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Based on interview, hospital policy review and medical record review it was determined the hospital failed to ensure the patient's nursing needs were met due to the registered nurse's failure to follow the hospital's policy and procedure for patients' with cardiac monitoring in use and failed to replace the battery for the telebox of the cardiac monitoring device for one (Patient #3) of one patient whose medical record was reviewed and whose cardiac monitoring telebox battery was low. This deficient practice placed the hospital's 93 patients who had battery operated cardiac monitoring devices in use at the time of the survey. The hospital census was 130 patients.

The cumulative effect of this systemic practice resulted in the hospital's inability to ensure that patients' nursing needs would be met.

Findings include:

For the findings of the hospital's failure to ensure the patient's nursing needs were met by ensuring the registered nurse followed the hospital's policy for cardiac monitoring, please refer to A0392.

Based on interview, policy review, and medical record review it was determined the hospital failed to ensure one staff nurse, followed the hospital's policy for replacing the cardiac monitor telebox battery for one (Patient #3) of five patients, who required cardiac monitoring in a sample of ten. This has the potential to affect the hospital's 93 patients who require cardiac monitoring.

Findings include:

Review of the medical record for Patient #3 was completed on 02/03/14 at 5:00 PM. The emergency department medical record revealed Patient #3 arrived through the emergency department (ED) on 01/17/14 at 9:31 AM., with complaints of fever, chills, muscle aches, shortness of breath and severe fatigue. Patient #3 was found to be positive for flu in the ED and a chest x-ray revealed pneumonia.

According to the admission nursing notes, Patient #3 was admitted to floor 2A, a stepdown unit, on 01/17/14 at 9:41 AM. The nursing notes dated 01/17/14 at 9:42 AM., revealed Patient #3 was administered continuous oxygen via a nasal cannula. Other physician admission orders dated 01/17/14, included cardiac monitoring, pulse oximetry (used to measure oxygen saturations) and continuous blood pressure monitoring. The history and physical form for Patient #3 identified the patient had multiple comorbidities, involving the heart, lungs, kidneys, diabetes mellitus, and hypertension.

Documentation in Staff L's personnel record indicated Staff L had stated "around midnight" the monitor indicated Patient #3's battery for the telebox was low. She had placed a new battery in her pocket and was headed to Patient #3's room to replace the low battery but was distracted by the nursing needs of another patient.

The medical record did not include documentation of the time Staff L observed Patient #3's monitor at the central monitoring station on 2A which indicated the battery for the telebox was low and needed to be changed.

The medical record contained documentation titled Code Blue Report, dated 01/20/14 at 3:36 AM., that revealed Patient #3 was found, by Staff M, to be unresponsive. Cardiopulmonary resuscitation (CPR) was started and a full code was performed. At 4:33 AM., when there was no pulse, the family requested all life saving measures be stopped. A physician, Staff R, pronounced Patient #3 dead, at 4:34 AM. Review of Patient #3's death certificate, on 02/02/14 at 12:30 PM., revealed Patient #3's cause of death was cardiac and respiratory arrest.

Several hospital administrative staff members requested and attended a meeting to discuss the incident involving Patient #3, that had occurred on 01/20/14, and to describe the actions the hospital had taken in response to the investigation of that incident. The meeting began at 9:15 AM., and lasted until approximately 10:00 AM., on 02/04/14. Staff F, Director of Nursing of 2A. reported Staff L had said, during the hospital's investigation of the incident, she had observed Patient #3 talking with her husband about the lottery at 2:36 AM., on 01/20/14.

During the meeting, on 02/04/14 between 9:15 AM., and approximately 10:00 AM., Staff I, Clinical Nurse Manager of 2A, revealed he/she was notified on 01/20/14 at 6:30 AM of Patient #3's death on the night shift and was told Staff L, who had provided care to Patient #3 from 7:00 PM., 01/19/14 until the time Patient #3 expired on 01/20/14, at 3:34 AM., had failed to change the battery for Patient #3's telebox used for the cardiac monitoring. Staff L was aware the battery was low and the battery needed to be changed because Staff L had observed Patient #3's monitor in the nurses' station which had indicated in bold print the battery for the telebox is low and needs to be changed. The investigation revealed Staff L had put a new battery in his/her pocket and was going to Patient #3's room to change the battery, but was sidetracked with another patient's nursing needs. Staff L did not change Patient #3's telebox battery.

The information shared by the hospital administration during this meeting revealed the hospital's plan had not been completely implemented. Those aspects that had been implemented had not been in effect long enough to evaluate the effectiveness.

Review of the hospital's policy and procedure for Telemetry Monitoring, 17.8, last revised on 01/20/12, was completed on 02/04/14 at 10:24 AM., and revealed the telemetry assessment and monitoring procedure included staff are to monitor, review and document rhythm strips every four hours.

An interview with Staff C, Director of Special Services, on 02/14/14 at 10:24 AM., revealed Staff L had not followed the hospital's Telemetry Monitoring policy and procedure.

This citation substantiates substantial allegation number OH00073476.