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Based on medical record reviews and interviews for 2 (P#1 and P#2) of 4 patients with a change in condition, the hospital failed to ensure that a practitioner's patient assessment was documented and/or that documentation was timed accordingly. The findings include:


A. Patient #1 was admitted to the hospital on 1/10/18 with diagnoses that included congestive heart failure (CHF), hypertension (HTN), chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). P#1's cardiac status was monitored via a telemetry monitor.

A cardiology progress note by Medical Doctor (MD) #1 dated 1/14/18 at an unidentified time indicated P#1's breathing had improved, had a regular cardiac rhythm and no further complaints were offered. The plan of care indicated P#1 would continue on a Lasix (diuretic) drip and his/her fluid and electrolytes would be monitored.

On 1/14/18 at 9:30 AM MD #1 ordered for P#1 to receive Metoprolol 5 milligrams (mg.) intravenous one time and Heparin 25000 units in 500 milliliters (ml) of 0.45% normal saline intravenous drip. Review of the medical record failed to identify that an assessment had been documented by MD#1 prior to initiation of the treatment with Metoprolol and Heparin for atrial fibrillation (a-fib).

A physician progress note by MD#2 dated 1/14/18 at 4:00 PM indicated MD#2 had been informed that P#1's telemetry monitor had been switched with another patient who was experiencing (a-fib) with rapid ventricular response (RVR). The note indicated before the error was identified, P#1 received a rate control agent and a heparin drip without bolus for two hours (in error). MD#2 indicated in the progress note the incident and subsequent treatment caused P#1 no ill effects.

During an interview with MD#1 on 5/31/18 at 8:00 AM, MD#1 indicated his initial assessment was not timed however had occurred prior to P#1 exhibiting atrial fibrillation on the monitor. MD#1 indicated when notified that P#1 was experiencing atrial fibrillation he/she did assess P#1 for symptoms of a-fib, however did not document the assessment in P#1's medical record.


B. Patient #2 was admitted to the hospital on 1/12/18 with diagnoses that included acute decompensated congestive heart failure (CHF) and persistent atrial fibrillation with rapid ventricular response. P#2's cardiac status was monitored via a telemetry monitor. Although P#2 was experiencing a-fib, P#2's monitor did not reflect that the patient was experiencing a-fib because P#1 and P#2's monitors had been switched in error.

An assessment of P#2 completed by MD#1 dated 1/14/18 lacked documentation of the time the assessment was completed. A subsequent assessment documented by MD#2 was dated 1/14/18 at 11:00 AM.

P#2 did not experience any ill effects due to the delay in receiving treatment for his/her a-fib.

Medical Staff bylaws indicated each member of the medical staff would provide patients with continuous high quality care meeting the professional standards of the medical staff of the hospital. In addition the medical staff rules and regulations indicated all written entries in the medical record should include the date and time of the note.

Based on review of hospital documentation and interviews for patients on cardiac telemetry monitoring the hospital failed to ensure monitoring documentation was recorded according to hospital practice. The findings include:

During a review of hospital investigative documentation it was identified on 1/14/18 that a print out of telemetry monitoring strips was not completed at 7:00 AM due to the unavailability of telemetry strip paper.

During an interview with Technician #1 on 5/31/18 at 10:20 AM he/she indicated that at the start of the shift on 1/13/18 at 1:00 PM telemetry strip paper was not available therefore Technician #1 printed the strips for all patients on telemetry on alternate paper.

During an interview with Technician #2 on 5/31/18 at 11:00 AM he/she indicated that at the start of the shift on 1/14/18 at 7:00 AM telemetry strip paper was not available. He/she did not know how to obtain additional paper therefore he/she did not print out telemetry strips for all patients on telemetry monitoring.

A hospital procedure for CMU (Cardiac Monitoring Unit) printing of telemetry strips indicated telemetry rhythm strips should be printed for all patients on telemetry at shift start and the strip should be measured and analyzed.

Subsequent to 1/14/18 all staff of the CMU was educated on how to obtain telemetry paper when stock is not available.

The Condition of Participation for Nursing Services has not been met.
Based on medical record review and interviews for 1 (P#1) of 12 patient reviewed who underwent cardiac monitoring via telemetry monitoring devices the hospital failed to ensure that staff followed the hospital procedure for wireless telemetry device application and monitoring resulting in P#1 receiving treatment for P#2's cardiac arrhythmia (atrial fibrillation).


