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Based on observation, interview and policy review, the hospital failed to ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients and failed to perform daily checks on the crash cart (mobile cart which contains emergency medical supplies and medication).

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 11/20/24, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were educated on telemetry monitoring and the need for constant observation. All remaining staff were educated prior to the start of their next shift.

Please refer to A-0144.

Based on observation, interview and policy review, the hospital failed to ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients and failed to perform daily checks on the crash cart (mobile cart which contains emergency medical supplies and medication).

Findings included:

1. Review of the hospital's policy titled, "Guidelines for Care in Intensive Care (ICU, a unit where critically ill patients are cared for)/Telemetry Unit," dated 01/2024, showed cardiac rhythm will be monitored continuously.

Observation on 11/18/24 at 2:12 PM, in the ICU and Telemetry Unit, showed eleven patients (#1, #2, #11, #12, #13, #14, #15, #16, #17, #18, and #20) on the telemetry monitor with no staff present to observe the monitor.

During an interview on 11/18/24 at 2:15 PM, Staff B, Physician, seated alone at the nurses' station, stated that he was not responsible for watching the telemetry monitors.

During an interview on 11/18/24 at 2:13 PM, Staff A, ICU/Telemetry Director, stated that the Unit Clerk or Patient Care Technician (PCT) should constantly watch the telemetry monitors.

During an interview on 11/18/24 at 2:25 PM, Staff C, Unit Clerk/PCT, stated that she was responsible for watching the telemetry monitors and there was always someone to relieve her.

During an interview on 11/19/24 at 12:12 PM, Staff AA, Professional Excellence Coordinator, stated that the ICU watched the telemetry for the medical/surgical (Med/Surg) unit. There was no specific person to monitor the telemetry, it was just monitored by whoever was at the nurses' desk.

During an interview on 11/9/24 at 2:35 PM, Staff Y, Chief Nursing Officer (CNO), stated that the hospital no longer had telemetry monitor technicians. They had not had monitor technicians for about six years. In the ICU and on the telemetry floor/space, there was central monitoring at the nurses' station. The ICU could see all patients on telemetry. There was no dedicated person to monitor telemetry, everyone was responsible for monitoring it. The PCTs and the unit clerks were trained to notify the nurse if the telemetry alarmed. The RNs and LPNs went through basic and advanced telemetry arrhythmia (irregular heartbeat) training.

2. Review of the hospital's policy titled, "Code/Procedure Carts and Airway Boxes," dated 09/2024, showed the crash cart check was to be completed daily.

Review of the hospital's document titled, "Adult Code Cart Checklist," dated 11/2024, showed missing daily checks on 11/03, 11/05, 11/10, 11/14, 11/15 and 11/16.

Review of the hospital's pediatric code cart document titled, "Broselow Checklist," dated 11/2024, showed missing daily checks on 11/03, 11/05, 11/10, 11/14, 11/15 and 11/16.

During an interview on 11/18/24 at 2:00 PM, Staff W, Med/Surg Director, stated that crash carts were to be checked daily.

During an interview on 11/20/24 at 10:04 AM, Staff Y, CNO, stated that the crash carts were to be checked daily.




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Based on observation, interview and policy review, the hospital failed to: label the intravenous (IV, in the vein) site for 11 patients (#1, #2, #3, #7, #10, #21, #22, #23, #24, #25, and #26) of 12 patients observed and label the IV tubing for 11 patients (#1, #2, #3, #7, #10, #19, #22, #23, #24, #25, and #26) of 12 patients observed.

Findings included:

1. Review of the hospital's policy titled, "IV Venipuncture, Initiation of IV Fluids," dated 10/2022, showed the dressing should be labeled and include the date and time of the IV insertion, gauge, and nurse's initials.

Observation on 11/18/24 at 2:17 PM, showed no label on the IV dressing for Patient #1.

Observation on 11/18/24 at 2:30 PM, showed no labels on two IV dressings for Patient #2.

Observation on 11/18/24 at 3:10 PM, showed no label on the IV dressing for Patient #3.

Observation on 11/19/24 at 8:30 AM, showed no label on the IV dressing for Patient #7.

Observation on 11/18/24 at 3:08 PM, showed no label on the IV dressing for Patient #10.

Observation on 11/19/24 at 9:10 AM, showed no labels on two IV dressings for Patient #21.

Observation on 11/19/24 at 9:45 AM, showed no labels on two IV dressings for Patient #22.

Observation on 11/19/24 at 8:45 AM, showed no label on the IV dressing for Patient #23.

Observation on 11/19/24 at 10:23 AM, showed no labels on two IV dressings for Patient #24.

Observation on 11/19/24 at 10:00 AM, showed no labels on two IV dressings for Patient #25.

Observation on 11/19/24 at 12:05 PM, showed no labels on two IV dressings for Patient #26.

During an interview on 11/18/24 at 3:18 PM, Staff M, Registered Nurse (RN), stated that IV dressings should be labeled with date, time and initials.

During an interview on 11/20/24 at 10:04 AM, Staff Y, Chief Nursing Officer (CNO), stated that she expected IV dressings to be labeled according to hospital policy.

2. Review of the hospital's policy titled, "IV Therapy Guidelines," dated 11/2022, showed the IV tubing should be labeled with the date and time of change and the initials of the nursing personnel that changed the tubing.

Observation on 11/18/24 at 2:17 PM, showed no label on the IV tubing for Patient #1.

Observation on 11/18/24 at 2:30 PM, showed no labels on two IV tubing for Patient #2.

Observation on 11/18/24 at 3:10 PM, showed no label on the IV tubing for Patient #3.

Observation on 11/19/24 at 8:50 AM, showed no label on the IV tubing for Patient #7.

Observation on 11/19/24 at 9:00 AM, showed no label on the IV tubing for Patient #10.

Observation on 11/19/24 at 9:30 AM, showed no label on the IV tubing for Patient #19.

Observation on 11/19/24 at 9:45 AM, showed no label on the IV tubing for Patient #22.

Observation on 11/19/24 at 8:45 AM, showed no labels on three IV tubing for Patient #23.

Observation on 11/19/24 at 10:23 AM, showed no labels on two IV tubing for Patient #24.

Observation on 11/19/24 at 10:00 AM, showed no labels on two IV tubing for Patient #25.

Observation on 11/19/24 at 12:05 PM, showed no labels on two IV tubing for Patient #26.

During an interview at 9:55 AM, Staff N, Licensed Practical Nurse (LPN), stated that the IV tubing should always be labeled.

During an interview on 11/20/24 at 10:04 AM, Staff Y, CNO, stated that she expected IV tubing to be labeled according to hospital policy.




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