HospitalInspections.org

Based on a review of facility documents, medical records (MR), observation, and staff interview(EMP), it was determined that the facility failed to supervise the patient's care to ensure the patient's cardiac status was being monitored at all times for one of 20 medical records reviewed (MR1), failed to follow the cardiac standards of care for two of 20 medical records reviewed (MR1 and MR2), and failed to ensure that a registered nurse (RN) supervised and evaluated patients under the care of a licensed practical nurse (LPN) consistent with professionally recognized standards of nursing practice for two of two medical records reviewed (MR21 and MR22).


Findings include:



On July 29, 2024, a review of the facility's Protocol for Patient Management, last reviewed July 17, 2024, revealed, "...Excela Health has created this policy in order to facilitate appropriate alarm management and decrease instances of alarm fatigue and alarm nuisance. ...ALARM RESPONSE. Patient care staff must respond to alarms immediately. ...Patient care staff identifies the reason for the alarm the reason for the alarm, corrects the issue or notifies the appropriate individual when patient monitoring issues arise that are outside the clinicians' scope of practice. ... DOCUMENTATION in EMR: All assessment and reassessment findings, Interpretation of the rhythm strips on admission, every 8 hours, and as needed. Alarms are functional, Any changes made to alarms, Any changes inpatient's vital signs or cardiac rhythm...".


On July 29, 2024, a review of the facility's Registered Nurse Standard Work, dated June 2020, revealed, "Primary RN will give verbal delegation and report to LPN and TP (technical partner) for appropriate patient needs and task completion...".



On July 30, 2024, a review of the facility's Registered Nurse job description, dated April 28, 2022, revealed, "Assure quality of care by adhering to therapeutic standards ...following system/hospital and nursing division's philosophies and standards of care set by state board of nursing, nurse practice act, and other governing agency regulations.... Document patient care services by charting in patient records ... Identify patient care requirements by establishing a personal rapport with potential and actuals patients, and other persons in a position to understand care requirements...".



On July 30, 2024, a review of the facility's Licensed Practical Nurse job description dated January 19, 2023, revealed, "Essential Job Functions- Assists the RN in collecting patient health care data on admission by completing a focused assessment."



On July 29, 2024, a review of MR1 revealed the patient was a 76-year-old female with a history of coronary artery disease, gout and diabetes and presented to the hospital on July 2, 2024, due to decreased urine output, urinary retention, an elevated troponin, a urinary tract infection, chest tightness, and short of breath. Cardiology was consulted and patient was admitted with hypoxia and a STEMI. MR1 had a stress test and was not medically stable to have a left heart catheterization at this time due to Chronic Renal Failure. On July 8, 2024, at 4:04 AM, Monitor tech alerted staff via text that the cardiac monitor came off. The charge nurse responded that they would let primary nurse know. Facility documents showed a call was made to the unit at 4:16 AM. At 4:32 AM, the monitor tech texted the charge nurse again that the monitor leads continued to read leads off without a change. At 4:46 AM, the tech went in to check the patient, found patient unresponsive and called out for help. A code blue was called. Staff initiated CPR immediately and on arrival of the Code team, underlying rhythm was asystole. After ten rounds of epinepherine and Bicarb, the patient was transferred to ICU for further management. There, the intensivist had multiple conversations with the family including the possibility of inadequate brain perfusion after a cardiac arrest and CPR for forty minutes. Family was notified that patient's neurological exam was poor. Later in the afternoon, the patient experienced seizure like activity. Another discussion with the family resulted in the decision to proceed with Comfort Measures Only. The patient passed away on July 8, 2024.



On July 29, 2024, a review of MR2, revealed that the 68 year old patient was admitted on July 26, 2024, via the Emergency Department with shortness of breath, chest pain, a recent weitght gain of 17 pounds and a valve replacement to a cardiac monitor unit. The patient had a history of hypertension, Supraventricular Tachycardia (SVT) and Sleep Apnea. Further review revealed that MR2 was ordered a Trans-Esophageal Echocardiogram (TEE) to rule out cardiac tamponade and the nurse obtained an order for the patient to go for testing off the the cardiac monitor on July 29, 2024.



On July 29, 2024 at 10:01 AM, MR2 was observed from the monitor room, returning to the nursing unit,off the cardiac monitor. At 10:06 AM, EMP9 placed a call to call to the third floor telemetry unit to place the patient back on the monitor. EMP9 stated that the nurse has five minutes to place the patient back on the monitor. The patient was observed being off the monitor until 10:13 AM.


On July 29, 2024, at 10:13 AM, EMP3 confirmed the above.


On July 30, 2024, during a review of assignment sheets while on tour, the following verbiage was noted on the standardized facility assignment sheet, "MUST indicate RN that is covering the LPN...".


On July 30, 2024, at 09:50 AM, during a tour of the first floor telemetry unit, nursing patient assignment sheets were reviewed. It was noted that the titles of registered nurse and licensed practical nurse were not delineated on the assignment sheets for six of six assignment sheets reviewed. It was also noted that LPN coverage by a RN was not delineated on the assignment sheet for six of six assignment sheets reviewed.