Please see A 395

Based on medical record review and interviews for 2 (Patients#1 and 2) of 12 patients reviewed for cardiac monitoring via telemetry monitoring devices, the hospital failed to ensure that staff followed the hospital procedure for wireless telemetry device application and monitoring resulting in Patient #1 receiving treatment for Patient #2's cardiac arrhythmia (atrial fibrillation). The findings include:


Patient #1 was admitted to the hospital on 1/10/18 directly from the cardiology clinic for decompensated heart failure. Patient #1's history included congestive heart failure, hypertension, chronic obstructive pulmonary disease and coronary artery disease. Patient #1 was admitted to Room 208 of the Intermediate Unit (IU). A cardiology progress note by Medical Doctor (MD) #1 dated 1/14/18, at an unidentified time, indicated Patient #1's breathing had improved, had a regular cardiac rhythm and no further complaints were offered. The plan of care indicated Patient #1 would continue on a Lasix (diuretic) drip and his/her fluid and electrolytes would be monitored.

Patient #2 was admitted to the hospital on 1/12/18 after elective right and left cardiac catheterization for rate control. Patient #2's history included decompensated congestive heart failure and persistent atrial fibrillation (a-fib) with rapid ventricular response. Patient #2 was admitted to Room 215 of the intermediate unit.


a. On 1/14/18 at 4:00 AM Registered Nurse (RN) #1 requested a telebox (portable telemetry monitoring device) for Patient #1 from the Cardiac Monitoring Unit (CMU) via phone. RN#1 was instructed by Technician #1 that a telebox was not available from the cardiac monitoring unit at that time and to obtain one from the intermediate unit as is usual procedure. RN #1 obtained telebox #13 and placed it on Patient #1. Review of the hospital's post incident analysis identified that following placement, RN#1 and Technician #1 failed to verify telebox #13's application (placement on the patient) and failed to obtain a patient rhythm, as is usual procedure.

The hospital process for telebox assignment included in part, assignment is based on the patient's room number.

Interview with RN#1 on 5/31/18 at 9:15 AM identified that on 1/14/18 at 4:00 AM he requested a telebox from the cardiac monitoring unit via phone and was instructed by Technician #1 that a telebox was not available and to obtain one from the intermediate unit as was usual procedure. RN#1 indicated after obtaining telebox #13 he put it on Patient #1 and notified Technician #1 that Patient #1 was on telebox #13. RN #1 identified that he did verify the rhythm on Patient #1's telebox and it indicated normal sinus rhythm.


b. At 5:51 AM RN#1 went to the cardiac monitoring unit, signed out, and removed telebox #15. RN#1 told Technician #1 that he was taking telebox #15 for room 215 (Patient #2). Review of the hospital's post incident analysis identified that following placement, RN#1 and Technician #1 failed to verify telebox #15's application (placement on the patient) and failed to obtain a patient rhythm, as is usual procedure.

Hospital process for obtaining a telebox was to call (not go to) the cardiac monitoring unit and request a box. Then transport staff would bring the telebox and appropriate paperwork to the intermediate unit for patient use.

At 5:52 AM, according to the Connexall system (the hospital's cardiac monitoring system), Patient#1 was switched from telebox #13 to telebox #15.

Interviews with RN #1 and Technician #1 failed to identify how Patient #1's telebox was switched from telebox #13 to telebox #15.

At 5:53 AM Technician #1 identified Patient #2's bedside monitor indicated "check leads". Technician #1 attempted to contact RN#1 to verify the telebox and bedside monitor readings however RN#1 was not signed into the Voalte system (staff communication system) and could not be reached via this communication system. At that time, Technician #1 failed to communicate with RN#1 in another manner and/or failed to contact another nurse regarding Patient #2's status. It was later identified that RN #1 was not signed into the staff communication system from 3:00 AM to 8:00 AM and should have been, as was the hospital process.

Interview with RN#1 on 5/31/18 at 9:15 AM identified that on 1/14/18 he went to the cardiac monitoring unit, signed out, and removed telebox #15. RN#1 told Technician #1 he/she was taking telebox #15 for room 215 (Patient #2). RN#1 then proceeded to Patient #2's room, applied telebox #15 and checked the rhythm, which showed normal a-fib. RN#1 indicated that he believed that the telebox switch occurred at 5:50 AM when Technician #1 had changed P#1 from telebox #13 to telebox #15.

