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Based on observations, interviews, and record reviews the facility failed to provide consistent cardiac monitoring for 33 of 65 patients in five units on telemetry (a screen-type monitor that receives the transmissions of signals from one electronic unit to another by radio waves using a device that provides real time measurement of a patient's cardiac rhythm and rate), the Intensive Care Unit (ICU), Cardiac Care & Critical Care Overflow (CCU), Critical Care Telemetry & Stroke Unit, Medical/Surgical Telemetry & Renal Unit, and Medical/Surgical Telemetry Unit.

This failure created an unsafe environment and had the potential to place all patients admitted to these units at risk for their safety and resulted in the overall non-compliance with 42 CFR 482.23 Condition of Participation: Nursing Services that resulted in a condition of Immediate Jeopardy (IJ).

The hospital census was 65.

The facility was notified of the IJ on 10/23/18 and as of 10/24/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ when they documented the following implementations:
- Telemetry monitoring was consolidated to ICU, CCU, Medical/Surgical Telemetry, and Critical Care Telemetry & Stroke.
- A telemetry trained personnel was stationed at the telemetry monitoring banks (designated area provided for telemetry monitoring of patients by assigned staff) on each unit, during all shifts, and only assigned to that job. Another equally trained staff member would relieve them for breaks.
- A monitor log was maintained at each unit to indicate assignment and who covered their break period.
- When an arrhythmia (a condition in which the heart beats with an irregular or abnormal rhythm) was detected, the monitoring personnel would call the nurse to respond to the patient. If the nurse was unavailable, a rapid response (an emergency response called to staff, to respond to a patient with early signs of deterioration, to prevent further deterioration) would be called.
- Nurse Managers were responsible for the day to day oversight of the schedule and that the monitor banks were staffed appropriately.
- House Supervisors audited each 12 hour shift to ensure compliance.
- The Chief Nursing Officer (CNO) reviewed staffing daily, to ensure that the correct compliment of staff were assigned to each area.

Based on observation, interview, and record review the facility failed to provide consistent cardiac monitoring for 33 patients, on telemetry (cardiac monitor, a screen-type monitor that receives the transmissions of signals from one electronic unit to another by radio waves using a device that provides real time measurement of a patient's cardiac rhythm and rate), in five units (Intensive Care Unit, Cardiac Care & Critical Care Overflow, Critical Care Telemetry & Stroke Unit, Medical/Surgical Telemetry & Renal Unit, and Medical/Surgical Telemetry Unit).

This failure created an unsafe environment and had the potential to place all patients admitted to these units at risk for their safety, and resulted in the overall non-compliance with 42 CFR 482.23 Condition of Participation: Nursing Services that resulted in a condition of Immediate Jeopardy (IJ).

The hospital census was 65.

Findings included:

1. Record review of the facility's policy titled, "Cardiac Monitoring: Care of the Inpatient on a Cardiac Monitor," revised 11/11/2015, showed the following directives for telemetry monitoring:
- Cardiac monitoring is considered a standard of care in the Intensive Care Unit (ICU), Critical Care Unit (CCU), and Critical Care Telemetry & Stroke Units, as it does operative or invasive (inside of the body) procedures, and during and after receiving sedation or anesthesia.
- If a monitored patient has a pacemaker or Implantable Cardioverter Defibrillator (ICD, a battery powered device placed under the skin that keeps track of the heart rate and delivers an electric shock to restore heartbeat to normal if irregular), the pacemaker (an artificial device for stimulating the heart muscle and regulating its pumping) detection function must be turned on to ensure proper rhythm identification.
- All alarms will be sufficiently audible for staff to hear at the default settings.
- Nursing staff, trained unit secretaries, and patient care assistants (PCA) on inpatient units, should respond to monitor alarm conditions within the scope of their role. In the ICU, only Registered Nurses (RN) will respond to monitor alarms.
- The primary RN or charge nurse must be alerted immediately to high urgency alarms (yellow or red) on the inpatient units.

Observation on 10/22/18 at 4:30 PM, showed that there were telemetry monitors at the nurses' stations on the ICU, CCU, Critical Care Telemetry & Stroke Unit, Medical/Surgical Telemetry & Renal Unit, and Medical/Surgical Telemetry Unit. There were cardiac patients on the telemetry monitor, but no one monitored them.