On July 30, 2024, at 10:00 AM, EMP15 described that the LPN was covered by the charge nurse or clinical nurse coordinator.


On July 30, 2024, a review of MR21 revealed that the patient was cared for by LPN EMP16 between July 27, 2024, at 7:00 PM, and July 28, 2024, at 7:00 AM. Further review of MR21 revealed no documentation to support that an RN supervised nursing care or evaluated the patient during this shift.



On July 30, 2024, a review of MR22 revealed that the patient was cared for by LPN EMP17 between July 27, 2024, at 7:00 PM, and July 27, 2024, at 3:00 PM. Further review of MR22 revealed no documentation to support that an RN supervised nursing care or evaluated the patient during this shift.


On July 30, 2024, at approximately 12:15 pm, EMP1 and EMP12 confirmed the above.

Based on a review of facility documentation, medical record (MR), and staff interview (EMP), it was determined the facility failed to ensure staff adhered to the policies and procedures of the hospital for the cardiac monitor standard of care in two of two medical records (MR1 and MR2), and failed to ensure that the standard for assessment/reassessment was met in one of two medical records reviewed (MR21).


Findings include:



On July 29, 2024, a review of the facility's Protocol for Patient Management, last reviewed July 17, 2024, revealed, "Excela Health has created this policy in order to facilitate appropriate alarm management and decrease instances of alarm fatigue and alarm nuisance. ...ALARM RESPONSE. Patient care staff must respond to alarms immediately. ...Patient care staff identifies the reason for the alarm the reason for the alarm, corrects the issue or notifies the appropriate individual when patient monitoring issues arise that are outside the clinicians' scope of practice, ... DOCUMENTATION in EMR: All assessment and reassessment findings, Interpretation of the rhythm strips on admission, every 8 hours, and as needed. Alarms are functional, Any changes made to alarms, Any changes inpatient's vital signs or cardiac rhythm...".



On July 30, 2024, a review of the policy, "Assessment/Reassessment of the Patient"
(Last Reviewed/Revised: January 2024) revealed, "... A head to toe re-assessment will be completed and documented by an RN/GN a minimum of every 12 hours, with change in patient condition, and when responsibility for a patient's care changes from one nurse to another."



On July 29, 2024, a review of MR1 revealed the patient was a 76-year-old female with a history of coronary artery disease, gout and diabetes and presented to the hospital on July 2, 2024, due to decreased urine output, urinary retention, an elevated troponin, a urinary tract infection, chest tightness, and short of breath. Cardiology was consulted and patient was admitted with hypoxia and a STEMI. MR1 had a stress test and was not medically stable to have a left heart catheterization at this time due to Chronic Renal Failure. On July 8, 2024, at 4:04 AM, Monitor tech alerted staff via text that the cardiac monitor came off. The charge nurse responded that they would let primary nurse know. Facility documents showed a call was made to the unit at 4:16 AM. At 4:32 AM, the monitor tech texted the charge nurse again that the monitor leads continued to read leads off without a change. At 4:46 AM, the tech went in to check the patient, found patient unresponsive and called out for help. A code blue was called. Staff initiated CPR immediately and on arrival of the Code team, underlying rhythm was asystole. After ten rounds of epinepherine and Bicarb, the patient was transferred to ICU for further management. There, the intensivist had multiple conversations with the family including the possibility of inadequate brain perfusion after a cardiac arrest and CPR for forty minutes. Family was notified that patient's neurological exam was poor. Later in the afternoon, the patient experienced seizure like activity. Another discussion with the family resulted in the decision to proceed with Comfort Measures Only. The patient passed away on July 8, 2024.



On July 29, 2024, a review of MR2, revealed that the 68 year old patient was admitted on July 26, 2024, via the Emergency Department with shortness of breath, chest pain, a recent weitght gain of 17 pounds and a valve replacement to a cardiac monitor unit. The patient had a history of hypertension, Supraventricular Tachycardia (SVT) and Sleep Apnea. Further review revealed that MR2 was ordered a Trans-Esophageal Echocardiogram (TEE) to rule out cardiac tamponade and the nurse obtained an order for the patient to go for testing off the the cardiac monitor on July 29, 2024.



On July 29, 2024 at 10:01 AM, MR2 was observed from the monitor room, returning to the nursing unit,off the cardiac monitor. At 10:06 AM, EMP9 placed a call to call to the third floor telemetry unit to place the patient back on the monitor. EMP9 stated that the nurse has five minutes to place the patient back on the monitor. The patient was observed being off the monitor until 10:13 AM.


On July 29, 2024, at 10:13 AM, EMP3 confirmed the above.


On July 30, 2024, at 12:00 PM, a review of MR21 was completed. On 7/27/2024, at 07:00PM, the responsibility for MR21 was assumed by another nurse. There was no documented patient assessment with the change of patient responsibility from one nurse to another.


On July 30, 2024, at approximately 12:10 PM, EMP1 and EMP12 confirmed this finding.