HospitalInspections.org

Based on policy review, staff interview, job description review, observation, staff roster review, personnel file review, medical record review, staffing sheet review, physician interview, Staff Meeting Minutes review, and Charge Nurse Meeting Minutes review, the Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights, an effective quality assessment and performance improvement program, and an organized nursing service to ensure the safety of patients.

The findings include:

1. The hospital failed to protect and promote patients' rights by failing to ensure a safe environment for the delivery of care to patients on cardiac telemetry monitors.

~cross refer to 482.13 Patient Rights' Condition: Tag A0115

2. The hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients on cardiac telemetry monitors.

~cross refer to 482.21 QAPI Condition: Tag A0263

3. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care, ensure qualified and competent staff continuously supervised cardiac telemetry monitors, and ensure nursing staff identified a patient per policy prior to the administration of medications.

~cross refer to 482.23 Nursing Services Condition: Tag A0385

Based on policy review, staff interview, job description review, observation, staff roster review, personnel file review, medical record review, staffing sheet review, and physician interview, the hospital failed to protect and promote patients' rights by failing to ensure a safe environment for the delivery of care to patients on cardiac telemetry monitors.

The findings include:

The hospital failed to ensure a safe environment for the delivery of care to patients on cardiac telemetry monitors by failing to ensure qualified and competent staff continuously supervised the cardiac telemetry monitors and failing to ensure staff immediately responded when cardiac monitor warning alarms activated due to the absence of cardiac activity for 1 of 9 sampled patients on a cardiac monitor.

~cross refer to 482.13(c)(2) Patients' Rights Standard: Tag A0144

Based on staff interview, medical record review, Staff Meeting Minutes review, and Charge Nurse Meeting Minutes review, the hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients on cardiac telemetry monitors.

The findings include:

1. The hospital failed to implement actions to ensure staff immediately evaluated and assessed patients when cardiac telemetry monitor alarms activated and warned of the absence of cardiac activity.

~cross refer to 482.21(c)(2) QAPI Standard: Tag A0288

Based on hospital policy review, staff interview, job description review, medical record review, staffing sheet review, physician interview, observation, and personnel file review, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care, ensure qualified and competent staff continuously supervised cardiac telemetry monitors, and ensure nursing staff identified a patient per policy prior to the administration of medications.

The findings include:

1. The hospital's nursing staff failed to supervise and evaluate patient care by failing to immediately evaluate and assess a patient when cardiac monitor warning alarms activated due to the absence of cardiac activity for 1 of 9 sampled patients on a cardiac monitor.

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

2. The hospital failed to ensure qualified and competent staff continuously supervised cardiac telemetry monitors for 7 of 7 staff that supervised cardiac telemetry monitors.

~cross refer to 482.23 (b)(5) Nursing Services Standard: Tag A0397

3. The hospital failed to ensure nursing staff identified a patient per policy prior to the administration of medications for 1 of 2 observed medication passes.

~cross refer to 482.23 (c)(1) Nursing Services Standard: Tag A0405

Based on policy review, staff interview, job description review, observation, staff roster review, personnel file review, medical record review, staffing sheet review, and physician interview, the hospital failed to ensure a safe environment for the delivery of care to patients on cardiac telemetry monitors by failing to ensure qualified and competent staff continuously supervised the cardiac telemetry monitors and failing to ensure staff immediately responded when cardiac monitor warning alarms activated due to the absence of cardiac activity for 1 of 9 sampled patients on a cardiac monitor (Patient #11).

The findings include:

Review of hospital policy, "Continuous Cardiac Monitoring (Telemetry)", revised 05/2010, revealed "It is the policy of XX hospital to ensure that cardiac monitoring is: ...2)once initiated, surveillance is consistently maintained by qualified staff; and 3) management of clinical changes related to cardiac monitoring, including response to emergencies by the interdisciplinary care team are consistent and timely. ...STAFF ORIENTATION, COMPETENCY REQUIREMENTS, AND COMPETENCY VALIDATION... 1. b. Cardiac Rhythm interpretation...If utilized, monitor technicians are required to satisfactorily complete a cardiac rhythm interpretation course and pass a written cardiac rhythm interpretation test administered by the education department of XX hospital c. Competency must be demonstrated and documented within 90 days of initial hiring and annually thereafter. Telemetry technicians will not be allowed to monitor rhythms without the presence of another competent staff member until competency has been validated. d. All documentation related to orientation and competency validation will be maintained in the employee's education and human resource file...."

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed the unit secretaries (US) monitor the cardiac telemetry monitors. Interview further revealed, "The unit secretaries should know what lethal cardiac rhythms are, like v-tach (ventricular tachycardia), v-fib (ventricular fibrillation) and asystole (absence of cardiac activity). The alarm is audible and the light flashes on the monitor. The rhythm strip also prints automatically when there's a problem." Interview revealed the rhythm strip automatically begins to print whenever a lethal cardiac rhythm or asystole is detected. Interview revealed the secretary should alert the patient's nurse when a lethal cardiac rhythm or asystole is detected on the cardiac monitor and the nurse should immediately evaluate and assess the patient.

Review of the hospital's job description for a Unit Secretary (US), revised 03/01/2006 revealed "JOB SUMMARY Under the supervision of the Nurse Manager and/or Director of Clinical Services, assists in planning, organizing, implementing and evaluating the activities occurring in the nursing station by performing clerical and receptionist duties and maintaining the physical environment of the area...". Review of the job description revealed no evidence that the Unit Secretary's "Essential Job Functions" included monitoring cardiac telemetry monitors. Review of the job description revealed no documented evidence that the Unit Secretary's "Abilities Required" included cardiac telemetry monitor competency.

