HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure a proper nursing assessment was conducted, a comprehensive treatment plan was implemented, staff were trained/competent and supervision of non-employed nursing staff was conducted. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 362 patients.

As a result the Condition of Participation CFR 482.23 Nursing Service was not met.

Findings include:

1. The Hospital failed to ensure patients were appropriately assessed as required. A-0395

2. The Hospital failed to ensure a comprehensive treatment plan. A-0396

3. The Hospital failed to ensure that 324 staff members that discharge patients with LifeVests, were trained and competent. A- 0397

4. The Hospital failed to ensure non-employed nursing staff were adequately supervised. A-0398

Based on document review and interview, it was determined in 2 of 5 (Pt #1 and #3) patient's records reviewed, the Hospital failed to ensure patients were appropriately assessed as required. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 362 patients.

Findings include:

1. The policy titled "Off-Site Telemetry" (dated 11/16) was reviewed on 5/18/17. The policy noted the purpose of off-site telemetry was to provide continuous electrocardiogram (EKG) monitoring to patients who are on nursing units other than 6 E, 6 G, Intensive Care Unit or IMC (Intermediate Care). The policy noted "Indications for Telemetry:... Decompensated CHF (Congestive Heart Failure)... Pulmonary Embolism... Potassium or magnesium abnormality... Recent cardiac arrest..."

2. The Zoll Life Vest Information for Patients pamphlet was reviewed on 5/18/17. The pamphlet noted "The Life Vest wearable defibrillator is worn by patients who are at risk for sudden death... The Life Vest is non-invasive and continuously monitors the patient's heart. If a life threatening heart rhythm is detected, the device delivers a treatment shock to restore normal heart rhythm..."

3. The clinical record of Pt #1 was reviewed on 5/16/17 at approximately 11:20 AM. Pt #1 presented to the ED (Emergency Department) on 3/17/17 with complaints of left lower leg pain and swelling and inability to urinate. Pt #1 was admitted to the Intermediate Care Unit for continuous cardiac monitoring due to a new diagnosis of cardiac and renal failure and elevated Potassium. A Cardiology Progress Note dated 3/20/17 noted "...remains at risk for SCD (Sudden Cardiac Death)... will recommend LifeVest" An order for Life Vest at discharge was obtained on 3/20/17. On 3/21/17 at 3:44 PM, Pt #1 was transferred to 2 E Medical-General floor room #240-01. The record lacked a physician's order to discontinue the telemetry. The record lacked documentation Pt #1 was monitored by telemetry during the 2 E stay until discharge on 3/24/17 at 6:30 PM.

4. The clinical record of Pt #3 was reviewed on 5/18/17 at approximately 3:30 PM. Pt #3 was admitted to the ICU with a diagnosis of septic shock, cardiogenic shock, myocardial infarction status post stent placement, acute and chronic heart failure, and nonsustained ventricular tachycardia. An "Indications for Offsite Telemetry" form noted telemetry was indicated due to Pt #3's nonsustained ventricular tachycardia which automatically triggered the electronic system to implement an "Off Site Telemetry" order on 4/16/17 at 8:18 AM. On 4/16/17 at 12:25 PM, Pt #3 was transferred to the 2 E Oncology floor room #279-01 on telemetry. On 4/18/17 an order for a LifeVest at discharge was obtained. The clinical record noted Pt #3's telemetry was discontinued on 4/18/17 although the indications for telemetry continued and Pt #3 required a LifeVest prior to discharge.

5. During a phone interview on 5/17/17 at approximately 10:30 AM, E#6 (Territory Manager for Life Vest) stated "Any patient who meets the criteria for a LifeVest should be monitored (Cardiac monitoring/telemetry) at all times. When a person who is LifeVest dependant comes to the ED or is admitted, the Vest should be removed and telemetry initiated until patient is discharged and the LifeVest is reapplied. These patients are sick and are at such high risk for sudden cardiac death, the LifeVest is their lifeline."

6. During an interview on 5/16/17 at approximately 1:45 PM, E#4 (Director of Nursing) verbally agreed that prior to the discontinuation of Pt #1's and Pt #3's telemetry, an order should have been obtained and/or clarified. E#4 verbally agreed Pt #1 and Pt #3 should have been monitored by telemetry until the LifeVest was initiated.