Observation on 10/22/18 at 4:30 PM showed the CCU telemetry monitor for Patient #19 could not detect the pacemaker signal, which showed an alarm on the telemetry monitor.

During an interview on 10/23/18 at 10:00 AM, Staff I, RN and Patient #19's nurse, stated that she could not hear the alarms when she was down the hall, or in another patient's room.

During an interview on 10/23/18 at 10:00 AM, Staff W, RN, stated each unit within the facility had a designated telemetry monitor station at the nurses' desk. Each RN monitored their own telemetry patients, as well as listened for alarms, and the charge nurse oversaw each unit.

During an interview on 10/23/18 at 10:30 AM, Staff N, RN, ICU/CCU Charge Nurse, stated that not all telemetry monitors could be seen when they provided patient care and were in a patient's room, which was a concern.

Because nurses were assigned to care for multiple patients, it was not possible for them to monitor their patients on telemetry while they provided care to individual patients.

During an interview on 10/23/18 at 10:02 AM, Staff G, ICU Charge Nurse, stated that:
- Central telemetry monitors were at the nurses' station.
- There were no telemetry technicians (specially trained staff who monitor telemetry monitors for changes in heart rate or rhythm) who watched the telemetry monitors.
- It was possible that no one would be at the desk.
- The nursing staff were concerned that there were no telemetry technicians to watch the telemetry monitors.

During an interview on 10/23/18 at 9:50 AM Staff H, CCU RN, stated that:
- She could not hear the telemetry monitor alarms unless she was at the nurses' desk.
- She depended on someone at the desk to alert her to cardiac telemetry monitor alarms.
- This process was not reliable because sometimes there may not be anyone at the desk to hear the alarm.
- The unit secretary was not trained to interpret the telemetry monitor activity.

During an interview on 10/23/18 at 10:15 AM Staff J, Unit Secretary, confirmed that she did not have any specific training for telemetry monitor activity.

During an interview on 10/23/18 at 11:15 AM, Staff P, Unit Secretary, stated that when she was away from the desk, someone nearby would hear the alarm and notify a nurse.

During an interview on 10/23/18 at 9:30 AM, Staff M, RN, ICU and CCU Manger, stated that:
- Most patients on these units were on telemetry and the telemetry monitors were located at the nurses' stations.
- There were no telemetry technicians who watched the telemetry monitors.
- There were unit secretaries who notified nursing if the telemetry monitor alarmed, but the unit secretaries weren't present for 12 to 14 hours per day.
- She said the patients on CCU were patients who had recently undergone heart procedures, had chest pain, or other related heart issues, and the nurses needed to hear the monitor alarms.
- She was concerned that when the telemetry monitors would alarm, but it wasn't always heard.
- She reported these concerns to the previous Chief Nursing Officer (CNO), but it was not corrected.
- She reported it to the new CNO.

During an interview on 10/23/18 at 11:00 AM, Staff O, RN, Medical Surgical Telemetry & Renal Manager, stated that:
- There were always patients on telemetry on the unit.
- There were no telemetry technicians who watched the monitors, but the unit secretary notified nursing if an alarm sounded.
- There was no unit secretary at the desk from 7:00 PM until 7:00 AM, which was a concern.

During an interview on 10/23/18 at 11:29 AM, Staff X, RN, Nurse Manager, stated that each RN monitored telemetry for their own patients, and if an alarm sounded, whomever was closest or could respond the fastest, responded. Staff X stated that there were no telemetry monitors in patient rooms and she wished there was a centralized telemetry monitor unit or designated telemetry technicians.

During an interview on 10/23/18 at 11:30 AM Staff F, RN, stated that:
- He had not been trained to interpret the telemetry monitor activity.
- He could not hear the telemetry monitor alarms in the hallway or from another patient's room.
- He depended on someone at the desk to alert him if there was an issue.

During an interview on 10/22/18 at 4:35 PM, Staff B, CNO, verified there was not a central telemetry monitor unit (area of the hospital with multiple telemetry monitors, which show all patients who are on a cardiac monitor, continuously monitored by designated staff ), and because of this nursing staff monitored and listened for alarms. Nursing phones (cordless phones carried by each nurse while working) were not notified of telemetry alarms, which was identified as an issue by the facility.








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