HospitalInspections.org

Based on review of the South Dakota Department of Health (SD DOH) complaint intake information, interview, record review, job description review, and policy review the provider failed to ensure:
*One of one sampled patient (4) who had and elevated heart rate that was identified by monitor technician (MT) (L) was reported to registered nurse (RN) M.
*One of one sampled patient (4) had vital signs monitored per physician's order during an infusion of diltiazem (a heart rate controlling medication) by RN M.
Findings include:

These failures have the potential to cause life threatening events to patients who are dependent upon the provider to ensure their safety while under their care.

Notice:
On 4/17/24 at 5:15 p.m. facility's chief operating officer (COO) N, chief nursing officer (CNO) H, director of cardiology A, director of quality and safety J, director of risk and patient relations K was informed of an IJ situation related to nursing services A385. The provider failed to ensure patient safety while monitoring the heart rate and blood pressure during care provided on 2/17/24.

Plan:
The facility provided the following acceptable removal plan on 4/18/24 at 2:30 p.m. for nursing services:
1." MT L will be off work until a 1:1 conversation occurs with the Director of Cardiology. During the conversation, further clarification will be received from MT L to determine what occurred, from her perspective, and to utilize the organization's Performance Management Decision Guide (PMDG). Upon completion of this conversation, the Director of Cardiology will consult Human Resources (HR) to determine the next steps of the employee's corrective action per the PMDG. If at any point during MT L's 1:1, the Director of Cardiology has concern for potential patient harm, MT L will remain off work."

2."The policy, "Clinical Alarm Management-Enterprise" was reviewed on 4/18/24 by the Chief Operating Officer, the Chief Nursing Officer, Vice President of Operations for Cardiovascular Services, Director of Cardiology, Director of Quality and Safety, and Accreditation Specialist. No changes were recommended at this time."

3."Starting on 4/17/24 Night Shift all Monitor studio staff that interpret heart rhythms and rates, including PRN staff, will be provided education regarding the urgency of notifying the nurse caring for monitored patients. Verification of compliance will be completed with a ready and sign where objectives are identified."

4."Starting on 4/18/24 Day Shift, education will be provided to nurses including PRN nurse, regarding the importance of following the physician's orders for monitoring vital signs during diltiazem infusions.These departments include 1000 Pulmonary, Pulm Acute, 4100 Surgical/Renal, 3000, 3800 Cardiology, 2000 Surgical Trauma, 2800 Surgical Cardiovascular Specialty, Critical Care2, Critical Care 3, Neuro Acute Care Unit (NACU), Emergency Department, PACU, Interventional Radiology, and Central Resource Pool. Verification of compliance will be completed with a ready and sign where objectives are identified."

5."For ongoing compliance monitoring of the MTs, 50 red alarms for heart rate and rhythm, per day, will be audited by the Director of Cardiology or designee for appropriate workflow and notification of the nurse caring for the monitored patient. This audit will remain in place for 1 month with a goal of achieving 95% compliance. Following the completion of this month, 25 red alarms for heart rate and rhythm will be audited on a weekly basis for 5 months with a goal of achieving 95% compliance."

6."For ongoing compliance of RNs monitoring vital signs during diltiazem infusions, 5 patients during the duration of their diltiazem infusion (dependent on patient volumes) will be audited by the department director or designee per week for 1 month with a goal of achieving 90% compliance. Following the completion of this 1 month, 5 patients during the duration of their diltiazem infusion (dependent on patient volumes) will be audited per month for 6 months with a goal of achieving 90% compliance."

7."Audits will be reported to Quality Council on a monthly basis for at least 6 months. Upon completion of the six months, Quality will determine the ongoing process."

The removal plan for the IJ was received and accepted on 4/18/24 at 2:30 p.m. On 4/18/24 at 3:00 p.m. the implementation of the plan was verified and the IJ status was removed while the surveyors were onsite.

