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.

ORLANDO HEALTH 52 W UNDERWOOD ST ORLANDO, FL 32806 Sept. 2, 2014
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and a review of facility documentation, the facility failed to ensure that a uniformly optimal level of nursing care in the form of a timely response by a monitor technician (tech) to cardiac monitor abnormalities and timely nurse response to an emergency situation which required CPR (cardio pulmonary resuscitation) was provided for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the emergency room (ER) on 3/31/14. A nursing triage note at 11:14 AM on 3/31/14 read, "Arrived complaining of left hip and neck pain status post fall. Patient states that he was going to car and lost consciousness." Physician orders of 3/31/14 at 2:24 PM read, "Monitored bed." Thus, the physician wanted the patient to be assigned to a hospital bed in which the patient would have continuous cardiac monitoring. The patient was transferred out of the ER to the Heart Failure unit at 7:20 PM on 3/31/14.

A review of a strip which was pulled from the cardiac monitor machine by the facility in the course of investigating events of 4/02/14, which are discussed in later text, below, involving a Code 90 (an emergency call for CPR), revealed on 4/02/14 at 2:34:39 AM the following text: "Pacing to V-fib HR 71 PVC 0." Per interview of the Risk Manager on 9/02/14 at 12:05 PM, she stated that prompt action should have been taken by staff with awareness of this finding, which would have been in view on the monitor screen.

The record had a telemetry strip dated 4/02/14 at 2:38:59 AM which had the following text: "Cannot analyze ECG HR (heart rate) 0 asystole PVC (pre-ventricular contractions) 12 25/mm/sec." This text was automatically generated by the machine. Another strip from the record of 4/02/14 at 2:38:59 AM read, "Asystole at 02:38:59."

A review of facility internal telephone documentation revealed that a call was placed from the station of the monitor tech #A to RN #B on 4/02/14 at 2:39 AM. Thus, there was a delay of approximately four and a half minutes between the visibly evident (on the monitor) development of cardiac problems with the patient and a point where there was evidence of an unfulfilled attempt at communication with staff to investigate the matter. The gap between these two stated times (4/02/14 at 2:34:39 AM & 4/02/14 at 2:39 AM) indicated that the situation with the patient had not been addressed with the patient himself, at least during the interval. Later text reveals facility conclusions regarding what had transpired during this general time period.

A review of the job description for the monitor tech revealed the following: "Essential function: ... Promptly notifies RN (Registered Nurse) of all changes in cardiac rhythm."

A review of facility policy "Telemetry Monitoring" revealed the following: "The RN or MT (Monitor Tech) assigned the responsibility for telemetry monitoring is also responsible for reporting any changes in patient's rhythm to the primary nurse."

Per interview of the Risk Manager on 9/02/14 at approximately 1:30 PM, their investigation revealed the following. Monitor tech #A noticed a discrepancy with a strip which she stated looked like patient movements or pacer malfunction, at approximately 2:38 AM on 4/02/14. The tech called nursing tech #E, to go check on the patient. Tech #E told her she was on break and to call RN #B. She did so, but it rang back to the station.

An interview of tech #A, who had notified a nurse about abnormal monitor readings with patient #1, was performed on 9/02/14 at approximately 4:16 PM. She stated that she thought the alarm had become disconnected at the point in which she noticed a problem. She stated that she first called another tech to check, but she stated she was on a break. She then attempted to call the patient's nurse, RN #B, but had difficulty in trying to contact her (see the above telephone time). She then grabbed a strip and told another nurse. She could not estimate how long it took between noticing the abnormality on the monitor and reaching the second nurse.

Since there is evidence that facility staff did not locate anyone to investigate cardiac monitor findings which were first evident from 4/02/14 at 2:34:39 AM, until some point after 4/02/14 at 2:39 AM, it can be concluded that the monitor tech had not responded in a timely manner to an emergency concern and was in violation of her job requirements and facility policy.

Another strip of 4/02/14 at 2:44:49 AM read, "Asystole at 02:45:00." As to whether this was printed out at this time for inclusion in the record, it was not (it was printed later)

A nurse's note of 4/02/14 at 2:45 AM by #B, RN read, "Cardiac monitor showed coarse V fib, pt. found unresponsive, code 90 called, ACLS initiated." The document "Code Blue Record" indicated that an event was recognized at 2:47 AM on 4/02/14 at that a code began at 2:48 AM. The code ended at 3:09 AM on 4/02/14. Thus, the code (2:48 AM on 4/02/14) did not start until approximately nine minutes after the monitor tech had first noticed the discrepancy on her monitor, as evidenced by the telephone call time of 2:39 AM on 4/2/14 (see prior text). A physician note of 4/02/14 at 3:19 AM read, "Preliminary cause of death was Cardiac arrest." A physician note of 4/02/14 at 6:49 AM read, "Type of arrest: Cardiopulmonary arrest. Initial rhythm assessed: [DIAGNOSES REDACTED] (VT) without a pulse.... Code Blue 90 called at 2:48 on 4/02/2014, on arrival patient noted to be pulseless and Vtach rhythm on monitor, ACLS prolonged initiated STAT.... Code was called at 3:09 AM on 4/02/2014 and patient was pronounced dead."

The above mentioned interview with the Risk Manager on 9/02/14 at approximately 1:30 PM continued. The monitor tech, #A, after being unable to reach #B on the telephone, then asked the nearby RN #C to look at the strips and to get RN #B to check her patient. RN #C recognized V Fib in the strip and ran to the family room where RN #B was charting and told her that we needed to check on her patient now. Both of these nurses went to the patient's room. The nurses found the patient without a pulse or respirations. RN #C told RN #B to stay with the patient while she went to get the code cart. Instead of pushing the code button and initiating CPR, RN #B left the room to get her paperwork. Then, RN#D heard commotion, walked into the patient's room, noticed no pulse or respirations. She then pressed the code button and started CPR.

An interview of the nurse who first went into the room of #1 with RN #B (RN #C) was performed on 9/02/14 at approximately 4:25 PM. She stated that a tech had asked her to look a monitor strip. She stated she did so and then went into emergency mode. She and RN #B then went to the patient's room. She stated that she noticed the patient was not breathing and told RN #B that the patient did not have a pulse. She told her that she, RN #C was going to get emergency equipment. She assumed that RN #B would push the Code button and start compressions, but when she returned with the emergency equipment, RN #B was not in the room.

Thus, once nursing staff had arrived in the patient's room and determined that the patient was in a life threatening situation, there was a failure to immediately summon assistance through pressing an available button for such situations and a failure to immediately start CPR.

During an interview of the Risk Manager on 9/02/14 at approximately 5 PM, she confirmed the findings.