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Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 1 of 3 sampled patients (Patient #5) as evidenced by failure to implement telemetry monitoring in a timely manner.


The findings included:


Facility policy "Continuous Cardiac Monitoring" dated 06/2017 documents "This procedure establishes guidelines to provide safe and effective care to patients requiring continuous cardiac care.
Cardiac monitoring is initiated and discontinued based upon facility MEC (Medical Executive Committee) approved criteria. Suggested clinical criteria for cardiac monitoring include:
Patient with dysrhythmias
Recent history of unstable cardiac rhythm
Patients with hypotension, respiratory failure or impending respiratory failure and others.
Procedure:
Attach appropriate leads wires from telemetry unit to electrodes
Notify telemetry technician that patient is attached to monitor
Record a rhythm strip a minimum of six seconds. The rhythm strip is reviewed by telemetry technician and validated by the Registered Nurse.
Document in the patients' medical record:
Time telemetry initiated, lead in which patient is being monitored, alarm parameters, rhythm, rate and vital signs and that initial recording strip has been run and assessed.

Clinical record review conducted on 05/22/19 revealed Patient #5 was admitted to the facility on 03/06/19 at 6:45 PM.

Admission Notification Record documents the level of care is Telemetry.

History and Physical from the transferring hospital documents the patient has acute respiratory failure, sepsis with hypovolemic component, respiratory infection, kidney injury. Progress Notes dated 03/05/19 documents the patient requires continued intensive care level of care for acute respiratory failure and case management is working on long-term acute care placement. The patient is a full code.

Physician's Order dated 03/06/19 documents Telemetry Monitoring

Review of the clinical record revealed no evidence the facility initiated telemetry monitoring for Patient #5.
Nurses notes dated 03/07/19 documents what transpired on 03/06/19:
At 7:50 PM the night nurse documents "received report from day nurse"
At 8 PM "Patient noted on ventilator appears to be in no distress."
At 8:10 PM "Called supervisor about no receiving report" (from transferring hospital)
At 8:20 PM "Went back to check on patient, called another nurse to look at patient, went to get monitor."
At 8:25 PM "Monitor placed on patient"
At 8:30 PM "Call code."

The record indicates the first rhythm strip was captured at 8:31 PM. Review of the Telemetry Log dated 03/06/19 revealed no entries for Patient #5. On 03/07/19 the log indicates Patient #5, Room 215 new admit, telemetry pack #31, code blue called at 8:28 and patient expired at 8:48 PM. Discharged.

Interview with Staff B, a Respiratory Therapist, conducted on 05/22/19 at 12:14 PM revealed Patient #5 was stable upon arrival, the staff reported a problem with the ventilator, and it just needed to reset a disc and it was functioning properly. The Therapist recalls the patient was not put on the computer system, so she was not able to chart all of her notes and also verbalized, she did not receive report on the patient prior to arrival.

Phone interview with Staff C, a Registered Nurse, conducted on 05/22/19 at 12:48 PM revealed upon arrival Patient #5 was alert, responded to name and was able to move extremities. Staff C was asked if she placed the cardiac monitor on the patient and responded the monitor was requested and that she obtained the paced rhythm noted in her notes from the paramedics. Staff C stated she checked on the patient prior to leaving from her shift and does not recall if the monitor was in place. Staff C also explained she did not get report on the patient, she was not aware she was getting a new admission and did not call the physician for orders; the next shift would have done that. Staff C recalls faxing the medication list to pharmacy as part of the admission process.

Interview with The Chief Clinical Officer (CCO) on 05/22/19 at approximately 1:22 PM revealed the staff documents rhythm strips every shift. The CCO then stated the facility recently changed to document strips on the electronic record every 12 hours, 10 AM and 10 PM. The CCO was not able to locate admission rhythm strips for Patient #5. Furthermore, the CCO then pulled a random newly admitted patient and showed how the staff documents the rhythm strips every shift, but was not able to provide evidence that this newly admitted patient had a rhythm strip from admission, around 5 PM, the first cardiac rhythm strip documentation was completed at the next required schedule of 10 PM.

Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of respiratory care provided to each patient is in accordance with established standards of practice. This failure affected 1 of 3 sampled patients (Patient #1) as evidenced by failure to document the provision of tracheostomy care.


The findings included:


Provision Of Respiratory Care Services documents "The goal of the respiratory Department is to identify, control and alleviate whenever possible, all elements of pulmonary impairment and to recondition the patient to their optimal functional capacity to perform daily activities in order to improve their quality of life. Therapeutic modalities delivered by the department includes Artificial Air Management, Tracheostomy Care."


Facility policy "Tracheostomy Tube Cannula and Stoma Care" revised 12/14/18 documents "The optimal frequency for cleaning the inner cannula is undetermined. Clean or change the inner cannula when needed and be sure to inspect it regularly or at least two times per day.
Record the date and time of the procedure, type of procedure performed, amount, consistency, color and odor of secretions; stoma and skin condition, and patient's respiratory status.


Clinical record review conducted on 05/21/19 revealed Patient #1 was admitted to the facility on 05/13/19 due to Respiratory Failure. The record indicates the patient had a tracheostomy.

Review of the Respiratory Therapist Notes and Nurses Notes including Shift Assessments failed to provide evidence the nursing or respiratory care staff consistently performed tracheostomy care every shift. The record had no documentation of tracheostomy care provided to the patient every shift on 05/20/19 and 05/18/19.


Interview with The Chief Clinical Officer, who navigated the electronic record, conducted on 05/21/19 at 2:44 PM confirmed there is no evidence the respiratory or nursing staff completed tracheostomy care every shift. Then, the CCO contacted a respiratory therapist (Staff C) who reviewed the record and confirmed the provision of tracheostomy care was not documented as the person who put in the orders, made the provision of care as needed instead of every shift.