HospitalInspections.org

Based on a review of facility documents and medical records (MR) and staff interviews (EMP), it was determined that the facility failed to ensure that a adequate number of staff were available to provide nursing care for all patients as needed

Findings include:

Review of the facility policy "Basic Monitoring Standard of Care for the Progressive Care Unit, Reviewed July 2011. ... Policy Statement: The Progressive Care Unit, in accordance with the philosophy and objectives of Excela Health Westmoreland Hospital, is committed to offering optimum health care with emphasis on the patient who requires cardiac monitoring on a 24 hour basis. ... Cardiac Monitoring: Monitoring is performed continuously via telemetry units. This system sends information to a central monitoring station. ... These are the minimum standards for all patients admitted to Progressive Care Unit. This protocol is maintained on all patients until transferred or otherwise ordered. ... ."

1. Review of MR1 revealed, "nursing notes, May 20, 2012, 1:10 AM, Patient restless up in chair, respiratory called ativan 0.5 mg given. ... 4:00 AM, Cardiac rhythm A FIB, 70's." ... Addendum to care plan notes, May 20, 2012, at 5:38 AM, checked on patient beeping IV. Found patient unresponsive, no pulse, heart monitor had leads off (2). Code blue called and CPR started. ... Dr Wood Pronounced death at 6:20 AM, ... ."

2. Interview with EMP7 on May 30, 2012, at approximately 10:00 AM revealed, "The alarm that sounds when the leads are off is a low level alarm. It can be heard if you are near the nurses station. We have changed the 'leads off' alarm to a high level alarm.."

3. Interview with EMP3, June 8, 2012, at approximately 2:05 PM revealed, "... The alarm for the monitor leads being off is a low beep. We do not have someone that watches the monitor closely." When asked if [EMP3] noticed that the leads were off before the IV alarm went off, EMP3 responded, "No, I didn't notice."

4. Interview with EMP5 on June 8, 2012, at approximately 2:30 PM revealed, " ... The low level alarm cannot be heard when you are in another room. You can hear a level 1 alarm. ... I feel there should be someone there all the time watching the monitors. ... ."

5. Interview with EMP6 on June 8, 2012, at approximately 3:30 PM revealed, " ... There is not someone in front of the monitors at all times. ... I don't think there is enough monitoring done on the floor. The charge nurse has a case load. There is no one watching the monitors."

6. Interview with EMP4 on June 8, 2012, at approximately 3:30 PM revealed, " ... We can't watch the monitors continuously. I was busy with my patients that night, I didn't notice anything else. I had an admission, I was with the admission for a half an hour to 40 minutes. ... ."

Based on a review facility documents and personnel files (PF), and staff interview (EMP), it was determined that the facility failed to ensure that nursing personnel assigned to each patient had the specialized qualifications and competence required for one of six registered nurse progressive care unit personnel files reviewed (PF6).

Findings include:

Review of facility document, "Excela Health Job Description, Reviewed December 2011, Registered Nurse, Progressive Care Unit, ... V. Required Skills and Knowledge: ... Current ACLS, ... ."

1. Review of PF6 on May 30, 2012, at approximately 11:30 AM revealed no current ACLS certification.

2. Interview with EMP1 on May 30, 2012, at approximately 1:00 PM verified that PF6 ACLS certification had expired.

Based on a review of facility documents and medical records (MR) and staff interviews (EMP), it was determined that the facility failed to ensure that a adequate number of staff were available to provide nursing care for all patients as needed

Findings include:

Review of the facility policy "Basic Monitoring Standard of Care for the Progressive Care Unit, Reviewed July 2011. ... Policy Statement: The Progressive Care Unit, in accordance with the philosophy and objectives of Excela Health Westmoreland Hospital, is committed to offering optimum health care with emphasis on the patient who requires cardiac monitoring on a 24 hour basis. ... Cardiac Monitoring: Monitoring is performed continuously via telemetry units. This system sends information to a central monitoring station. ... These are the minimum standards for all patients admitted to Progressive Care Unit. This protocol is maintained on all patients until transferred or otherwise ordered. ... ."

1. Review of MR1 revealed, "nursing notes, May 20, 2012, 1:10 AM, Patient restless up in chair, respiratory called ativan 0.5 mg given. ... 4:00 AM, Cardiac rhythm A FIB, 70's." ... Addendum to care plan notes, May 20, 2012, at 5:38 AM, checked on patient beeping IV. Found patient unresponsive, no pulse, heart monitor had leads off (2). Code blue called and CPR started. ... Dr Wood Pronounced death at 6:20 AM, ... ."

2. Interview with EMP7 on May 30, 2012, at approximately 10:00 AM revealed, "The alarm that sounds when the leads are off is a low level alarm. It can be heard if you are near the nurses station. We have changed the 'leads off' alarm to a high level alarm.."

3. Interview with EMP3, June 8, 2012, at approximately 2:05 PM revealed, "... The alarm for the monitor leads being off is a low beep. We do not have someone that watches the monitor closely." When asked if [EMP3] noticed that the leads were off before the IV alarm went off, EMP3 responded, "No, I didn't notice."

4. Interview with EMP5 on June 8, 2012, at approximately 2:30 PM revealed, " ... The low level alarm cannot be heard when you are in another room. You can hear a level 1 alarm. ... I feel there should be someone there all the time watching the monitors. ... ."

5. Interview with EMP6 on June 8, 2012, at approximately 3:30 PM revealed, " ... There is not someone in front of the monitors at all times. ... I don't think there is enough monitoring done on the floor. The charge nurse has a case load. There is no one watching the monitors."

6. Interview with EMP4 on June 8, 2012, at approximately 3:30 PM revealed, " ... We can't watch the monitors continuously. I was busy with my patients that night, I didn't notice anything else. I had an admission, I was with the admission for a half an hour to 40 minutes. ... ."

Based on a review facility documents and personnel files (PF), and staff interview (EMP), it was determined that the facility failed to ensure that nursing personnel assigned to each patient had the specialized qualifications and competence required for one of six registered nurse progressive care unit personnel files reviewed (PF6).

Findings include:

Review of facility document, "Excela Health Job Description, Reviewed December 2011, Registered Nurse, Progressive Care Unit, ... V. Required Skills and Knowledge: ... Current ACLS, ... ."

1. Review of PF6 on May 30, 2012, at approximately 11:30 AM revealed no current ACLS certification.

2. Interview with EMP1 on May 30, 2012, at approximately 1:00 PM verified that PF6 ACLS certification had expired.