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Based on record review, document review, policy review, staff interviews, and direct observation, it was determined the facility failed to identify a high risk, high volume concern, failed to collect data, track and trend, analyze data, develop an effective plan of correction, and monitor the results to ensure continuous cardiac monitoring of patients was maintained in compliance with the physician ordered plan of care for 5 of 8 (#1, #9, #11, #12, #13) sampled telemetry patients, of a total of 13 sampled records.

Findings include:

1. The Emergency Department (ED) Report dated 10/15/13 and signed by the ED physician indicated Patient #1 was admitted to PCU on 10/15/13 with diagnoses including abnormal EKG with ischemic changes in the infero-lateral leads. Patient #1 underwent a left heart cardiac catheterization on 10/15/13.

The Nurses Notes dated 10/16/13 at 9:00 a.m. indicated Patient #1 left his room to be taken for an x-ray procedure. The Nurses Notes dated 10/16/13 indicated Patient #1 returned to his room at 10:30 a.m.

The Nurses Notes dated 10/16/13 at 6:00 p.m. and signed by the staff nurse documented she failed to re-establish cardiac monitoring for Patient #1 when he returned to his room. Cardiac monitoring was not resumed until 6:00 p.m., indicating the patient was without physician ordered continuous cardiac monitoring for a period of approximately 8 hours.

2. Patient #9's cardiac monitor was observed to have no signal and the notation "MRI" on the monitor screen at the time of the tour of the 3rd Floor Medical/Telemetry unit on 11/25/13 at approximately 1:30 p.m. The Unit Secretary confirmed the patient was in the radiology department. A tour was conducted of the Telemetry Room on 11/25/13 at approximately 3:00 p.m. where Patient #9's cardiac monitor was again observed to have no signal and the notation "MRI" on the screen. The Telemetry Tech referred to her notes and indicated Patient #9 had not been monitored since approximately 12:45 p.m. that day. She presented her documentation indicating she had placed a call to the nurse who confirmed the patient was in her room at 2:20 p.m. a repeat call to Patient #9's nurse at 3:00 p.m. failed to result in restoration of Patient #9's cardiac monitoring signal within 5 minutes, the surveyor returned to the 3rd Floor Medical/Telemetry unit to confirm the patient's status. Observation of Patient #9 at approximately 3:10 p.m. established she was in no acute distress.

The Transport Log Book located at the 3rd Floor Medical/Telemetry Nurses' Station dated 11/25/13 indicated Patient #9 had left her room at 12:45 p.m. and returned to her room at 1:45 p.m.

An interview was conducted with the RN Staff Nurse assigned to the care of Patient #9 on 11/25/13 at approximately 3:15 p.m. She confirmed the finding she took no action when the Telemetry Tech notified her at 2:20 p.m. that Patient #9 was not transmitting a signal. She confirmed the finding Patient #9 had been without continuous cardiac monitoring as ordered by her physician for approximately 1 1/2 hours after returning to her room from an x-ray procedure.

3. The Telemetry Report Sheet dated 11/25/13 was reviewed on 11/26/13 and included the following documentation:

11/25/13 2:05a.m.: (Patient #11), Room 306, Nurse (#1) notified transmitter off. Repeat call at 5:19 a.m. transmitter off, no answer.

11/25/13 4:30 a.m. - (Patient #12), Room 321 Nurse (#2) notified to replace patient battery; repeat call 5:20 a.m. replace battery.

11/25/13 11:31 a.m. (Patient #13), Room 320 Nurse (#3) notified leads off. Repeat call 12:01p.m., nurse will check the patient if she gets a chance.

11/25/13 12:30 p.m. (Patient #9), Room 312 MRI. 2:20 p.m. Nurse (#4) confirmed patient in room. Repeat call 3:00 p.m.

The Plan for the Provision of Patient Care 2013, 900 A 1104, revised 12/12, was reviewed on 11/25/13. Page 64, Telemetry Monitoring Room, included documentation indicating a Physician's Order was required for telemetry monitoring for patients on the Medical unit. Page 81, Medical/Telemetry Unit (3rd Floor), indicated the Scope of Care included providing telemetry monitoring for adults with stable cardiac disease. Page 100, Progressive Care Unit (PCU) (2nd Floor), indicated the Scope of Care included every patient admitted to the PCU will be placed on cardiac monitoring unless otherwise specified.

