HospitalInspections.org

Based on the seriousness of the non-compliance identified during the survey and the effect and the potential effect on patient outcome, the facility failed to substantially comply with the condition.

This condition is not met as evidenced by:

Review of facility documentation "Telemetry Management" reviewed/revised August 2020, revealed "Note: Nurses will print cardiac rhythm strips at time of admission to telemetry, with dysrhythmia, and at change of caregiver. ... 2. Nursing responsibility: ... a. Once patient is connected to heart monitor and signal is verified at monitor station on nursing unit, an initial rhythm strip is to be printed and mounted in the patent medical record. ... Interpretation of the rhythm should be documented on the strip. Rhythm strips are to be printed and documented every shift and/or with change in rhythm ... A shift is defined as the period when responsibility and accountability for the care of the patient changes from on nurse to another. B. The RN or LPN will print a strip and place it on the medical record and document the rate, rhythm, PRI, and QRS, interpretation. ...c. In case of dysrhythmia, unstable patients, or changes in condition, the RN will print strips and place on chart under 24 hour cardiac monitoring log and document rate, rhythm and intervention with each event in the electronic health record in the event/change status section, and notify physician."

Review of facility policy revealed "Assessment/Reassessment Of Patients" dated October 2020, revealed "1. Ultimate responsibility for patient assessment/reassessment lies with the professional nurse or graduate nurse. ... 1. Initial Admission Assessment: b. An initial admission assessment must be completed by the RN and documented within 24 hours. ... 2. Reassessment: b. Patients will be reassessed and documentation will be done by the RN or Graduate Nurse, Nurse Intern, LPN or SN, under the direction of the RN, at change of care giver and in response to change in physical status and upon transfer to and from critical care units, the OR or procedural areas, and as per unit standards. ... c. Reassessment and documentation should meet the following guidelines. Physician orders, unit specific polices and standards will take precedence when indicated or with a change in patient's condition.

Review of MR1 revealed a physician order, "Cardiac Monitor" on January 29, 2021 at 7:43 PM. Further review revealed no documented evidence that the cardiac monitor was applied as per the physician order. Continued review revealed no documentation that a nursing assessment was completed.
Interview with EMP2 on February 25, 2021, at 10:40 AM confirmed the above findings and revealed "No the patient was not put on the monitor or assessed by the nurse on the unit."
These following standards were cited to show a systemic nature of non-compliance:

482.23(b)(3); RN Supervision of Nursing Services (A-0395)

Based on review of facility documentation, medical record review (MR) and interview with staff (EMP), it was determined the facility failed to ensure inpatient cardiac monitoring was performed as ordered for the delivery of patient care services and to ensure Registered Nurse (RN) supervision of staff and patients was provided per standards of practice.

482.23(b)(6); Supervision of Contracted Services (A-0398)

Based on review of facility documentation and interview (EMP), it was determined the facility failed to ensure that delivery of care was provided per facility policy and physician order.

Based on review of facility documentation and medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to ensure inpatient physician orders were performed as ordered for the delivery of patient care services and to ensure Registered Nurse (RN) supervision of staff and patients was provided per standards of practice for seven of 11 medical records reviewed (MR1, MR6, MR7, MR8, MR9, MR10, and MR11).

Findings include:

Review of facility documentation "Telemetry Management" reviewed/revised August 2020, revealed "Note: Nurses will print cardiac rhythm strips at time of admission to telemetry, with dysrhythmia, and at change of caregiver. ... 2. Nursing responsibility: ... a. Once patient is connected to heart monitor and signal is verified at monitor station on nursing unit, an initial rhythm strip is to be printed and mounted in the patent medical record. ... Interpretation of the rhythm should be documented on the strip. Rhythm strips are to be printed and documented every shift and/or with change in rhythm ... A shift is defined as the period when responsibility and accountability for the care of the patient changes from on nurse to another. B. The RN or LPN will print a strip and place it on the medical record and document the rate, rhythm, PRI, and QRS, interpretation. ...c. In case of dysrhythmia, unstable patients, or changes in condition, the RN will print strips and place on chart under 24 hour cardiac monitoring log and document rate, rhythm and intervention with each event in the electronic health record in the event/change status section, and notify physician."

