The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|DOMINICAN HOSPITAL||1555 SOQUEL DRIVE SANTA CRUZ, CA 95065||Feb. 18, 2015|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interviews and record reviews, the hospital failed to evaluate the nursing care of a patient when continuous cardiac monitoring was not implemented according to hospital policy and procedure for one of 15 sampled patients (1). Patient 1's heart rhythm was not monitored. Failure to implement the policy and procedure for continuous cardiac monitoring may result in failure to detect changes in the patient's heart condition. Findings:
Patient 1 was a [AGE] year old female admitted on [DATE] with diagnoses including hyperosmolar hyperglycemic state (condition with extremely high blood sugar level without presence of ketones. Ketones are waste products of fat breakdown), and non ST myocardial infarction (when blood supply to the heart is decreased, usually from one or more blocked blood vessels).
Review of Patient 1's clinical record indicated Patient 1 was admitted to the telemetry care unit. This is a unit where patients are connected continuously to a monitor in their room and each patient's cardiac activity is transmitted to a central monitoring area observed continuously by a monitor technician.
During a tour of the telemetry care unit on 2/17/15 at 8:30 a.m., the monitor station was located at the corner of the nurse's station. It was manned by a monitor technician and had 44 monitor screens. The screens show the patient's cardiac monitoring rhythms.
Review of Patient 1's physician's order dated 9/12/14 indicated an order for continuous cardiac monitoring.
During a telephone interview conducted on 2/18/15 at 9:35 a.m., monitor technician A reconfirmed his interview statements conducted last 11/7/14 at 4:09 p.m. Monitor technician A (MT A, a person who observes the monitor area in the telemetry unit) stated Patient 1 had a normal heart rhythm at the start of his night shift on 9/14/14. MT A stated at 12:50 a.m., he was unable to interpret Patient 1's heart rhythm in the cardiac monitor. MT A stated he requested multiple times for registered nurse A (RN A) to check Patient 1's cardiac monitoring leads so MT A could have an interpretable rhythm. MT A stated he requested a break and asked the charge nurse (CN) to relieve him. MT A informed the CN about Patient's 1 uninterpretable cardiac monitoring rhythm.
During an interview conducted on 11/4/14 at 8 a.m., the CN confirmed MT A asked her to watch the monitors while MT A went on a break. Before leaving the monitor station, MT A informed the CN, Patient 1 "had been off the monitor awhile." The CN stated she asked MT A how long Patient 1 had been off the monitor and MT A stated to her "it may have been 15 minutes." The CN stated "that's a fairly long time, which would be an issue" The CN stated she asked registered nurse B (RN B) to go to Patient 1's room and check Patient 1. The CN stated RN B went into Patient 1's room and yelled for the CN to come in Patient 1's room. The CN stated she went to Patient 1's room and saw Patient 1 who "appeared to be purple/bluish, and cold to touch". A Code Blue (an emergency cardiopulmonary resuscitation procedure) was called.
During a telephone interview with registered nurse A (RN A) on 10/21/14 at 10:30 a.m., she confirmed MT A called her about the uninterpretable cardiac rhythm of Patient 1. RN A stated she was not able to go to Patient 1's room as she was doing a wound dressing on another patient.
Review of Patient 1's Nursing Progress Note dated 9/14/14 indicated RN A administered Morphine 2 milligrams (a pain medication) to Patient 1 at 2:30 a.m. as Patient 1 complained of spasms and tingling of both her legs.
Review of Patient 1's 9/14/14 Code Record (record of cardiopulmonary resuscitation) indicated Patient 1 received cardiopulmonary resuscitation beginning at 2:55 a.m. and ended at 3:19 a.m. The Code Record indicated Patient 1's heart rhythm at 2:59 a.m. was ventricular fibrillation (V-Fib), an abnormal heart rhythm. The 9/15/14 Discharge Summary indicated Patient 1 expired on [DATE] at 3:19 a.m. due to cardiac arrest from a myocardial infarction (heart attack).
Review of the hospital's 1/16/2011 policy and procedure titled "Telemetry Monitoring" indicated continuous telemetry monitoring via a telemetry transmitter would be initiated upon a physician's order. The policy indicated the continuous cardiac monitoring facilitated the early detection of cardiac rhythm changes and provided information regarding the patient's response to therapy. Any rhythm changes were to be immediately reported by the monitor technician to the patient's nurse who would then assess the patient and report the clinical status of the patient to the charge nurse. Nurses as well as nursing assistants could apply the electrodes on a patient using the five lead cables.