HospitalInspections.org

Based on review of facility policy, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure the provision of safe patient care when staff failed to respond to an identified change in a patient's cardiac rhythm for one of one medical records reviewed (MR1).

Findings include:

Review of the facility policy "Telemetry Monitoring" revised September 2014 revealed, "GUIDELINES...3. Monitor technician notifies RN of any pertinent changes...TELEMETRY ASSIGNMENTS...2. For a change in rhythm or lead failure the monitor tech will notify a responsible RN on the unit who then responds to and cares for the patient and/or corrects lead placement...3. In the event of a life threatening monitor change while the patient is off the unit, the monitor technician alerts a responsible RN on the unit who then responds to and cares for the patient."

1. On September 9, 2015, at approximately 8:30 AM an interview with EMP1 and EMP2 revealed that on August 31, 2015, MR1 was transported to the nuclear medicine area of the facility on a telemetry monitor for the nuclear imaging portion of a cardiac stress test. At approximately 9:44 AM the telemetry monitor on the fifth floor monitor bank showed a drop off in reception for this patient. Only intermittent cardiac signal was being received at the monitor bank. At approximately 10:12 AM the monitor tech alerted the assigned RN of a possible bradycardic (slow) rhythm for MR1. The assigned RN did not alert the nuclear medicine room or attend directly to the patient of MR1. At 10:23 AM, at the completion of the nuclear imaging scan the patient of MR1 was noted to be unresponsive and pulseless and a code alert was called.

2. On September 9, 2015, at approximately 9:00 AM review of MR1 revealed a code sheet which confirmed that the patient was found to be unresponsive at the conclusion of the nuclear scan. There was no documentation by the assigned RN notating that they attended to this patient when a possible lethal arrhythmia concern was brought to their attention.

3. On September 9, 2015, at approximately 3:00 PM during an interview EMP12 stated, "The patient was bradycardic and I should have checked. I assumed they were monitoring the patient at the stress testing room. ...I did not call the stress room for this event."

Based on review of facility policy and staff interview (EMP), it was determined the facility failed to provide evidence that staff were assigned to patient care and other job duties on the Progressive Care Unit in a manner which promotes patient safety, minimizes the risk of cross-infections and considers the qualifications of each nurse as well as the needs of the patient.

Findings include:

Review of the job description for the Monitor Technician last reviewed by the facility September 2013 revealed, "The incumbent may be sedentary for long periods of time, watching monitors for any emergent situation; must be able to maintain focus of attention on monitors."

Review of the "Heritage Valley - Sewickley Staffing Plan" reviewed October 2014 revealed, "Assignments are made commensurate with the qualifications of each nursing staff member, the identified nursing needs of the patient, and the prescribed medical regimen. ...Staffing Patterns...Progressive Care Unit: This 54 bed telemetry unit. The goal staffing plan is one RN for every 4 patients on days and 5 patients on evenings and one RN for every 6 patients on nights. There is one Patient Care Associate I or II (PCA) for every 10 patients on days, evenings and on nights. There are also Monitor Technicians for each shifts. Two Monitor Techs on days, evenings and nights for maximum census."

1. During a tour of the Progressive Care Unit on September 9, 2015, at 9:40 AM, EMP4 was observed watching the telemetry monitors, answering telephones and contacting the nursing staff.

During an interview on September 10, 2015, at approximately 8:50 AM, EMP20 stated that there are two sides to the nursing unit, one where the monitor banks are located and one without monitor banks. EMP20 also stated, "When you're the unit clerk on the one side that is your only job but if you're the monitor tech you also are the unit clerk."

During an interview on September 11, 2015, EMP14 indicated that in addition to being responsible for watching the monitor banks, monitor techs were simultaneously responsible for calling physician ordered consults, answering telephones, answering the call bell monitor, placing papers from the copier onto charts, setting up transports if a patient is being transferred, copying charts and faxing information for continuing care. EMP14 also noted that they assisted visitors with questions in person. EMP14 indicated that it was stressful at times trying to continuously watch the monitor banks and perform all the above described duties. "Being the Monitor Tech should be the only job they have."

2. On September 11, 2015, at approximately 9:00 AM a request was made to review staffing assignment sheets of the Progressive Care Unit from 8/30/15 - 9/11/15. The facility provided a "Daily Schedule Summary" sheet for each of the dates requested. These sheets only listed the name and shift of scheduled staff for each nursing unit.

During an interview on September 17, 2015, at approximately 8:15 AM EMP2 indicated that there are no staff assignment sheets available for the time period requested. EMP2 stated that staff assignments are written on a white board which is continually updated throughout the shift due to the high turnover rate of patients on the Progressive Care Unit. When asked how to confirm that RN staffing assignments were completed based on the regulatory requirements, EMP2 stated that a census from the date in question would need to be generated and each patient record would have to be reviewed to identify specific nursing staff patient assignments.

Based on review of facility policy and staff interview (EMP), it was determined the facility failed to ensure a consistent process was followed for all requests for service on malfunctioning equipment.

Findings include:

Review of the "Requests for Emergency Repairs or Service after Normal Duty Hours" policy revised September 23, 2014, revealed, "1. Equipment support is normally provided by the Clinical Engineering Department Monday through Friday, 7:30 a.m. to 4 p.m. 2. If an emergency need arises for equipment support at other times, the supervisor or clinician-in-charge will request that Communications contact the Biomedical Engineering Technician, BMET or Radiology Engineering Technician, RET on-call. 3. The BMET or RET on-call will contact the supervisor or clinician-in-charge to determine the proper disposition of the repair request. 4. In all cases, responding Clinical Engineering personnel will follow normal repair procedures and Inspection/Preventive Maintenance protocols."

1. During an interview on September 9, 2015, at approximately 11:00 AM, EMP10 stated that until August 31, 2015, he/she had no knowledge that there was an intermittent signal loss reading on the telemetry monitor bank when patients were taken to the third floor nuclear imaging area. EMP10 further stated that staff call on the phone at times with equipment concerns and if troubleshooting can fix the problem over the telephone there is no work order generated or any tracking mechanism related to these calls. EMP10 stated staff can give the information to whoever answers the phone or leave a message.

2. During an interview on September 10, 2015, at approximately 8:50 AM EMP20 stated that he/she had called and spoken to EMP10 twice in the past regarding concerns that there was intermittent signal loss on the telemetry monitor bank when patients would go to the third floor for stress testing. EMP20 stated that "I assumed it was ok. I never heard back from [EMP10] but I figured they were working on it. ...No I never reported it to my supervisor. ...No there is no way to track on our end when we call them [biomedical engineering]."

3. During another interview on September 10, 2015, at approximately 10:50 AM, EMP10 again reiterated having no recollection of receiving any phone calls from EMP20 or anyone else on the PCU in relation to intermittent telemetry signal loss. EMP10 stated there would be no tracking mechanism for equipment repair requests in the biomedical engineering department unless a work order was generated. EMP23 also confirmed the above information.

When asked about preventative maintenance and/or monitoring of the telemetry monitor system EMP10 stated that the monitor bank is looked at on a routine basis, however "The patients check the monitors daily as they move throughout the facility. We don't do anything else with them. If a telemetry pack isn't working staff call and we come get it and repair it."

4. During an interview on September 11, 2015, at approximately 9:30 AM, EMP14 confirmed that he/she has also recognized that there is an intermittent signal loss on the telemetry monitor bank when patients go to the nuclear/stress testing area. However it was believed that the patients were being directly monitored by another staff member while in the stress testing area so this was not considered to be a concern. EMP14 confirmed he/she never reported this to biomedical engineering or the unit manager.