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The Governing Body failed to assure that the hospital was compliant with all the Conditions of Participation in the areas of Patient Rights and Nursing Services as it relates to the provision of nursing care for telemetry (cardiac monitored patients) in a safe patient environment.

See findings under Tag 115, 144, 385, and 397

The hospital did not ensure the protection and promotion of patient rights for patients on telemetry. On 4/18/13 at 5:05am, Patient #1 was found expired with rigor mortis. An asystole-paced (flat line with pacer spikes) rhythm had been recorded for approximately 4 hours, but was undetected by nursing staff. It was also determined that the telemetry alarms had been deactivated for approximately 3 days.

Based on the above finding, an immediate jeopardy situation related to the disabling of telemetry alarms and questionable competency of the nursing staff was identified. Measures taken by the facility to abate the situation included:

1.) Clinical engineering disabled the alarm feature that allowed staff to turn the alarm off.
2.) Suspension of the involved RN pending an investigation.
3.) Rhythm strips will include a rhythm interpretation and initialed by the responsible RN prior to placing the strip in the chart. Rhythm strips will be obtained three times a day and anytime a patient's condition changes.
4.) All telemetry patients will have a full disclosure report printed of their entire hospital stay while on telemetry prior to the discontinuance of telemetry. The report will be placed in the medical record.
5.) Hourly Rounding will be " purposeful rounding " , in which the nursing staff will go to the patient bedside and check on patient status instead of observing the patient from the doorway.
6.) An Advanced Life Support (ACLS) certified telemetry expert will conduct daily audits of monitoring strips in all areas where cardiac monitoring is in place with immediate review of strip misinterpretation with the involved nurse.

See findings under Tag 144, 385, and 397.

Based on document review, medical record review and interview, the facility failed to provide care in a safe setting as evidenced by inactivation of auditory alarms on telemetry monitors.

Findings include:

Review of telemetry disclosure report for Patient #1 revealed notation on page borders of "alarms off" since 4/15/13.

Interview with the Float Staff Nurse on 4/30/13 at 6:45am revealed she did not know the alarms were disabled on the telemetry device or why they had been disabled. At the time of Patient #1's death she was not aware that the monitor was displaying a paced asystolic rhythm despite having completed the EKG/telemetry class in February 2013.

The hospital did not ensure nursing staff competency relative to the monitoring of patients who required intravenous cardiac medications and telemetry. On 4/18/13 at 5:05am, Patient #1, who was on telemetry and receiving intravenous Amiodarone, was found expired with rigor mortis. An asystole-paced (flat line with pacer spikes) rhythm had been recorded for approximately 4 hours, but was undetected by nursing staff. Six hours had also elapsed since vital signs had been obtained on the patient. It was also determined that the telemetry alarms had been deactivated for approximately 3 days.

Based on the above finding, an immediate jeopardy situation related to the disabling of telemetry alarms and questionable competency of the nursing staff was identified. Measures taken by the facility to abate the situation included:

1.) Clinical engineering disabled the alarm feature that allowed staff to turn the alarm off.
2.) Suspension of the involved RN pending an investigation.
3.) Rhythm strips will include a rhythm interpretation and initialed by the responsible RN prior to placing the strip in the chart. Rhythm strips will be obtained three times a day and anytime a patient's condition changes.
4.) All telemetry patients will have a full disclosure report printed of their entire hospital stay while on telemetry prior to the discontinuance of telemetry. The report will be placed in the medical record.
5.) Hourly Rounding will be " purposeful rounding " , in which the nursing staff will go to the patient bedside and check on patient status instead of observing the patient from the doorway.
6.) An Advanced Life Support (ACLS) certified telemetry expert will conduct daily audits of monitoring strips in all areas where cardiac monitoring is in place with immediate review of strip misinterpretation with the involved nurse.


See findings under tag 115, 144, 396, and 397.

Based on medical record review and interview, the nursing staff did not develop careplans for each patient in 20 out of 20 patients (Patient #1-20).

Findings include:

Review of medical records #1-20 on 4/30-5/2/13 revealed no evidence of nursing care plans.

Review of policy #NS 240 - Care Planning, last reviewed 3/10 revealed nursing would develop patient specific care plans within 12 hours of admission and they would be reviewed every 24 hours by a RN. Collaborative care plans could be used as an alternative.

These findings were verified with the Performance Management Supervisor and Shift Supervisor on 5/2/13.

Based on document review, observation and interview, the facility did not assign nursing personnel in accordance with the patient needs and the specialized qualifications and competence of the nursing staff.

Findings include:

Review of policy titled, " Mananagement of Intravenous Amiodarone Hydrochloride (Cordarone) " indicated the following assessments would be completed:

Cardiac Monitoring with rhythm strips obtained at the initation of therapy, with any rhythm disturbances and according to unit specific standards. Upon initiation of therapy, blood pressure will be taken every 15 minutes x1 hour, every 30 minutes x2 hours, and every 4 hours until discontinuation of IV Amiodarone.

