HospitalInspections.org

Based on a random observation, staff interviews, review of medical records, and review of facility documents, it was determined that the facility failed to provide care in a safe setting by ensuring: 1) telemetry request forms with patient demographics (Date/Time, patient name, Tele pack number, patient location, and Registered Nurse (RN) name and contact number) are sent to the Monitor Technicians (MTs) in the "War Room" prior to the patient being placed on the telemetry pack in the Transitional Care Unit (TCU) within the Emergency Department (ED); and 2) a policy outlining the process of telemetry monitoring for TCU patients is developed and implemented.

Findings include:

1. On 1/23/23 at 10:05 AM, a tour of the "War Room" (Telemetry Monitoring Room), on the third floor Telemetry Unit, was conducted. At 10:08 AM, an observation of the telemetry monitor revealed two patients to be on telemetry monitoring in the TCU within the ED. The only information in the monitoring system was the Tele pack number (Tele pack 11 and Tele pack 12). There was no patient name or room number identified on the monitor. Staff (S) 8 indicated that when a patient is placed on the Tele pack in the TCU, the TCU nurse is to call the "War Room" and notify the MTs prior to applying the Tele pack and then send a "Tele War Room Request" form, with the patient demographics and the patient's nurses name and contact number, through the pneumatic tube system next to the "War Room."

S8 indicated that the patients utilizing Tele pack 11 and Tele pack 12, appeared on the monitor at approximately 9:40 AM and he/she had not received a phone call or a Tele War Room Request form. There was no call from the TCU nurse to confirm connectivity. S8 stated that he/she tried to call the Charge Nurse in the TCU to let them know the MTs did not receive a Tele request form and while attempting to call the Charge Nurse, the other phone rang, and it was the TCU nurse notifying the MT that two patients were placed on the monitor and the request form will be sent up through the pneumatic tube system.

At 10:15 AM, S7 indicated that he/she checked the tube system twice and the request had not yet been sent. At 10:20 AM, while the surveyors were in the "War Room," the Tele request form was not present. S7 then went and checked the pneumatic tube again and the request was there. S7 indicated that from the time the patients were placed on the monitor at 9:40 AM until 10:20 AM, the MTs had no patient information (name), no patient location (room number) and no patient RN phone number to call if an arrhythmia occurred. The Tele request forms were reviewed. Tele pack 11, Patient (P) 1 and Tele pack 12, P2 were found to be complete.

At 2:15 PM, S10, the Interim TCU RN Manager, indicated that the TCU nurses are each provided with a cell phone. If a patient in the TCU were to have an arrhythmia, the MTs in the "War Room" would notify the patients RN via the cell phone number provided. The nurse would then check on the patient and then review the strip via Clinical Access through EPIC. If it were a true event, the TCU nurse would then initiate an RRT (Rapid Response Team) or Code Blue if needed.

At 2:30 PM, S2, the Director of Patient Safety, indicated that if the MTs do not have a Tele request form with the patient information and an RN phone number and the patient were to have an arrhythmia, the MTs would call the TCU Charge Nurse. The TCU Charge RN has the "Telemetry Box Tracker" form, which indicates the Tele pack number, the patent initials, the patient location and the patients nurse. The Charge RN can then use that information to go and assess the patient and review the strip.

S6 provided a document titled "Telemetry Monitoring Process." The "Telemetry Monitoring Process" form was reviewed and stated, "...When TCU patient needs to be placed on tele box the below request will be tubed up to Tele for the Monitor Tech. The TCU will call the monitor room to let them know the request is coming. They will use the tube station by the monitor room number 131. Monitor Tech will retrieve paper request from the tube station. The Monitor Tech will verify this information is correct on the monitor. ..." S6 and S9, the TCU Assistant Nurse Manger, stated that the TCU nurse is to call the MTs and send the request prior to the patient being placed on the monitor. The document failed to address a timeframe that the Tele War Room Request form is to be sent up to the MTs in the "War Room." The document also failed to address the process of whom to contact in the event of an alarm/arrhythmia.

At 10:05 AM and again at 12:28 PM, S8 indicated that at times, he/she has to call the TCU multiple times for the request to be sent. S8 stated that if an event happens (arrhythmia) and the patient's information is not entered into the system, the event doesn't get saved. The rhythm on the strip before the patient's information is entered, is lost. S8 also indicated that often the Telemetry Request forms are filled out incorrectly and do not have the nurses cell phone number listed. The phone number is either missing or the ED number 17700 is listed. S8 indicated when you call 17700 it's hard to get a hold of someone, there is a voice message. On 1/23/23 at 10:20 AM, the number was called for the surveyors, and it went to a voice recording to select options.

Thirteen (13) Tele War Room Request forms were selected and reviewed. Nine of the 13 forms were missing the nurse's cell phone number and six of the nine had the ED 17700 number listed as a contact number.

2. The facility policy addressing the TCU was requested. At 2:07 PM, S2 confirmed that the facility does not have a policy for the TCU. The Telemetry Monitoring policy was requested. The policy titled "Telemetry Alarm Monitoring" dated March 2021, was provided and reviewed. The policy stated, "This applies to the monitoring of all inpatients on telemetry packs and patients on hardwired monitors in IMCU/CCU, CDU, Peri-Op and Senior Care ED." S2 confirmed that the policy did not address the telemetry monitoring process of TCU patients.

At 2:45 PM, S2 reviewed the document titled "Remote Telemetry Monitoring Alarm Management Changes" with the surveyor. The document was a Huddle Sheet dated December 2022 and was created in an effort to improve patient safety and response to alarms. The form indicated the following process:

If the alarm indicates "Off the Monitor," the MT is to call the Nurse to place the patient back on the monitor. If no resolution within 2 minutes than the MT will call the Charge Nurse and if there is still no resolution within 2 minutes than the MT will call a Rapid Response.

If the alarm indicates Ventricular Fibrillation or Asystole, the MT will call the Charge RN within 30 seconds of the lethal arrhythmia and if unable to reach the Charge Nurse within one minute the MT is to call a Code Blue.

If the alarm indicates a Potential Lethal or Dangerous Arrhythmia, the MT will call the Charge RN within 30 seconds of the potential lethal or dangerous arrhythmia and if unable to reach the Charge RN within one minute the MT will call a Rapid Response.

S2 confirmed that this process is to be followed for all Telemetry patients. The "Remote Telemetry Monitoring Alarm Management Changes" document is in algorithm format and posted in the "War Room" for the MTs to follow. During the tour of the "War Room," S8 was able to provide the document and explain the process.

It was determined that the process varied between documents and the facility failed to have a clear delineated process for the TCU nurses and MTs to follow for the TCU unit.