HospitalInspections.org

Based on a review of the medical record (MR1), facility documentation and staff interview (EMP), it was determined that Conemaugh Memorial Medical Center failed to provide care in a safe setting by failing to ensure that a cardiac monitoring unit was appropriately attached to a patient and failed to document an unusual incident in one of one medical record. (MR1).

Findings Include:


Conemaugh Memorial Medical Center ... PolicyStat ID: 161804 ... Last Reviewed: March 2015 ... Policy Area: Risk Management ... Event/Incident Reports policy and procedure. "Statement of Policy: It is the policy of Memorial Medical Center that all events/incidents be reported promptly. Prompt reporting of events/incidents is necessary to protect patients, visitors, employees and students against hazards as well as to provide a complete and accurate record of the event/incident. ... Requirements An event/incident is defined as: A. Any bodily injuries, regardless of severity, to employees, patients and visitors. ... D. The Event/Incident Report should be reported in SRM on the hospital intranet by the employee or staff member who discovers or witnesses the event, i.e., the employee or staff member most closely involved. ... Procedures for SRM Event/Incident Reports Patients and Visitors: Statement of Procedure ... Requirements ... 7. Prompt completion of Events/Incident Reports is essential. The fact that an event/incident report was completed must not be written in the chart. Entries made into the medical record should contain objective and factual information necessary for continuity of care. ... Specific Examples of Patient Events/Incidents ... A. Treatment/Procedure Events/Incidents ... Other events/incidents involving treatment or procedure that should be reported. ... D. Miscellaneous Events/Incidents ... Patient trauma, miscellaneous, including self-inflicted injury. ... Safety hazards ... Other miscellaneous events/incidents. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 1970090 ... Last Reviewed: December 2015 ... Policy Area: Organization-Clinical ... Patient Rights policy. "Statement of Policy: It is the policy of Conemaugh Health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating patient's personal values and belief systems and strive to protect each patient's dignity. ... 1. You have the right to respectful care given by skilled staff. ... 2. ... You have the right to treatment symptoms that may be associated with your illness. You have the right to expect prompt response to your report of pain. ... 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 4192533 ... Last Reviewed: November 2017 ... Policy Area: Nursing ... "Policy - All staff caring for patients requiring remote cardiac monitoring will follow established procedures, guidelines and responsibilities to provide a safe environment for our patients. ... Process: d. ... a. Patients with loose leads/off monitor/low battery/poor tracing: ... If the patient is fine, check the electrodes/leads/monitor/battery. If new electrodes/battery is needed, the NA/RN replaces the electrodes/battery within 10 minutes. If not contacted within 10 minutes, the Monitor Tech contacts the NA/RN for an update, if not resolved ... Responsibilities: The nursing unit staff: ... RN or designee re-preps the skin and applies fresh moist electrode as needed, if one electrode needs to be replaced, replace all electrodes. ... Place telemetry transmitter into carrying pouch or pocket on gown. ... ."



1. MR1 Physician Orders documentation dated December 13, 2017, at 11:34 AM revealed an order for "Cardiac Monitoring, Indefinite Monitoring; Acute MI."


2. An interview was conducted on February 2, 2018, at 10:15 AM with EMP2. "The Nursing Assistant saw that the patient's was loose and ready to fall off, they stepped out to get fresh monitor pads and when the patient leaned over, the monitor did come loose and bump the patient's leg. ... We addressed all concerns and apologized that the monitor hit their leg. ... EMP3 addressed with the nurse that an incident report should have been filled out.

3. An interview was conducted on February 2, 2018, at 10:45 AM with EMP4. "I was not in the room when the heart monitor fell and hit the patient on the leg, did not witness it. ... I did go in and looked at the patient's legs, there were no marks, no edema and patient had stated to me that they always had knee problems. ... I did not document any of this in the medical record. I did not do an incident report because I did not witness or see any broken skin, no marks on shin either."

4. A second telephone interview was conducted on March 19, 2018, at 10:30 AM with EMP3. "... Nurse said that the family member told them what happened with the monitor and the nurse looked at the patient's legs and didn't see anything, so there was nothing to document in the record. ... ."