HospitalInspections.org

Based on observations, review of video tape, medical record (MR), and policy and procedures, the facility failed to ensure patient care was provided in a safe setting for emergency department patients by failure to ensure provision of an acceptable level of nursing care services and standards were provided by the Registered Nurse (RN) with the provision of Nursing Supervision,; failure to provide continuous cardiac monitoring to emergency department patients as ordered by the medical provider; failure to ensure that medical record documentation was reflective of the patient's condition and provision of the resources required to maintain the level of care ordered by the medical provider.

Findings include:

These following standards were cited and show a systemic nature of non-compliance with regards to Patient Rights and Nursing Services as follows:

482.13(c)(2) Tag A-0144: Patient Rights: Care in Safe Setting
The information reviewed during the survey provided evidence that the facility failed to ensure emergency department patients received care in a safe environment with the oversight and the provision of the care ordered provided and reviewed by the licensed registered nurse to meet the patient needs.

482.23(b)(3) Tag A-0395: RN Supervision of Nursing Care
The information reviewed during the survey provided evidence of the facility's failure to provide an acceptable level of nursing care by the registered nurse with oversight by nursing supervision to ensure the provision and the safe delivery of care as ordered by the medical provider to meet the needs of emergency department patients receiving continuous cardiac monitoring with orders for ultrasound and radiology tests in the radiology department.

A discussion took place between the survey team and the facility's administrative staff (EMP1, EMP2, EMP4, EMP5, EMP15, EMP20) on October 22, 2020, at 11:00 AM regarding the survey team's concerns related to the failure of nursing services to provide the level of care as ordered for patients in the emergency department and hospitalized inpatients receiving continuous cardiac monitoring.

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined Bryn Mawr Hospital failed to maintain a safe environment for emergency department patients ordered to receive continuous cardiac monitoring during transport to obtain X-ray and/or ultrasound tests for five of five medical records reviewed (MR1 through MR5).

Findings include:

Review of facility policy "Cardiac Monitoring: Alarm Communication, Safe Patient and Equipment Management, and Documentation" last reviewed March 2020 revealed "Policy Purpose: To provide guidelines for cardiac alarm management, telemetry monitoring of patients with cardiac conditions, equipment use, and direct the use of verbal communication between the Monitor Technicians and Care providers...B. 1. Limit cardiac monitor interruptions for testing and care; any interruptions in continuous monitoring requires a Provider order. 3. Maintain the same level of care including vital signs and hemodynamic requirements as clinical condition warrants throughout transport. 4. Transporting RN (registered nurse) must document any change in patient condition during transport in a clinical note."

Review of MR1 admitted on September 19, 2020, admitting diagnosis "Fall" revealed physician orders for "continuous cardiac monitoring 'no exceptions', x-ray of hip with or without pelvis and bilateral leg venous ultrasound tests". Further review revealed MR1 was transported to the Department of Radiology by a transporter via stretcher without continuous cardiac monitoring and without the assistance of a RN. MR1 contained no evidence of documentation of a physician's order for the interruption of continuous cardiac monitoring during the transport to and from the radiology department.

Review of MR2 admitted on September 10, 2020, admitting diagnosis "Abdominal Pain" revealed physician orders for "continuous cardiac monitoring 'no exceptions' and abdominal ultrasound test." Further review revealed MR2 was transported to the Department of Radiology by a transporter via stretcher without continuous cardiac monitoring and without the assistance of a RN. MR2 contained no evidence of documentation of a physician's order for the interruption of continuous cardiac monitoring during the transport to and from the radiology department.

Review of MR3 admitted on August 11, 2020, admitting diagnosis "Chest Pain" revealed physician orders for "continuous cardiac monitoring 'no exceptions' and Chest X-ray (2) Views." Further review revealed MR3 was transported to the Department of Radiology by a transporter via stretcher without continuous cardiac monitoring and without the assistance of a RN. MR3 contained no evidence of documentation of a physician's order for the interruption of continuous cardiac monitoring during the transport to and from the radiology department.

Review of MR4 admitted on September 29, 2020, admitting diagnosis "Acute Kidney Injury" revealed physician orders for "continuous cardiac monitoring 'no exceptions' and ultrasound of the kidneys. Further review revealed MR4 was transported to the Department of Radiology by a transporter via stretcher without continuous cardiac monitoring and without the assistance of a RN. MR4 contained no evidence of documentation of a physician's order for the interruption of continuous cardiac monitoring during the transport to and from the radiology department.

