HospitalInspections.org

Based on a review of facility documents and medical records (MR), and staff interviews (EMP) it was determined that the Chief Executive Officer/President failed to protect the rights of the patient (MR) ensuring good quality care and high professional standards.

Findings include:

Review of facility job description for the President/CEO last updated on September 20, 2012 revealed "...Administers, directs, and supervises all activities in fulfilling the mission to provide quality healthcare..."

Review of facility "Amended and Restated Bylaws" reviewed January 2016 revealed "...The Chief Executive Officer shall be responsible for the general and active management of the business and affairs of the Corporation and shall exercise general supervision and authority over all of its agents and employees..."

Review of facility policy "Patient Rights and Responsibilities" last revised October 2014 revealed "...Care Delivery: You have the right to...Receive care in a safe setting free from any form of abuse, harassment, and neglect...Receive efficient and quality care with high professional standards that are continually maintained and reviewed..."

Review of facility "Red Alarm Monitoring Policy" dated August 2014 revealed "...The following rhythms are considered RED alarms and require and IMMEDIATE response...No signal...Immediate response is defined as the following: The MT/RN (Monitor Tech)/(Registered Nurse) will immediately notify an RN or if not available any staff member to check the patient and take appropriate steps...If there is no one available in the immediate area, the MT/RN will announce a "Red Alarm" plus the room number...All staff are expected to respond to the alarm until an RN is seen entering the room to check the patient and take appropriate steps...If the electrodes are the issue, the staff member will use the call light to verify with the MT that the patient's rhythm s visible on the central monitor...After one minute of the Red Alarm, if there is no response from a staff member or no rhythm visible on the central monitor, the MT/RN will notify the supervisor or charge nurse...Continue to escalate the situation through appropriate support channels until rhythm can be confirmed. When in doubt, get immediate help; do not hesitate to call a Code Blue if necessary."

1) 1) Review of physician orders for MR1 dated 6/6/2016 revealed "Cardiac Monitoring."

2) Review of MR1 nurse's note dated 7/19/2016 at 7:45 PM revealed "Pt. stated he has chest pain. Team 5 notified. Dr...called back. Doctor stated, "patient has been complaining about everything but to be on the safe side he was ordering tropinin levels to done and a ECG."

3) Review of MR1 nurse's note dated July 19, 2016, at 9:00 PM revealed a "...Critical lab value came back for Tropinin. Dr...notified. Dr. stated he was putting in an order for a CT scan..."

4) Review of MR1 nurse's note dated 7/19/2016 at 11:00 PM revealed "...ER CT called stating they had time for patient and had the room ready. No patient transportation on duty this evening, monitor tech stated she would go with me. Monitor tech helped get Patient on to gurney. Pt. was transported with monitor, O2 and face mask due to current TB status. Monitor tech and nurse wore appropriate protection gear. Patient was transported to CT in ER department. Pt. was returned to room after procedure..."

5) Review of MR1 nurse's note dated 7/20/2016 at 1250 AM revealed "...paged Dr...asking if patient could have something to calm him down patient appeared restless all evening. Dr. stated he wanted to make sure the CT scan was clear before he would put order in."

6 Review of MR1 physician significant event note dated 7/20/2016 at 2:41 AM revealed "...I received a phone call from Radiology at 1:37 AM. They told me that the CT scan that was done did not show a PE but showed a large right sided tension pneumothorax. I immediately called cardiothoracic surgery and informed them of the findings and asked them to place a chest tube. They indicated they would be right down. Upon hanging up from the conversation, I immediately called the nurse taking care of the patient on my cell phone to tell her of the CT scan findings and the plan. Upon picking up the phone she indicated that the Pateint was coding. I am not sure how long the patient was down for upon returning from CT scan but immediately went to bedside with the Pateint and found he was unresponsive and with out a pulse. Chest compressions were immediately started and the patient was hooked up to a monitor..."

7) Review of facility event documentation dated 7/20/16 at 17:33 revealed "...Patient with dx TB, in isolation, had c/o chest pain...CT scan ordered to evaluate, r/o PE (pulmonary embolism) . Patient returned from transport...accompanied by RN (Registered Nurse). Patient placed on monitor at bedside. RN exited isolation room. MT (Monitor Tech) notified RN that there was no trace visible at central station. When RN re-entered room patient was apneic, pulseless. Code called. Patient transferred to ICU (intensive Care Unit). Patient remains in critical condition..."

