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Based on record review, document review and staff interview, it was determined that that the facility:

Failed to implement tracking of indicators related to adverse patient event, following the death of a patient who had been ordered to be placed on telemetry, but telemetry was not initiated. (refer to A 0267)

Failed to monitor indicators related to identified patient safety concerns to ensure conditions that existed at the time of the patient's death had been corrected (refer to A 0285)

Failed to ensure implementation of corrective action that included provision for staff education. Three patients were identified on 12/30/11 who had telemetry orders that were not implemented when ordered by the physician. One patient had order for telemetry that was not implemented for greater than 48 hours. Nursing staff and monitor technicians did not implement plan of correction regarding use of nursing status board and electronic report of all telemetry orders to ensure all patients with telemetry orders were on telemetry. (see A 288)

Failure of the governing body to ensure implementation and monitoring of corrective action plan related to an adverse patient event, that may have resulted in a patien'st death. This failed to ensure that the conditions that existed at the time of the patient's death had been corrected (Refer to A 0311).

The cumulative effect of the facility's failure to ensure implementation of the plan of action following an adverse patient event resulting in death, failure to effectively educate the staff regarding the plan of action and failure to monitor the effectiveness of the plan to relieve the risk of death for patients ordered to be on telemetry, resulted in the determination that that the Condition is out of compliance and Immediate Jeopardy was present and ongoing.

Based on record review and staff interview it was determined that the facility failed to initiate tracking of indicators following identification of an adverse incident. This resulted in failure to identify missed telemetry order. This practice places patients at risk of death if a lethal arrhythmia were to occur.

Findings include:

Review of the medical record of Patient # 1 revealed that she was admitted to the facility on 5/4/11 at approximately 11:15 p.m.. with the diagnosis of gastrointestinal bleeding. The physician ordered that the patient be placed on telemetry at the time of admission. Review of nursing documentation revealed no evidence that the patient was placed on telemetry. A nurses' note written at 8:02 a.m. on 5/5/11 documented that "around 0555 when we went to change the patient, found her not responding to our wake up call. Found her not breathing. Called Code Blue right away and started CPR.." "Passed away at 0619".

The Risk Manager was interviewed on 12/30/11 at approximately 11:30 a.m. She explained that following the event, the facility implemented an action plan to ensure all patients with telemetry orders are placed on telemetry. The plan called for a report listing all patients with telemetry orders to be pulled by the telemetry technician (tech) every shift to ensure that all patient with telemetry orders are on telemetry. In addition, the electronic physician order system was changed so that the order for telemetry would be displayed on the nurses' status board, providing the nursing staff with an easy way to identify all patients with telemetry orders.

The facility's policy "Telemetry" # 2.600.124, revised 11/1/11 (after the date of the adverse event), did not include the requirement that the telemetry tech was to run the electronic report of all patients with telemetry orders, which should have been done to ensure staff was aware of the requirement.

1. Interview with the three telemetry techs who were on duty on 12/30/11 revealed that none of them were aware of the report listing all telemetry orders that they were to be print each shift.

2. The Risk Manager was interviewed on 12/30/11 at approximately 11:30 p.m. She stated that no monitoring of the above action plan had been implemented.

3. Patient #10 was admitted to the facility on 12/27/11 at approximately 3:00 p.m. The medical records revealed that the telemetry order was not implemented until approximately 6:00 p.m. on 12/29/11 over forty eight hours later.

4. Patient #4 was admitted to the facility on 12/24/11. She was sent to 4 South at approximately 11:00 p.m. with the diagnosis of mental status change. Telemetry was ordered at the time of admission. Review of the medical record revealed that there was a nursing assessment at 11:40 p.m., but no nursing assessment of the telemetry rhythm. The first nursing assessment of the telemetry rhythm was at 2:13 a.m., which was 3 hours after the patient was admitted.

5. Patient #6 had a delay of 4 hours in the implementation of the telemetry order from the physician.

The fact that the corrective action plan was not included in the policy, effectively communicated to the monitor techs and was not being monitored for effectiveness by nursing management resulted in the patients remaining at risk if telemetry was not initiated when ordered and a lethal cardiac arrhythmia should occur and go undetected and untreated.

Based on staff interview and review of quality assessment performance improvement indicators it was determined that the facility failed to implement monitoring of areas that are found to be problem prone relative to telemetry patient safety. The facility's failure to implement ongoing monitoring of the identified problem prone safety issue places patients at risk of death if a potentially lethal cardiac arrhythmia is not promptly identified and treated.

