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ASCENSION ST VINCENT'S RIVERSIDE 1 SHIRCLIFF WAY JACKSONVILLE, FL 32204 Feb. 20, 2020
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, policy review, and staff interview, the facility failed to maintain record of telemetry monitoring strips in the medical record for 1 of 6 patients reviewed for telemetry monitoring. (Patient #1)

The findings include:

The facility's Policy and Procedure on Telemetry Monitoring was reviewed on 02/20/2020 at 3:10 PM. The Policy and Procedure for Telemetry Monitoring states,"monitoring strips will be printed and posted on admission to the unit, at the beginning of each shift, with any rhythm change, prior to being transferred to a higher level of care, when requested by RN, or following a code blue." The Policy and Procedure state following a code blue or transfer to a higher level of care the monitor technician will:
a.) Review all classes in the monitor memory and print the 4 most recent strips
b.) Print out any abnormal rhythms or beats that occurred in the last 24 hours prior to the event, if available
c.) Review the strips with the RN prior to the patient being removed from the monitor making sure no additional information or strips are needed for documentation.
d.) Place the strips on the patient's telemetry log sheet.
(photographic evidence obtained)

A record review was conducted on 02/20/2020 at 4:00 PM. Patient #1 was admitted on [DATE] for bradycardia with telemetry monitoring.

The telemetry strip log form was reviewed during Patient #1's record review. There was a posted telemetry strip for Patient #1 as a new admission to 4 Center on 12/02/2019 at 6:27 PM. There were telemetry strips posted for the beginning of each shift 12/02/2019 at 8:31 PM and 12/03/2019 at 7:15 AM. On 12/03/2019 at 1:33 PM, there was a telemetry strip for Patient #1 prior to leaving the unit for dialysis. The patient was transferred from 4 Central while at dialysis to 4 West. There was a telemetry strip as a new admission to 4 West at on 12/03/2019 at 10:08 PM. The next strip posted in Patient #1's chart was once resuscitation efforts were stopped on 12/04/2019 at 4:49 AM. (photographic evidence obtained)

Nursing notes were reviewed. Staff Member #3 Registered Nurse (RN) charted on 12/03/2019 at 9:40 PM, Patient #1 was picked up from dialysis, alert and oriented. Staff Member #3 charted patient refused medication and requested Benadryl for itching at 10:45 PM. On 12/03/2019 at 11:55 PM, Staff Member #3 charted the Monitor Technician notified her Patient #1 was in v-fib (a lethal heart rhythm, not sustainable with life), Patient #1 was found unresponsive in the room, a code blue was called and cardiopulmonary resuscitation (CPR) efforts began. The patient was then transferred to a higher level of care. (photographic evidence obtained)

An interview was conducted with Staff Member #1, RN, Director of Nursing (DON) and Staff Member #2, RN, Unit Manager on 02/20/2020 at 5:05 PM. They stated Staff Member # 4, was the Monitor Technician for the shift Patient #1 was a code blue. Staff Member #1 and #2 stated they questioned Staff Member #4, Monitor Technician about the missing telemetry strips after review of the code blue for Patient #1. They were told by Staff Member #4, stated the telemetry strips were printed for the entire event from the time the patient went into v-fib and during the code up until the patient was transferred to the Intensive Care Unit (ICU), but the strips were taken by the House Supervisor and Rapid Response Team (RRT). Staff Member #1 and #2 stated they looked for the strips but never found them and it was unclear what happened to the telemetry strips for Patient #1 during the cardiac rhythm change and code blue.