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Based on record review and interview the facility failed to ensure that patient medical records contained information necessary to monitor Patient's (P#1) condition and provide appropriate care.

Findings included:

Review of Emergency Department Physician's Note dated 02/17/15 documented P#1 presented to the facility on 02/17/15 with a chief complaint of chest pain. Further medical examinations confirmed diagnoses including Pneumonia, Pneumothorax, Pulmonary Edema and Sinus Bradycardia (low heart rate). P#1 was admitted to the facility on 02/17/15 and the attending physician ordered continuous cardiac monitoring. The patient was placed on central monitor telemetry.

Review of Central Monitor Telemetry Disconnection and Event Log dated 02/17/15 7 pm to 7 am shift documented that on 02/18/15 at 0541 am, Staff #3 notified Staff #2 (primary nurse) that cardiac leads (electrodes used to monitor cardiac activity) for P#1 were disconnected. There was no data entry or other documentation including nursing notes that indicated the cardiac leads were reconnected to P#1 or reason for the disconnection. There was no documentation the charge nurse and or Unit Director for that area were notified in following the facility's policy to ensure every effort was followed to assure the cardiac leads were reconnected and monitored by nursing staff and central monitor telemetry technician.

Review of Central Monitor Telemetry Disconnection and Event Log dated 02/18/15 7 am to 7 pm shift documented that on 02/18/15 at 1012 am, P#1's cardiac leads were disconnected. There was no data entry or other documentation including nursing notes that documented the patient's cardiac activity was monitored by nursing staff or continuously monitored by central monitor telemetry technicians on 02/18/15 from 0541 am to 1012 am.

Review of Central Monitoring System Monitor Technician Protocol dated 10/00 documented in part:

II. Procedure
6. Alarm Notification
e. Priority Three/Level Three Call:

i. For Leads off or loss of signal:
1. Technician notifies Primary nurse immediately
2. Primary nurse assesses patient and notifies technician of resolution.
3. Technician verifies leads are attached and notifies primary nurse of patient's rhythm.

iii. Nurse's aide or available nursing staff unable to respond immediately:
1. Technician notifies Charge Nurse

iv. Charge nurse unavailable immediately to check patient:
1. Technician immediately notifies Unit Director for that area.

Interview with Staff #1 on 09/25/15 confirmed the above findings. Staff #1 indicated she was not able to determine whether P#1's cardiac activity was monitored by nursing staff and central monitor telemetry technicians on 02/18/15 from 0541 am to 1012 am based on nursing and telemetry technician documentation. Staff #1 said there was no documentation that the charge nurse and or department director were called during the 0541 am disconnect time to escalate the electrode reconnect process. Staff #1 also indicated an EKG strip (cardiac test) for P#1 was not documented to have occurred on 02/18/15 at 7 am as ordered by the physician.

During the Exit Conference on 09/25/15, facility personnel were given an opportunity to ask questions and provide additional information regarding the deficient practice identified during the complaint survey. No additional information was given.