8) Review of facility documentation " Current Summary Provision of Care Event ... Entered date 07-20-2016... MR1 returned from CT scan around 00:55am. I asked EMP2 multiple times to place patient back on telemetry. EMP2 told me multiple times she was going back in his room because she/he had to draw MR1's blood...EMP2 went into the room around 1:43 AM to place MR1 back on monitor and found MR1 unresponsive. I called the code blue. ... EMP7 offered to put patient back on right after CT scan. EMP2 insisted that he/she would do it since he/she was going in to do blood work anyway. ..."

9) Review of facility monitor log for Room 566 dated July 20, 2016, revealed that MR1's telemetry monitor was placed on standby mode at 12:24 AM (566 Equipment in standby)while patient was taken to Radiology for testing. At 12:49 AM MR1 returned from Radiology and the telemetry monitor was taken off standby mode (566 Equipment not in standby). At 1:48 AM on July 20, 2016, monitor log for Room 566 revealed (566***Asystole Generated at 01:48:49. (HR=) ).

During interview conducted on July 26, 2016, at approximately 9:15 AM EMP1 confirmed the above findings and revealed "...there were five RNs, a secretary, myself, and another Monitor Tech Trainee scheduled that night...MR1's room was located directly in front of the nursing station...After EMP2 returned with MR1 from CT, patient was put back in bed and as EMP2 was exiting room I told EMP2 that the monitor was unplugged. EMP7 offered to go back in because they were still garbed but EMP2 said he/she would take care of it because the patient had bloodwork that needed to be drawn...I tried to remind EMP2 several times after that...the Charge Nurse EMP6 and two other nurses plus the secretary heard me tell EMP2 that the patient was still off the monitor, we were all right there at the nurses station...I should have called the house supervisor...I did not know I could call a Code Blue..."

During interview on July 26, 2016, at approximately 10:15 AM EMP2 revealed the following "...we got MR1 back in bed...I wanted to let doctor know the test was done and get something to calm him down...I wanted to get my PPE off, I was absolutely drenched and if I did not get it off I was going to pass out...I remember someone telling me about the monitor...my mind was racing and I was thinking about my other patients...I remember saying I was going back in to get blood...EMP6 told me not to go in and get his blood...I just remember starting to go back in and then I was stopped...After that...I went to see my other patients...I remember going back to MR1's room and EMP1 telling me about the tracing...As soon as I went into the room...I was in shock MR1 was not breathing...I do not remember if the telemetry box was connected but I remember EMP6 banging the box several times trying to get it to work..."

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure the protection and promotion of the rights of patients and failed to provide care in a safe setting (0144); facility failed to respond immediately and execute the necessary steps to address an issue with a patients's telemetry monitoring unit not transmitting a signal at the central monitoring station for one of 20 medical records reviewed (MR1).

This situation constitutes an Immediate Jeopardy situation.

Findings include:

1) Review of facility documents and medical records, and staff interviews revealed that the facility staff failed to respond immediately and execute the necessary steps to address an issue with a patients's telemetry monitoring unit not transmitting a signal at the central monitoring station (0144).

Cross reference with:
482.13 Patient Rights(c)(2) The patient has the right to receive care in a safe setting.

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Based on a review of facility documents and medical records (MR), and staff interviews (EMP) it was determined that the facility staff failed to provide care in a safe environment by not responding immediately and executing the necessary steps to address an issue with a patients's telemetry monitoring unit not transmitting a signal to the central monitoring station resulting in harm for one of 20 medical records reviewed (MR1).

Findings include:

Review of facility policy "Patient Rights and Responsibilities" last revised October 2014 revealed "...Care Delivery: You have the right to...Receive care in a safe setting free from any form of abuse, harassment, and neglect...Receive efficient and quality care with high professional standards that are continually maintained and reviewed..."

Review of facility "Red Alarm Monitoring Policy" dated August 2014 revealed "...The following rhythms are considered RED alarms and require and IMMEDIATE response...No signal...Immediate response is defined as the following: The MT/RN (Monitor Tech)/(Registered Nurse) will immediately notify an RN or if not available any staff member to check the patient and take appropriate steps...If there is no one available in the immediate area, the MT/RN will announce a "Red Alarm" plus the room number...All staff are expected to respond to the alarm until an RN is seen entering the room to check the patient and take appropriate steps...If the electrodes are the issue, the staff member will use the call light to verify with the MT that the patient's rhythm s visible on the central monitor...After one minute of the Red Alarm, if there is no response from a staff member or no rhythm visible on the central monitor, the MT/RN will notify the supervisor or charge nurse...Continue to escalate the situation through appropriate support channels until rhythm can be confirmed. When in doubt, get immediate help; do not hesitate to call a Code Blue if necessary."

1) 1) Review of physician orders for MR1 dated 6/6/2016 revealed "Cardiac Monitoring."