Findings include:

Interview of the Risk Manager on 12/30/11 at approximately 11:30 a.m. revealed that an adverse incident involving patient #1 had resulted in the implementation of a plan of action regarding telemetry monitoring. The patient had been ordered to be placed on telemetry at the time of admission on 5/4/11. The telemetry was not initiated. The patient was found unresponsive on 5/5/11 at approximately 5:55 a.m. Resuscitation efforts were unsuccessful.

Review of the facility's quality indicators revealed there were no indicators in place regarding telemetry monitoring. The Risk Manager confirmed there was no quality indicator regarding telemetry monitoring.

Review of the medical records of patient #10 revealed the patient had telemetry that was not implemented for 2 days. The patient was admitted with a physician's order for telemetry on 12/27/11 at approximately 3:00 p.m. The telemetry was not implemented until 12/29/11 at approximately 6:00 p.m.

Patient # 4 had a delay of 3 hours in the implementation of the telemetry order from the physician.

Patient #6 had a delay of 4 hours in the implementation of the telemetry order from the physician.

The facility had identified a concern that patients' safety may be at risk regarding failure to implement telemetry monitoring when ordered by the physician. The facility failed to initiate quality indicators to monitor this. The risk that a lethal cardiac arrhythmia might go undetected resulting in a patient death still existed.

Based on staff interview it was determined that the facility failed to ensure implementation of preventive actions and provide education regarding the preventive measures following an adverse patient event. This practice does not ensure that the planned measures will have the desired outcome.

Findings include:

The Risk Manager was interviewed on 12/30/11 at approximately 11:30 a.m. She indicated that an adverse patient incident had been identified regarding failure to implement telemetry for patient #1. She explained that following the event, the facility placed an action plan into place to ensure all patients with telemetry orders are placed on telemetry. The plan called for a report listing all patients with telemetry orders to be printed by the telemetry technician (tech) every shift to ensure that all patients with telemetry orders are on telemetry. In addition, the electronic physician order entry system was changed so that the order for telemetry would be displayed on the nurses' status board, providing the nursing staff with an easy way to identify all patients with telemetry orders.

Record review performed on 12/30/11 revealed that patient #10's physician ordered telemetry on 12/27/11. The telemetry was not implemented until 12/29/11. This was not noted by the telemetry techs or the nursing staff.

The three telemetry techs who were on duty during the 7 a.m.-7 p.m. shift were interviewed. All of them indicated they were not printing the report and were unaware they were to do it. One of the techs had been on the job for approximately 50 days. The other two had been in their positions for several years.

The Risk Manager was interviewed on 12/30/11 at approximately 11:30 a.m. She confirmed that there had been no follow up regarding implementation of the plan of action regarding the adverse incident. Although a plan was developed it appeared it had not been effectively communicated to the staff. There was no monitoring to ensure all staff was aware of the new requirement.

Based on staff interview it was determined the governing body did not ensure there was follow up regarding implementation of a plan of action regarding an identified adverse incident regarding failure to implement telemetry resulting in a patient death (#1). The governing body did not take action to ensure the conditions that existed at the time of the patient's death were corrected, leaving telemetry patients at risk.

Findings include:

The Risk Manager was interviewed on 12/30/11. She stated that an adverse patient event had been identified in 5/11 regarding failure to implement telemetry for patient #1, who had a cardiac arrest and expired. A plan of action was developed. She stated that there had been no monitoring of the implementation or effectiveness of the plan that was implemented. There was no evidence the governing body had been involved in the monitoring of the plan of action to ensure that the unsafe conditions were abated.

Review of the medical record of patient #10 revealed that he was admitted with a physician order for telemetry on 12/27/11 at approximately 3:00 p.m. The telemetry was not implemented until 12/29/11 at approximately 6:00 p.m., leaving the patient at risk for greater 48 hours.

Patient #6 was admitted to the facility on 12/29/11 at approximately 1:30 a.m. Telemetry was ordered at the time of admission. Review of telemetry documentation revealed no rhythm strip had been documented until 5:40 a.m. The nurse did not document an assessment of the telemetry rhythm until 8:43 a.m. The patient was at risk for approximately 4 hours.

Patient #4 was admitted to the facility on 12/24/11 at approximately 11:00 p.m. with the diagnosis of mental status change. Telemetry was ordered by the physician at the time of admission. Review of the medical record revealed that there was a nursing assessment at 11:40 p.m., but no nursing assessment of the telemetry rhythm. The first nursing assessment of the telemetry rhythm was at 2:13 p.m., which was 3 hours after the patient was admitted. Review of the telemetry documentation by the telemetry tech revealed the first rhythm strip was not posted until approximately 2:00 p.m. The patient at risk for 3 hours.

The governing body failed to take action to ensure the conditions that existed at the time of the patient's death were corrected, leaving telemetry patients at risk for a delay in treatment or death.

