HospitalInspections.org

Based on staff interview and review of medical records, the facility failed to provide adequate delivery of care for one (#1) of 20 medical records reviewed. This failure created the potential for negative patient outcome.

The findings were:

The medical record for patient #1 was reviewed on 1/11/11. The patient was admitted to the medical telemetry unit on 10/11/10 at approximately 1:40 p.m. with physician orders to initiate telemetry monitoring. The patient was experiencing asthma exacerbation on admission and was assigned to a registered nurse (RN). The RN had concerns regarding the patient's respiratory condition and was primarily focusing on initiating respiratory interventions. The RN did not follow the new process of allowing the Health Unit Coordinator to admit the patient to the Central Telemetry Station and supply the telemetry box and leads. Instead, the RN took the telemetry box and leads from the drawer and placed them on the patient bypassing the Coordinator. Also, the RN did not attempt to run an initial rhythm strip after placing the monitoring device on the patient. (This cannot be done until the patient is admitted to the Central Telemetry Station.) In bypassing the initial steps, no one else but the RN was aware that the patient needed telemetry monitoring. The RN was a float nurse and handed off the patient to the on-coming RN at 3:00 p.m.

The on-coming RN that assumed care for the patient reportedly was not told during the hand off that the patient was to have continuous telemetry monitoring. At 8:45 p.m., the night shift charge nurse discovered that the patient was a telemetry patient and was not being monitored. The RN was informed of the omission and went to the patient's room and noted the telemetry box and leads were on the patient; however, there was no monitoring occurring due to the patient had not been programed into the Central Telemetry Station. The RN had failed to follow the usual routine of checking her/his charts at the beginning of the shift so had missed this physician order.

An interview was conducted with the director of the medical telemetry unit on 1/10/11 at approximately 1:15 p.m. during the tour of the unit. The director stated that the new telemetry monitoring system had been implemented on 9/23/10 with education provided to all staff including the float pool. The new process for staff to follow with the new system was not properly executed by either RN. The director further stated that due to the incident of 10/11/10, an audit tool was revised and implemented on 10/19/10.

The audit tool was reviewed on 1/10/11. The audit tool is a spread sheet that is completed every hour 24/7 (24 hours a day/seven days a week) by the director and/or charge nurse. The audit tool is used to identify the list of patients who have been prescribed telemetry and then compared to the central monitoring station to make sure the monitoring is happening.

Further interview with the director revealed the incident of 10/11/10 needed further reviewing and another step added to the process. The added step to the process is there will be a time frame for implementation of the telemetry box with leads attached to the patient by the RN. The revised process now is that after the Coordinator enters the patient into the Central Telemetry Station, a telemetry box with the leads would be set out and the RN in charge of the patient would be called and given 15 minutes to respond and to place the monitoring device on the patient and run an initial rhythm strip. If the RN did not respond in that time frame, the coordinator would again page the RN and also inform the charge nurse.

In summary, although the deficient practice occurring on 10/11/10 had been identified by the facility and corrective processes put in place, the incident was a series of errors that would benefit further review by the facility.

Based on staff interview and review of medical records, the facility failed to implement a nursing care plan for one (#7) of 20 medical records reviewed. Specifically, the facility failed to develop and implement a plan of care that would be reviewed and revised as necessary to meet the care needs of the patient. The failure of the facility to identify and address the medical needs of the patient had the potential for the patient to experience negative outcome and a prolonged hospital stay.

The findings were:

The medical record for patient #7 was reviewed on 1/11/11. The patient was admitted to the facility on 10/19/10 with a primary diagnosis of chest pain and discharged on 10/21/10. The Electronic Medical Record (EMR) portion of the medical record review revealed there was no nursing care plan implemented during the three days of the hospitalization.

An interview was conducted with the director of the unit on 1/11/11 at approximately 2:15 p.m. The director stated that when a patient is admitted to the unit, the admission data and initial nursing assessment will automatically identify the care planning needs. However, the facility staff agreed that the EMR had failed to interface correctly and patient #7 did not have a nursing care plan during his/her three-day hospitalization.