Review of MR5 admitted on September 21, 2020, admitting diagnosis "Right Upper Quadrant Pain" revealed physician orders for continuous cardiac monitoring 'no exceptions' and ultrasound of the abdomen. Further review revealed MR5 was transported to the Department of Radiology by a transporter via stretcher without continuous cardiac monitoring and without the assistance of a RN. MR5 contained no evidence of documentation of a physician's order for the interruption of continuous cardiac monitoring during the transport to and from the radiology department.

An interview conducted on October 21, 2020, at 10:47 AM with EMP2 and EMP15 confirmed MR1, MR2, MR3, MR4 and MR5 did not receive continuous cardiac monitoring during the transport to and from the Department of Radiology. Further interview confirmed a physician's order was not obtained for the interruption of continuous cardiac monitoring during the transport to the Department of Radiology for MR1, MR2, MR3, MR4 and MR5 for X-ray and/or ultrasound tests, and that an RN did not accompany these patients to the Department of Radiology. EMP2 stated "A nurse must accompany the patient to the radiology department for a patient to receive continuous cardiac monitoring. When a transporter takes patients for X-ray and ultrasound studies without the nurse, the patients do not receive continuous cardiac monitoring."

Cross Reference:
482:23(b)(3) RN Supervisior of Nursing Care

Based on the systemic nature of the standard-level deficiencies related to Nursing Services and Patient Rights, the facility failed to substantially comply with this condition.

The findings included:

These following standards were cited and show a systemic nature of non-compliance with regards to Nursing Services and Patient Rights as follows:

482.13(c)(2) Tag A-0144: Patient Rights: Care in Safe Setting
The information reviewed during the survey provided evidence that the facility failed to ensure emergency department patients received care in a safe environment with the oversight and the provision of the care ordered provided and reviewed by the licensed registered nurse to meet the patient needs.

482.23(b)(3) Tag A-0395: RN Supervision of Nursing Care
The information reviewed during the survey provided evidence of the facility's failure to provide an acceptable level of nursing care by the registered nurse with oversight by nursing supervision to ensure the provision and the safe delivery of care as ordered by the medical provider to meet the needs of emergency department patients receiving continuous cardiac monitoring with orders for ultrasound and radiology tests in the radiology department.

A discussion took place between the survey team and the facility's administrative staff (EMP1, EMP2, EMP4, EMP5, EMP15, EMP20) on October 22, 2020, at 11:00 AM regarding the survey team's concerns related to the failure of nursing services to provide the level of care as ordered for patients in the emergency department and hospitalized inpatients receiving continuous cardiac monitoring.

Based on facility policy, documents, medical record review (MR) and interview with staff (EMP), it was determined the facility failed to ensure emergency department patients received an acceptable standard of nursing care by the Registered Nurse (RN) with oversight of RN Nursing Supervision to meet the needs of the patient for the delivery of patient care services.

Findings include:

Review of facility policy "Cardiac Monitoring: Alarm Communication, Safe Patient and Equipment Management, and Documentation" last revised March 2020 revealed "Table 1, Set-up, Rhythm Interpretation, Continuous Monitoring and Required Documentation for Monitored Patients...RN (registered nurse) Print, interpret, verify correct patient information present on the strip and mount in chart...MT (monitor tech) complete an initial rhythm review, interpret and send to RN"

1) Review of facility documentation "MR1-Room #10, "Monitor Tech-Cardiac Monitoring Flowsheet" revealed "9/19/2020 at 10:55 AM "vp". Further review revealed "vp" was an acronym for cardiac rhythm interpretation for: "ventricular paced".

Review of MR1 "Progress Note"-dated September 19, 2020, at 10:44 AM authored by EMP 13 revealed " EKG 10:44-junctional rhythm about 60 bpm (beats per minute), rbbb (right bundle branch block), poor rwp (R wave progression), wide QRS (slower spread of ventricular depolarization)."

A telephone interview conducted on October 18, 2020, at 6:45 AM with EMP16 who stated "I received him [MR1] into emergency department room #10 at 10:35 AM. When he arrived to the emergency department on a stretcher his lower body was covered with feces and the charge nurse and I washed him and then put him on the cardiac monitor. The patient said he was in extreme pain all over his body and that he had fallen. When I looked at the cardiac monitor, he was in some form of a sinus rhythm. I understand now that he was ordered for continuous cardiac monitoring by the physician, but I did not think he needed continuous cardiac monitoring in the emergency department at the time. I guess I should have looked closer at the physician's admission orders." EMP1 further stated "I did not receive rhythm strips or any form of communication from the monitor tech for this patient about his baseline rhythm when he was admitted."

