HospitalInspections.org

Based on policy review, facility document review, medical record review and interview, the facility failed to ensure a registered nurse appropriately monitored 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "Telemetry and Cardiac Monitoring: Patient Care Guidelines - Adult" policy revealed, "...A rhythm strip analysis is completed and placed in the patient's medical record on admission, every shift or per unit standard, and with any change in rhythm...Once Cardiac Monitoring is initiated, an order is required for temporary disconnection (e.g. [for example], for showers, walking in hallway, leaving the unit for test/procedures)...If the patient does not have an order for temporary disconnection for transport, a portable cardiac monitor is used to continue Cardiac Monitoring when the patient requires transport off the patient care unit. In addition, the patient is accompanied by an RN, Emergency Medical Technician (EMT)-Paramedic, or physician..."

2. Review of the unit specific guidelines revealed, "...[unit Patient #1 was residing on]...Level of Care...Monitoring: Vital Signs (T [temperature], HR [heart rate], RR [respiratory rate], SaO2 [oxygen saturation]), Focus system assessment (neuro [neurological] checks, pulses, I & O [intake and output])...Unit standards are typically q4 [every 4 hours], specific q2 [every 2 hours] orders must be written..."

3. Medical record review for Patient #1 revealed an admission date of 8/1/18 with diagnoses which included Severe Symptomatic Atherosclerosis, Severe Aortic Stenosis, Diabetes Mellitus, Congestive Heart Failure and Peripheral Artery Disease with Left Below the Knee Amputation.

A physician's order dated 8/1/18 at 9:12 PM revealed, "...Telemetry monitoring Continuous ...Reason for telemetry: Syncope with strong suspicion for cardiac involvement...Can patient leave unit with unmonitored transport to another unit, test or procedure...MAY NOT...Can the patient come off monitor for shower of physical therapy...MAY NOT..."

There was no documentation of rhythm strips or analysis completed for Patient #1's continuous cardiac monitoring from 8/3/18 at 8:43 AM to 8/4/18 at 7:17 AM.

The "Clinical Update" dated 8/4/18 revealed, "...I was notified by RN that patient's BPs were 70s/40 at 1130a [AM]. She was tachycardic to the 110s, mentating appropriately, but in distress. BP did not improve with supine positioning. She then became diaphoretic and nauseous. She was satting [oxygen saturation] 85% and we started 2L [liters] NC [nasal cannula] and her sats [oxygen saturation] recovered to 93%...STAT [immediately] ECG [electrocardiograph], troponin-1 and CKMB [creatinine kinase-muscle/brain] were ordered. Before the bolus was started, her pressures recovered to the 140s systolic and the patient subjectively felt better with resolved nausea and diaphoresis...ECG at 11:48 [AM] demonstrated global ischemia, most remarkable for ST depressions in a lateral distribution. Repeat ECG still showed signs of global ischemia with improvement of the previously mentioned ST depressions...."

The "Default Flowsheet Data" revealed there were no vital signs documented for Patient #1 from 8/4/18 at 8:21 AM to 8/4/18 at 5:57 PM (9 hours 36 minutes).

The "Default Flowsheet Data" dated 8/4/18 at 2:00 PM revealed, "...pt's [patient's] bp dropped to 55 systolic...md [medical doctor] made aware...Ekg [electrocardiograph] initially showed depreed [depressed] st segment, but correted [corrected] itself. Trop [troponin] and ck [creatinine kinase] were elevated..." There was no other documentation of Patient #1's condition or assessment by the RN during this episode or afterward until an assessment was documented on 8/4/18 at 9:06 PM. There was no documentation in the physician's note the physician was aware Patient #1's systolic blood pressure had dropped to 55.

4. During an interview in the conference room on 9/4/18 at 12:30 PM, Senior Patient and Quality Advisor #1 confirmed there was no documentation of vital signs for Patient #1 from 8/4/18 at 8:21 AM to 8/4/18 at 5:57 PM.

During a phone interview on 9/4/18 at 1:00 PM, when asked about Patient #1's vital signs not documented from 8/4/18 at 8:21 AM to 8/4/18 at 5:57 PM, the Nurse Manager for [unit Patient #1 was residing on] stated the vital signs should have been documented between those times.

During an interview in the conference room on 9/4/18 at 2:00 PM, Accreditation and Regulatory Specialist #1 confirmed no rhythm strip was documented or analysis completed for Patient #1's continuous cardiac monitoring from 8/3/18 at 8:43 AM to 8/4/18 at 7:17 AM.

5. During an interview in the conference room on 8/28/18 at 1:44 PM, RN #1 stated the telemetry order for each patient indicated whether the patient could be taken off the monitor to leave the unit for a test or taken off the monitor for a shower. RN #1 stated she had not checked the order for Patient #1 and did not know whether Patient #1 could be taken off the monitor to leave the unit or take a shower.

During a phone interview on 9/4/18 at 1:30 PM, Care Partner #1 stated she took Patient #1 off the cardiac monitor while she gave the patient a bath on 8/4/18. Care Partner #1 stated she asked RN #1 if Patient #1 could be taken off the monitor for a bath, and RN #1 had told her the patient could be taken off the monitor.

The facility failed to ensure Patient #1 was monitored per policy and physician's order.