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Based on medical record review, policy review and interview the facility failed to provide nursing supervision while the patient was removed from the physician ordered cardiac monitor and alone. (A395) The cumulative effect of this systemic practice resulted in the facility's inability to ensure the patient was safe. This deficient practice had the potential to affect all 483 patients.

Based on review of medical record and staff interview the facility failed to provide supervision to one of six patients who received nursing care on the 9th floor. (Patient #2) A total of 10 medical records was reviewed.

Findings include:

1. Patient # 2 was admitted to the intermediate care unit on the ninth floor for continuous cardiac monitoring with physician activity orders to advance as tolerated on 12/24/13. The record revealed Patient #2's diagnosis was acute renal failure. On 12/25/13 at 7:13 PM the cardiac monitoring strip revealed the patient was in atrial fibrillation with multiform PVC's (premature ventricular contractions). At 7:44 PM the patient's blood pressure reading was 108/52. At 11:01 PM on 12/25/13 the atrial fibrillation was revealed again on an ECG ordered by the patient's physician. On 12/26/13 at 6:51 PM an EKG strip revealed an irregular heart rate of 82-94 beats per minute with PVC and recorded an oxygen saturation of 98 percent.


2. The Risk Management Report report reveals the date and time of the event as 12/27/13 at 5:45 AM. The report reads," patient was taken to the bathroom around 5:30 AM; when Staff C, nurse assistant, went back into room to check on Patient #2 around 5:45 AM, Staff C opened door to the bathroom, Staff C saw patient lying face down on the floor. Staff C pushed the call light in bathroom, yelled the patients name and checked for a pulse. Staff C pushed code blue button in the room and yelled out into the hallway for help. Soon after, there were multiple nurses in the room who began CPR." The "preparer of the report" is an optional field to populate and was left blank.

Review of the Resuscitation Record indicates the date and time the code was called as 12/27/13 at 5:40 AM. Further down the page on the record, the time the code was called is listed as 5:50 AM. The resuscitation record indicates Patient #2 was in cardiac and respiratory arrest and was intubated the at 5:55 AM. Resuscitative efforts using medications and chest compressions continued but Patient #2 remained asystole (without a heart rhythm) and was pronounced dead at 6:04 AM.

3. Interview with Staff A, accreditation specialist, on 5/20/14 at 10:00 AM revealed the nursing assistant, Staff C and the Registered nurse (Staff E) were both interviewed by their unit director (Staff D) at the time of the event. Staff C reported to his/her unit director that both Patient #2 and the patient in the room next door requested assistance to the bathroom at the same time. Staff C delegated another nursing assistant to assist Patient #2 to the bathroom as he/she was a minimal assist. Patient #2 was hardwired to the cardiac monitoring device and did not have a mobile monitoring device. This necessitated the nursing assistant disconnect the patient from the cardiac monitoring device and assist the patient to the bathroom. Staff C entered the room of Patient #2 when he/she finished with the patient next door and found Patient #2 unresponsive on the floor in his bathroom.

The medical record review lacked evidence Patient #2 was supervised while off the cardiac monitor.

Review of documentation of the current patient care practice for the 9th floor intermediate care unit dated June 4, 2014 revealed when the patient is ordered to be on an EKG monitor and is permitted to ambulate then the patient must be placed on a portable EKG monitor (telemetry) when off the fixed monitor.

A request for telemetry policy was made on June 4, 2014. Review of policy dated August, 2009 with subject: Transport of Adult Patients Intrafacility revealed Care, treatment, and services are maintained by the patient care team throughout the patient's hospital admission including during transportation between patient care areas. If the patient is medically unstable an RN accompanies the patient. Typical situations requiring RN monitoring include patients with potentially life threatening arrhythmias.

Review of a draft policy for Adult Cardiac Monitoring: Intermediate Level of Care dated June 2014 reveals this policy is new and does not supercede any old policy. This policy states a physician order to the intermediate unit implies cardiac monitoring as standard practice. Under Procedure at Number 8, the policy states: Ensure that temporary discontinuation of cardiac monitoring during patient transfer for personal care does not occur unless ordered by prescriber.