An interview was conducted with the RN Director of PCU and Medical on 11/25/13 at approximately 4:00 p.m. He indicated he was aware there was an on-going problem with staff nurses on the nursing units under his responsibility failing to initiate, or return patients to, continuous cardiac monitoring on a timely basis. He indicated he had begun retrospectively reviewing the Telemetry Report Sheets for indicators of prolonged lack of cardiac monitoring in August 2013. He indicated he reviewed patient records and counseled 13 nurses as a result of confirmed findings of failure to maintain telemetry patients on continuous cardiac monitoring in compliance with facility policies and the physician-ordered plan of treatment since August 2013. He indicated he had submitted 1 incident report related to the 13 confirmed findings. He indicated he had not kept statistics on his activities and had not reported his findings to anyone. He confirmed the finding he could not identify whether compliance with continuous cardiac monitoring had increased, decreased, or remained the same as a result of his counseling of staff nurses.

An interview and document review was conducted with the Risk Management Director on 11/26/13 at approximately 3:30 p.m. She indicated since January 2013 she had received a total of 6 incident reports related to failure to maintain continuous cardiac monitoring on patients on telemetry. She had not identified a trend or need for corrective action based on those 6 reports over the course of 10 months. She confirmed the finding that the Telemetry Report Sheet documented multiple daily occurrences of patients failing to be maintained on continuous cardiac monitoring in compliance with the physician ordered plan of treatment. She confirmed the finding she was unaware of the extent of the non-compliance with facility policies regarding cardiac telemetry. She confirmed the finding that failing to maintain continuous cardiac monitoring for patients who require it puts patients at risk for unwitnessed cardiac events with significant potential for adverse outcomes for those patients.

Based on record review, policy review, document review, staff interviews and direct observation, it was determined the facility failed to:

1. Provide a sufficient number of staff in compliance with facility policy for the Telemetry Monitoring Room. (A392).

2. Ensure the nursing staff delivered care and services in compliance with the physician directed plan of treatment and facility policies for 5 of 8 sampled telemetry patients, of a sample of 13 records; failed to ensure the nursing staff was fully integrated into the Quality Assurance Performance Improvement program; and failed to reassess, evaluate and provide appropriate nursing intervention for 5 (#1, #9, #11,#12, #13) of 8 sampled telemetry patients, of a sample of 13 records (A395)

3. Ensure non-employee nursing staff were evaluated in compliance with facility policies for 5 of 5 reviewed personnel files of non-employee Registered Nurses.(A398)

As a result of the review of all of the evidence indicating the involvement of multiple patients, nurses, and nursing units in past and on-going deficient nursing practices, it was determined the facility is not in compliance with the Condition of Participation for Nursing Services, CFR 42 482.13, requirements for hospitals.

Based on policy review, staff interview, and direct observation, it was determined the facility failed to provide a sufficient number of staff in compliance with facility policy for the Telemetry Monitoring Room.

A tour of the Telemetry Monitoring Room was conducted on 11/25/13 at approximately 3:00 p.m. accompanied by the Interim Chief Nurse Executive (CNE) and the Risk Management Director. The room was observed to have 62 patients on cardiac telemetry at the time of the tour. The room was observed to be staffed with one Telemetry Tech. The room was observed to have two employee work spaces in front of the monitors.

The Plan For the Provision of Patient Care 2013, revised 12/12, was reviewed on 11/25/13. Page 65, Telemetry Monitoring Room, stated the Monitor Room is staffed by (2) two trained monitor technicians on each shift.

An interview was conducted with the RN Director of ICU at the time of the tour on 11/25/13. She indicated the Telemetry Technicians reported to her. She confirmed the finding only one Monitor Tech was staffing the Monitoring Room for this shift.

Based on record review, document review, staff interview and direct observation, it was determined the facility failed to ensure the nursing staff delivered care and services in compliance with the physician directed plan of treatment and facility policies for 5 (#1, #9, #11,#12, #13) of 8 sampled telemetry patients, of a sample of 13 records; failed to ensure the nursing staff was fully integrated into the Quality Assurance Performance Improvement program; and failed to reassess, evaluate and provide appropriate nursing intervention for 5 (#1, #9, #11,#12, #13) of 8 sampled telemetry patients, of a sample of 13 records.

