HospitalInspections.org

Based on observation and interview the facility failed to protect and promote each patient's rights. Specifically, facility staff failed to promptly address critical cardiac alarms that were audibly ringing and displayed on the telemetry monitors in the nursing unit and assess the patient. This lack of staff response to the alarms may result in changes in a patient's cardiac status and/or condition not being identified.

The facility's failure to promptly address cardiac alarms, if left uncorrected, may result in serious injury, serious harm, serious impairment, or death to other patients if immediate action is not taken.

Findings include:

In 2 of 2 observations the facility failed to ensure patients on cardiac monitors with critical cardiac alarms that were audibly ringing were promptly addressed by staff and the patient was assessed.

Please see Tag A-0144.

Based on interview and document review the facility lacked a physician in the role as Director of Respiratory Therapy.

This lack of required oversight by a physician of the respiratory therapy program does not ensure the needs of the patients are met in accordance with acceptable standards of practice.

Findings include:

-- The facility failed to have a physician as Director of Respiratory Therapy to oversee the respiratory therapy program.

(Please see Tag A-1153)

Based on observation, document review and interview, during a tour of inpatient unit (3rd Memorial) surveyors noted audible "red" critical cardiac alarms not being addressed by staff. Specifically, alarms were displayed as "VTACH (ventricular tachycardia [a fast abnormal heart rhythm])" and "ECG (electrocardiogram [checks the heartbeat and records electrical signals in the heart]) off." There were also cardiac monitors located on the coronary care unit (CCU), that displayed 3rd Memorial's patient's cardiac rhythms. This failure to promptly address cardiac alarms, if left uncorrected, may result in serious injury, serious harm, serious impairment, or death if immediate action is not taken.

Findings include:

-- Per observation on 5/16/2024 at 2:00 pm, a 3rd Memorial patient's cardiac alarm was ringing for approximately 5 - 7 minutes indicating ventricular tachycardia. The nurse responsible for the care of the patient had to be directed by another staff member to respond to the alarm and assess the patient.

-- Per observation on 5/16/2024 at 3:15 pm, 3 nursing staff were sitting at the nurse's station on 3rd Memorial while a patient's cardiac alarm was ringing for approximately 5 minutes indicating "ECG off." The staff had to be directed by the Chief Nursing Officer to respond to the alarm and assess the patient.

-- Review of the facility's policy and procedure titled "Telemetry Guidelines & Protocols," approved 11/2022 indicated "to provide continuous ambulatory monitoring (telemetry) on 3rd Memorial Nursing Unit, 4 Central Nursing Unit, and 2nd Memorial Nursing units. The responsibility and appropriate intervention as needed of the telemetry monitor lies with the patient's assigned nurse on the assigned unit. ... Any change in rhythm will be immediately reported to the primary nurse by anyone witnessing the rhythm change. Sustained V Tach (tachycardia) or V (ventricular) fib (fibrillation [abnormal heartbeat]) will be handled as an emergency situation when noted on the monitor. Due to the existence of a remote screen being housed on CCU (coronary care unit), the responsibility of the CCU (coronary care unit) staff is solely to inform the 3rd Memorial nurse of any sustained alarm or rhythm change noted. The alarms on the remote screen are not to be turned off or down. The 3rd Memorial nurse remains responsible for any intervention required."

-- Per interview of Staff A, Registered Nurse, Coronary Care Unit, on 5/16/2024 at 12:25 pm, confirmed there is a telemetry monitor in the coronary care unit that displays cardiac rhythm strips from the 3rd Memorial medical unit. No one in the coronary care unit is assigned to watch the monitor and it doesn't audibly alarm if there is a problem. The staff on the medical unit (3rd Memorial) should be following up on their own monitors.

-- Per interview of Staff B, Registered Nurse, 3rd Memorial, on 5/16/2024 at 1:45 pm, has previous experience with interpreting cardiac rhythm strips. If they hear an alarm, they would respond and do a clinical assessment of the patient, check vital signs and symptoms. At the end of their shift a cardiac strip is printed once (once per shift) and put in the patient's medical record. There is a monitor in the coronary care unit which displays the medical floors (3rd Memorial) cardiac rhythm tracings however it does not audibly alarm. The coronary care unit staff don't monitor the medical floors (3rd Memorial) cardiac rhythm tracings. Regarding the first observation of the patient's audible alarm indicating ventricular tachycardia, Staff B stated the physician was with the patient in the patient's room going over the patient's medications for discharge. The only person the Department of Health surveyors saw in the patient's room at the time of the alarm was the patient.

