HospitalInspections.org

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Based on observation, medical record review, document review, and interview, in one (1) of 12 observations, nursing staff failed to monitor a patient (Patient # 7) on continuous cardiac telemetry monitoring in accordance with the physician's orders, and the facility's policy and procedure on "Cardiac Monitoring on Telemetry Units."

This failure may result in serious adverse outcomes to patients at risk for cardiac arrhythmias.

Findings include:

Review of the facility's policy and procedure on "Cardiac Monitoring on Telemetry Units," last reviewed on 4/22, documented the following:
"Purpose:
1. To establish guidelines for monitoring all patients on telemetry and provide a process for monitoring.
2. To promptly identify and report to the physician, any significant cardiac rhythm changes from the patient's baseline.
Policy:
1. Patients admitted to a medical/surgical telemetry unit will be placed on telemetry monitoring per physician order.
2. A written physician order must be obtained to continue or discontinue telemetry monitoring.
3. If a patient refuses telemetry monitoring, the Registered Nurse (RN) MUST explain the importance of continuous monitoring to the patient, notify the physician, and document such in the EMR (Electronic Medical Record)..."

During a unit tour on the 11th Floor (Family Health Observation Unit/Telemetry Unit) on 8/19/2022 at 1:10 PM, it was observed that the Central Telemetry Monitor in the Nurses' Station was flashing red alerts for vital signs readings, and for cardiac monitor alarms that was inaudible.

Patient #7 was observed not connected to the bedside cardiac telemetry monitor.

Review of medical record for Patient #7 revealed a 68-year-old with admit date of 08/17/2022.
The patient presented to the Emergency Department with chest pain and dizziness, and shortness of breath for three (3) days. Her medical history was significant for hypertension, hypothyroidism, and chronic dizziness. On 08/17/2022 at 7:18 AM, MD Order documented, "Cardiac Monitor, Bedside Device."

During interview with Staff A, RN 11th Floor, on 8/19/2022 at 1:10 PM, Staff A was asked for reason the patient was not connected to the bedside cardiac telemetry monitor? Staff A stated that the patient had the right to refuse telemetry.

During interview with Staff B, RN Assistant Nurse Manager on 8/19/2022 at approximately 1:20 PM, Staff B stated that if a patient disconnects him or herself from the cardiac monitor, it is expected that the RN will educate the patient on the need for telemetry. If the patient refuses telemetry monitoring, the doctor is notified, and the information is documented in the patient's medical record.

These findings were acknowledged on 8/19/2022 at approximately 2:00 PM by Staff C, Nurse Manager, and Staff D, Director of Nursing.

Review of the "Biomedical Engineering Department Occurrence Report" for the 11th Floor, dated August 19, 2022, at 2:02 PM revealed the alarms for the Central Station and Bedside monitors were at the lowest settings.

On 8/23/2022 at 1:13 PM, during interview with Staff X, Director of Biomedical Engineering Department, and Staff Y, Biomedical Engineer, both staff acknowledged findings and reported that the volume for the Central Station and Bedside monitors had a range of one (1) to eight (8). The volume was set at one (1) at the time the equipment was inspected.