Review of Patient #1's medical record revealed intravenous Amiodarone Hydrochloride was initiated at 1:55pm on 4/17/13 while in the post anesthesia recovery unit (PACU) following a transesophageal echocardiogram. While in the PACU the patient's vital signs were obtained every 15 minute x 1 hour and every 30 minutes x 2 hours. Following the patient's return to the inpatient unit at 4:42pm, vital signs were obtained at 4:42pm, 5:04pm, 6:05pm and 11:18pm. Although vital signs were ordered every four hours, the last recorded vital signs were obtained approximately 6 hours prior to the patient being pronounced dead at 5:05am.

Review of Patient #1's medical record indicated the nurse and clinical staff performed hourly rounds on the patient at 1:02am, 2:06am, 3:27am, and 4:34am on 4/18/13. The documentation indicates the patient was resting comfortably. Although the patient demonstrated an asystolic paced rhythm at 1:15am on 4/18/13, it was not until 5:05am on 4/18/13 that it was recognized that the patient had expired.

Review of the telemetry disclosure report dated 4/18/13 revealed Patient #1 had an asystolic paced rhythm starting at 1:15am on 4/18/13. The disclosure report indicated the telemetry alarms had been off since 4/15/13.

Interview with the Nursing Shift Supervisor on 5/1/13 indicated that following Patient #1's death, the Float Nurse was questioned regarding the pacer spikes on the telemetry printout. She was unaware that the patient was asystolic with pacer spikes. Although the patient was demonstrating an asystolic paced rhythm since 1/15am on 4/18/13, shift report regarding the patient was documented on 4/18/13 at 4:30am.

During interview on 4/30/13 with the Unit 4B Charge Nurse it was reported that all nurses could monitor telemetry banks of any patient regardless of assignment. She reported that generally the nurses are alert to irregularies of cardiac rhythms and would tell another co-worker if a bad rhythm were overlooked for their patient. On 4/18/13, no other nurses noted Patient #1's asystolic paced rhythm. The last rhythm strip obtained on the patient had been at 5:04pm on 4/17/13, 7 hours prior to the onset of an asystolic paced rhythm and 12 hours prior to being pronounced dead.

During observation on 4/29/13 of unit 4B it was noted that a telemetry monitor bank is located in the nursing station. This bank displays the rhythms of all of the unit's telemetry patients. In addition to this, if a patient is experiencing a dysrhythmia, an illuminated display in the unit patient care hallways identifies the patient's room number and a written interpretation of the dysrhythmia.

Review on 05/02/13 at 9:30am of procedure " Cardiac Monitoring " last revised 07/07/2012 revealed that monitor strips will be printed and placed on the medical record three times in 24 hours. This should be done at the beginning of day, evening and night shifts at a minimum and with any patient condition changes or as otherwise indicated. Document a rhythm strip at least every shift.

Interview on 04/30/13 at 10:45am with the 4B Unit Director revealed that the standard is that rhythm strips are printed at the beginning of the shift and placed in the chart. Shifts are 12 hours so there are possibly 2 strips per day or every 12 hours. There would be additional strips if there was an abnormal rhythm and/or the patient had a procedure.

Medical record review on 05/01/13 at 9:00am identified the following documentation of rhythm strips on patients with telemetry orders:
-Patient # 3: admitted on 11/15/12 at 6:40pm and discharged on 11/17/12. Rhythm strips were documented on 11/15/12 at 6:40pm and 11:47pm. On 11/16/12 a rhythm strip was documented at 11:48pm with no further documentation of the patients rhythm strip prior to discharge on 11/17/12.
-Patient # 4: admitted on 11/13/12 at 10:15pm and discharged on 11/04/12 at 1:34pm. A rhythm strip was documented on 11/04/12 at 3:07am.
-Patient # 5: admitted on 11/01/12 at 12:34am and discharged on 11/03/12 at 11:50am. Rhythm strips were documented on 11/01/12 at 6:50am and 2:37pm and again on 11/3/12 at 6:40am. No rhythm strips were documented on 11/2/12.
-Patient # 8: admitted on 3/27/13 at 5:53am and discharged on 3/28/13. Rhythm strips were documented on 3/27/13 at 3:22pm and 3/28/13 at 6:53am.
-Patient # 10: admitted on 1/23/13 at 10:38am and discharged on 1/25/13 at 3:01pm. Rhythm strips were documented on 1/24/13 at 4:16am, 2:41pm, and 11:40pm.
-Patient #12: admitted on 8/28/12 at 1:08pm and transferred to a skilled nursing facility on 9/4/12. Rhythm strips were documented on 9/2/12 at 3:13am and 7:10am. No rhythm strips were documented on 9/3/12 and 9/4/12.