-- Per interview of Staff C, Interim Director of Inpatient Unit, (3rd Memorial), on 5/16/2024 at 2:20 pm, relayed that the coronary care unit staff are not technically monitoring the cardiac strips from 3rd Memorial. All 3rd Memorial staff are able to monitor and read cardiac strips. There are 6 main cardiac rhythms staff are to be able to recognize and diagnose within so many months of being hired. At times staff has to be reminded to respond to alarms due to "alarm fatigue" (when staff become desensitized to safety alerts due to an overwhelming number of them. This can lead to missed or ignored alerts, delayed response, longer response time and patient harm).

-- Per interview of Staff D, Interim Nurse Manager Coronary Care Unit on 5/16/2024 at 2:55 pm, staff on the coronary care unit look at telemetry strips for their patients in their unit every 2 hours and document. Staff D stated there should be a telemetry technician assigned to the telemetry monitors and that the alarms are ignored.

-- Per interview of Staff E, Chief Nursing Officer on 5/16/2024 at 3:30 pm, a cardiac monitor technician on the medical unit would be very useful, however no one has brought this to their attention. The monitor in the coronary care unit with the 3rd Memorial cardiac strips is more for the providers to be able to view cardiac strips on their patients not for staff to provide additional monitoring.

-- Per interview of Staff F, Registered Nurse Coronary Care Unit on 5/17/2024 at 9:55 am, revealed the cardiac monitor in the critical care unit with the 3rd Memorial strips is glanced at by staff but is the responsibility of the 3rd Memorial nurses. If they saw something (unusual/concerning) they would call over to 3rd Memorial and alert the nurse.

-- Per interview of Staff G, Registered Nurse, 3rd Memorial on 5/17/2024 at 12:15, reads rhythm strips. If an alarm is sounding, you go check on the patient. Staff G doesn't think you can differentiate between the different tones of alarms (if one alarm indicates an urgent or emergent tracing). If an alarm is ringing you go to the patient or first nurse you see to address the alarm. There is alarm fatigue, Staff G hears the alarms in their head. There is a monitor in the coronary care unit with cardiac rhythm strips from the medical unit. The coronary care staff doesn't monitor these strips but if they glance at the monitor and see something questionable, they call the medical unit.

-- During interview of Staff E, Chief Nursing Officer on 5/22/2024 at 2:00 pm, they acknowledged the above findings.

Based on interview and document review, the facility lacked a physician in the role as Director of Respiratory Therapy. This lack of required physician oversight of the respiratory therapy program does not ensure the needs of the patients are met in accordance with acceptable standards of practice.

Findings include:

-- Per interview of Staff H, Clinical Lead Respiratory Care Therapist on 5/15/2024 at 12:30 pm, has acted as the supervisor for respiratory therapy the past 4 years. Staff H provides updates on staffing and policies and procedures to the chief operating officer (non-clinical personnel). There are 2 respiratory therapists for the day shift (7:00 am - 7:00 pm) and 1 and 2/3 staff for the night shift (7:00 pm - 7:00 am). The therapists divide up the medical unit's responsibilities and the emergency department is shared.

Staff H has started to do huddles with respiratory staff. Staff H is trying to update and streamline policies and procedures to be reviewed and approved. Staff H tries to encourage staff to take proper steps to report occurrences and to let them know about issues in real time. Respiratory equipment preventative maintenance is handled by Biomed.

-- Per interview of Staff I, Pulmonologist on 5/16/2024 at 1:10 pm revealed they are not formally the Director of the Respiratory Therapy program. Staff I has been asked by hospital administration if they can discuss respiratory related issues with Staff I. Staff I opined there are no recent respiratory therapy problems. Staff I meets informally with the clinical lead of respiratory therapy to discuss e.g., staff and pulmonary function tests but doesn't take or have notes on these meetings.

-- Per interview of Staff J, Respiratory Therapist on 5/16/2024 at 3:05 pm, there is no medical director over the respiratory therapy department, they would go to the clinical lead of respiratory therapy for a problems. There are no respiratory therapy meetings.

-- Per interview of Staff K, Pulmonologist on 5/17/2024 at 7:30 am, is not the official director of the respiratory therapy department. Staff K is sent respiratory policies and procedures pertaining to the intensive care unit to review. There are no specific respiratory therapy meetings. Respiratory therapy is invited to the monthly coronary care and quality assurance meetings and Staff K sees the meeting minutes.

-- During interview of Staff E, Chief Nursing Officer on 5/22/2024 at 2:00 pm, they acknowledged the above findings.