteria, as she understood it, included:

- No continuous intravenous (IV) drip medications to regulate the heart rhythm;

- No need for more than six liters per minute of oxygen;

- No elevated cardiac markers (defined by her as a troponin [laboratory test that measures damage to the heart] value of greater than 1.0 [normal troponin less than or equal to 0.04]); and,

- No change in arrhythmia since admission.

CN 1 stated the nurse should document in the medical record any time their the patient left the floor, and if there was or was not a nurse and/or a cardiac monitor in place during the transport.

a. The record for patient 10 was reviewed. Patient 10, a 79 year old male, was admitted to the facility on March 12, 2016, with diagnoses that included cerebrovascular disease (stroke).

Physician admitting orders dated on March 12, 2016, at 4 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 1, indicated on March 14, 2016, at 3:45 p.m., Patient 10 was, "Taken off the unit at this time by transporter to nuclear medicine for kidney ultrasound. Patient is off telemetry monitor because patient is stable, he is sinus rhythm with first degree AVB (atrial ventricular block), has has no arrhymias, is also a DNR (do not resuscitate). Patient meets criteria for being off unit without nurse escort as per protocol."

During an interview with Registered Nurse (RN) 1 on March 14, 2016, at 4 p.m., RN 1 stated Patient 10 was transported without a nurse to nuclear medicine for a kidney ultrasound. She stated Patient 10 met the criteria for going off the unit without a nurse. According to RN 1, the patient was stable, in normal sinus rhythm with first degree block (an arrythmia), and his rhythm had not changed. The RN stated he was a DNR (Do Not Resuscitate).

The employee file for RN 1 was reviewed on March 15, 2016. There was no evidence in the file RN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

b. The record for Patient 11 was reviewed. Patient 11, a 57 year old male, was admitted to the facility on March 12, 2016, with diagnoses that included pancreatitis (inflammation of the pancreas).

The admitting orders, written by the physician on March 12, 2016, at 1:17 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 1, indicated on March 14, 2016, at 3:55 p.m., Patient 11 was, "Taken off unit to nuclear medicine by transporter for kidney biopsy, he is stable and is sinus rhythm on monitor. Patient has had no arrhythmia's and meets the criteria for going off unit without a nurse escort as per protocol."

During an interview with RN 1 on March 14, 2016, at 4:05 p.m., RN 1 stated Patient 11 was transported without a nurse because he was stable, and had no arrhythmia's. She stated he met the criteria according to policy.

The employee file for RN 1 was reviewed on March 15, 2016. There was no evidence in the file RN 1 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

c. The record for Patient 12 was reviewed. Patient 12, a 37 year old female, was admitted to the facility on March 2, 2016, with diagnoses that included aneurysm (ballooning and weakened area in an artery).

The admitting orders, written by the physician on March 10, 2016, at 1:59 p.m., indicated the patient was to be admitted to the telemetry unit (where telemetry monitoring was done continuously). The nurse's notes written by RN 2, indicated on March 14, 2016, at 3:58 p.m., Patient 12 was, "Leaving floor in gurney with transporter, patient meets unit protocol to leave without nurse escort. patient is sinus rhythm, in no acute distress, and VSS (vital signs stable)."

During an interview with RN 2 on March 14, 2016, at 4:10 p.m., RN 2 stated Patient 12 was transported without a nurse because he was stable, and had no arrhythmia's. She stated he met the protocol according to policy.

The employee file for RN 2 was reviewed on March 15, 2016. There was no evidence in the file RN 2 had undergone training and/or demonstrated competence in use of the telemetry transfer protocol, or interpretation of EKG's for determining ST segment and EKG changes.

d. The medical record for Patient 14 was reviewed. Patient 14 was admitted to the facility on March 12, 2016, with diagnoses of syncope (fainting) and a motor vehicle accident with a lumbar 1 (lower back) fracture. Physician order's dated March 12, 2016, at 10:10 p.m., by the emergency department physician and on March 13, 2016, at 1:52 p.m., by the admitting physician, indicated Patient 14 was to be admitted to telemetry (cardiac [heart] monitoring).

On March 14, 2016, at 8:50 a.m., Patient 14 left the unit, was r