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Based on review of records and interviews, the facility failed to follow the written order of a licensed physician for 1 of 6 Sampled Patients (SP) for a Magnetic Resonance Imaging (MRI) to rule out stroke in a prompt manner. SP#1

Findings include:

Record review conducted on 07/12/2023 revealed a Cardiac Surgery Progress Note/Encounter dated 06/15/2023 that documented SP#1's chief complaint as Mitral Valve (MV) Endocarditis (inflammation of heart valve). Further review of the note revealed that the plan was to transfer SP#1 to a sister facility for Mitral Valve Replacement (MVR).

Additional review revealed SP#1's history of present illness dated 06/15/2023 documented the chief complaint as Valvular vegetation. Review of SP#1's past medical history included but wasn't limited to End-Stage renal disease on hemodialysis, hypertension and hyperlipidemia who was transferred from another facility for MVR.

Neurology consult dated 06/16/2023 documented on physical exam today, SP#1 was noted to be awake, alert, and oriented x3, answering questions, following commands, and moving all extremities equally. No new focal or lateralizing deficits were noted. Will rule out a potential stroke due to endocarditis.

Further review of SP#1's record revealed the following:
Order: MR head/brain wo contrast Routine
Order: 06/16/23 08:38
Start: 06/16/23 08:38
Category: MRI
Is this test related to the Acute Reason for This Visit: Yes
What diagnosis Are you trying to find: Stroke

Further review revealed the following nursing documentation on 06/16/2023:

9:54 PM - SP#1 off the floor at this time to MRI. Tele Tech notified.
10:32 PM - SP#1 was sent back from MRI - unable to get done because of anxiety and claustrophobia. Will contact physician for further orders.
10:47 PM - Spoke to physician. Medication order obtained to be administered prior to MRI. Spoke to MRI Tech. Will re-attempt to complete pending MRI orders after medication administration.
10:57 PM - SP#1 off the floor at this time to MRI after medication administration. Tele Tech notified.
11:54 PM - Spoke to MRI Tech. SP#1 back in the room at this time. SP#1 unable to complete MRI despite administration of ordered medication, earplugs, and all reassurance. SP#1 is very anxious. States the MRI space is just too small and no matter how hard, it just couldn't be tolerated. SP#1 requested medication to help fall asleep.

During an interview conducted on 07/13/2023 at 10:20 AM, MD1 stated that an MRI was requested to rule out stroke for surgical clearance.

During an interview conducted on 07/13/2023 at 12:05 PM, the Radiology Director stated that there is an open MRI that is used when the closed MRI is down. The Radiology Director stated that it's in the outpatient unit and is not staffed 24 hours, but outpatient business hours.

MD1 ordered the MRI on 6/16/2023 at 8:38 AM, however SP#1 wasn't taken down to the radiology department until 9:54 PM, a total of 13 hours and 16 minutes after MD1 placed the order. The facility failed to promptly implement the physician's order for an MRI to rule out stroke in SP#1, which resulted in SP#1 not having the option to have an open MRI due to the time that the order was carried out.

Based on policy and procedure review, review of records and interviews, the facility failed to provide nursing services within recognized standards, specifically, the facility failed to ensure continuous heart monitoring (telemetry) occurred as ordered for 1 of 6 Sampled Patients (SP). (SP#1)

Findings include:

Review of the facility Policy and Procedure (Policy number not identified/Policy not updated). Subject: Telemetry Monitoring, Last Reviewed: 06/2019 included but was not limited to:

Purpose: To provide for the care of the patients on remote telemetry monitoring throughout the hospital.

Policy: It is the policy of the facility that all patients who require continuous telemetry monitoring are monitored according to an established set of guidelines.
Procedure: The procedures as contained in the appendices are utilized for training and operating a consistent care of the patient on telemetry monitoring through the facility.

B. Section 2 - Alarm/Arrythmia Notification
ii. Notification Procedure: (1) The telemetry monitoring technician calls the nurse taking care of the patient via a Spectralink phone and identifies the arrythmia to the nurse.
a. If the nurse does not answer the phone or cannot immediately visualize the patient, the Monitor Technician will notify the Charge Nurse, If no response then call Nursing Director or their design of the unit the patient is assigned (during the daytime) (nights and weekends) call the house supervisor.
b. If there is no response, the RRT will be called.
c. The telemetry monitoring technician documents the phone conversation on the
Central monitoring telemetry Log.

F. Patient Transport
a. The American Heart Association Class I monitoring standards were used as a guide to determine if the patients must be continuously monitored while off the unit. The following listed below must be continuously monitored either by remote telemetry monitoring or accompanied by nurse when being transported off the unit (If the patient meets criteria below and is going for an MRI or MRA nurse must accompany patient): ii. ST elevation or non-ST elevation myocardial infarction (MI).
b. Patients that must be transported by nurse when going off the unit:
ST elevation or non-ST elevation myocardial infarction (MI) going to Radiology for an MRI or MRA.

