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ST. VINCENT'S MEDICAL CENTER 2800 MAIN ST BRIDGEPORT, CT 06606 Dec. 6, 2018
VIOLATION: NURSING SERVICES Tag No: A0385
A substantial allegation survey concluded at Saint Vincent's Medical Center on 12/6/18 in response to CT #

The Condition of Participation reviewed included:

CFR 482.23 Nursing Services

The Condition of Participation for Nursing Services has not been met.

Saint Vincent's Hospital
280 Main Street
Bridgeport, CT

The total census is 288
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, review of facility competencies, review of facility staffing and interviews, the facility failed to ensure that Registered Nurses (RN) who worked on specialty units were adequately trained.
The finding includes:

Patient#1 was admitted on [DATE]. Patient #1's history included hypertension and MI (myocardial infarction) times two and was admitted to the Observation (7E) unit on 3/16/18 at 12:32 AM for monitoring. Review of physician orders by APRN (Advanced Practice Registered Nurse) #1 dated 3/16/18 at 12:42 AM directed to monitor the patient with remote telemetry that was verified/signed by RN #3 at 12:45 AM. Review of the Observation unit RN competencies identified that a monitoring class and ACLS (advanced cardiac life support) were required unit training.

Interview with RN #3 on 12/7/18 at 8:36 AM noted that she floated to the observation unit at 11:00 PM on 3/15/18, had never worked on the observation unit prior to this and had basic but not advanced cardiac life support training. Interview with Director #1 on 12/6/18 at 11:52 AM noted that ACLS certification was required on the observation unit as well as a cardiac dysrhythmia course.

In addition, review of the staffing for the float pool dated 3/15/18-3/16/18 identified that RN #4 worked on the cardiac (6N) unit during this timeframe. The 6S/N unit RN competency identified that a monitoring class and ACLS (advanced cardiac life support) were required unit training.

Interview with Director #1 on 12/6/18 at 1:30 PM noted that ACLS training for the float pool staff was required and they became aware that RN #4 was not ACLS trained on 3/16/18 and is in the process of being trained.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record reviews, review of facility documentation, review of facility practice and policies for three of ten patients (P #1, #5 and #6), the facility failed to ensure that cardiac monitoring was initiated timely.

The finding includes:

a. Patient #1's was admitted on [DATE] with complaints of Chest Pain. Patient #1's history included hypertension, MI (myocardial infarction) times two, pulmonary embolism and a IVC (inferior vena cava) filter. Cardiac testing was negative in the ED (EKG cardiac enzymes), Patient #1 was bradycardic (low pulse in 50's) and the physician assessment/plan was to place on remote telemetry, cycle cardiac enzymes, observation status and full code. Review of facility documentation (time line) indicated that the patient arrived on the observation (7E) unit on 3/16/18 at 12:32 AM. Review of an order by APRN (Advanced Practice Registered Nurse) #1 dated 3/16/18 at 12:42 AM directed remote telemetry and was verified/signed by RN #3 at 12:45 AM. Review of the medication record noted that Patient #1 received an antihypertensive medication, hydralazine, intravenously and tums for epigastric pain/discomfort at 1:08 AM as ordered. Review of facility documentation indicated that RN #3 assisted Patient #1 to the bathroom and Patient #1 vomited a small amount of digested material. Patient #1's BP (blood pressure) documented on 3/16/18 at 1:59 AM identified that the patient's blood pressure was slightly lower, 180/89 than the previous BP of 204/91 documented at 1:13 AM and 1:22 AM. Further review identified that the initiation of remote telemetry and/or cardiac monitoring was not documented in the patient's record following order verification on 3/16/18 from 12:45 AM to 2:35 AM (1 hour 50 minutes). The facility "time line" noted that RN #3 found Patient #1 unresponsive at 2:33 AM. Review of the cardiac flow sheet dated 3/16/18 identified a time of
2:35 AM for initiation of cardiopulmonary resuscitation for asystole, the patient was intubated and was resuscitated for 16 minutes unsuccessfully. Review of the progress notes by the Intensivist who ran the code (MD #1) and dated 3/16/18 indicated that the exact "downtime" of the patient was unknown as the patient was not on a monitored bed and "downtime" was not greater than 10-15 minutes. Review of the death certificate dated 3/16/18 identified cardiac arrest as the immediate cause of death. A call for interview with RN #3 was placed on 12/6/18 and returned on 12/7/18. Interview with RN #3 on 12/7/18 at 8:36 AM noted that she floated to the observation unit at 11:00 PM on 3/15/18 and had never worked on the observation unit prior to this. RN #3 further indicated that she saw the remote telemetry order, helped settle the patient and gave the patient medications. RN #3 noted that she was documenting outside of Patient #1's room, no longer heard the patient belching, went into the room, found the patient unresponsive and she initiated CPR (cardiopulmonary resuscitation). Further interview with RN #3 on 12/7/18 at 8:36 AM identified that she was aware of the process for obtaining remote telemetry monitors and recalled thinking that she had yet to get the telemetry monitor.

b. Patient #5 was admitted to the 9N unit at 8:45 PM on 11/16/18 with diagnoses of weakness, fever and abnormal laboratory testing. Review of the physician order for remote telemetry on 11/16/18 identfied that the the order was documented and verified by the RN at 8:56 PM. Review of Patient #5's clinical record and interview with
Director #1 on 12/6/18 at 10:33 AM identified that the first monitored reading/initiation of the cardiac monitor was documented at 10:36 PM on 11/16/18 (1 hour 37 minutes after RN verification).

c. Patient #6 was admitted to 7N unit on 12/3/18 at 5:31 PM with a diagnosis of upper gastrointestinal bleed. Review of the physician order for remote telemetry dated 12/3/18 at 9:59 PM was verified by the RN at 10:02 PM. Review of patient's clinical record and interview with Director #1 on 12/6/18 at 10:40 AM identified that the first monitored reading/initiation of the cardiac monitor was documented at 1:00 AM on 12/4/18 (2 hours 58 minutes after RN verification).

Interview with Director #1 on 12/6/18 at 10:49 AM noted that the expected timeframe for remote telemetry monitor placement was within one hour after the RN reads the order. The facility remote telemetry policy lacked direction for obtaining the monitor and/or timeframe for placement. The facility staff nurse job description identified a responsibility to note and carry out physician orders.

Subsequent to the event, RN #3 received education regarding remote telemetry monitoring and timely placement. In addition, the hospital attempts to conduct audits regarding the timeliness of remote monitor placement were unsuccessful due to a changes in the computerized system. The facility submitted an immediate action plan to include remote telemetry policy revisions, staff education and audits regarding the timeliness of remote telemetry initiation.