1. Review of patient 4's electronic medical record (EMR) revealed:
*He:
-Had been admitted on 2/15/24 with diagnoses of weakness, diarrhea, and then developed uncontrolled atrial fibrillation (an elevated heart rate and an irregular heart rhythm).
-Had an elevated heart rate on 2/17/24 at 8:17 a.m. of 161 beats per minute (normal heart rate is 60-100 beats per minute).
-Was started on a diltiazem infusion at 5 milligram (mg) per hour per physician's order.
*"Administration orders:"
-"Initiate infusion at 5 mg per hour or continue dose if transferred in."
-"Increase or decrease the infusion by 5 mg per hour every 30 minutes as needed to maintain heart rate less than 100 beats per minute, not to exceed ordered dose."
-"Hold for heart rate less than 60 beats per minute or a systolic blood pressure less than 90 millimeter of mercury (mm HG)."
-"Notify the provider if maximum ordered dose is not sufficient to achieve hemodynamic (blood flow) goal."
-"When discontinuing, decrease infusion by 5 mg per hour every 30 minutes until off, while maintaining goal parameters."
-"Vital signs every 30 minutes x 2. Then vital signs every 1-hour x 2. Then check every 4 hours. Restart vital sign frequency with each rate change."
*On 2/17/24 at 1:45 p.m. the diltiazem infusion was increased to 10 mg per hour.
-At 4:59 p.m. the infusion was decreased to 5 mg per hour.
-At 5:52 p.m. the infusion was discontinued.
*On 2/17/24 at 4:58 p.m. a heart rate of 88 beats per minute and a blood pressure of 107/68 had been documented.
*There were no other vital signs documented for patient 4 during the diltiazem infusion.

Interview on 4/16/24 at 8:45 a.m. with MT O regarding monitor alarms and nurse notification revealed:
*She:
-Monitored patient's heart rate, rhythm, and oxygen saturation.
-Had parameters to follow for each patient depending on their diagnosis.
-Would have notified the nurse caring for the patient if there were any changes not within those parameters.

Interview on 4/17/24 at 8:21 a.m. with director of cardiology A regarding heart rate monitoring revealed:
*She:
-Had taken a "deep dive" into patient 4's chart since there was a complaint associated with the patient.
-Had identified that MT L had not notified the nurse caring for patient 4 with an elevated heart rate.
-Would have expected other nursing staff to respond to alarms if the nurse caring for the patient was unavailable.
-Had not been able to speak with MT L regarding the incident due to illness and scheduling.
-Had coached MT L last year for not reporting identified abnormal heart rates to the nurse caring for a patient.
-Had concluded her investigation regarding this complaint on 2/29/24.

Review of MT L's work schedule from 2/17/24 through 4/15/24 revealed she had worked 10 shifts.

Interview on 4/17/24 at 9:45 a.m. with accreditation specialist I and director of risk and patient relations K regarding the monitoring of patient 4's vital signs by RN M during a diltiazem infusion revealed they both agreed:
*There had been only one set of vital signs taken from the start to the stop of the infusion.
*The physician order had not been followed.

Interview on 4/17/24 at 10:05 a.m. with director of cardiology A and CNO H regarding RN M monitoring patient 4's vital signs during a diltiazem infusion revealed:
*CNO H had spoken to RN M, she had forgotten to data validate the vital signs.(ensures the vital signs are documented into the patient's EMR)
*They both believed that RN M had monitored the vital signs they just were not documented.
*They would have expected the staff to document the patient's vital signs in their EMR.

Interview on 4/18/24 at 8:30 a.m. with accreditation specialist I, regarding documentation of RN M's coaching regarding data validating vital signs revealed:
*He had coached RN M that morning regarding data validating vital signs.
*There was documentation to support he had coached RN M that morning.

Review of the provider's job description for cardiac/monitor technician revealed:
*"The cardiac technician conducts a wide range of non-invasive cardiac test, under direct supervision, for diagnostic and therapeutic purposes."
*"Performs cardiac tests and monitors patient heart functions using diverse cardiology equipment. As needed- per department, employees place electrodes correctly for an electrocardiogram (EKG) machine or telemetry (Holter) monitoring and operate machines correctly. Checks, calibrates, and maintains cardiology equipment to ensure proper operation and accurate test results. Provided care and counseling for cardiac patients to ensure their comfort and safety during cardiac tests and treatments. Alert nurses or physicians of critical values, abnormalities, or change in patient response. Obtain and records patient information and medical histories; interprets electrocardiogram (EKG) results and generates factual written reports. In some departments, employees will monitor multiple patients at the same time while critically interpreting rhythms and communicating concerns effectively with staff."

Review of the provider's Cardiology Monitor Studio Call Routines revealed:
*"Call RN:"
-"Acute change in heart rate from baseline heart rate greater than 110 beats per minute of less than 60 beats per minute."
-"Heart rate greater than 125 beats per minute of less than 45 beats per minute, atrial fibrillation heart rate greater than 100 beats per minute."
-"Blood Pressure systolic blood pressure greater than 160 or less than 90. Diastolic blood pressure greater than 90."
-"Rhythm run of ventricular tachycardia (a life threatening heart rhythm) or 3 beats of premature ventricular contractions, new arrhythmia, QTC greater than 550, pauses greater than 2.5 seconds."