HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure the registered nurse (RN) immediately assessed a patient on cardiac monitoring upon notification of a rhythm change.

Findings include:

On June 16, 2021, review of the facility's policy "Remote Cardiac Monitoring" last revised 11/2019, revealed "Policy Scope: This standard applies to all Allegheny Valley Hospital staff or physicians who have clinical contact with our patients. Policy Statement: The purpose of the cardiac monitoring process is to provide monitoring to patients who are at risk for an arrhythmic event that would require intervention. Policy Purpose: 1. Provide a detailed procedure for the application, use and maintenance of remote cardiac monitoring 2. Define criteria for instituting or discontinuation of remove cardiac monitoring ... Guidelines / Procedures: Process for Remote Cardiac Monitoring ... 5. The RN is to immediately assess patient upon notification of rhythm change. ... The RN will document time of notification, assessment of patient, and interventions performed (vital signs, notified MD, RRT initiated). ... "

Review of facility documentation revealed that when the telemonitor technician notified the RN (EMP7) that MR1 was "off monitor," EMP7 asked an aide to check the patient and to place the leads back on the patient.

Review of MR1 revealed the following Nursing note dated June 10, 2021, at 8:50 AM: At 0718 the nurse was notified by the monitor tech that the patient was off the monitor. The nurse instructed the patient care associate to place the patient back on the monitor.

During an interview on June 16, 2021, at approximately 10:30 AM, EMP3 confirmed the documentation in the nursing note for June 10, 2021.