HospitalInspections.org

Based on a review of facility policy, facility documentation, observation, medical record review (MR) and interview with staff (EMP), it was determined the facility failed to ensure that the patient's right to care in a safe setting was provided for two of ten medical records reviewed (MR1 and MR2).

Findings include:

A review of facility policy "Patient Rights and Responsibilities" last reviewed February 2017 revealed, "13. You have the right to good quality care and high professional standards that are continually maintained and reviewed, to receive care in a safe setting. ... ."

A review of facility policy "Cardiopulmonary Central Monitoring Alarm Management PP 3-8" last revised October 7, 2016, revealed, "Monitoring of vital signs, especially heart rate and rhythm, is accomplished through various continuous monitoring devices. A clinical alarm is defined as patient generated or activated audible and/or visual notification that a patient's immediate physiological or health status is, or could be, life threatening. Center alarm management can improve the nurses' routine practices related to continuous ECG monitoring, frequency and types of alarms, their associated nursing interventions, and the impact on the patient's plan of care. ... . Monitor Batteries A. The batteries in each monitor in use must be changed every eight (8) hours and with any new admission or as needed. ... ."

A review of facility policy "Patient Services Cardiopulmonary Central Monitoring Alarm Management ADM-2WWWW" last revised September 30, 2016, revealed, "Equipment with clinical alarm systems are on a regular preventative maintenance schedule, which includes testing to the alarm function and volume. The Clinical engineer program tracks the inspection, testing, and maintenance of medical equipment. ... . clinical engineering shall test and document the proper function of clinical alarms on all like support and diagnostic monitoring equipment... . All patient care staff and equipment users shall be responsible for proper use, responsiveness to, and management of clinical alarm systems commonly used in there assigned work areas. ... . Each Clinical Educator/Clinical Director is responsible for ensuring that their staff is educated on the use of and response to clinical alarms. ... . Clinical Engineering will schedule evaluations of alarm audibility every 2 years, at minimum. Clinical Engineering will evaluate the ability of the alarm to sound. Nursing will evaluate the clinical appropriateness of the alarm volume as necessary."

1. A review of MR1 revealed EMP4's nursing progress note dated August 16, 2017, at 11:45 PM, "Upon arrival for shift and awaiting report, RN went to print cardiac monitor strip, noted monitor displayed "replace battery". Went to patient's room with battery and pt noted to have no pulse and no resps... ." The patient's telemetry strip printed a "flat line" (no cardiac tracing) from 9:43 PM to 10:45 PM when the patient was found pulseless. Further review revealed the patient was on the 2 South Telemetry unit and the telemetry status was unknown from 10:20 PM to 10:45 PM.

An interview conducted on October 12, 2017, at 10:30 AM with EMP3 confirmed that the staff did not respond to the "replace battery" message shown on either the nursing station or hallway telemetry monitors for MR1 on August 16, 2017, from 9:43 PM to 10:45 PM, when the patient was found pulseless. Further interview confirmed that the battery of the patient's telemetry pack was not working from 9:43 PM to 10:45 PM and the telemetry monitor was not set to alarm when it went flat line and the leads were still on the patient. Furthermore, it was confirmed that MR1 did not contain documentation that the battery of the patient's telemetry pack had been changed every eight hours or as needed and there was no requirement for the staff to do so. EMP3 confirmed that all of these factors led to an unsafe care setting for MR1.

2. A review of staffing assignments for all four telemetry units (2 South, 2 North, 3 South and Step Down) for July 2017 to September 20, 2017, revealed no staff was assigned specifically for telemetry monitor oversight for any of the four telemetry nursing units.

An interview conducted on October 12, 2017, at 4:00 PM with EMP2 confirmed that, prior to September 21, 2017, no staff was assigned to watch the patients' telemetry monitors at the nursing stations on all four telemetry units. Further interview revealed that it was the responsibility of the nursing and ancillary staff to react to all telemetry issues as identified on the nursing station and hallway telemetry monitors.

3. A tour of 2 South, 2 North, 3 South and Step Down telemetry units on October 12, 2017, revealed that the two hallway telemetry monitors in each of the two hallways did not interchangeably display telemetry patient monitoring. Also, there was no telemetry monitors in any of the telemetry patients' rooms and no staff had telemetry linked staff phones.

An interview conducted on October 12, 2017, at 4:00 PM with EMP2 confirmed that on the four telemetry units the hallway telemetry monitors did not display telemetry patients in a different hallway. Further interview confirmed that there were no telemetry monitors in the telemetry patients' rooms and no staff had telemetry linked staff phones.