A telephone interview conducted on October 21, 2020, at 10:45 AM with EMP23 who stated "I remember calling the nurse to ask if the patient should be on or off the monitor because I remember the patient's rhythm came on the monitor and quickly popped off the monitor. The nurse confirmed that the patient should be on the monitor but that the patient would be going for testing." EMP23 further stated "I thought I documented that the patient was in some form of an idioventricular rhythm on the Cardiac Monitoring Flowsheet. I did not send a rhythm strip to the patient's nurse in the emergency department for her interpretation and I did not confirm the patient's rhythm on the monitor was some form of an idioventricular rhythm when I spoke to the nurse."

A telephone interview conducted on October 21, 2020, at 1:30 PM with EMP24 who stated " I initially went into the room when the patient was admitted, to put the patient (MR1) on the monitor. I remember during the admission process spending quite a bit of time helping the nurse [EMP16] name redacted clean the patient as he was covered with feces on his lower half. I'm not sure what rhythm the patient was in."

An interview conducted on October 16, 2020, at 2:21 PM with EMP13 confirmed that the patient (MR1) was not in a sinus rhythm and was not in ventricular paced rhythm. EMP13 stated "The patient was in a junctional rhythm and this was confirmed via the EKG." EMP13 confirmed that the documentation "ventricular paced rhythm" on the Monitor Technician's Cardiac Monitoring flowsheet dated September 19, 2020, was incorrect.
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2) Review of facility documentation "Lab Results for MR1 dated September 19, 2020, 11:52 AM revealed "Potassium Level of 9.6" with collection date/time September 19, 2020 at 10:50 AM and Processing Run time of September 19, 2020, 11:40 AM."

Review of MR1 "Progress Note" authored by EMP26 revealed "11:20 AM Free Text, EKG reviewed. Suspect metabolic derangement; possible hyperkalemia (high potassium level) ... Will closely monitor."

Review of MR1 "12:45 PM, Progress Note" authored by EMP15 revealed "BMP (basic metabolic profile) blood draw has not yet resulted, Lab called [EMP16], named redacted
a repeat blood draw for the BMP will need to be redrawn for the patient (MR1)."

An interview conducted on October 16, 2020, at 2:30 PM with EMP 13 who stated "now that I have reviewed the BMP results including the potassium (K) , I believed the BMP blood sample which contained the potassium level of 9.6 is not contaminated and that the integrity of the sample was not compromised and that the BMP results and potassium level (K) of 9.6 was a true value which reflected the patient's condition and the blood sample did not need to be redrawn. I suspected potassium (K) (9.6) level from the pending BMP blood sample would be a critical value, but I was not informed of the BMP results from the blood sample collected at 11:52 AM on September 19, 2020."

An interview conducted on October 18, 2020, at 7:10 AM with EMP 16 confirmed that the BMP blood sample was to be redrawn. EMP16 stated "I thought it was necessary to redraw the BMP blood sample because the potassium (K) result of 9.6 did not seem to represent the patient ' s condition. I agreed with the lab scientist (EMP21) that the high result of the potassium (K) in the BMP was contaminated and blood sample would need to be redrawn from the patient (MR1) to obtain blood the potassium results again."

An interview conducted on October 21, 2020, at 10:20 AM with EMP21 confirmed that the nurse (EMP16) was contacted to discuss possible contamination of the BMP blood sample. EMP21 stated "To the best of my ability I believe I said to the nurse, 'Do you think we should recollect the blood for the BMP blood sample' which the nurse confirmed the K (potassium level) of 9.6 was high and she was not expecting the level to be that high. I agreed with her because the potassium (K) level of 9.6 was not compatible with life. I put the BMP blood sample in for recollect. I did not call the physician about the high Potassium (K) value because I was not calling about a critical value, I was calling the nurse about the integrity of the blood sample and to confirm that she was agreeable to obtaining another blood sample for the BMP." In addition, EMP21 stated "In hindsight, if I had to do this all over again, I would have called the physician and or the physician's assistant for a final decision about the results."
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Review of facility policy "ED Triage" last dated September 2019 revealed "Performed by: An ED Registered Nurse (RN)...to ensure that priorities for patient care are established through triage assessment, reassessment and according to pre-established medically-approved guidelines. To immediately intervene in life-threatening situations...Also to decrease patient delays by initiating diagnostic procedures...Emergency nurses shall triage every patient entering the ED to determine priorities of care based on physical and psycho-social needs, as well as factors influencing patient flow through the ED (emergency department)...Categorization is determined by the evaluation of subjective and objective data as appropriate for determination of immediate needs regarding treatment and/or initiation of laboratory and radiology studies. ...ESI-2 Condition potentially unstable and definitive assessment needed within 5-15 minutes. Patient has a high-risk situation, confusion/lethargy/disorientation, or severe pain/distress. Patient may be reassessed every 15 minutes until determined stable. ESI-3 Condition stable, no distress, but requires treatment to avoid possible worsening. Patient needs two or more resources and/or may have danger zone vital signs as listed in ESI guidelines. Patient may be reassessed every 30-60 minutes."