Findings include:

1. The Medication Administration Record for Patient #1, dated 10/15/13, documented 1 liter (1000 ml) of intravenous (IV) 1/2 Normal Saline at 100 ml per hour was initiated at 10:36 a.m., indicating the 1000 ml would infuse over 10 hours and be complete at approximately 8:30 p.m. The Post Procedure Physician Orders for Patient #1 dated 10/15/13 at 2:00 p.m. and signed by the interventional cardiologist included an order to continue the pre-procedure fluids at 100 ml per hour for the remainder of the liter, indicating the patient should receive a total of 1000 ml of IV fluid. The Nurses Notes dated 10/15/13 indicated Patient #1 returned to his room at 3:30 p.m. following his heart catheterization. The Patient Daily Care Record revealed no documentation of the IV fluid intake on 10/15/13 between 7:00 a.m. and 7:00 p.m., and no documentation the IV was discontinued. The Record documented the patient received 100 ml of 1/2 Normal Saline IV fluid each hour between 7:00 p.m. on 10/15/13 and 9:00 a.m. on 10/16/13, indicating Patient #1 received a total of approximately 2200 ml of IV fluid or 1200 ml more than was ordered by the physician. The record contained no evidence the physician was notified of the error in IV fluid administration. The Incident Log for 2013 did not include a report of the medication error.

The Nurses Notes for Patient #1 dated 10/16/13 indicated the patient left his room on PCU (Progressive Care Unit) at 8:45 a.m. to go to the radiology department, and returned to his room on PCU at 10:30 a.m. The Notes dated 10/16/13 at 6:00 p.m. indicated the patient had not been reconnected to cardiac monitoring equipment when he returned to his room at 10:30 a.m. and had been without continuous cardiac monitoring for a period of approximately 7 1/2 hours following his return to the unit. The final cardiac monitoring strip in the patient's record was dated 10/16/13 at 2:00 a.m. There is no evidence of cardiac monitoring in the patient's medical record between 2:00 a.m. and the patient's discharge from the facility on 10/16/13 at some time after 6:00 p.m.

The Plan for the Provision of Patient Care 2013, 900 A 1104, revised 12/12, was reviewed on 11/25/13. Page 64, Telemetry Monitoring Room, Page 100, Progressive Care Unit (PCU) (2nd Floor), indicated the Scope of Care included every patient admitted to the PCU will be placed on cardiac monitoring unless otherwise specified.

The Patient Daily Care Record for Patient #1, dated 10/16/13, included documentation the patient's blood pressure at 8:00 a.m. was 147/89, at 9:00 a.m. was 147/89, at 12:00 noon was 188/89, at 4:00 p.m. was 177/79, and at 6:00 p.m. was 165/107. The Discharge Instructions dated 10/16/13 included a section labeled Evaluation. The MAR indicated Elision 40 mg tablet now was ordered by the attending physician and administered to the patient at 5:30 p.m. vital signs at time of discharge included documentation the patient's blood pressure was 165/107. The documentation indicated the discharge evaluation was completed on 10/16/13 at 5:56 p.m. by the RN Charge Nurse. The Physician Orders dated 10/16/13 (no time indicated) included a telephone order from the attending physician to the RN Staff Nurse to discharge the patient home. The record contained no evidence of the time the patient left the facility on 10/16/13. The record contained no evidence the physician was notified of the patient's abnormally high blood pressure following the administration of additional blood pressure medication. There was no evidence the patient's blood pressure was reassessed prior to his departure from the facility.

2. Patient #9's cardiac monitor was observed to have no signal and the notation "MRI" on the monitor screen at the time of the tour of the 3rd Floor Medical/Telemetry unit on 11/25/13 at approximately 1:30 p.m. The Unit Secretary confirmed the patient was in the radiology department. A tour was conducted of the Telemetry Room on 11/25/13 at approximately 3:00 p.m. where Patient #9's cardiac monitor was again observed to have no signal and the notation "MRI" on the screen. The Telemetry Tech referred to her notes and indicated Patient #9 had not been monitored since approximately12:45 p.m. that day. She presented her documentation indicating she had placed a call to the nurse who confirmed the patient was in her room at 2:20 p.m. a repeat call to Patient #9's nurse at 3:00 p.m. failed to result in restoration of Patient #9's cardiac monitoring signal within 5 minutes, the surveyor returned to the 3rd Floor Medical/Telemetry unit to confirm the patient's status. Observation of Patient #9 at approximately 3:10 p.m. established she was in no acute distress.

