HospitalInspections.org

Based on interview and a review of facility documentation, the facility failed to ensure the maintenance of a care plan for each patient which conformed to telemetry documentation requirements as described in policy for 1 of 5 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the facility from the Emergency Department on 1/19/22. During the patient's stay, she was placed on telemetry.

The document "Chain of Command", which was used in the telemetry room, on 1/23/22, was completed by Telemetry Technician A. It indicated that registered nurse (RN) B was called at 3:20 PM. The document also indicated "change in rhythm". (as a checkmark in a column on the page) for the 3:20 PM entry. This document indicated another call to the same nurse on 1/23/22 at 3:26 PM. The entry for this time also indicated a "change in rhythm".

A review of facility policy "Telemetry Monitoring" revealed the following: "Central Monitoring Unit Responsibilities . . . Notify remote nursing unit RN or Charge Nurse of rhythm change. Document notification, time and nurse's name on rhythm strip." As to whether or not such a rhythm strip was created on 1/23/22 at 3:20 PM and 3:26 PM, during an interview of the Risk Manager on 2/10/22 at 2:05 PM, she stated that they could not produce a rhythm strip for these two times.

Thus, the facility was not in compliance with policy. During an interview of the Risk Manager on 2/10/22 at 2:05 PM, she confirmed the failure to follow policy.