Interview with Technician #1 on 5/31/18 at 10:20 AM identified that on 1/14/18 at approximately 5:00 AM a staff member hurriedly came into the cardiac monitoring unit, took telebox #15, indicated several times that he was taking the telebox for room 215 (Patient #2), and then ran out of the room. Technician #1 indicated the staff member did not identify who he was, but another technician in the room (Technician #3) identified him as RN#1. According to the Voalte system (staff communication system) the nurse assigned to room 215 was not RN#1. Technician #1 indicated that after RN#1 left the room, Technician #1 and Technician #3 together assigned telebox #15 to room 215 (Patient #2). Technician #1 indicated that normal procedure was that when a telebox is removed from the cardiac monitoring unit, a form attached to the telebox is completed with the patient name, room number, date and time and placed in the slot where the specific telebox is stored. Once the telebox is connected to the patient the nurse calls or sends a message to the cardiac monitoring unit verifying that the patient is connected. However in this situation RN#1 did not complete the form and the cardiac monitoring unit did not receive a confirmation message from RN#1. Technician #1 was able to see on the monitoring system that room 215 (Patient #2) had been removed from the bedside monitor. Therefore Technician #1 and Technician #3 connected room 215 (Patient #2) to telebox #15, which completed an 11 step process to register the telebox to that particular patient. Technician #1 indicated that shortly after connecting Patient #2 to telebox #15, room #208 (Patient #1's) telebox was registering a heart rate in the 150's. Technician #1 messaged the nurse assigned to room #208 (Patient #1) via the Voalte system (staff communication system) but did not receive a response back. Technician #1 then reported off to Technician #2 between 7:00 AM and 7:30 PM.



c. At 7:30 AM Technician #1 reported off to Technician #2. Technician #2 noticed telebox #15 (assigned to Patient #2) was alarming high heart rate (203) and was unable to reach RN#1 so she called the intermediate unit and reported the high heart rate. Technician #2 was unable to identify who she reported the high heart rate to.

At 8:00 AM Technician #2 notified RN#1, via the Volte system (staff communication system), that telebox #15 continued to sustain a heart rate of 180's-190's. RN#1 responded and indicated he would evaluate the high heart rate.

At 8:26 AM Technician #2 notified RN#1 that telebox #15 continued to indicate a high heart rate. RN#1 responded via the Voalte system "OK".

At 8:38 AM Technician #2 notified RN#1 that Patient #2 had been on the bedside monitor and was now "off monitor". At 8:39 AM RN#1 indicated Patient #2 was in the bathroom. Technician #2 notified RN#1 that if RN#1 wanted Patient #2 on a telebox, telebox #15 should be located in Patient #2's room (room 215).

At 8:44 AM the Connexall log identified that Patient #2 was placed on telebox #13. According to the Voalte (communication) system log, Technician #2 notified RN#1: "Patient #1 (room 208) is on tele box #15 and Patient #2 (room 215) is on telebox #13". There was no response from RN #1.

At 9:21 AM MD#1 was notified that telebox #15 indicated Patient #1 was exhibiting atrial fibrillation. MD#1 verified the a-fib on the monitor and instructed RN#1 to obtain an Electrocardiogram (EKG). The EKG showed normal sinus rhythm (NSR). MD#1 consulted with MD#2.

At 9:30 AM MD#1 ordered Patient #1 to receive Metoprolol 5 milligrams (mg.) intravenous one time. Interview with RN #1 on 5/31/18 at 9:15 AM identified that at that time, he had to take another patient for an immediate CT-scan and asks RN#2 to cover his patients. RN#2 noted the order for Metoprolol and messaged RN#1 to verify that it had not yet been given. RN#1 verified the Metoprolol had not been given and RN#2 administers the Metoprolol 5 mg. IV at 10:19 AM.

At 10:43 AM MD#1 ordered Patient #1 to receive Heparin 25000 units in 500 milliliters (ml) of 0.45% normal saline intravenous (IV) drip. Between 10:43 AM and 1:16 PM, 2 EKS's were obtained, an additional IV access was obtained as well as ordered laboratory bloodwork according to protocol, followed by initiating the Heparin drip which was started at 1:16 PM.

At approximately 2:00 PM RN#1 went to the cardiac monitoring unit to verify Patient #1 and Patient #2's monitor rhythms. At that time, it was identified that Patient #1 and Patient #2's telebox's were on the wrong corresponding patients. Therefore Patient #2 was experiencing a-fib, not Patient #1. MD#1 was notified and Patient #1's Heparin drip was immediately stopped.