The Transport Log Book located at the 3rd Floor Medical/Telemetry Nurses' Station dated 11/25/13 indicated Patient #9 had left her room at 12:45 p.m. and returned to her room at 1:45 p.m.

An interview was conducted with the RN Staff Nurse assigned to the care of Patient #9 on 11/25/13 at approximately 3:15 p.m. She confirmed the finding she took no action when the Telemetry Tech notified her at 2:20 p.m. that Patient #9 was not transmitting a signal. She confirmed the finding Patient #9 had been without continuous cardiac monitoring as ordered by her physician for approximately 1 1/2 hours after returning to her room from an x-ray procedure.

3. The Telemetry Report Sheet dated 11/25/13 was reviewed on 11/26/13 and included the following documentation:

11/25/13 2:05a.m.: (Patient #11), Room 306, Nurse (#1) notified transmitter off. Repeat call at 5:19 a.m. transmitter off, no answer.

11/25/13 4:30 a.m. - (Patient #12), Room 321 Nurse (#2) notified to replace patient battery; repeat call 5:20 a.m. replace battery.

11/25/13 11:31 a.m. (Patient #13), Room 320 Nurse (#3) notified leads off. Repeat call 12:01p.m., nurse will check the patient if she gets a chance.

11/25/13 12:30 p.m. (Patient #9), Room 312 MRI. 2:20 p.m. Nurse (#4) confirmed patient in room. Repeat call 3:00 p.m.

The review of the Telemetry Report Sheets for each shift for dates from October 1, 2013 to 11/24/13 revealed documentation of multiple daily occurrences of telemetry patients failing to be maintained appropriately on continuous cardiac monitoring.

4. An interview was conducted with the RN Director of PCU and Medical on 11/25/13 at approximately 4:00 p.m. He indicated he had begun retrospectively reviewing the Telemetry Report Sheets for indicators of prolonged lack of cardiac monitoring in August 2013. He indicated he reviewed patient records and counseled 13 nurses as a result of confirmed findings of failure to maintain telemetry patients on continuous cardiac monitoring in compliance with facility policies and the physician-ordered plan of treatment since August 2013. He indicated he had submitted 1 incident report related to the 13 confirmed findings. He indicated he had not kept statistics on his activities and had not reported his findings to anyone. He confirmed the finding he could not identify whether compliance with continuous cardiac monitoring had increased, decreased, or remained the same as a result of his counseling of staff nurses.

Interviews were conducted with the Chief Nursing Executive, the Division Director of Quality and Patient Safety, and the Risk Management Director at various times on 11/25/13 - 11/27/13. They confirmed the above findings.

Based on document review, policy review, and staff interview the facility failed to ensure non-employee nursing staff were evaluated in compliance with facility policies for 5 of 5 reviewed personnel files of non-employee Registered Nurses.

A sample of 5 personnel files were selected at random from a list of names of non-employee Registered Nurses (RNs) actively utilized by the facility within the past year. The sample consisted of 3 RNs from an outside staffing agency and 2 RNs who were former employees of the facility but currently worked on a per diem basis as independent contractors.

3 of 3 of the outside agency RN files contained no evidence of performance evaluations having been conducted by the facility at any time. Each of the files contained self-assessments of the RN's knowledge and skills, but no evidence of demonstrated competencies evaluations by the facility.

2 of 2 of the independent contractor RN files contained no evidence of performance evaluations or competency assessments within the previous 12 calendar months.

The Plan for the Provision of Patient Care 2013 , revised 12/12, Medical/Telemetry Unit, page 82, and Progressive Care Unit, page 100, indicated staff competencies are demonstrated at the time of initial hire and are to be reviewed no later than the 90 day evaluation. Competencies are re-evaluated at the time of the annual performance appraisal.

An interview was conducted with the Director of Risk Management on 11/27/13 at approximately 1:00 p.m. She confirmed the above findings.