Based on document review and interview, it was determined in 1 of 5 (Pt #1) clinical records reviewed, the Hospital failed to ensure a comprehensive treatment plan. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 362 patients.

Findings include:

1. The policy titled "Patient Discharge" was reviewed on 5/18/17. The policy noted "...a coordinated comprehensive discharge planning process involving a hospital-wide interdisciplinary team... nursing staff, physicians, patient... Discharge Specialist... others... Collaboration: Sharing of relevant verbal and written information regarding the patient among the professional disciplines involved for the purpose of developing a comprehensive treatment plan..."

2. The Zoll Life Vest Information for Patients pamphlet was reviewed on 5/18/17. The pamphlet noted "The Life Vest wearable defibrillator is worn by patients who are at risk for sudden death... The Life Vest is non-invasive and continuously monitors the patient's heart. If a life threatening heart rhythm is detected, the device delivers a treatment shock to restore normal heart rhythm... charge the other...every day you will need to exchange one battery while you charge the other... If you receive an alarm... press and hold the response buttons... If you get other alerts or messages, look at the display and follow the indicated instructions..."

2. The clinical record of Pt #1 was reviewed on 5/16/17 at approximately 11:20 AM. Pt #1 was admitted to the Hospital on 3/17/17 with diagnoses of left leg pain, cardiac and renal failure. Pt #1 was greater than 400 pounds, had been living in an extended care facility due to a right ankle fracture, required assistance with all activities including a mechanical lift to transfer from bed to chair and back and was intermittently incontinent of urine and/or stool. A LifeVest prior to discharge was ordered for Pt #1 on 3/20/17. The document titled General/Miscellaneous Education dated 3/24/17 noted "Comment: LifeVest to be sent with patient..." The record lacked an assessment of the LifeVest prior to discharge. The record noted Pt #1 was discharged 3/24/17 with the LifeVest unplugged and expired upon transfer to receving facility.

3. During an interview on 5/17/17 at approximately 12:35 PM, E#7 (Registered Nurse) stated "I have been a nurse here for 29 years. I had never gotten any training on the LifeVest.... I remember Pt #1 not being sure what to do with it (LifeVest). He/She was very overwhelmed by it (LifeVest). He/She had a lot of back pain and didn't think it would be tolerable. As far as I knew, the LifeVest Representative was responsible for deciding who was a candidate for it, ordering and bringing it here, putting it on the patient and educating the patient. Now (since training on 5/9/17) I realize that Pt #1 was not probably able to care for the LifeVest and understand the instructions."

4. During an interview on 5/18/17 at approximately 11:00 AM, E#1 (Nurse Coordinator of Patient Safety) verbally agreed E#7 should have notified the physician or voiced the concern's that Pt #1 had to the LifeVest Representative. E#1 verbally agreed the nurse is responsible to ensure patient's are educated, assess their level of understanding, coordinate care with the interdisciplinary team and safely discharge the patient.

Based on document review and interview, it was determined the Hospital failed to ensure that 324 staff members (183- Registered Nurses (RN), 2- Licensed Practical Nurses (LPN) and 139- Patient Care Technicians (PCT) who provide direct patient care on the 7 units (2 E Medical General, 2 E Oncology, 3 E, 3 G, 6 B, 6 E and 4 G) that discharge/care for patients with LifeVests, that staff were trained and competent. This has the potential to affect all patients with LifeVests.

Findings include:

1. An audit sheet of Patients with LifeVest Orders dated 1/2/17 through 5/15/17 was reviewed on 5/16/17. The audit sheet noted 38 patients on 7 units were ordered a LifeVest prior to discharge. The audit sheet noted 62 patients were ordered a LifeVest prior to discharge in 2016.