Review of facility policy revealed "Assessment/Reassessment Of Patients" dated October 2020, revealed "1. Ultimate responsibility for patient assessment/reassessment lies with the professional nurse or graduate nurse. ... 1. Initial Admission Assessment: b. An initial admission assessment must be completed by the RN and documented within 24 hours. ... 2. Reassessment: b. Patients will be reassessed and documentation will be done by the RN or Graduate Nurse, Nurse Intern, LPN or SN, under the direction of the RN, at change of care giver and in response to change in physical status and upon transfer to and from critical care units, the OR or procedural areas, and as per unit standards. ... c. Reassessment and documentation should meet the following guidelines. Physician orders, unit specific polices and standards will take precedence when indicated or with a change in patient's condition.


Review of MR1 revealed a physician order, "Cardiac Monitor" on January 29, 2021 at 7:43 PM. Further review revealed no documented evidence that the cardiac monitor was applied as per the physician order. Continued review revealed no documentation that a nursing assessment was completed.

Interview with EMP2 on February 25, 2021, at 10:40 AM confirmed the above findings and revealed "No, the patient was not put on the monitor or assessed by the nurse on the unit."

Interview with EMP1 on February 25, 2021, at 11:30 AM when asked about the process to inform Central Telemetry the patient in on a monitor, EMP1 replied, "The nurse has to call the tech in Central Telemetry and let them know the patient's name and the telemetry box number. It is still up to the nurse to make sure that happened." During additional interview EMP1 confirmed that the process was not completed for MR1.

A review of MR6 revealed a physician order for a "monitored bed" placed on January 24, 2021, at 7:08 AM. The nurse signed the order as taken off at 9:07 AM on the same date; however, the first documentation in the record by the nurse that the monitor was placed on the patient and a rhythm strip was taken did not occur until January 24, 2021, at 9:00 PM. During an interview on February 24, 2021, at 10:45 AM, these findings were confirmed by EMP2.

Review of MR7 revealed a physician order, "Neurological Checks ... January 29, 2021 at 19:34:00 EST, Routine Q [every] 4H [hours]." Further review revealed no documented evidence of the 4 hour neurological checks until January 31, 2021 at 12:00 AM.

Review of MR8 revealed a physician order, "Cardiac Monitor ... January 30, 2021 at 3:26 AM, Routine, Nurse Driven Cardiac Monitor Removal." Further review revealed a physician order "Neurological Checks ... January 30, 2021 at 12:30 AM, Routine Q 4H." Continued review revealed no documentation that the cardiac monitor was applied until January 31, 2021 at 7:08 PM. Further review revealed the four hour neurological assessment were not completed from January 30, 2021 at 3:00 PM until January 31, 2021 at 10:00 AM.

Review of MR9 revealed a physician order, "Cardiac Monitor ... January 29, 2021 at 00:51, Routine, Nurse Driven Cardiac Monitor Removal." Further review revealed the first documented evidence the cardiac monitor was applied was January 30, 2021 at 8:49 AM.

Review of MR10 revealed a physician order, "Neurological Checks ... January 29, 2021 15:18, Routine Q 4H." Further review revealed no documented evidence of the four hour neurological checks from January 29, 2021 at 9:00 PM until January 30, 2021 at 9:11 AM.

Review of MR11 revealed a physician order, "Neurological Checks ... January 29, 2021 at 19:34:00 EST, Routine Q 4H." Further review revealed no documented evidence of the four hour neurological checks until January 31, 2021 at 12:00 AM.

Interview with EMP3 on February 24, 2021, at 3:57 PM confirmed the above findings and EMP3 revealed "We can't find anything."

Based on review of facility documentation, medical records (MR) and interviews (EMP), it was determined the facility failed to ensure facility policies were followed by nursing staff for seven of eleven medical records reviewed (MR1, MR6, MR7, MR8, MR9, MR10, and MR11.)

