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Based on observation, review of facility policies, review of medical record (MR) and interview with staff (EMP), it was determined that the facility failed to ensure the safety and well-being of a patient by failing to respond to a cardiac monitor alarm, as per facility policy, for one medical record reviewed (MR1).

Findings include:

Review on February 26, 2018, of facility's policy, "Patient's Rights and Responsibilities," dated November 13, 2017, revealed, " ... Patient Rights: ... F. to expect emergency procedures to be implemented without unnecessary delay; G. to good quality care and high professional standards that are continually maintained and reviewed."

Review on February 26, 2018, of facility's policy, " ... Telemetry Monitoring Documentation and Communication," dated October 6, 2017, revealed, " ... Statement: This program is designed to establish a process for effective communication between the monitor technicians and the RNs (registered nurse) caring for telemetry patients. ... Communication: ... 3. Any changes in rhythm will be immediately communicated to the RN responsible for the care of the patient, including but not limited to ... . 4. Only red alarm dysrhythmias will be called to the RN responsible for the care of the patient via the red phone. If unable to reach the RN via the red phone, the charge RN will be immediately notified."

Review on February 26, 2018, of facility's policy, " ... Alarm Management," dated October 6, 2017, revealed, " ... Procedure: 3. An alarm will not be disabled or inactivated at any time, nor will it be set to such extremes as to fail to detect significant changes in patient's condition ... . 6. If an alarm occurs the patient will be checked immediately. The cause of alarm will be determined and addressed. ... . Cardiac Alarm Guidelines: 1. ... a. Red Alarms: 1) Red Alarms are potentially life-threatening event: asystole, ventricular tachycardia, ventricular fibrillation, tachycardia, bradycardia. 2) The nurse will check the patient immediately upon notification of a red alarm. 3) The audible red alarm is continuous, high pitched rapid sound."

Review on February 26, 2018, of MR1, " ... Nurse Notes," dated December 7, 2017 at 4:53 PM, revealed, " ... Rapid response/code blue. Found PT [patient] unresponsive. Called rapid response. Initiated CPR. PT not breathing. Code Blue Called. Death pronounced by MD ... . Family notified by Dr. [doctor] ... . Nursing Supervisor ... and Nurse Manager ... notified."

Review on February 26, 2018, of MR1, "Discharge Summary," A code blue was called for asystole lasting for 24 minutes."

Review on February 26, 2018, of MR1, "Certificate of Death," dated 12/7/17, revealed, " ... date signed 12/7/17 ... time of death 4:09 PM. ... Cause of death ... Cardiac Arrhythmia."

Review on February 28, 2018 of facility document, dated December 7, 2017, revealed " ... Patient on cardiac monitor. Alarm undetected by monitor tech. RN [registered nurse] entered the room. Patient unresponsive. Code Blue called. Unsuccessful."

Interview with EMP1 and EMP2 on February 27, 2018 between 1:10 PM and 1:35 PM, indicated that a root cause analysis was performed. EMP1 and EMP2 confirmed, in reviewing Cardiac Rhythm strip for patient related to MR1, initially artifact was correctly identified by Monitor Tech (MT), however when rhythm changed to a dangerous dysrhythmia MT did not correctly identify change, silenced the alarms without verifying the rhythm and did not notify Nursing staff of alarm. Further confirmed, RN found patient during rounds approximately 20 minutes after monitor alarm and called the rapid response code."

Based on a review of facility policy and procedures and facility documents and personnel files (PF), and interview with staff (EMP), it was determined the facility failed to ensure the restraint educator was qualified as evidenced by specific education, training, and experience in techniques used to address patients' behaviors and restraint application for one of six personnel files reviewed (PF7).

Findings include:

A request was made to EMP6, on February 27, 2018, at approximately 1:20PM, for facility policy and procedures for Restraint Educator Training Requirements. None was provided.
Review of PF2, PF3, PF4, PF5 and PF7 revealed PF7 as the designated restraint educator. Further review of PF7 revealed no documented evidence PF7 was qualified through higher level of knowledge and education, training, and experience in techniques to address patients' behaviors and restraint application. Further review of PF "... Skills Checklist - Restraint Application ..." revealed PF2, PF3, PF4, PF5, PF6 and PF7 all had the same level of training, education in techniques used to address patients' behaviors.

Interview on February 27, 2018, with EMP6 at 1:17PM, confirmed PF7 was the designated restraint educator for the facility. Further interview confirmed no documented evidence PF7 was qualified through higher level of knowledge and education, training, and experience in techniques to address patients' behaviors and restraint application. Further interview with EMP6 confirmed PF2, PF3, PF4, PF5, PF6 and PF7 all had the same level of training, education in techniques used to address patients' behaviors. Interview confirmed no policy and procedure for Restraint Educator Training Requirements.