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Based on observation, interview, record review and policy review, the hospital failed to ensure there was a telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) trained staff member monitoring the telemetry screen at all times on the Medical/Surgical (Med/Surg) unit and that nursing staff followed their internal policy and documented and monitored the patient's heart rhythm every four hours.

These failures resulted in a systemic failure and non-compliance with 482.23 Condition of Participation: Nursing Services. The hospital census was 11.

The severity and cumulative effect of these practices had the potential to place all telemetry patients on the Med/Surg unit at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 10/18/22, the survey team informed the hospital of the IJ. The hospital staff created educational tools, began educating all nursing staff and implemented interventions to protect the patients.

As of 10/19/22, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- An employee who had completed a telemetry class with at least 80% competency or has a current Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) certification would immediately be stationed at the centralized telemetry monitoring station. Moving forward, an appropriately trained employee would remain at the centralized telemetry monitoring station at all times when a patient was on a telemetry monitor.
- The Centralized Telemetry Monitoring policy had been updated to add that an appropriately trained employee would remain at the centralized telemetry monitoring station at all times. This employee would notify the patient's primary nurse with any significant changes and would document these findings in the patient's medical record. The patient's primary nurse would also be responsible for documenting any significant heart rhythm changes in the patient's medical record. Patients that are on telemetry will have specific documentation requirements. The primary nurse would be responsible for charting the patient's heart rate and specific cardiac rhythm in the nursing assessment each shift under the cardiac assessment. For the remainder of the shift, the primary nurse would document every four hours, the patient's heart rate and specific cardiac rhythm under the cardiac care plan.
- All Med/Surg staff would be educated on the updated changes to the Centralized Telemetry Monitoring Policy.
- The Med/Surg director or Registered Nurse (RN) charge nurse would complete chart reviews daily on each telemetry patient to ensure accuracy of charting and monitoring.

Based on observation, interview, record review, and policy review, the hospital failed to follow the standard of practice and provide consistent and competent cardiac monitoring by a trained nurse on the Medical/Surgical (Med/Surg) unit and failed to follow their internal policy and document and monitor the patient's heart rhythm every four hours for five current patients (#7, #11, #12, #14 and #15) and two discharged patients (#16 and #17) on cardiac telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen). These failures had the ability to affect Med/Surg patients on cardiac telemetry, creating the potential for negative outcomes if abnormal heart rhythm changes were to go unnoticed.

Findings included:

1. Review of the hospital's policy titled, "Centralized Telemetry Monitoring, Med/Surg," revised 06/2009, showed the following:
- Centralized Telemetry Monitoring (CTM) is the use of telemetry on non-cardiac units with viewing of heart rhythms occurring at a centralized monitoring station by a certified monitoring nurse, who has completed a telemetry class with at least 80% competency or has a current Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) certification.
- Telemetry monitoring will be initiated by trained nursing staff upon notification of order.
- Nursing staff will monitor and document rhythm in patients chart every four hours.
- It is the responsibility of the director of the unit using telemetry monitoring to ensure that personnel are aware of and adhere to this department policy.

Review of the hospital's policy titled, "Job Description Registered Nurse (RN)/Licensed Practical Nurse (LPN) Telemetry Monitoring and Shift Routine," revised 06/2009, showed that the RN/LPN identifies and documents the cardiac rhythm every four hours and as needed and ensures monitors are on patient at all times unless approved by RN/primary nurse.

Observation on 10/17/22, at 3:05 PM, showed four nurses stations located throughout the Med/Surg unit. There were telemetry monitors located at two of the nurses stations. At the main nurse's station, the centralized telemetry monitor showed three patients' heart rhythms displayed. Staff T, Unit Secretary, was in close proximity performing tasks, no staff member directly observed the telemetry monitor. Observation on 10/17/22 at 3:10 PM, at the second telemetry monitoring station on the Med/Surg unit, showed no nursing staff located at the telemetry monitor.

During an interview on 10/17/22 at 3:07 PM, Staff T, Med/Surg Unit Secretary, stated that she had no telemetry training. If the telemetry monitor alarmed and it didn't look normal, she would let the nurse know.

During an interview on 10/17/22 at 3:15 PM, Staff U, Med/Surg RN Charge Nurse, stated that she usually sat at the nurses station and could watch the telemetry monitor. No one was assigned to directly watch the telemetry monitors. There was a second nurse's station with a telemetry monitor that staff could sit and view the monitors while they charted. If a patient was on telemetry, the nurse should be documenting the patient's heart rhythm every four hours.