3) Review of MR1 "10:42 AM Progress Note: Acuity/Destination" dated September 19, 2020, authored by EMP16 revealed "Patient Acuity:3 Triage Complete. Chief Complaints Updated: Fall (Patient fell at home attempting to get out of the bed. Patient states he was unable to bear weight on left leg. Able to sit up in chair per EMS. Patient complains of pain "Everywhere:"

Review of MR1"Progress Note-dated September 19, 2020, at 10:44 AM authored by EMP 13 revealed " EKG 10:44-junctional rhythm about 60 bpm (beats per minute), rbbb (right bundle branch block), poor rwp (R wave progression), wide QRS (slower spread of ventricular depolarization)."

Review of MR1 "11:22 AM Progress Note: Circulation (Adult)" dated September 19, 2020, authored by EMP 16 revealed " Edema: foot, left; foot, right; knee, right; knee, left; leg, right; leg, left; ankle, right; ankle, left (=2/=3 edema)."

Review of MRI "11:24 AM Progress Note: Gastrointestinal (Adult)" dated September 19, 2020, authored by EMP16 revealed GI Signs/Symptoms: abdominal pain, nausea."

Review of MR1 "11:30 AM Progress Note" dated September 19, 2020, authored by EMP 13 revealed " Patient seen and evaluated states complaints of 'bladder pain' Will continue to address symptoms. Await further lab work."

Review of MR1 "11:35 AM Progress Not" dated September 19, 2020, authored by EMP16 revealed: Pain (Adult) Pain Body: Location: Abdomen Pain Rating (0-10)-Pain at Rest: 10. [0=no pain and 10=severe pain]."

An interview conducted on October 21, 2020, at 11:05 AM with EMP1 confirmed that ESI-3 level (Condition Stable) assigned at triage by EMP16, remained unchanged. EMP1 stated "I also questioned EMP16 as to why the patient (MR1) was assigned a score of ESI-3, considering the patient's distress, extreme pain '(pain all over)' and the cardiac and gastrointestinal distress he was having, I would have expected the triage category would not have remained at a ESI-3 level."
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Review of facility policy "Cardiac Monitoring: Alarm Communication, Safe Patient and Equipment Management, and Documentation last reviewed March 2020 revealed "Policy Purpose: To provide guidelines for cardiac alarm management, telemetry monitoring of patients with cardiac conditions, equipment use, and direct the use of verbal communication between the Monitor Technicians and Care providers...Table 1. Setup, Rhythm Interpretation, Continuous Monitoring and Required Documentation for Monitored Patients, Activity: Setup, Admission and Independent Double Check, Units Monitored by a Monitor Technician Remotely: RN/LPN/PCT revealed RN (Registered Nurse): Print, interpret, document and mount strip in chart. Obtain admission strip from MT (monitor technician). RN mount both initial strips to EHR (electronic health record) scanning. This will serve as the baseline cardiac rhythm and initial patient related communication."

4) Review of MR1 admitted on September 19, 2020, admitting diagnosis: "Fall" revealed "Order Placed" dated September 19, 2020, at 10:47 AM... "Cardiac Monitoring: -ED ONLY-Continuous -No Exceptions." Further review of MR1 revealed no evidence of documentation that a RN had obtained an initial telemetry strip as documentation of the baseline cardiac rhythm.

Review of MR6 admitted on August 1, 2020, admitting diagnosis "Drug Overdose" revealed
"Order Placed " dated August 1, 2020, at 12 midnight... Cardiac Monitoring-ED ONLY- Continuous-No Exceptions." Further review of MR2 revealed no evidence of documentation that a RN had obtained an initial telemetry strip as documentation of the baseline cardiac rhythm.

Review of MR7 admitted on August 12, 2020, admitting diagnosis "Lightheaded and Dizzy revealed "Order Placed" dated August 12, 2020, at 8:11 AM Cardiac Monitoring-ED Only-Continuous-No Exceptions"-Continuous-No Exceptions." Further review of MR3 revealed no evidence of documentation that a RN had obtained an initial telemetry strip as documentation of the baseline cardiac rhythm.

An interview conducted on October 21, 2020, at 10:50 AM with EMP1 confirmed that MR1, MR6 and MR7 had no evidence of documentation that an initial telemetry strip was obtained by the RN. In addition, EMP1 confirmed the emergency department RN staff had failed to follow the facility's policy for obtaining the required initial telemetry strips as documentation of the initial baseline cardiac rhythm for MR1, MR6 and MR7.

Cross Reference:
482.13(c)(2): Tag 0144 Patient Rights: Care in Safe Setting