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ST VINCENT'S MEDICAL CENTER 2800 MAIN ST BRIDGEPORT, CT 06606 Nov. 20, 2014
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of clinical records, review of hospital policies, review of hospital documentation and interviews with hospital personnel for one patient (Patient #1), the condition of Nursing has not been met.

Nursing services failed to ensure that communication, assessment, and documentation for a patient on remote telemetry were provided in accordance with hospital policies and failed to ensure that a sitter was with the patient, per order and policy.

Please see A395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of the clinical records, review of hospital policies, review of hospital documentation and interviews with hospital personnel for one (Patient #1) of ten patients on cardiac telemetry, documentation and interviews failed to reflect that communication, assessment, and documentation for a patient on remote telemetry were provided in accordance with hospital policies and failed to ensure that a sitter was with the patient, per order and policy. The findings include:

1a. Patient #1 was admitted to the hospital's Emergency Department (ED) on 10/2/14 at 6:21 PM following a fall at work. The patient was alert and oriented on admission and did not recall the event. Patient #1 was admitted to the trauma service, observation unit at 10:25 PM with the diagnosis of syncope. Review of the History and Physical (H & P) dated 10/3/14 identified that the patient's past medial history included atrial fibrillation, mild pulmonary hypertension, right-sided heart failure, alcohol abuse, hypertension, depression and status post (s/p) gastric bypass (2006). Admission Physician Orders included clinical withdrawal assessment scale for alcohol (CIWA-Ar), remote telemetry, seizure precautions, vital signs (VS) every 8 hours and intake and output (I & O). The patient received Ativan 1 mg every 4 hours on 10/3/14 as per CIWA protocol.

Review of the clinical record, review of hospital documentation and interview with RN #1 on 11/19/14 at 10 AM identified that RN #1 was assigned to Patient #1 on 10/3/14 from 7:30 PM to 7:00 AM. The Medication Administration Record (MAR) identified that RN #1 administered the scheduled Ativan 1 mg by mouth (po) at 10:46 PM to the patient. However, at 11:00 PM, the patient became more confused and was attempting to get OOB. VS at 11:00 PM: HR=54 (with dynamap machine, although cardiac monitor indicated 100's) and BP = 111/84. No respiratory rate was noted. RN #2 identified that the patient was cold, clammy and diaphoretic and the patient was desatting (blood oxygen level) to 80's. RN #1 warmed the patient's hand (with own hands) and then the pulse oximetry rose to 92% on 2L nasal oxygen (O2).

RN #1 notified APRN #1. Interview with APRN #1 on 11/19/14 at 1:30 PM identified that APRN #1 evaluated the patient at between 11:00 PM - 11:15 PM and believed that Patient #1 was in alcohol withdrawal. APRN #1 ordered Ativan 1 mg intravenously (IV) and a sitter. RN #1 administered Ativan 1mg IV at approximately 11:20 PM (time taken from Pyxis printout, however, MAR noted 23:53). According to RN #1, RN #1 sat with Patient #1 for a few minutes (? time), left the patient alone (? time) and directed CNA #1 to sit with the patient (? time). The patient was not reassessed after the IV Ativan was administered at 11:20 PM.

Interview with CNA #1 on 11/19/14 at 2:30 PM identified that on the way to the patient's room, 758 (? time), RN #1 directed CNA #1 to attach the patient's monitor lead and change the battery. CNA #1 indicated that Patient #1 was lying on his/her back with eyes closed and CNA #1 attached the brown lead (? time). CNA #1 identified that he/she did not speak with Patient #1. CNA #1 indicated that there was no monitor reading and took out the old battery. CNA #1 retrieved a new battery from the medication (med) room and placed the new battery in the patient's cardiac monitor compartment. CNA #1 identified that this process took approximately less than one minute.

Review of the cardiac monitor strips dated 10/3/14 identified that the patient's monitor tracing was not present for 9 minutes, between 11:49 PM-11:58 PM. Review of the monitor strip timed 23:58:24 (11:58:24 PM) on 10/3/14 identified that the telemetry signal was found and noted Patient #1 was bradycardic with HR=23. RN #1 identified that when he/she went into the room, the patient was pulseless, without respirations and RN #1 called a code at midnight. Patient #1 was resuscitated, intubated and transferred to the ICU. Patient #1 was diagnosed with anoxic brain injury and expired on [DATE].

