HospitalInspections.org

Based on observation, record review and interviews, the hospital failed to ensure services were provided that were free of neglect as evidenced by:
1) failing to ensure a patient was immediately assessed after notification by the telemetry technician that a telemetry pattern was not maintained for 1 (#1) of 3 (#1, #2, #4) telemetry patients sampled;
2) failure of the telemetry technician to notify the nurse, charge nurse, or rapid response team that a patient's rhythm could not be visualized for 1 (R1) of 61 patients observed at the telemetry monitoring station; and
3) failing to ensure quality assurance instituted corrective action, including staff education, regarding identified lapses in telemetry patient's care for 1 (#1) out of a total of 5 patients sampled.
Findings:

1) Failing to ensure a patient was immediately assessed after notification by the telemetry technician that a telemetry pattern was not maintained.

Review of the hospital's policy titled, "Telemetry Monitoring Guidelines" revealed in part: E. Monitoring - 1. The telemetry tech will call the primary nurse or nursing unit immediately if they cannot visualize a patient's rhythm or a drop in the SPO2, and if the patient is experiencing an arrhythmia. 2. If a potentially lethal arrhythmia or a lethal drop in SPO2 is noted and the telemetry tech cannot reach the primary nurse, the telemetry tech will immediately notify the Rapid Response Nurse and/or Charge Nurse/House Supervisor. 3. If the telemetry tech is unable to contact the primary nurse after 1-3 minutes for lead dislodgement or non-life threatening arrhythmias and drop in SPO2, the telemetry tech will call the Rapid Response Nurse and/or Charge Nurse/House Supervisor for assistance. 4. It is the primary nurse's responsibility to immediately check the patient and maintain a clear telemetry pattern at all times.

Review of Patient #1's medical record revealed in part: Physician's orders 06/05/2021 - O2 therapy- Cardiac Telemetry - Continuous pulse oximetry. Notify physician for HR >120 <50. RR >24. Further review revealed a
Rapid Response Note dated 9/6/20 at 1:52 p.m. revealed in part: Patient found lying partially out bed with her head hanging toward the ground unresponsive with BIPAP mask on disconnected from BIPAP, apneic and pulseless code blue called and ACLS(Adult Cardiac Life Support) protocol followed.

Review of Telemetry Call Sheet revealed on 9/6/2020 at 1:40 p.m. Patient #1 off Monitor. First call noted to nurse S3RN. No other calls were noted for Patient #1.

The medical record failed to reveal Patient #1's was immediately checked to ensure a telemetry pattern was maintained following notification by the telemetry technician.

Interview on 06/21/2021 at 1:00 p.m., S1RM stated S3RN did not follow the hospital's policy.

2) Failure of the telemetry technician to notify the nurse, charge nurse, or rapid response team that a patient's rhythm could not be visualized for 1 (R1) of 61 patients observed at the telemetry monitoring station.

Observation of the telemetry monitoring station on 06/22/20211 at 12:36 p.m. revealed Patient R1's telemetry was off line and not being monitored.

Interview on 06/22/2021 at 12:38 p.m., S5TelTech acknowledged patient R1 was not being monitored and could not tell the surveyor why Patient R1's telemetry pattern was not being monitored. S5TelTech stated she did not notify the nurse that Patient R1's telemetry pattern had stopped.

Review of the telemetry data revealed Patient R1 telemetry pattern had stopped at 11:03 a.m. (discovered by surveyor 1 hour and 33 minutes later).

Review of the Telemetry Call Sheet failed to reveal a nurse was notified that Patient R1's telemetry pattern had stopped.

Interview on 06/22/2021 at 1:00 p.m., S4RN stated she was unaware Patient R1's telemetry pattern had stopped and continued to state that she was not notified Patient R1's telemetry monitoring had stopped.

Interview on 6/22/21 at 2:20 p.m., S2Director acknowledged there is a continued problem of the nursing staff not being notified when a patient's telemetry pattern has stopped.

Interview on 06/22/2021 at 2:40 p.m., S1RM acknowledged the telemetry technician did not follow the hospital's policy. S1RM acknowledged the practice of not contacting the nurse when a patient's telemetry pattern has stopped is currently an ongoing problem.

3) Failing to ensure quality assurance instituted corrective action, including staff education, regarding identified lapses in telemetry patient's care for 1 (#1) out of a total of 5 sampled patients.

Review of the hospital's Quality Assurance failed to reveal corrective actions were taken to address the incident of neglect in telemetry monitoring and failed to reveal staff had been educated regarding identified lapses in patient care.

Review of Incident Report (Event Record #260) dated 9/8/20 at 5:06 p.m. revealed in part: On Sunday 9/6/20 at 1:55 p.m. patient found apneic and pulseless, cyanotic with BIPAP mask on but not connected to BIPAP. Informed by S6TelTech at telemetry desk that the patient was off the telemetry monitor for 15 minutes prior to code. Pt disconnected at 1:40 p.m. he stated floor was notified and he spoke to Crystal unit secretary. He stated he called again 5 minutes later and spoke directly to the nurse Sandy who stated she would check on the patient. Code was called at 1:55 p.m.
"Was there a deviation from Generally Accepted Performance Standards - YES
Did the deviation reach the patient - YES
Did the deviation cause moderate to severe harm or death - YES-Serious Safety Event
CASE WILL BE REFERRED TO THE RISK MANAGER FOR FINAL CLASSIFICATION BEFORE IT CAN BE CLOSED".

Interview on 06/21/2021 at 1:00 p.m., S1RM clinical risk manager stated after a nurse is contacted for a patient off of the monitor, the nurse is to immediately respond and check on the patient. If the patient is not reattached within five minutes, the charge nurse was to be called and if the charge nurse was unavailable, the Rapid Response Nurse was to be called.

Interview on 6/22/21 at 2:20 p.m. S2Director stated he is part of the QA (Quality Assurance) team. He continued to state he did not recall being involved in a Corrective Action Plan regarding identified lapses in patient care. He continued to state his department did not complete a telemetry wide education program for the telemetry technicians regarding telemetry patterns stopping or lapses in patient care.

Interview on 06/22/2021 at 2:45 p.m., after review of a Corrective Action Plan dated 09/15/2020, S1RM acknowledged a revision to the telemetry policy was discussed but the process was never completed and an evaluation was never performed.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the registered nurse failing to reassess a patient when a significant change occurred in the patient's condition for 1 (#1) of 1 (#1) reviewed for a change in condition.
Findings:

Review of the hospital's policy titled, "Admission of Patient - Assessment and Reassessment" revealed in part: Reassessments: A. 2. RN must reassess for the following: When a significant change occurs in the patient's condition.

Review of the hospital's policy titled, "Telemetry Monitoring Guidelines" revealed in part: E. Monitoring - 1. The telemetry tech will call the primary nurse or nursing unit immediately if they cannot visualize a patient's rhythm. 4. It is the primary nurse's responsibility to immediately check the patient and maintain a clear telemetry pattern at all times.

Review of Telemetry Call Sheet revealed on 9/6/2020 at 1:40 p.m. S3RN was notified Patient #1's telemetry pattern had stopped.

Review of Patient #1's medical record failed to reveal S3RN assessed Patient #1 following notification the patient's telemetry pattern had stopped.

Interview on 06/21/2021 at 1:00 p.m., S1RM clinical risk manager stated when a nurse is contacted for a patient whose telemetry pattern has stopped, the nurse is to immediately respond and check on the patient.

Interview on 06/22/2021 at 1:50 p.m., S1RM stated S3RN did not follow the hospital's policy.