Based on record review, policy review and staff interview, it was determined that the nursing staff:

failed to initiate telemetry orders, follow policy and implement corrective action following an adverse incident for failure to implement telemetry monitoring for a patent. The patient was found unresponsive and subsequently expired. A plan of correction was developed, Nursing staff and telemetry technicians failed to implement the plan. One current patient (#10) was found to have telemetry orders that had not been implemented for greater than 48 hours. Two other patients (#6, #9) had delays in implementing the physician orders for telemetry for 3-4 hours. (Refer to A0395)

failed to ensure the timely implementation of the nursing plan of care regarding implementation of telemetry orders, which are part of the plan of care. (Refer to A396).

The cumulative effect of the failure of the nursing staff to implement the plan of correction to ensure all patients with telemetry orders are placed on telemetry has resulted in the determination that the Condition of Nursing Services is out of compliance. Immediate Jeopardy was identified and was ongoing.

Based on record review, policy review and staff interview, it was determined the Registered Nurse failed to ensure staff provided care to telemetry patients according to physician's order, facility policy and plan of correction following identification of an adverse incident for 5 (#1, #4, #6. #9, #10) of 10 sampled patients.. This practice does not ensure significant cardiac events are identified and immediate action taken to prevent lethal adverse patient outcome.

Findings include:

1. Patient #1 was admitted to 3 East on 5/4/11 at approximately 11:15 a.m. with the diagnosis of gastrointestinal bleeding. The physician ordered that the patient be placed on telemetry at the time of admission and that vital signs were to be recorded every 4 hours. Review of nursing documentation revealed no evidence that the patient was placed on telemetry. Further review of nursing documentation revealed that the patient's vital signs were documented at the time of the admission assessment at 11:34 p.m., but were not recorded again. A nurses' note written at 8:02 a.m. documented that "around 0555 when we went to change the patient, found her not responding to our wake up call. Found her not breathing. Called Code Blue right away and started CPR.." "Passed away at 0619".

The Risk Manager was interviewed on 12/30/11 at approximately 11:30 a.m. She explained that following the event, the facility implemented an action plan to ensure all patients with telemetry orders are placed on telemetry. The plan called for a report listing all patients with telemetry orders to be pulled by the telemetry technician (tech) every shift to ensure that all patient with telemetry orders are on telemetry. In addition, the electronic physician order system was changed so that the order for telemetry would be displayed on the nurses' status board, providing the nursing staff with an easy way to identify all patients with telemetry orders.

2. The facility 's policy "Telemetry" # 2..600.124, revised 11/1/11 required that on initiation of telemetry the telemetry tech was to run an admission strip and place it on the medical record. The monitor tech was also to run a strip and place in the medical record every 6 hours. The Registered Nurse was to review the rhythm at least every shift or as the patient's condition warrants. The requirement for the monitor tech to pull the electronic report of all patients with telemetry orders was not part of the policy.

3. Patient # 10 was admitted to 3 East on 12/27/11 at approximately 3:31 p.m. with the diagnosis of pulmonary infiltrate/pneumonia. The patient was ordered to be placed on telemetry on 12/27/11 at 2:34 p.m. Review of the medical record revealed no documentation of telemetry being in place until 6:02 p.m. on 12/29/11. There were no posted strips and no documentation by the Registered Nurse. This placed the patient at risk of developing a cardiac arrhythmia that would go undetected and untreated, possible resulting in death.

The Director of Nursing was present during the review of the medical record on 12/30/11 at approximately 12:00 noon. She stated there was no evidence that the patient had been on telemetry before 12/29/111 at 6:00 p.m. She also provided the monitor tech log that lists each patient who was on telemetry each shift. Patient #10 was not listed. She could not explain how the order had been missed by the nursing staff.

Interview with the monitor tech on 3 East, which was where patient #10 had been located, revealed that she was unaware of the electronic report that was to be pulled and reviewed each shift by the monitor tech.

4. Patient #9 was also a patient on 3 East. She was admitted to the facility on 12/28/11 at approximately 11:32 p.m. Telemetry was ordered by the physician at the time of admission. Review of nursing documentation revealed no documentation of the telemetry rhythm by the Nurse until 12/29/11 at 12:30 p.m. A telemetry strip was posted in the record shortly after midnight.

The Director of Nursing confirmed the nurse failed to assess the telemetry rhythm as required during the admission assessment, during an interview on 12/30/11 at approximately 1:00 p.m.

5. Patient #6 was also a patient on 3 East. She was admitted to the facility on 12/29/11 at approximately 1:30 a.m. Telemetry was ordered at the time of admission. Review of telemetry documentation revealed no rhythm strip had been documented until 5:40 a.m. The nurse did not document an assessment of the telemetry rhythm until 8:43 a.m. The patient was at risk if a cardiac arrhythmia were to have occurred during the four hours that the patient was not monitored.