Review of a Physician's Progress Note dated 10/7/14 identified that the patient was not on telemetry monitoring for approximately 9 minutes between the time the telemetry signal was lost and the patient was discovered to be in cardiac arrest on 10/3/14.

Review of the cardiac monitor strips, review of hospital documentation and interview with Monitor Technician (MT) #1 on 11/19/14 at 9:00 AM identified that the patient's HR decreased between 11:32 PM (HR= 103) -11:49 PM (HR= 50's-60's), the time the signal was lost. MT #1 identified that he/she called and spoke with RN #1 approximately four times during that time. MT #1 informed RN #1 that the monitor leads were off and that the battery was low. MT #1 indicated that he/she told RN #1 that the HR was "better, in the 80's" on one phone call. The next phone call, MT #1 identified that the patient's HR was dropping, but could not verify it because MT #1 could not see it due to the lead being off. MT #1 indicated that the second to last phone call to RN #1, MT #1 could not see the monitor rhythm at all. RN #1 identified that MT #1 did not tell RN #1 that the patient was bradycardic. RN #1 identified that he/she called MT #1 twice from the nurses' station to verify that the monitor was connected, but it wasn't. Review of the monitor strip dated 10/3/14 at 23:58 (11:58 PM) identified that Patient #1 was bradycardic with HR in the 20's.

Review of the Cardiac Monitoring: Operations and Responsibilities for Remote identified that when there are changes in rate, rhythm or interval measurements, the MT reports the findings to the RN caring for the patient and documents the changes. The MT would call the RN if a patient has a clinical meaningful alarm. The MT documents the name of the RN caring for the patient and the time of the discussion directly onto the rhythm strip. The strips would be mounted and delivered to the appropiate floor. MT #1 identified that he/she wrote RN #1's name on the cardiac strips which noted the time of the calls and tubed them to the observation unit. However, review of Patient #1's mounted rhythm strips in the clinical record dated 10/3/14 (23:32:05 through 23:58:24) failed to reflect RN #1's name and times that MT #1 called RN #1 as per policy.

Additionally, the Leads Off Procedure noted in the policy identified that the MT notifies RN and within 5 minutes the leads must be reapplied and the RN should verify this with the MT. RN #1 indicated that he/she called MT #1, however, documentation and interviews failed to reflect the time that this occurred. Additionally, the policy identified that the staff nurse checks the patient's apical pulse every 4 hours, verifies it with the MT and documents it on the nursing assessment documentation form. Review of the record and interview with RN #1 failed to reflect that the apical pulse check was completed every 4 hours as per policy.

1b. Patient #1 was on remote telemetry on 10/3/14. Interview with CNA #1 on 11/19/14 at 2:30 PM identified that on the way to the patient's room, 758 (? time), RN #1 directed CNA #1 to attach the patient's monitor lead and change the monitor battery. CNA #1 attached the brown lead and took out the old battery. CNA #1 retrieved a new battery from the locked medication room using RN #1's identification badge to get into the locked medication room. Interview with NM #1 identfied that the CNA should not have had access to the locked medication room utilizing the RN badge.

1c. Review of the clinical record, review of hospital documentation and interview with RN #1 on 11/19/14 at 10 AM identified that Patient #1 was given the scheduled Ativan 1 mg by mouth (po) at 10:45 PM. However, the patient became more confused, was attempting to get OOB at 11 PM. RN #1 notified APRN #1. APRN #1 evaluated the patient, ordered Ativan 1 mg intravenously (IV) and a sitter. RN #1 administered Ativan 1mg IV at approximately 11:20 PM (Pyxis time). RN #1 sat with Patient #1 for a few minutes (? time), left the patient alone (? time) and directed CNA #1 to sit with the patient (? time). Interview with CNA #1 on 11/19/14 at 2:30 PM identified that on 10/3/14, on the way to the patient's room, 758 (? time), RN #1 directed CNA #1 to attach the patient's monitor lead and change the battery. CNA #1 indicated that he/she went to Room 758 (? time), attached the brown lead, took out the old battery and retrieved a new battery from the med room. CNA #1 placed the new battery in the patient's cardiac monitor compartment (? time).
Review of the Instruction for Sitters policy directed never to leave the patient alone.