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The information reviewed during the survey provided evidence that the facility failed to follow established protocol for following a physician order to implement cardiac monitoring during the transfer of a patient to an inpatient unit . Medical record documentation confirmed the patient was found unresponsive and lifeless several hours after admission to the nursing unit and attempts at resuscitation were not successful.

A discussion took place with the survey team and the facility's administrative staff (EMP1) regarding the survey team's concerns related to Patient's Rights for care and services on January 26, 2022, at approximately 1:24 PM.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting.

Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined that Lansdale Hospital failed to provide care in a safe setting by failing to follow documented physician order for telemetry cardiac monitoring for one of one medical record. (MR1)

Findings

Review on January 26, 2022, of facility document revealed, "Situational awareness: the telemetry tech was not aware that the patient needed a telemetry monitor, the nurse was aware but was unable to apply the telemetry monitor, there was no back up process to close the loop and ensure the patient was on the monitor at transfer..."

Review on January 26, 2022, of facility document revealed, A Rapid Response Team was called when the patients oxygen did not return to baseline. Patient treated with an IV diuretic... Patient returned to pre-event oxygen level... Nurse returned to patient's room at 0600 and found patient without oxygen in nose and lifeless... Code blue called but patient expired... During initial investigation it was determined the patient was not placed on a telemetry monitor."

Review on January 26, 2022, of facility policy "Patients Rights and Responsibilities: Patients have the right to: Care Delivery: Receive kind, respectful, safe, quality care..."

Review on January 26, 2022, of facility policy " Telemetry Utilization on a Medical Surgical Area-Initiation and Discontinuation Criteria 3. Patient Care For Initiation of Telemetry: a. All orders and documentation associated with routine patient care will follow the established standards of care.. b. The primary nurse will notify the monitor technician that a patient requires telemetry monitoring..."

Review of MR1 on January 26, 2022, revealed, cardiac monitoring was ordered by the physician on December 31, 2021 at 3:55 PM. There was no documented evidence in MR1 that the cardiac monitoring was implemented by the nurse of the receiving medical surgical unit.

Interview with EMP on January 26, 2022 at 12:15 PM confirmed, An interview conducted with the receiving nurse confirmed there was an order for cardiac monitoring but " It just was not implemented."

Interview with EMP16 on February 1, 2022 at 10:30 AM confirmed, "I did not review the patient orders until after the fact... the patient had an order for cardiac monitoring." Further interview with EMP16 confirmed telemetry monitoring was ordered and not implemented by the nurse of the receiving medical surgical unit.