2) Review of MR1 nurse's note dated 7/19/2016 at 7:45 PM revealed "Pt. stated he has chest pain. Team 5 notified. Dr...called back. Doctor stated, "patient has been complaining about everything but to be on the safe side he was ordering tropinin levels to done and a ECG."

3) Review of MR1 nurse's note dated July 19, 2016, at 9:00 PM revealed a "...Critical lab value came back for Tropinin. Dr...notified. Dr. stated he was putting in an order for a CT scan..."

4) Review of MR1 nurse's note dated 7/19/2016 at 11:00 PM revealed "...ER CT called stating they had time for patient and had the room ready. No patient transportation on duty this evening, monitor tech stated she would go with me. Monitor tech helped get Pateint on to gurney. Pt. was transported with monitor, O2 and face mask due to current TB status. Monitor tech and nurse wore appropriate protection gear. Patient was transported to CT in ER department. Pt. was returned to room after procedure..."

5) Review of MR1 nurse's note dated 7/20/2016 at 1250 AM revealed "...paged Dr...asking if patient could have something to calm him down patient appeared restless all evening. Dr. stated he wanted to make sure the CT scan was clear before he would put order in."

6 Review of MR1 physician significant event note dated 7/20/2016 at 2:41 AM revealed "...I received a phone call from Radiology at 1:37 AM. They told me that the CT scan that was done did not show a PE but showed a large right sided tension pneumothorax. I immediately called cardiothoracic surgery and informed them of the findings and asked them to place a chest tube. They indicated they would be right down. Upon hanging up from the conversation, I immediately called the nurse taking care of the patient on my cell phone to tell her of the CT scan findings and the plan. Upon picking up the phone she indicated that the Pateint was coding. I am not sure how long the patient was down for upon returning from CT scan but immediately went to bedside with the Pateint and found he was unresponsive and with out a pulse. Chest compressions were immediately started and the patient was hooked up to a monitor..."

7) Review of facility event documentation dated 7/20/16 at 17:33 revealed "...Patient with dx TB, in isolation, had c/o chest pain...CT scan ordered to evaluate, r/o PE (pulmonary embolism) . Patient returned from transport...accompanied by RN (Registered Nurse). Patient placed on monitor at bedside. RN exited isolation room. MT (Monitor Tech) notified RN that there was no trace visible at central station. When RN re-entered room patient was apneic, pulseless. Code called. Patient transferred to ICU (intensive Care Unit). Patient remains in critical condition..."

8) Review of facility documentation " Current Summary Provision of Care Event ... Entered date 07-20-2016... MR1 returned from CT scan around 00:55am. I asked EMP2 multiple times to place patient back on telemetry. EMP2 told me multiple times she was going back in his room because she/he had to draw MR1's blood...EMP2 went into the room around 1:43 AM to place MR1 back on monitor and found MR1 unresponsive. I called the code blue. ... EMP7 offered to put patient back on right after CT scan. EMP2 insisted that he/she would do it since he/she was going in to do blood work anyway. ..."

9) Review of facility monitor log for Room 566 dated July 20, 2016, revealed that MR1's telemetry monitor was placed on standby mode at 12:24 AM (566 Equipment in standby)while patient was taken to Radiology for testing. At 12:49 AM MR1 returned from Radiology and the telemetry monitor was taken off standby mode (566 Equipment not in standby). At 1:48 AM on July 20, 2016, monitor log for Room 566 revealed (566***Asystole Generated at 01:48:49. (HR=) ).

During interview conducted on July 26, 2016, at approximately 9:15 AM EMP1 confirmed the above findings and revealed "...there were five RNs, a secretary, myself, and another Monitor Tech Trainee scheduled that night...MR1's room was located directly in front of the nursing station...After EMP2 returned with MR1 from CT, patient was put back in bed and as EMP2 was exiting room I told EMP2 that the monitor was unplugged. EMP7 offered to go back in because they were still garbed but EMP2 said he/she would take care of it because the patient had bloodwork that needed to be drawn...I tried to remind EMP2 several times after that...the Charge Nurse EMP6 and two other nurses plus the secretary heard me tell EMP2 that the patient was still off the monitor, we were all right there at the nurses station...I should have called the house supervisor...I did not know I could call a Code Blue..."

During interview on July 26, 2016, at approximately 10:15 AM EMP2 revealed the following "...we got MR1 back in bed...I wanted to let doctor know the test was done and get something to calm him down...I wanted to get my PPE off, I was absolutely drenched and if I did not get it off I was going to pass out...I remember someone telling me about the monitor...my mind was racing and I was thinking about my other patients...I remember saying I was going back in to get blood...EMP6 told me not to go in and get his blood...I just remember starting to go back in and then I was stopped...After that...I went to see my other patients...I remember going back to MR1's room and EMP1 telling me about the tracing...As soon as I went into the room...I was in shock MR1 was not breathing...I do not remember if the telemetry box was connected but I remember EMP6 banging the box several times trying to get it to work..."