2. The clinical record of Pt #1 was reviewed on 5/16/17 at approximately 11:20 AM. Pt #1 was admitted to the Hospital on 3/17/17 with diagnoses of left leg pain, cardiac and renal failure. A LifeVest prior to discharge was ordered for Pt #1 on 3/20/17. The Discharge Plan dated 3/24/17 noted Pt #1 had a LifeVest on. The record lacked documentation of any assessment of the LifeVest. The record noted Pt #1 was discharged on 3/24/17 with the LifeVest unplugged and expired upon transfer to receiving facility.

3. The clinical record of Pt #3 was reviewed on 5/18/17 at approximately 10:30 AM. Pt #3 was admitted to the Hospital on 3/25/17 with a diagnosis of congestive heart failure. The clinical record noted on 4/21/17 the LifeVest was placed on Pt #3. The record lacked any further documentation of an assessment of the LifeVest.

4. The clinical record of Pt #4 was reviewed on 5/18/17 at approximately 9:00 AM. Pt #4 was admitted to the Hospital on 3/25/17 with severe cardiac disease. The document titled Cardiac education dated 3/27/17 noted a LifeVest was in place although lacked any further documentation of an assessment of the LifeVest. Pt #4 was readmitted on 3/28/17. The Cardiology Progress Note dated 3/30/17 noted "The patient was wearing a LifeVest prior to hospitalization which will be resumed upon discharge." The record noted Pt #4 was discharged on 3/31/17 and lacked any documentation the LifeVest was placed or assessed.

5. During an interview on 5/17/17 at approximately 12:35 PM, E#7 (Registered Nurse) stated "I have been a nurse here for 29 years. I never received any training on the LifeVest. I just figured when the LifeVest Representative (rep) came in, he/she was responsible to determine if that patient could or could not wear it. I would assume the rep wouldn't leave until the patient knew what to do with it (LifeVest and equipment). We (staff) don't know what they (rep) teach the patient. We don't document anything about the machine or who the rep is, when they are here or anything."

6. During an interview on 5/17/17 at approximately 1:00 PM, E#2 (Systems Director of Patient Safety) stated staff education had been conducted after an adverse event on 3/24/17. E#2 provided an "Attendance Record" titled "LifeVest" and dated 5/9/17 and 5/11/17. The Attendance Record noted 15 of the 57 staff members on 2 E Medical General had been educated. E#2 stated the immediate action to the 3/24/17 event was to educate the 2 E Medical General staff members involved in the event on 5/9/17 and 5/11/17. E#2 verbally agreed education should have been provided to all staff who potentially provide direct patient care to patients who may have a LifeVest and had not been.

Based on interview and document review, it was determined the Hospital failed to ensure non-employed nursing staff were adequately supervised. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 362 patient

Findings include:

1. During a phone interview on 5/17/17 at approximately 10:30 AM, E#6 (Territory Manager for Life Vest) stated the LifeVest Patient Service Representatives are contracted employees who cover multiple areas. E#6 verbalized when an order is received from the hospital, a Patient Service Representative will go to the hospital and screen each patient, measure and fit the patient with the appropriate LifeVest and provide education to the patient. E#6 stated the patients have a competency check and a sign off sheet that must be completed with the Patient Service Representative prior to the patient's discharge. E#6 stated there is not any documentation or coordination of care protocols or policies.

2. During an interview on 5/17/17 at approximately 12:35 PM, E#7 (Registered Nurse) stated "I have been a nurse here for 29 years. I never received any training on the LifeVests. I just figured when the LifeVest Representative (rep) came in, he/she was responsible to determine if that patient could or could not wear it. I would assume the rep wouldn't leave until the patient knew what to do with it (LifeVest and equipment). We (staff) don't know what they (LifeVest rep) teach the patient. We don't document anything about the machine or who the rep is, when they are here or anything. If they need help a Patient Care Technician may go in and help..."

3. The Hospital was unable to provide a LifeVest contract to ensure Patient Service Representatives were licensed Registered Nurses, were competent, delineated responsibilities or were informed of Hospital policies.

4. An audit sheet of Patients with LifeVest Orders was reviewed on 5/16/17. The audit sheet noted 38 patients on 7 units were ordered a LifeVest prior to discharge between 1/2/17 and 5/17/17. The audit sheet noted 62 patients were ordered a LifeVest prior to discharge in 2016.