HospitalInspections.org

Based on observations, review of policy, telemetry logs, medical records, and interviews with the staff, the facility staff failed to adhere to policies and procedures for patients with telemetry leads for 1 of 1 observations (Patient #13).

The findings include:

Observation on 06/18/2024 at 1335 of the telemetry monitoring room revealed 3 monitor technicians sitting in front of 2 telemetry monitors each. Each technician had handwritten entries of the events of the day on the monitor log. Review of Monitor Technician #1's monitor log dated 06/18/2024 revealed an entry at 0800 for patient in room 3620 of "leads off" with "Person Notified" and "Time Tele (Telemetry) Restored" as "not fix." Observation of the next entry revealed at 0818, the same patient in 3620 with leads off with restoration time at 0826, 26 minutes since original documentation of leads off.

Observation on 06/18/2024 at 1340 of the telemetry monitoring room revealed a document posted on the wall above the telemetry monitors. The document read: "Calling Process: If a leads off alarm sounds, the Monitor Technician should: 1. Call the unit and speak with the unit and notify them of the monitor is off. a. Fill out the telemetry log (Date, time, Room#, Patient Name, etc.) 2. If still no rhythm after 5 minutes, call the unit second time and notify the House Supervisor. If no one answers the phone, the Monitor Technician will hang up and call back on the 'red phone.' If the red phone is not answered, notify the House Supervisor."

Review of open medical record of Patient #13 revealed a 47 year old male admitted on 06/13/2024 with kidney problems with continuous telemetry orders on 06/13/2024 at 2255. Telemetry was resumed at 0826 on 06/18/2024 with no change in condition.

Interview on 06/18/2024 at 1340 with Monitor Technician #1 revealed monitor leads were documented as being off at 0800 with documentation of leads being off for over 20 minutes. Interview revealed no reason why the supervisor was not notified of the leads being off over 5 minutes. Interview revealed the Monitor Technician #1 called the primary nurse at 0800 and spoke to the nurse. Interview revealed another phone call to the patient care floor was made at 0818 when the leads were still off, adding another floor nurse placed the leads back on at 0826.

Interview on 06/20/2024 at 1300 with CNO revealed "unsure why policy and procedures were not followed" to escalate the off leads. Interview revealed the policy and procedure was not followed.

NC00214436, NC00210156, and NC00217003