A physician progress note by MD#2 dated 1/14/18 at 4:00 PM indicated MD#2 had been informed that Patient #1's telemetry monitor had been switched with another patient and that the other patient was experiencing a-fib with rapid ventricular response, not Patient #1. The note indicated before the error was identified, Patient #1 received a rate control agent and heparin drip without bolus for two hours. MD#2 indicated in the progress note the incident and subsequent treatment did not cause Patient #1 any ill effects.

Interview with Technician #2 on 5/31/18 at 11:00 AM identified that communication between Technician #2 and RN#1 occurred at several points in the morning on 1/14/18. Communication included verifying the elevated heart rate of Patient #1 and/or Patient #2's telebox's and the patients being on or off bedside monitor. Technician #2 identified that RN#1 would respond to the messages, however there were several times when Technician #2 and RN#1 differed on what they were seeing on the monitors. Example: Technician #2 would identify that the patient was off monitor and RN#1 would indicate he thought the patient was on the telebox.

Interview with MD#1 on 5/31/18 at 8:00 AM MD#1 indicated he/she was notified by RN#1 that Patient #1's telebox was showing a-fib. MD#1 then verified Patient #1's rhythm on the monitor in the charting room as a-fib (room 208). MD #1 indicated he/she then ordered an EKG and went to examine Patient #1. Upon exam and questioning, Patient #1 exhibited no signs or symptoms of a-fib. A review of the EKG showed Patient #1 was in normal sinus rhythm. MD#1 indicated it is not uncommon for a patient to go in and out of a-fib, therefore explaining why the EKG showed a normal sinus rhythm. MD#1 consulted with MD#2, and P#1 was diagnosed with new onset a-fib for which heparin was indicated. MD#1 indicated that at approximately 2:00 PM, he/she was notified that Patient #1 and Patient #2's telebox's were on the wrong corresponding patients and the heparin drip had been turned off.

Interview with MD#2 on 5/31/18 at 8:00 AM identified that he/she had been consulted by MD#1 and the course of treatment provided to Patient #1 based on his/her a diagnoses of atrial fibrillation was appropriate. MD#2 indicated there were no complications or ill effects to Patient #1 as a result of receiving Metoprolol and Heparin. In addition, Patient #2 did not experience any ill effects due to the delay in receiving treatment for his/her a-fib.

According to the Instructions for application and use of the wireless telemetry monitoring device: 1) call the cardiac monitoring unit with the patients name, bed number, and request a telebox; 2) when transport arrives with the telebox collect the telebox and complete the form and confirm the patient identification; 3) Disconnect the bedside monitor wires and connect to the telebox; 4) Voalte message with patients name, bed number and request for transmission confirmation; 5) wait for confirmation from the cardiac monitoring unit.

Interviews and a review of events with Compliance Officers #1 and #2 on 6/4/18 identified that the hospital implemented the following interventions after the incident occurred: 1) reeducation on nursing communication systems (Voalte), telebox verification and the implementation of a telebox tracking log; 2) implementation of an escalation (notification) process for cardiac monitoring staff when telemetry alarms are sustained, including the addition of rhythm log and communication log; 3) reeducation on monitoring of supplies in the cardiac monitoring unit and how to acquire additional supplies; 4) monitoring and audits of compliance as scheduled.

On 6/27/18 at approximately 3:00 PM P#16 (room 226) was switched from bedside wired monitor to a telebox to ambulate with Physical Therapy and Nursing. Upon return of P#16 to room 226 Nursing called the central monitoring unit (CMU) to tell them to place room 226 back on hardwire monitor. CMU immediately called indicating room 225 had been placed on telebox not room 226. Error was corrected within 3-5 minutes and no ill outcome to either patient.
The patients in room 225 and 226 continued to be monitored by either hardwired bedside monitor or telebox during this time.

During an interview with Senior Nursing Director on 7/12/18 at 10:15 AM he/she indicated telebox's have been removed from the Intermediate Unit (IU) and all patients will be monitored when ambulating via the cube of the hardwired bedside monitor and with an escort of a registered nurse. Senior Nursing Director indicated in September 2018 it is planned that the IU will begin using a program in which the switch over from BSM to portable will be done automatically and will not require manual entry of patient information therfore eliminating possible entry of incorrect information.