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UPMC PRESBYTERIAN SHADYSIDE 200 LOTHROP STREET PITTSBURGH, PA 15213 Aug. 19, 2016
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on a review of medical records (MR) and facility documentation and staff interview (EMP), it was determined that the facility failed to complete the medical record consistent with facility policy and procedure for one of 20 medical records reviewed. (MR1)

Findings include:

Review of facility policy "Cardiac and Physiologic Monitoring (ECG, invasive arterial pressures, pulmonary arterial pressures, pulse oximetry, transporting monitored patients, transfers to ICU) last reviewed December 15, 2015, revealed "...Arrhythmia Monitoring....Rhythm strips are to be printed and documented every shift ( a shift is defined as the period when responsibility and accountability for the patient care changes from one nurse to another or at a minimum every 12 hours), when arrhythmia are present and/or changes in patient condition occurs. ..."

1) Review of MR1 revealed that no rhythm strip was printed, documented, and posted on the medical record from approximately 7:00 PM on August 12, 2016 until approximately 5:30 PM on August 13, 2016, a total of twentyone and a half hours (21.5 hrs).

During interview conducted on August 18, 2016, at approximately 11:00 AM EMP4 confirmed not completing the medical record consistent with facility policy and procedure by not printing, documenting, or posting a copy of MR1's rhythm strip on August 13, 2016, at 7:00 AM and revealed "...I did not do it that day... ."