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Based on review of the medical record, facility polices and procedures, job descriptions, personnel files, and staff interviews, it was determined that Nursing Leadership failed to supervise patient care in a manner that ensured that the monitoring of telemetry patients was provided by qualified personnel (refer to A 397) for 8 of 8 nursing units providing telemetry (3 West, 4 Main, 5 East, 6 Main, 8 Main, 9 Main, Medical Observation, and Emergency Department).

Based on review of medical record #1, policies and procedures, job descriptions, and staff interviews, it was determined that Nursing Leadership failed to implement policies and procedures and failed to appropriately supervise and evaluate the personnel who were providing telemetry monitoring for 8 of 8 units providing telemetry (3 West, 4 Main, 5 East, 6 Main, 8 Main, 9 Main, Medical Observation (MOU), and the Emergency Department (ED).

Findings were:

A review of the medical record for patient #1 revealed that the patient was on continuous cardiac monitoring (telemetry). Approximately a week after admission, an interpretation of a cardiac monitoring strip completed by the monitoring technician (MT- employee #1) at 11:50 a.m., reviewed and co-signed by an RN (registered nurse), revealed that the patient's heart rate was 76 and no life threatening arrhythmia (irregular heart rhythm) noted. Nursing documentation at 1:23 p.m. indicated that the RN assigned to the patient was called to the patient's room and found the patient unresponsive and an emergency code was called immediately and Advanced Cardiac Life Support (ACLS) was initiated. A second strip, ran at 1:23 p.m. on the same day, interpreted and reviewed by the same MT and RN as before, indicated that the patient's cardiac rhythm had changed, heart rate had increased to 133, and the patient was in ventricular fibrillation/ventricular tachycardia (life threatening arrhythmia). The patient was resuscitated and transferred to Intensive Care Unit. The patient died several days later.

A review of the cardiac rhythm strip for the above event, provided and interpreted by the facility at the time of the survey revealed that at 1:12 p.m. the patient's cardiac rhythm changed to ventricular tachycardia and remained in that arrhythmia until the patient was found unresponsive at 1:23 p.m. No one had been aware that the patient had been in the arrhythmia for nine (9) minutes, from 1:12 p.m to 1:23 p.m.

An interview at 10:30 a.m. on 02/26/2010 with the Nursing Director for the unit where the event occurred, revealed that employee #1 was assigned as the MT for the shift. Employee #3 was asked to relieve the MT for break and took over the responsibility at 12:50 p.m. At 1:05 p.m. employee #2 was asked to relieve employee #3 and was the person responsible for telemetry monitoring during the time the patient developed and continued in ventricular tachycardia rhythm. The director revealed that monitor technicians were to notify the nurse within one (1) minute if there was a change in rhythm and the employee (#2) failed to do so. The director stated that employee #2 had failed to recognize and correctly interpret the arrhythmia when it first occurred.

An interview at 3:00 p.m. on 03/02/2010 and 10:30 a.m. on 03/03/2010 with employee #1 and employee #3 confirmed that they were responsible for telemetry monitoring as stated by the Nursing Director. Both employees stated they were not at the monitor station at the time the patient developed a change in cardiac rhythm. When questioned about how monitor technicians were relieved for breaks, employee #1 revealed that there was no formal system in place or documentation for hand off of telemetry responsibilities and that anyone that was designated as a monitor technician was able to relieve another.

An interview at 11:15 a.m. on 02/26/2010 with employee #2 confirmed that he/she was asked to relieve employee #3 at the telemetry monitoring station, but was unaware as to the time he/she assumed the responsibility. The interviewee stated that he/she was at the telemetry monitoring station only a few minutes and shortly after assuming the responsibility, the employee noted a change in the patient's cardiac rhythm. The employee reported that at the same time he/she proceeded to call the nurse, the nurse was calling a code for the patient. The employee (#2) reported that he/she usually worked as a patient care technician and was assigned to monitor technician approximately one (1) time a month. The employee related that all employees on the unit were expected to function in the role of MT. In addition to the responsibility of telemetry monitoring, the employee stated that the MTs were to answer patient call lights and respond to in-house phone calls.

A review of the facility policy entitled, "Cardiac Monitoring in Adult (non-critical care) Patient Care Areas" effective date 12/01/2007 revealed the telemetry monitor technician responsibilities. The responsibilities included never leaving the monitors without being relieved. All of the responsibilities listed involved task related to telemetry, such as obtaining rhythm strips, interpreting strips and submitting to them to the nurse, and management related to lethal and non-lethal arrhythmias. The policy reflected no evidence of responsibilities for answering patient call lights or in-house phone calls.

