HospitalInspections.org

Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to execute the admitting physician orders for implementation of continuous cardiac monitoring for one of fourteen medical records reviewed (MR1).

Findings include:


On January 2, 2025, a review of the policy, "Telemetry Monitoring" (HS-HD-CP-22; Last Reviewed: September 4, 2024) was completed and revealed the following: "I. Policy: It is the policy of UPMC to provide standardized, consistent care of patients undergoing continuous cardiac monitoring ...IV: Procedure: 1. Monitor Orders and Association: a. Monitor Orders and Evaluation: 1. A physician and/or the advanced practice provider will assess the need and provide the order for the cardiac rhythm monitoring ... b. Monitor Associations 1. Confirm cardiac monitor order 2. Upon admission to the designated area, the patient who is ordered cardiac rhythm monitoring will be connected to the bedside monitor and/or telemetry, as is appropriate to the unit monitoring system 3. Associate the telemetry product with the patient by confirming the telemetry equipment number and verify correct patient identifiers 4. Confirm monitor is in view in all necessary locations. Section 4. Cardiac Monitor Nursing Documentation: a. Electronic Health Record Documentation: 1. The patient's cardiac rhythm waveform will be documented at transition or handover of care personnel and with any condition change that requires provider notification. b. Printed Cardiac Waveform Documentation: 1. Cardiac rhythm will be captured upon admission to the designated area and with any condition change that requires provider notification."


On January 2, 2025, a review of MR1 revealed that MR1 was admitted on November 6, 2024, at 23:45. The admitting physician ordered continuous cardiac monitoring on November 7, 2024 at 00:40. Continuous cardiac monitoring was not initiated. On November 7, 2024, at 08:30, MR1 was found without a pulse.


On January 2, 2024, the above findings were confirmed at 10:57 AM by EMP4 and EMP9.