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.
|WEST PENN HOSPITAL||4800 FRIENDSHIP AVENUE PITTSBURGH, PA 15224||March 13, 2015|
|VIOLATION: PATIENT RIGHTS||Tag No: A0115|
|Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure the protection and promotion of the rights of patients and failed to provide care in a safe setting (0144); failed to respond to an EKG monitor alarm that resulted when a monitor cable was disconnected for one of six medical records reviewed (MR1).
This situation constitutes an Immediate Jeopardy situation.
1) Review of facility documents and medical records, and staff interviews revealed that the facility failed to respond to a an EKG monitor alarm that resulted when a monitor cable was disconnected by MR1 (0144).
Cross reference with:
482.13 Patient Rights(c)(2) The patient has the right to receive care in a safe setting.
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on a review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to provide care in a safe environment by neglecting to respond to an EKG monitor alarm when a monitor cable was disconnected by a patient for one of six medical records reviewed (MR1).
Review of facility policy "Alarm Monitoring Policy" last reviewed October 2014, revealed "...It is the responsibility of all RN/GN to address any sounding alarms as they occur. ..."
Review of facility "Patient Rights Policy" approved April 1, 2014, revealed "...You have the right to receive care in a safe setting free from any form of abuse, harassment and neglect..."
1) Review of MR1's Monitor Alarm History dated March 4, 2015, revealed that MR1's "Electrode Off" alarmed at 11:18: 50 and continued to alarm until 11:43:50, a period of 24 minutes and 14 seconds. At the time MR1was placed back on the monitor the description of the MR1's rhythm was "Asystole."
2) Review of MR1 Event Note dated March 4, 2015, at 13:34 revealed "...Brief Description: Patient found unresponsive and off the monitor at 11:42. Dr...informed and CPR initiated...Patient given 2 doses of EPI(nephrine) and 2 doses of bicard. Dopamine and Epinephrine started. Central line placed in the left femoral artery, art line placed in right femoral ...Swan Ganz placed in right IJ (internal jugular)..."
3) Review of MR1 Physician Progress Note dated March 4, 2015, at 13:35 revealed "...ICU Staff called emergently to see pt. where pt. found off monitor, legs dangling of bed, unresponsive...placed on monitor, wide complex-rate 20 pulled up in bed, CPR board placed, ALS protocol began CPR...ETT placed...eventually obtained pulse. ..."
4) During interview conducted on March 10, 2015 at approximately 11:10 AM, EMP5 revealed "...[EMP1] took other patient to X-ray around 11:20 AM...[EMP2] checked on [MR1] around 5 minutes after [EMP1] left the unit...around 11:30 [EMP2] went into room to discharge...other patient...[EMP2] came back from X-ray found [MR1] unresponsive and leads disconnected at cable hub...alarms were set at advisory level turns solid yellow at room and at nursing station...it beeps...low level alarm...patient set off the alarm at 11:18 AM...the minimum volume for all alarms should be set at 5 and I believe it was set at 3..."
5) During interview conducted on March 10, 2015, at approximately 1:30 PM, EMP1 revealed "...I gave report off to [EMP2] around 11:15 AM...I had other patient hooked up and ready and left the unit shortly thereafter around 2 or 3 minutes later...when I returned I placed my patient back in bed...there was no alarm going off, no alarm going off....went into [MR1's] room and I saw my patient in bed off monitor off O2 unresponsive...I left room and grabbed my intensivist...[MR1] still had leads on was just disconnected from monitor..."
6) During an interview conducted on March 10, 2015, at approximately 1:45 PM, EMP2 revealed "...I was in room getting ready to discharge my patient... [EMP1] asked me for help...no, I did not hear any alarms..."
7) During an interview on March 11, 2015, at approximately 1:30PM, it was revealed that EMP3 was present on the nursing unit on March 4, 2015, at the time the monitor cable was disconnected by MR1. When asked if the monitor alarm could be heard inside another patient room EMP3 revealed, " ...No...Probably out of the room, it's a soft ding..."
8) Additional interviews were conducted on March 11, 2015 at approximately 2:00 PM with EMP11, EMP12, EMP13, and EMP14 who were working on the opposite side of the nursing unit that MR1's room was located on March 4, 2015 between 11:18 AM and 11:43 AM. When asked if any of them heard MR1's monitor alarm EMP11, EMP12, EMP13, and EMP14 all revealed "...No..."
9) During an interview on March 12, 2015, at approximately 10:00 AM, EMP6 confirmed the above findings and when asked if the time documented on the Alarm History for MR1 on March 4, 2015, between 11:18:50 and 11:43:57 of 24 minutes and 14 seconds confirmed that the alarm was properly functioning and indicated how long the audible and visual alarm sounded after MR1 disconnected the monitor cable, EMP6 replied "Yes."
Cross reference with:
482.13 Patient Rights