Observation on 10/18/22 at 8:30 AM, at the Med/Surg Unit nurses station, showed the centralized telemetry monitor with four patients' heart rhythms displayed. There was no nursing staff located at the telemetry monitors at either of the nurses' stations. Observation on 10/18/22 at 9:00 AM, showed no trained staff located at either of the telemetry monitoring stations.

During an interview on 10/18/22 at 9:05 AM, Staff DD, RN, stated that Staff U, RN Charge Nurse, usually sat at the nurse's station, close by the telemetry monitor. Staff T, Unit Secretary, also sat close by and would inform the nurse if an alarm was going off. Staff DD documented the patient's heart rhythm once a shift or if there was a change in the patient's heart rhythm.

During an interview on 10/18/22 at 9:30 AM, Staff R, RN, stated that she looked at the telemetry monitor before she went in the patient's room to assess them. Assessments were done once a shift.

During an interview on 10/18/22 at 9:45 AM, Staff AA, RN, stated that she documented the patient's heart rhythm every shift or if any changes. The unit secretary printed the rhythm strips of patients on telemetry every four hours, but she was not sure where the unit secretary put the strips. Staff can usually hear the telemetry alarms if they were going off, someone was usually sitting at the monitor.

During an interview on 10/18/22 at 10:30 AM, Staff J, Med/Surg Director, stated that the charge nurse usually sits at the nurse's station where the telemetry monitors were located. If the charge nurse was not sitting there, the unit secretary would inform the nurse if an alarm was going off. The unit secretary had no telemetry training. At night, the nurses sat in close proximity of the telemetry monitors.

Review of Patient #7's medical record showed that she was a 62 year-old female admitted to the Med/Surg unit on 10/09/22 for chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing) exacerbation versus pneumonia. Patient #7 was hypokalemic (low potassium in the blood; can cause fatigue, muscle cramps and abnormal heart rhythms). She had an order for telemetry monitoring. The patient's heart rhythm was not documented every four hours by nursing staff.

Review of Patient #11's medical record showed that he was an 85 year-old male admitted to the Med/Surg unit on 10/18/22 for shortness of breath and weakness. The patient had a past medical history of COPD and high blood pressure. He had an order for telemetry monitoring. Documentation on 10/18/22 at 7:05 AM, showed cardiac telemetry, regular rhythm. There was no specific heart rhythm documented.

Review of Patient #12's medical record showed that she was a 48 year-old female admitted to the Med/Surg unit on 10/17/22 for bilateral lower extremity cellulitis (an infection of the skin) and an abdominal abscess (collection or pocket of thick fluid caused by an infection). The patient had a past medical history of high blood pressure. She had an order for telemetry monitoring. The patient's heart rhythm was not documented every four hours by nursing staff.

Review of Patient #14's medical record showed that he was a 48 year-old male admitted to the Med/Surg unit on 10/12/22 for a urinary tract infection (UTI). The patient was a quadriplegic (the loss of the ability to use both arms and legs, typically caused by a spinal cord injury). He had an order for telemetry monitoring. The patient's heart rhythm was not documented every four hours by nursing staff.

Review of Patient #15's medical record showed that he was a 50 year-old male admitted to the Med/Surg unit on 10/16/22 for left sided weakness. The patient had a past medical history of prior stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients). He had an order for telemetry monitoring. The patient's heart rhythm was not documented every four hours by nursing staff.

Review of discharged Patient #16's medical record showed that she was a 76 year-old female admitted to the Med/Surg unit on 10/03/22 for congestive heart failure (CHF, a weakness of the heart that causes it to not pump like it should leading to a buildup of fluid in the lungs and surrounding body tissues) and COPD exacerbation. She had a past medical history of atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow). She had an order for telemetry monitoring. The patient expired on 10/06/22. The patient's heart rhythm was not documented every four hours by nursing staff.

Review of discharged Patient #17's medical record showed that he was a 88 year-old male admitted to the Med/Surg unit on 10/10/22 for increased abdominal distention and discomfort and shortness of breath. The patient had a past medical history of heart disease. He had an order for telemetry monitoring. The patient expired on 10/11/22. The patient's heart rhythm was not documented every four hours by nursing staff.

During an interview on 10/18/22 at 12:30 PM and 10/20/22 at 8:30 AM, Staff A, Chief Nursing Officer, stated that if a patient was on telemetry, the nurse should document the patient's heart rhythm every four hours or as needed with any change in heart rhythm. There should be a trained staff member monitoring the patient's heart rhythm at all times.