HospitalInspections.org

1. Based on observation, review of medical records, policy and procedure, and staff interview, the facility failed to ensure that a registered nurse evaluate and document the review of EKG out of parameter alarms for patients on continuous cardiac monitoring and notify the physician when appropriate.

The findings include the following:

a. Based on observation on 9/17/13 from 11:15a.m. to 12:15p.m. in the nurses' station revealed the telemetry monitoring station was being monitored by the unit clerk. The unit clerk was observed multiple times leaving the telemetry monitor station area to perform other assigned duties. During the time of observation the EKG Monitor was observed flashing multiple times to indicate an out of parameter alarm. Observation of the staff did not indicate any response to the EKG monitor flashing. There was no audible alarms to indicate out of parameter alarms at the nurses station.

b. Review of medical records on 9/16/13 and 9/17/13 at the facility nurse's station revealed that patients receiving continuous cardiac monitoring did not have consistent documentation that a registered nurse reviewed the patient's rhythm strip when out of parameter alarms occurred.

The following was noted:

Review of EKG Alarm Table for (P3) on 09/17/13 at 11:45p.m. for a time period from 0915 a.m. to 11:40a.m for 09/17/13 revealed 27 out of parameter alarms. 19 of those out of parameter alarms were for Bradycardia (heartrate <50). 4 of those alarms were for a heartrate < 40. There was no documentation found that the RN was notified of the out of parameter alarms, no documentation found that the EKG strips were reviewed, and no documentation found that the physician was notified.

Review of EKG Alarm Table for (P4) on 09/17/13 at 12:05p.m. for a time period from 0915 a.m. to 11:50a.m for 09/17/13 revealed 18 out of parameter alarms. One of those alarms were for Nonsustained Ventricular Tachycardia. There was no documentation found that the RN was notified of the out of parameter alarms, no documentation found that the EKG strips were reviewed, and no documentation found that the physician was notified.

Review of EKG Alarm Table for (P5) on 09/17/13 at 12:05p.m. for a time period from 0415 a.m. to 06:55a.m for 09/17/13 revealed 14 out of parameter alarms. 9 of those alarms were for Irregular Heart Rate. There was no documentation found that the RN was notified of the out of parameter alarms, no documentation found that the EKG strips were reviewed, and no documentation found that the physician was notified.

c. Policy and Procedure titled:Telemetry and cardiac monitoring stated: To assure patient safety by providing consistent care of the patient on centralized telemetry monitoring. Cardiac rhythm will be evaluated and documented every shift or more often as defined in unit practice guidelines. (No unit practice guidelines were found)

d. Staff interview with (S13) on 9/17/13 at 12:45p.m. in the facility's conference room confirmed that the unit clerk was assigned to monitor the telemetry monitors. (S13) confirmed that there was no audible alarms at the nurses station to indicate an out of parameter alarm was occurring. (S13) confirmed that a staff member would have to be looking at the telemetry monitor to be aware of any alarms. (S13) confirmed that the unit clerk had other assigned duties which would have her leaving the telemetry monitors area to complete. (S13) confirmed that there was not a process in place that would notify the
RN of out of parameter alarms and (S13) confirmed that no documentation was available for the above patients to indicate that the out of parameter alarms were addressed.

Staff interview with (S12) on 9/17/13 at 1:30p.m. in the facility conference room confirmed that the unit clerks were assigned to monitor the telemetry monitors. (S12) stated that the unit clerks do not have training in EKG monitoring. (S12) stated that the unit clerks are not telemetry monitor techs they basically monitor that the patient is on the telemetry screen. (S12) stated that the charge RN monitor the telemetry monitors. (S12) confirmed that the charge RN were assigned the supervision of the medical-surgical and special care units and would not be able to stay at the nurses station to monitor continuously. (S12) confirmed that there was no audible alarms to indicate out of parameter alarms at the nurses station.

1. Based on inspections of anesthesia carts, review of quality assurance reports,and staff interviews Memorial Hospital failed to enforce nationally accepted infection control practices in the administration of medications.

The findings included:
a. During an inspection of the operating suite with staff members # 33 and # 35 at 1:50 p.m. on 9/16/13 we discovered six (6) open multi-dose vials in the anesthesia cart in operating room one (1). The drugs used by the anesthesia provider were not labeled according to hospital policies developed using nationally recognized infection control guidelines.

The open multimode vials included:
Glycopyrrolate
Rocuronium (2)
Labetalol
Xylocaine 2%
Neostigmine

An inspection of operating room two (2) revealed the anesthesia cart contained an unlabeled 3 cc syringe with a clear liquid fluid, open multimode vial of Rocuronium , pre-drawn or used syringes of pitocin, narcan, and ephedrine. The multimode vial and the syringes all failed to include the necessary information of pintails, time, or date drawn and expiration date.

b. A review of quality assurance and infection control reports made available during the survey process failed to identify the deficient practices.

c. Interviews with the clinical director and infection control coordinator (S7) at 2:00pm on 9/16/13 in the operating room suite about staff following their own review of the findings revealed they could not provide evidence of compliance with the requirements.

1. Based on inspections of anesthesia carts in operating rooms 1 and 2, Memorial Hospital's Infection Control Program failed to monitor, identify, and correct/educate deficient practices of staff members.
The findings included:

a. During an inspection of the operating suite at 1:50 p.m. on 9/16/13, we discovered drug preparation techniques used by the anesthesia providers failed to adhere to nationally recognized infection control practices aimed at reducing or eliminating healthcare acquired infections.

b. No evidence was provided to demonstrate the anesthesia providers were monitored for compliance with infection control standards.