A review of the job description for monitor technician revealed that in addition to the responsibilities related to telemetry monitoring, the technician was expected to answer the unit telephone promptly and appropriately and coordinate the patient intercom activity (call lights) and ensure prompt communication of patient needs to the nursing staff.

An interview at 10:30 a.m. on 02/26/2010 with the Nursing Director for the unit where the event occurred, confirmed that telemetry technicians had other responsibilities besides duties related to telemetry. The director acknowledged that the additional job responsibilities required in the job description were not addressed in the telemetry policy. In a later interview at 2:40 p.m. with the Nursing Director, the director stated that most all of the staff on the unit were cross trained and had telemetry monitoring responsibilities. The director stated that in order to maintain competency, the employee should work as the MT at least one (1) day a week. However, the director was unable to confirm via the schedule that the expectation of one day a week was being met. The director confirmed that some employees were only scheduled one (1) time a month. Employee #2 and #3 were scheduled only monthly. The director also stated that the employee files were inconsistent in regard to what was required for competency. The expectations for competency were unclear and the director indicated that this may be the case throughout the facility.

An interview at 1:40 p.m. on 02/26/2010 with the Nurse Educator for the unit where the event occurred, revealed that there was nothing in writing to provide guidelines for the number of hours required for technicians to monitor telemetry in order to maintain on-going competency. The educator also revealed that identifying lethal arrhythmias was not a requirement for successful completion for passing the test. An overall 80% on the test was the only requirement.

? Immediate action requested and received on 02/26/2010: The facility put a plan in place for all telemetry units with monitor technicians. 1. Only MTs with the following qualifications could perform duties: completed Basic Cardiac Rhythm course, annual competency (if appropriate), and routinely performs as a MT or seen as an "expert" on the unit. 2. Leadership was to implement the following: eliminate secondary responsibilities for the MTs, establish a log that staff can log in and out while performing duties (require dual signatures), ensure that relief monitors will meet or exceed same qualifications. Charge nurses or ACLS nurses were to review strips every four (4) hours and evaluate any lethal arrhythmia alarms. Clinical coordinator was to do rounds to each telemetry unit each shift to monitor for compliance. Nursing Directors were to review for compliance daily.

An interview at 10:50 a.m. on 03/02/2010 with the Senior Vice President/Chief Nursing Officer (CNO) and the Assistant Vice President of Nursing, and supported by job description, revealed that the Director of Nursing for each area was responsible for 24/7 accountability and reported directly to the Senior Vice President/CNO. It was the nursing director's ultimate responsibility to ensure that employees were competent and in compliance with their job description. This included the education, evaluation, and supervision of the employees. The Senior Vice president/CNO related that at the time the above action plan was to be implemented, each Nursing Director of the telemetry units was given instructions and a copy of the action plan.

A review of facility policy entitled, "Basic Cardiac Rhythm Recognition and Cardiovascular System Knowledge and Assessment Competency Standard" effective, June 1998, last revised November 2007 indicated that the employee was required to complete a Basic Cardiac Rhythm (BCR) course, complete the assigned homework, and complete a skills checklist before taking a test. Monitor time was also to be completed and the rhythm interpretation packet reviewed prior to the examination. The test was to be a hospital approved examination and a passing score of 80% was required. Employees who were unsuccessful in their first attempt of the examination were expected to review the test with the course coordinator and a second test was to be attempted. Two (2) attempts was the established limit to successfully pass the course. Any additional testing had to be approved by the director on an individual basis. The policy further indicated that on-going competency was required. Six (6) months after the initial competency was met, another passing test score was required. Twelve (12) months after the initial competency was met, another passing test score was required and then annually thereafter.

An interview at 2:20 p.m. on 03/01/2010 with the Clinical Nurse Specialist involved in the BCR course/education confirmed that the above requirements were to be met for telemetry monitor technicians and evidence of meeting the requirements was to be in the employee's educational files. The Manager of Accreditation, however, reported at 1:15 p.m. on 03/02/2010 that the above policy had not been fully implemented. The use of the skills checklist prior to the examination and the six (6) month competency examination had not been followed and not all Nursing Directors were aware of the policy requirements due to communication failure.