Based on review of facility documentation, medical record (MR), and staff interview (EMP), it was determined that the facility failed to provide nursing services consistent with professionally recognized standards of nursing practice (0395); Facility failed to initial the transportation log sheet to verify that the patient's heart rhythm is seen on the monitor and failed to respond immediately to take steps to address a "Red Alarm."

This situation constitutes an Immediate Jeopardy situation.

Findings include:

1) Review of facility documents and medical records, and staff interviews revealed that the facility failed to initial the transportation log sheet to verify that the patient's heart rhythm was seen on the monitor and failed to respond immediately to take steps to address a "Red alarm." (0395)

Cross reference with:
482.23 Nursing Services(b)(3) RN supervision of nursing care.

Based on review of facility documentation, medical record (MR), and staff interview (EMP), it was determined that the facility failed to follow nursing care policies and procedures consistent with professionally recognized standards of nursing practice resulting in harm for one of 20 medical records reviewed (MR1).

Findings include:

Review of facility policy and procedure " Bedside And Telemetry Monitoring System " dated December 2015, revealed " II. Outcome: 1. Patient's monitor pattern is identified, clear and visible, ... Standards: ...f. After electrodes applied, confirm signal on bedside and/or central monitoring station. Confirm other waveforms on bedside and/or central monitoring station. ... 3. Monitored Units ... d. When a transport monitor tech or nurse transports a monitored patient on/off the nursing unit, the home-based tech at the central monitoring station must be notified before leaving and upon return to the unit. There must be a verbal hand off communication between the transport monitor tech/RN, ancillary transport staff and the home-base monitor/RN at the central monitoring station. In addition the home based monitor tech/RN must initial the transportation log sheet to verify that the patient ' s heart rhythm is seen on the central monitoring station. "
1. Review of facility log " July 20, 2016 Monitored Patient Transport Log " revealed the patient's name was not documented on the log. "
2. Review of facility documentation revealed the patient's monitor was placed on standby July 20, 2016, at 00:24 and was placed back on the monitor at 00:51.
Interview with Bob Unit Manager on July 25, 2016, at 12:15 PM revealed " We deviated from the process because we used our own staff. That's where the break in the process was. I did realize that when I reviewed the log. "
Review of facility "Red Alarm Monitoring Policy" dated August 2014 revealed "...The following rhythms are considered RED alarms and require and IMMEDIATE response...No signal...Immediate response is defined as the following: The MT/RN (Monitor Tech)/(Registered Nurse) will immediately notify an RN or if not available any staff member to check the patient and take appropriate steps...If there is no one available in the immediate area, the MT/RN will announce a "Red Alarm" plus the room number...All staff are expected to respond to the alarm until an RN is seen entering the room to check the patient and take appropriate steps...If the electrodes are the issue, the staff member will use the call light to verify with the MT that the patient's rhythm s visible on the central monitor...After one minute of the Red Alarm, if there is no response from a staff member or no rhythm visible on the central monitor, the MT/RN will notify the supervisor or charge nurse...Continue to escalate the situation through appropriate support channels until rhythm can be confirmed. When in doubt, get immediate help; do not hesitate to call a Code Blue if necessary."
1) Review of facility event documentation dated 7/20/16 at 17:33 revealed "...Patient with dx TB, in isolation, had c/o chest pain...CT scan ordered to evaluate, r/o PE (pulmonary embolism) . Patient returned from transport...accompanied by RN (Registered Nurse). Patient placed on monitor at bedside. RN exited isolation room. MT (Monitor Tech) notified RN that there was no trace visible at central station. When RN re-entered room patient was apneic, pulseless. Code called. Patient transferred to ICU (intensive Care Unit). Patient remains in critical condition..."
During interview conducted on July 26, 2016, at approximately 9:15 AM EMP1 confirmed the above findings and revealed "...there were five RNs, a secretary, myself, and another Monitor Tech Trainee scheduled that night...MR1's room was located directly in front of the nursing station...After EMP2 returned with MR1 from CT, patient was put back in bed and as EMP2 was exiting room I told EMP2 that the monitor was unplugged. EMP7 offered to go back in because they were still garbed but EMP2 said he/she would take care of it because the patient had bloodwork that needed to be drawn...I tried to remind EMP2 several times after that...the Charge Nurse EMP6 and two other nurses plus the secretary heard me tell EMP2 that the patient was still off the monitor, we were all right there at the nurses station...I should have called the house supervisor...I did not know I could call a Code Blue..."