A phone interview conducted on October 13, 2017, at 1:30 PM with EMP5, revealed that on 2 South telemetry unit, prior to and including August 16, 2017, there had been delays in identifying a telemetry patient's issues due to a delay in staff response. Further interview revealed that this happened when nurses were busy in patient rooms and did not hear the hallway telemetry monitors alarm. Also EMP5 confirmed that, prior to and including August 16, 2017, no staff was assigned to view the telemetry monitors at the nursing station.
4. A review of facility documentation revealed that on June 12, 2017, the facility had switched from Procell 9 volt batteries to MedCell 9 volt batteries.
A review on October 12, 2017, of the monthly staff meeting minutes and "Staff Huddle" documentation for June 2017 to August 16, 2017, did not reveal any documentation that the battery life of the telementry packs had decreased to less than the expected eight hours.
An interview conducted on October 12, 2017, 4:00 PM with EMP2 confirmed that the brand of batteries used at the facility changed in June 2017. Further interview confirmed that, after that change, the nursing staff identified shorter battery life but did not communicate this to management.
A telephone interview conducted on October 13, 2017, at 1:30 PM with EMP5 revealed that, for some time prior to August 16, 2017, the staff had noticed the batteries of the patients' telemetry packs did not last the entire shift. Further interview revealed that, the staff had discussed the battery life for the telementry monitors among themselves and mentioned it during "Shift Huddle" on 2 South, but nothing was done.
5. A review of MR2 revealed the patient on the Step Down Telemetry unit had no cardiac tracing for one hour 45 minutes prior to the patient's code, due to a dead battery.

An interview conducted on October 12, 2017, with EMP7 at 2:30 PM confirmed that MR2's telemetry monitor did not alarm because the battery of the patient's telemetry pack had not worked for one hour 45 minutes. Further interview confirmed that MR1 and MR2 patients' rights to care in a safe setting were not met.

Based on a review of facility policy, documentation and interview with staff (EMP), it was determined that the facility failed to identify a performance improvement indicator related to telemetry patient monitoring safety.

Findings include:

A review of the facility's Quality Performance and Improvement Plan Fiscal Year 2017 revealed, "Functions of the Quality Performance & Improvement Process I order to accomplish the purpose of the Quality Performance and Improvement process, the following functions are undertaken to improve organizational performance. ... . 7. Identifying issues for study; collection and assessment of data and development of educational and/or improvement activities. ... . The following activities and functions are undertaken by the Organization's leaders to implement the Improvement process: ... 4. Setting priorities for performance improvement and patient safety activities. ... . 6. Implementing improvement and patient safety activities based on assessment; ... 8. Ensure that important internal processes and activities throughout the organization are continuously and systematically assessed and improved; 9. Allocate adequate resources for assessing and improving the organization. ... . all hospital-based departments and ambulatory services shall have a Quality Assessment and Performance Improvement (QAPI) plan. ... . The Hospital Services Committee (HSC) serves as a multidisciplinary forum for monitoring and evaluating the quality and safety of patient care, treatment and services as well as patient and family experience of care. ... ."
A review of the Nursing Department's Quality measures tracked in fiscal year October 2016 - September 2017 for the four telemetry nursing units (2 South, 2 North, 3 South and Step Down) did not reveal any measures related to telemetry monitored patients.
A review of the facility's departments' Quality measures tracked in fiscal year October 2016 - September 2017 did not reveal any measures related to telemetry monitors or telemetry patient monitoring safety.
A review of the Hospital Services Committee meeting minutes for January 2017 through September 9, 2017, revealed "Reported recent safety event which occurred related to replacement of Tele Batteries. Lessons learned included that every nurse has a busy schedule and a team approach is necessary, " Everybody checks everybody. "
An interview conducted on October 12, 2017, with EMP1 and EMP2 at 2:15 PM confirmed that no telemetry monitoring performance measures had been identified as a Quality Assurance Performance Improvement measure for nursing or any other department of the hospital for the 2016 -2017 fiscal year.

Based on a review of facility policy, personnel files (PF) and interview with staff (EMP), it was determined that the facility failed to provide continuing education for telemetry patient care for 20 of 20 PF files reviewed (PF1 through PF20).

Findings include:

A review of facility policy "Cardiopulmonary Central Monitoring Alarm Management PP 3-8" last revised October 7, 2016, revealed, "Monitor Batteries A. The batteries in each monitor in use must be changed every eight (8) hours and with any new admission or as needed. ... ."

An interview conducted on October 12, 2017, at 4:00 PM with EMP2 confirmed that not all staff were aware of this policy that required changing the batteries of patients' telemetry packs every eight hours.

A review on October 16, 2017, of PF1 through PF20 revealed no documentation that the employees had received education that required changing the batteries of patient's telemetry packs or the "Cardiopulmonary Central Monitoring Alarm Management PP 3-8" policy.

A telephone interview conducted on October 13, 2017, at 1:30 PM with EMP5, revealed that EMP5 had worked the past three years on the 2 South Telemetry unit but was not familiar with the protocol to change the telemetry pack batteries every eight hours.
A telephone interview conducted on October 16, 2017, with EMP1 confirmed that PF1 through PF20 did not contain documentation that the staff had received this education.