A review of the job description for the Senior Vice President/CNO revealed that the Senior Vice President/CNO was responsible for the overall administration of designated departments and for all nursing practice rendered at the organization. This individual was accountable for nursing standards and the nursing plan for provision of care. There was no evidence that the Nursing Directors had been held accountable for the implementation of the policy requirements for telemetry monitoring competency.

A review of the personnel files on 02/26/2010 for employee #2 and #3 who were involved in the care of the patient, revealed that employee #1 was hired in 2006 and became a MT in March 2007. The employee received a score of 50% on the first test, a 72% on the second test, and was given a third test with a score of 80%. There was no documented evidence in regard to why a third test was allowed. The file lacked evidence of the written test and of a skills checklist having been completed. Employee #3's file revealed that the employee was hired in September 2007 and became a MT in March 2008. The employee received a score of 80% on the test. The file lacked evidence of the written test and of a skills checklist having been completed. The file also lacked evidence of a six (6) month competency examination.

A review of the personnel files (#'s 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) on 03/01-03/02/2010 for the employees who were working in the role of MT after the facility's implementation of the action plan at 5:00 p.m. on 02/26/2010, revealed that three (3) of eight (8) telemetry units (3 West, 4 Main, and ED) had employees who failed to meet the requirements specified in the facility's immediate action plan of 02/26/2010. Employee # 34 (4 Main) lacked evidence of competency from 2008 until February 26, 2010, the day the action plan was implemented. Employee # 36 (ED) lacked evidence of competency from 2007 until February 28, 2010, after the action plan was implemented. Employee # 39 (ED) lacked evidence of competency from 2008 until March 1, 2010, again after the action plan had been implemented. Employee #30 (3 West) had evidence of BCR course completion in November 2009. Documentation provided by the facility revealed that the employee had worked only one shift as a telemetry monitor technician prior to working on 2/28/2010. The Assistant Vice President of Nursing confirmed at 11:00 a.m. on 03/02/2010 that this did not meet the criteria for experience or expertise, as required by the action plan. In addition, review of the above personnel files revealed that seven (7) of eight (8) telemetry units had employees that did not meet the facility policy requirements for telemetry competency. Employee #'s 4, 5, 6, 7, 8 (5 East), 12 (6 Main), 14 (8 Main), 19 (MOU), 31 (3 West), 38 (ED) 40, and 43 (9 Main) all took the BCR course in 2008 or 2009 and lacked evidence of a six (6) month competency examination. Employee #'s 5, 7, 8 (5 East), 9, 10, 11,12 (6 Main), 14, 15, 16 (8 Main), 17, 18, 19 (MOU), 29 (3 West), 37, 38 (ED), and 40 (9 Main) lacked evidence of a skills checklist.

A review of the personnel files (#'s 20, 21, 22, 23, 24, 25, 26, 27, 28) on 03/01-02/2010 for the additional MT's on the unit where the event occurred (3 West) revealed that four (4) of nine (9) (#'s 24, 25, 27, 28) employees lacked documented evidence of current annual competency for telemetry monitoring.

Overall review of the personnel files revealed inconsistency in the competency tests with number of questions varying from ten (10) questions to one hundred (100) questions. Some of the tests required the identification of cardiac rhythms and other tests included multiple choice or true/false questions. There was no evidence that the tests were hospital approved. Interviews with management and educators throughout the survey revealed they were unable to identify or verify if the tests were hospital approved.

? Immediate action requested and received on 03/03/2010: The facility's Nursing Leadership (CNO/Assistant Vice President) were to ensure the safety of telemetry monitoring throughout patient care services. To ensure compliance, the Nursing Leadership was to develop a list of individuals for each unit who were competent to monitor telemetry rhythms. The list was to be displayed at each unit. Only EMTs and cross trained patient care technicians/unit secretaries on the approved list and had completed the BCR course requirements and had a current annual competency were to be allowed to monitor telemetry. The director or designee was to review schedule assignments to ensure that only approved individuals worked as a MT. Flex pool would be utilized as a resource to assist with universal coverage. Deviations from the pre-planned schedule was to be reported to and reviewed by Nursing Leadership. The facility was to continue with MTs responsibilities being limited to telemetry duties.
? Further actions that will be addressed by Nursing Leadership included relocation of the telemetry stations to allow for the least interruptions and reassessing the requirements for telemetry competency.