HospitalInspections.org

Based on interview and record review, the facility failed to provide sufficient number of staff for 1 out of 11 sampled patients (SP) #1 who had written physician's orders for continuous cardiac monitoring, and one to one supervision.



The findings:

1. Record review revealed that sampled patient (SP) #1 presented to the hospital on 9/16/17 after a mechanical fall. The patient had history of pacemaker, coronary artery disease, end stage renal disease and was on hemodialysis, and had a quadruple heart bypass. The Pt (patient) was noted to have a left hip fracture.

Review of SP #1 physician's Orders showed on 09/16/2017 at 04:41 AM an order for cardiac monitoring and on 9/19/17 at 5:59 pm, an order for a constant observer - one to one observation.

Review of the Encounter Location History showed that SP #1 was assigned to room # 508W.

Interview of the Director of Stepdown unit on 10:56 am 11/2/17 and review of the 7p-7a staffing of the stepdown unit showed that no sitter was assigned for room # 508 W (SP #1), as noted on the Daily Staffing Assignment Sheet dated 09/19/2017.

2. At 12:38 am on 9/19/17, the nursing notes of Staff F who was the charge nurse on duty showed that the spouse came to the telemetry room station stating the pt. is very restless, aggressive, and requesting patient to be placed on restraints to prevent pt. from removing his monitor and oxygen. Staff accompanied family to the room and found pt. unresponsive, and called for help then a code blue (resuscitation) was activated.

Review of the Central Monitor Telemetry Disconnection Log provided by the Director of Stepdown revealed that Room 508W with SP#1 initials. The log showed the monitor was disconnected on 9/20/17 at 12:15 am and the primary nurse was contacted at 12:16 am. The reconnect time showed 12:44 am. A Code Blue was called at 12:45 am, and the patient was transfer to ICU (Intensive Care Unit). It is noted in the comments that the pt. is confused removing everything, and the RN (Registered Nurse) was informed.

Interview with the Director of Stepdown on 10:56 am 11/2/17 revealed that when leads are off, the teletech (staff) calls the nurse to connect, and the telemetry monitors should be connected at all times.

Review of the Policy and Procedure Subject: "Telemetry Monitoring" showed it is the policy of the facility that all patients who require continuous telemetry monitoring are monitored according to an established set guidelines. Procedure III showed that
1. Monitor patients routinely in default Lead 11 and V.
3. Verify that Life Threatening (Red Alarms) are on. These are never to be turned off.
5. Notify the patient's RN for reportable rhythm changes. If RN cannot be reached, notify the charge nurse, house supervisor or director / manager if necessary to obtain timely and necessary response.
The facility failed to follow their Policy and Procedure.

Based on interview and record reviews, the nursing staff failed to supervise and evaluate the nursing care of 1 out of 11 sampled patients (SP) #1 who had written physician's orders for continuous cardiac monitoring, and one to one supervision.


The findings:

1. Record review revealed that sampled patient (SP) #1 presented to the hospital on 9/16/17 after a mechanical fall. The patient had history of pacemaker, coronary artery disease, end stage renal disease and was on hemodialysis, and had a quadruple heart bypass. The Pt (patient) was noted to have a left hip fracture.

Review of SP #1 physician's Orders showed on 09/16/2017 at 04:41 AM an order for cardiac monitoring and on 9/19/17 at 5:59 pm, an order for a constant observer - one to one observation.

Review of the Encounter Location History showed that SP #1 was assigned to room # 508W.

Interview of the Director of Stepdown unit on 10:56 am 11/2/17 and review of the 7p-7a staffing of the stepdown unit showed that no sitter was assigned for room # 508 W (SP #1), as noted on the Daily Staffing Assignment Sheet dated 09/19/2017.

2. At 12:38 am on 9/19/17, the nursing notes of Staff F who was the charge nurse on duty showed that the spouse came to the telemetry room station stating the pt. is very restless, aggressive, and requesting patient to be placed on restraints to prevent pt. from removing his monitor and oxygen. Staff accompanied family to the room and found pt. unresponsive, and called for help then a code blue (resuscitation) was activated.

Review of the Central Monitor Telemetry Disconnection Log provided by the Director of Stepdown revealed that Room 508W with SP#1 initials. The log showed the monitor was disconnected on 9/20/17 at 12:15 am and the primary nurse was contacted at 12:16 am. The reconnect time showed 12:44 am. A Code Blue was called at 12:45 am, and the patient was transfer to ICU (Intensive Care Unit). It is noted in the comments that the pt. is confused removing everything, and the RN (Registered Nurse) was informed.

Interview with the Director of Stepdown on 10:56 am 11/2/17 revealed that when leads are off, the teletech (staff) calls the nurse to connect, and the telemetry monitors should be connected at all times.

Review of the Policy and Procedure Subject: "Telemetry Monitoring" showed it is the policy of the facility that all patients who require continuous telemetry monitoring are monitored according to an established set guidelines. Procedure III showed that
1. Monitor patients routinely in default Lead 11 and V.
3. Verify that Life Threatening (Red Alarms) are on. These are never to be turned off.
5. Notify the patient's RN for reportable rhythm changes. If RN cannot be reached, notify the charge nurse, house supervisor or director / manager if necessary to obtain timely and necessary response.
The facility failed to follow their Policy and Procedure.