During an interview conducted on 07/12/2023 at 9:45 AM, RN1 (assigned to SP#1 on night of 06/16/2023) stated that SP#1 was constantly removing the monitor leads. RN1 stated when SP#1 was asked what was wrong, he reported anxiety. RN1 stated that every time the monitor leads are off, the nurse is notified by the telemetry technician. RN1 stated that SP#1 reported claustrophobia but agreed to try to do the MRI. The second time SP#1 went down, medication was given to help him tolerate the test. RN1 stated that SP#1 was gone a long time. RN1 stated SP#1 returned and said the MRI could not be done, he was too anxious to tolerate it. RN1 stated that SP#1 was pacing in the room and removing the monitor leads. RN1 stated that the other patient in the room had to be moved due to the lights and pacing in the room. RN1 stated that SP#1 took a shower after the MRI. RN1 stated that between 4:30 AM - 4:40 AM, the monitor was connected, but was unsure of how long SP#1 was disconnected. RN1 stated that hourly rounds are done buy but they are not always documented. RN1 stated that SP#1 was found unresponsive around 5:00 AM and a code blue was called. Telemetry strips reviewed from the night of 06/16/2023 and early morning of 06/17/2023 did not show any brief heart rhythm interruptions expected to be seen when monitor leads taken are off and re-attached. RN1 asked if a physician's order was obtained to remove SP#1 from the monitor for specific activities and if SP#1 was accompanied by a nurse to the MRI. RN1 stated that a physician's order was not obtained for SP#1 to be transported to the MRI center off the monitor. RN1 stated that SP#1 was taken by a transporter without a monitor.

Interview with the Nurse Manager on 07/13/2023 at 11:07 AM revealed the standard process is to call the physician to obtain an order.

SP#1 was not observed according to the American Heart Association Class I monitoring standards for patients with ST elevation or non-ST elevation myocardial infarction (MI). On admission to the facility on 06/14/2023, the physician documented SP#1's indication for telemetry as ACS-NSTEMI (Acute Coronary Syndrome, Non ST Elevated Myocardial Infarction.

Interview with the telemetry technician on 07/13/2023 at 9:35 AM revealed that every time the patient's leads are off, the nurse is notified to reconnect the patient. The telemetry monitoring technician did not document any phone conversation with the nurse on the Central monitoring telemetry Log during the night of 06/16/2023 as specified in the telemetry monitoring policy.

All documented concerns were discussed with RN1, Tech1, Nurse Manager, and Nursing Director of the unit.

The facility failed to ensure continuous telemetry monitoring during transportation to the MRI center, and during the night of 06/16/2023 (morning of 06/17/2023) when there was no documentation of SP#1's heart rhythm beginning at 4:43 AM.

Based on policy and procedure review, observation and interviews, the facility failed to ensure that the Medication Administration policy was followed when the "Right documentation" which is identified as one the six rights of drug administration was performed inappropriately for 1 of 6 Sampled Patients (SP). SP#1

Findings include:

Review of the facility Policy and Procedure Medication Administration Chapter: Medication Management Policy Number: MM 21, origination date: 7/24/2012, Last Revised 02/28/2023 included but was not limited to:

Procedure: (E) Administer Medications Safely (1) Medications are administered to one patient at a time. (2) The individual who will be administering the medication verifies the "six rights' of drug administration: Right patient, Right medication, Right dose, Right time, Right route, and Right documentation.

Observation of SP#1 medication administration performed by RN2 (Intensive Care Unit Registered Nurse) conducted on 07/13/2023 at 2:49 PM in the ICU revealed that RN2 verified the medication from the computer terminal prior to removing the medication from the storage area. RN2 washed hands, donned gloves, scanned SP#1's armband and the medication. RN2 reviewed the medication with SP#1's family and administered the medication via the percutaneous endoscopic gastrostomy (PEG) tube.

It was noted that when the medication was scanned for verification in the electronic medical record, the time of administration was also documented merging the two processes although the medication preparation included crushing the medication ,placing it into a medication cup and dissolving it in water, filling the irrigation container with water, removing patient items from the bedside table to hold supplies, educating the patient/family and flushing the PEG tube with water to determine patency, which took at least 10 minutes. Once the medication was inserted, the PEG tube was flushed again with water and the supplies used were cleaned before RN2 removed gloves and sanitized hands. There was no further documentation in the electronic medical record.

The surveyor discussed the sequence of events with RN2 who stated the medication administration was already documented. The issue was also discussed with the Nurse Manager and the Nursing Director of the unit. The medication was not administered as documented at 2:49 PM.

The facility policy was not followed for the "Right documentation" when the electronic medication scanning process also documented the medication administration time in the record prior to the medication being given.