The Director of Nursing was present during the record review on 12/30/11 at approximately 1:45 p.m. and confirmed there was no evidence the patient was on telemetry until 5:30 a.m. and that the nurse failed to assess the patient according to facility policy.

6. Patient #4 was admitted to 4 South on 12/24/11 at approximately 11:00 p.m. with the diagnosis of mental status change. Telemetry was ordered at the time of admission. Review of the medical record revealed that there was a nursing assessment at 11:40 p.m., but no nursing assessment of the telemetry rhythm. The first nursing assessment of the telemetry rhythm was at 2:13 a.m., which was 3 hours after the patient was admitted. Review of the telemetry documentation by the telemetry tech revealed the first rhythm strip was not posted until approximately 2:00 a.m. The patient was at risk for 3 hours should a cardiac arrhythmia have developed and went undecked and untreated.

The Director of Nursing was present at the time of the record review at approximately 3:00 p.m. and confirmed that there was a delay in initiating the telemetry order, placing the patient at risk.

Based on record review and staff interview it was determined the nursing staff failed to ensure the timely implementation of the plan of care related to telemetry monitoring for 4 (#1, #4, #6, #10) of 10 sampled patients. This practice does not ensure the patient goal to promptly identify and treat potentially lethal cardiac arrhythmias is achieved, placing patients at risk.

Findings include:

1. Patient # 1 was admitted to the facility on 5/4/11 at approximately 11:15 a.m. with the diagnosis of gastrointestinal bleeding. The physician ordered that the patient be placed on telemetry at the time of admission and that vital signs were to be recorded every 4 hours. Review of nursing documentation revealed no evidence that the patient was placed on telemetry. Further review of nursing documentation revealed that the patient's vital signs were documented at the time of the admission assessment at 11:34 p.m., but were not recorded again. A nurses' not written at 8:02 a.m. documented that "around 05555 when we went to change the patient, found her not responding to our wake up call. Found her not breathing. Called Code Blue right away and started CPR.." "Passed away at 0619".

The facility 's policy "Telemetry" # 2..600.124, revised 11/1/11 required that on initiation of telemetry the telemetry tech was to run an admission strip and place it on the medical record. The monitor tech was also to run a strip and place in the medical record every 6 hours. The Registered Nurse was to review the rhythm at least every shift or as the patient's condition warrants. The requirement for the monitor tech to pull the electronic report of all patients with telemetry orders was not part of the policy.

2. Patient # 10 was admitted to the facility on 12/27/11 at approximately 3:31 p.m. with the diagnosis of pulmonary infiltrate/pneumonia. The patient was ordered to be placed on telemetry on 12/27/11 at 2:34 p.m. Review of the medical record revealed no documentation of telemetry being in place until 6:02 p.m. on 12/29/11. There were no posted strips and no documentation by the Registered Nurse.

The Director of Nursing was present during the review of the medical record on 12/30/11 at approximately 12:00 noon. She stated there was no evidence that the patient had been on telemetry before 12/29/111 at 6:00 p.m. She also provided the monitor tech log that lists each patient who was on telemetry each shift. Patient #10 was not listed. She could not explain how the order had been missed.

3. Patient #6 was also located on the same unit. She was admitted to the facility on 12/29/11 at approximately 1:30 a.m. Telemetry was ordered at the time of admission. Review of telemetry documentation revealed no rhythm strip had been documented until 05:40 a.m. The nurse did not document an assessment of the telemetry rhythm until 8:43 a.m.

The Director of Nursing was present during the record review on 12/30/11 at approximately 1:45 p.m. and confirmed there was no evidence the patient was on telemetry until 5:30 a.m.

4. Patient #4 was admitted to the facility on 12/24/11 at approximately 11:00 p.m. with the diagnosis of mental status change. Telemetry was ordered at the time of admission. Review of the medical record revealed that there was a nursing assessment at 11:40 p.m., but no nursing assessment of the telemetry rhythm. The first nursing assessment of the telemetry rhythm was at 2:13 a.m., which was 3 hours after the patient was admitted. Review of the telemetry documentation by the telemetry tech revealed the first rhythm strip was not posted until approximately 2:00 a.m.

The Director of Nursing was present at the time of the record review at approximately 3:00 p.m. and confirmed that there was a delay in initiating the telemetry order.

Since telemetry is ordered to promptly detect and treat potentially lethal cardiac arrhythmias, the patient is at significant risk that may result in death when the telemetry is not implemented promptly as ordered.