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UPMC PRESBYTERIAN SHADYSIDE 200 LOTHROP STREET PITTSBURGH, PA 15213 July 18, 2019
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of Facility documentation, medical records (MR), and staff interview(s) (EMP) it was determined the facility failed to initiate an order for cardiac monitoring and failed to supervise the patient's care to ensure the patient's cardiac status was being monitored at all times for 1 of 10 medical records reviewed (MR1), and the facility failed to ensure frequent assessments for cardiac rhythms were completed in accordance with facility policy for 11 of 11 medical records reviewed (MR1 - MR11).
Findings include.
1) Policy review on 7/3/19 revealed " ...Policy Title: Cardiac and Physiologic Monitoring ...Policy number: PC01 ...Last Review Date: January 15, 2019 ...POLICY ...Monitoring is the responsibility of trained personnel who have successfully completed the UPMC Basic Arrhythmia Course or challenge exam in rhythm recognition and/or hemodynamic monitoring where applicable ...PROCEDURE ...1. On admission to the designated area, the patient who is ordered cardiac rhythm monitoring will be connected to the bedside monitor and/or telemetry, as it is appropriate to unit monitoring system ...6. Document cardiac rhythm interpretation in eRecord twice daily ...8. Remember the 5 C ' s of Cardiac Monitoring Safety: a. Check the patient. b. Check and replace electrodes every 24 hours. C. Check the lead set connection to the telemetry pack ...d. Check to see that there is a good rhythm tracing on the telemetry pack screen and at the Central Station Monitor or hallway Overview Monitor. E. Clear Alarm: Do not clear alarm until all above checks are completed. 9. Alarms are to be set and maintained throughout monitoring ...10. Alarm volumes are to be set at levels that enable personnel to audibly detect the alarm ...12. Alarms should be reviewed at least every shift or more frequently based on the patient ' s condition ... "

2) Review of MR1 revealed patient was admitted to the facility on on [DATE] at approximately 9:52 AM with a chief complaint of a fall and diagnoses that included coronary artery disease.
3) Review of physician orders for MR1 revealed an order for cardiac monitor was written on May 24, 2019, at 3:22 PM.
4) Review of MR1 cardiac monitor log revealed that cardiac monitoring activity did not commence until May 25, 2019, at 7:45 AM.
5) During interview with on July 3, 2019 at approximately 10:45 AM EMP2 confirmed the above findings and revealed " ...the monitor was previously ordered but was not on at shift change .... "
6) A subsequent review of MR1's cardiac monitor log post implementation of the physician's order for cardiac monitor revealed an action was generated on May 25, 2019, at 11:32 AM that indicated "Leasdset Unplugged Generated at 11:32:20."
8) Further review of MR1's cardiac monitor log revealed no action was generated that indicated facility staff responded to the alarm generated by the action that indicated the patient was not actively being monitored due to the patient's Leadset being unplugged.
8) Further review of MR1 revealed patient was observed on May 25, 2019, at approximately 3:52 PM in bed breathless and pulseless and no alarm was triggered to alert staff MR1 had an acute event that required an emergent response.
9) Review of eleven medical records 7/2/19 and 7/3/19 revealed cardiac rhythm interpretation not documented 2 times daily per facility policy in the medical records under the " Frequent Assessment ...Cardiac Rhythm ... " section of the electronic medical record for the following telemetry patient records reviewed:
MR1, admitted [DATE] revealed:
5/24/19, No documented evidence of cardiac rhythm assessment completed.
5/25/19, No documented evidence of cardiac rhythm assessment completed.
MR2 admitted [DATE] revealed:
7/1/19, One cardiac rhythm assessment completed at 8:45 AM.
MR3 admitted [DATE] revealed:
6/22/19, One cardiac rhythm assessment completed at 8:30 PM.
6/23/19, One cardiac rhythm assessment completed at 7:59 PM.
6/26/19, One cardiac rhythm assessment completed at 9:15 PM.
6/27/19, One cardiac rhythm assessment completed at 7:07 PM.
6/28/19, One cardiac rhythm assessment completed at 7:00 PM.
7/2/19, One cardiac rhythm assessment completed at 6:36 PM.
MR4, admitted [DATE] revealed:
7/2/19, One cardiac rhythm assessment completed at 5:45 PM.
MR5, admitted [DATE] revealed:
6/7/19, One cardiac rhythm assessment completed at 10:00 AM.
6/29/19, One cardiac rhythm assessment completed at 8:00 AM.
MR6, admitted [DATE] revealed:
7/2/19, One cardiac rhythm assessment completed at 9:26 AM.
MR7, admitted [DATE] revealed:
6/13/19, One cardiac rhythm assessment completed at 6:05 AM.
6/15/19, One cardiac rhythm assessment completed at 8:37 PM.
6/16/19, One cardiac rhythm assessment completed at 8:12 PM.
6/18/19, One cardiac rhythm assessment completed at 8:24 AM.
6/19/19, One cardiac rhythm assessment completed at 8:31 AM.
6/20/19, One cardiac rhythm assessment completed at 8:00 AM.
6/28/19, One cardiac rhythm assessment completed at 9:00 AM.
6/30/19, One cardiac rhythm assessment completed at 7:00 AM.
7/1/19, No documented evidence of cardiac rhythm assessment completed.
MR8, admitted [DATE] revealed:
7/2/19, One cardiac rhythm assessment completed at 6:30 PM.
MR9, admitted [DATE] revealed:
6/28/19, One cardiac rhythm assessment completed at 8:00 AM.
7/1/19, One cardiac rhythm assessment completed at 9:00 PM.
MR10, admitted [DATE] revealed:
7/2/19, One cardiac rhythm assessment completed at 6:30 PM.
MR11, admitted [DATE] revealed:
6/28/19, One cardiac rhythm assessment completed at 11:45 AM.
6/30/19, No documented evidence of cardiac rhythm assessment completed.

During interview with on July 3, 2019 at approximately 10:45 AM EMP2 reported patient cardiac rhythm strips print out daily for monitored patients at 6:00 AM and 6:00 PM and may be printed manually as needed for nursing assessment/interpretation and documentation into the medical record.

During interview on July 9, 2019 at approximately 9:30 AM, EMP3 and EMP4 confirmed the above findings based on a review of the MR1 and MR1's cardiac monitor log.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to administer drugs and biologicals according to the orders of a practioner for one of three medical records reviewed (MR13).

Findings include:

Review of facility policy, "Venipuncture," revised May 18, 2018, revealed, "... Implementation: Verify the practitioner's order. ..."

Review of MR13 revealed a physician order for vancomycin trough on June 17, 2019 at 3:21 pm. Further review of MR13 revealed a vancomycin trough was not drawn on June 17, 2019.

Further review of MR13 Pharmacy documentation dated June 19, 2019 at 1:18PM, revealed, "Current regimen yielded a supratherapeutic trough of 34.6 yesterday, the trough results were delayed until this morning 6/19, therefore patient already received 2 more doses. Repeat trough today, 6/19, was also supratherapeutic at 43.5. AKI (Acute Kidney Injury)noted ..."

Review of MR13 Nephrology Consult dated June 20, 2019, revealed, "This patient has no known history of kidney disease. On admission his renal function was normal. Now in nonoliguric acute renal failure. Dosing and blood levels are consistent with vancomycin nephrotoxicity."

Emp 6 confirmed the above findings on July 9, 2019 at 10:30 am.