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Based on medical record review, interview, document review and policy and procedure review, lapses in generally accepted standards of nursing care were identified in telemetry monitoring of patients and verbal order authentication.

See findings under Tags #A0395 and A0407.

Based on medical record review, interview and document review, the hospital failed to have an effective telemetry alarm system to provide for the ongoing evaluation of patient condition, as evidenced for Patient #1.

Findings include:

Medical record review for Patient #1 revealed that on 1/21/15 at 3:30 AM, nursing staff found the cardiac telemetry monitor cable to be disconnected from Patient #1.

Review of Patient #1's cardiac telemetry strips on 3/25/15 at 10:00 AM with Registered Nurse (RN) Patient Safety Officer Staff #2 revealed that Patient #1's disconnection from telemetry monitoring occurred at 3:10 AM on 1/21/15.

Interview on 3/25/15 at 11:40 AM with RN Director of Nursing Staff #3 revealed that if telemetry comes off or there is a drop in oxygen level, the alarm goes off at the nurse's station.

Interview on 3/25/15 at 3:00 PM with RN Staff #7 revealed that Staff #7 was sitting at the workstation prior to entering Patient #1's room and discovering that Patient #1's telemetry monitor cable was disconnected, and never heard an alarm.

Interview on 3/26/15 at 8:45 AM with Staff #3 revealed between the time the patient was last seen on telemetry and then discovered without connected telemetry, there were no alarms that sounded to alert the staff when the telemetry leads were disconnected.

Interview on 3/26/15 at 10:30 AM with Biomedical Manager Staff #15 revealed the telemetry alarm system did not go off after the telemetry leads were disconnected from Patient #1.

On 3/26/15, review of hospital documentation provided by Director of Quality Performance Staff #1 revealed that the hospital became aware on 1/21/15, during their investigation of the issue with Patient #1's telemetry disconnection, that silencing one alarm in the telemetry monitoring system at the central station of the intensive care unit (ICU) silences all like and lower criticality alarms on that monitor. For example, if a red alarm is silenced from the central monitor, all red alarms, all yellow alarms and all blue alarms are silenced for a period of two minutes, unless another red alarm is triggered. If a yellow alarm is silenced at the central monitor, all yellow and blue alarms are silenced for a period of two minutes. However, red alarms remain audible. If silenced at the central station, all alarms continue to appear on the central alarm station with visual cues. The hospital began to perform alarm software updates as a result of their investigation findings.

Review of the equipment functions check document (dated 3/27/15) revealed that on 1/21/15 at 2:45 PM, the ICU patient telemetry monitors were checked and found to be working properly. This was confirmed via telephone interview with Staff #15 on 3/27/15 at 1:51 PM.

Based on policy and procedure review, medical record review and interview, the hospital does not have an effective process to ensure verbal orders are authenticated within 48 hours as required by hospital policy, as evidenced for Patients #2, 9 and 10.

Findings include:

Review of hospital policy #IM.004.3201 "Verbal or Telephone Physician Orders Policy" (dated 9/2014) revealed, "Telephone/verbal orders are to be written on the physician order sheet and must be countersigned by the physician next time he or she provides care to the patient or documents information in the patient's medical record . . . The prescribing practitioner must sign or initial the verbal order within 48 hours (consistent with Federal and State law or regulation)."

Review of 10 medical records revealed that 6 verbal orders were not authenticated by the physician, as follows:
- Patient #2: Verbal orders taken by a staff nurse on 3/22/15 at 4:00 PM and 4:30 PM were not signed by the physician as of 3/25/15.
- Patient #9: Verbal orders taken by a staff nurse on 3/16/15 at 6:00 PM, and on 3/19/15 at 10:30 AM, were not signed by the physician as of 3/25/15.
- Patient #10: Verbal orders taken by a staff nurse on 3/17/15 at 4:00 PM, and on 3/22/15 at 4:30 PM, were not signed by the physician as of 3/26/15.

These findings were verified by Director of Nursing Staff #3.