Findings include:

Review of facility documentation "Telemetry Management" reviewed/revised August 2020, revealed "Note: Nurses will print cardiac rhythm strips at time of admission to telemetry, with dysrhythmia, and at change of caregiver. ... 2. Nursing responsibility: ... a. Once patient is connected to heart monitor and signal is verified at monitor station on nursing unit, an initial rhythm strip is to be printed and mounted in the patent medical record. ... Interpretation of the rhythm should be documented on the strip. Rhythm strips are to be printed and documented every shift and/or with change in rhythm ... A shift is defined as the period when responsibility and accountability for the care of the patient changes from on nurse to another. B. The RN or LPN will print a strip and place it on the medical record and document the rate, rhythm, PRI, and QRS, interpretation. ...c. In case of dysrhythmia, unstable patients, or changes in condition, the RN will print strips and place on chart under 24 hour cardiac monitoring log and document rate, rhythm and intervention with each event in the electronic health record in the event/change status section, and notify physician."

Review of facility policy revealed "Assessment/Reassessment Of Patients" dated October 2020, revealed "1. Ultimate responsibility for patient assessment/reassessment lies with the professional nurse or graduate nurse. ... 1. Initial Admission Assessment: b. An initial admission assessment must be completed by the RN and documented within 24 hours. ... 2. Reassessment: b. Patients will be reassessed and documentation will be done by the RN or Graduate Nurse, Nurse Intern, LPN or SN, under the direction of the RN, at change of care giver and in response to change in physical status and upon transfer to and from critical care units, the OR or procedural areas, and as per unit standards. ... c. Reassessment and documentation should meet the following guidelines. Physician orders, unit specific polices and standards will take precedence when indicated or with a change in patient's condition.


Review of MR1 revealed a physician order, "Cardiac Monitor" on January 29, 2021 at 7:43 PM. Further review revealed no documented evidence that the cardiac monitor was applied as per the physician order. Continued review revealed no documentation that a nursing assessment was completed.

Interview with EMP2 on February 25, 2021, at 10:40 AM confirmed the above findings and revealed "No, the patient was not put on the monitor or assessed by the nurse on the unit."

Interview with EMP1 on February 25, 2021, at 11:30 AM when asked about the process to inform Central Telemetry the patient in on a monitor, EMP1 replied, "The nurse has to call the tech in Central Telemetry and let them know the patient's name and the telemetry box number. It is still up to the nurse to make sure that happened." During additional interview EMP1 confirmed that the process was not completed for MR1.

A review of MR6 revealed a physician order for a "monitored bed" placed on January 24, 2021, at 7:08 AM. The nurse signed the order as taken off at 9:07 AM on the same date; however, the first documentation in the record by the nurse that the monitor was placed on the patient and a rhythm strip was taken did not occur until January 24, 2021, at 9:00 PM. During an interview on February 24, 2021, at 10:45 AM, these findings were confirmed by EMP2.

Review of MR7 revealed a physician order, "Neurological Checks ... January 29, 2021 at 19:34:00 EST, Routine Q [every] 4H [hours]." Further review revealed no documented evidence of the 4 hour neurological checks until January 31, 2021 at 12:00 AM.

Review of MR8 revealed a physician order, "Cardiac Monitor ... January 30, 2021 at 3:26 AM, Routine, Nurse Driven Cardiac Monitor Removal." Further review revealed a physician order "Neurological Checks ... January 30, 2021 at 12:30 AM, Routine Q 4H." Continued review revealed no documentation that the cardiac monitor was applied until January 31, 2021 at 7:08 PM. Further review revealed the four hour neurological assessment were not completed from January 30, 2021 at 3:00 PM until January 31, 2021 at 10:00 AM.

Review of MR9 revealed a physician order, "Cardiac Monitor ... January 29, 2021 at 00:51, Routine, Nurse Driven Cardiac Monitor Removal." Further review revealed the first documented evidence the cardiac monitor was applied was January 30, 2021 at 8:49 AM.

Review of MR10 revealed a physician order, "Neurological Checks ... January 29, 2021 15:18, Routine Q 4H." Further review revealed no documented evidence of the four hour neurological checks from January 29, 2021 at 9:00 PM until January 30, 2021 at 9:11 AM.

Review of MR11 revealed a physician order, "Neurological Checks ... January 29, 2021 at 19:34:00 EST, Routine Q 4H." Further review revealed no documented evidence of the four hour neurological checks until January 31, 2021 at 12:00 AM.

Interview with EMP3 on February 24, 2021, at 3:57 PM confirmed the above findings and EMP3 revealed "We can't find anything."