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.

Based on review of facility documents, and staff interviews (EMP), it was determined the facility failed to follow their established Patient's Bill of Rights, by failing to ensure care was rendered in a safe setting, and by failing to follow adopted policies related to constant observation of patients on the telemetry monitors.

Findings include:

A review on May 16, 2011, of Carlisle Regional Medical Center's policy entitled "Patient Rights & Responsibilities," dated 2010 revealed " ... Care Delivers You have the right to: ... Receive care in a safe setting free from any form of ... and neglect ... "

A review on May 16, 2011, of the job description "Unit Secretary/Nursing Assistant/Monitor Tech" revised 12/12/03 revealed, "... The Monitor Tech will perform cardiac monitoring on clinical area and trend reports as required, notify appropriate personnel of abnormalities and document as required ... "

Observation on May 16, 2011, of the Critical Care Unit (CCU) revealed a group of four cardiac monitors each with capability of showing eight tracings of heart rhythms located in an open area adjacent to the nurses' station in the CCU unit.

An interview conducted on May 16, 2011, at 9:15 AM with EMP2 revealed the cardiac monitors show tracing of heart rhythms of patients that were placed on a telemetry monitor throughout the hospital.

An interview conducted on May 16, 2011, at 9:45 AM with EMP3 revealed that sometimes the nurses expect the monitor tech to also be the certified nurse assistant (CNA) and secretary.

An interview conducted on May 17, 2011, at 2:24 PM with EMP8 revealed that there were times when the monitor tech had to leave the area and asked a nurse to watch the monitor. When the monitor tech returned the nurse was in the critical care patient room assisting the patient and no one was watching the monitors.

An interview conducted on May 18, 2011, at 10:45 AM with EMP5 revealed many times the secretary/CNA that was assigned to the CCU was pulled to another area and the monitor tech must then act as the secretary and the CNA.

An interview conducted on May 18, 2011, at 2:30 PM with EMP9 confirmed when the Progressive Care Unit (PCU) was open the secretary was pulled to the PCU and the monitor tech assumes the responsibilities of the secretary. If the nurse needs help and the monitor tech helps the nurse, about 50 % of the time, the nurse that was asked to watch the monitor was not watching the monitors. The monitors were left unattended.