Observation of the facility on 08/24/2010 at 1305 revealed a centralized nursing station with telemetry monitors at the far left of the desk. Observation revealed a cardiac telemetry monitor with channels to monitor 16 patients. Observation revealed Unit Secretary (US) #7 was stationed in chair at the desk in front of the cardiac telemetry monitor. Observation and interview with US #7 revealed 11 patients were currently being monitored. Observation and demonstration by US #7 revealed the monitors were connected to a printer at the monitors. Observation and interview with US #7 further revealed 2 portable monitors, plugged into the wall and covered with plastic across from the nursing station. Interview with US #7 revealed these monitors were used for critical monitoring of "sicker patients" and monitored blood pressure and oxygen saturation in addition to cardiac rhythm. Interview revealed when these monitors were used, they also were viewed on one of the channels at the nursing station. Observation revealed a green plug on the back of the monitors that enables the audible alarms to sound at the nursing station. Observation revealed the monitor alarms were audible. Interview with US #7 revealed, "We are not allowed to lower the volume or to disconnect the green plug. We also can't change anything set on the monitors." Observation further revealed no monitor screens in any of the patient rooms. Interview with the charge nurse during the observation revealed all cardiac monitoring was done remotely at the nursing station. Further interview with the charge nurse revealed the unit secretary was assigned to watch the monitor screens and alert the nurse to alarms each shift.

Observation of the nursing station desk on 08/24/2010 at 1330 revealed the monitors were being watched by the receptionist (US #6). Interview with the receptionist during the observation revealed "I'm relieving the unit secretary for lunch. I use to be a unit secretary so I've been trained on the monitors."

Review of staff roster revealed 6 Unit Secretaries (including US #6 - the receptionist, US# 2, US #3, US #4, US #5, and US #7) were currently employed at the hospital. Reviews of personnel files for all 6 of the Unit Secretaries currently employed revealed no documented evidence of a competency validation for cardiac telemetry monitoring or a written cardiac rhythm interpretation test.

Interview on 08/24/2010 at 1700 with the clinical educator confirmed there was no competency validation and no written cardiac rhythm interpretation test for the Unit Secretaries. Interview revealed, "The only training I've given the unit secretaries was a one hour class."

Review of the hospital's policy, "Assessment and Reassessment", revised 05/2010, revealed "...Nursing...B. Reassessment...Additional reassessment will also be conducted and documented in the following circumstances: a) With any change in medical condition or status b) Code Blue (cardiac/respiratory life-threatening emergency)...."

Closed medical record review of Patient #11 revealed an 80 year-old female admitted on 05/20/2010 from a local community hospital with respiratory failure, status post tracheostomy (airway provided via a tube in the trachea), chronic atrial fibrillation (cardiac arrhythmia), coronary artery disease (heart disease), clostridium difficile colitis (inflammation of the colon), chronic pleural effusion (accumulation of fluid in the lining of the lungs and chest cavity) and severe protein malnutrition. Review of the physician's History and Physical dated 05/20/2010 revealed the patient was alert and oriented on admission. Record review revealed the patient was on a continuous cardiac telemetry monitor. Review of the Patient Care Flow Sheet dated 05/24/2010 at 0730 revealed the patient was alert and oriented with no distress noted. Further record review revealed a cardiac rhythm strip printed on 05/24/2010 at 2034. Review of the cardiac rhythm strip at 2034 revealed "Event: Asystole" automatically printed in the left upper corner of the strip. Further review of the cardiac rhythm strips revealed a strip dated 05/24/2010 at 2051 also noted "Event: Asystole". Record review revealed the first available documentation that staff responded to the patient after the monitor alarmed and showed "asystole" was at 2052 (18 minutes after the printed cardiac rhythm strip first indicated asystole), when the nurse noted the patient had no heart rate or blood pressure. Review of the Hospital Code Report Flowsheet dated 05/24/2010 revealed "Time of Arrest 2052". Further review of the Code Flowsheet revealed chest compressions, mechanical ventilations, and cardiac drugs (Epinephrine and Dopamine) were started at 2052. Review of the Code Flowsheet revealed the first documentation the patient had a heart rate was at 2100 (8 minutes after Code started and 26 minutes after the printed cardiac rhythm strip first indicated asystole). Review of RN #1's notes dated 05/24/2010 at 2052 revealed, "Pt (patient) found unresponsive 0 pulse 0 resp (respirations) pupils fixed and dilated...2115 family @ bedside requested...pt to be full code...." Record review revealed at 2109 the patient was placed on a mechanical ventilator (artificial life support). Further review of the record revealed the patient remained unresponsive and on the ventilator until her death on 06/04/2010, after the family requested the patient be removed from life support and signed for a "Do Not Resuscitate" form.

Review of the staffing sheet for 05/24/2010 revealed RN #2 (Registered Nurse) was the assigned charge nurse, RN #1 was assigned to Patient #11, CNA #1 (Certified Nursing Assistant) was assigned to Patient #11, and the Unit Secretary from 1500 until 2300 was Unit Secretary #7.

Interview on 08/26/2010 at 0830 with CNA #1 revealed the CNA was assigned to Patient #11 on 05/24/2010 beginning at 1900. Interview revealed, "I check on my patients every 30 minutes. I was making my rounds and went into her room. Her face looked pale and I knew something was wrong. She was in room 2 so I called for help. The nurses came in then and started working on her."

Interview on 08/25/2010 at 1650 via telephone with RN #1 revealed the nurse was Patient #11's assigned primary nurse on 05/24/2010 beginning at 1900. Interview revealed the RN remembered Patient #11 and was at the desk charting when she heard a call for help. Interview revealed, "I didn't hear any alarms and the secretary didn't tell me about an alarm. I reviewed her (Patient #11's) strips after the code and I couldn't understand why the time difference in the monitor strip and when she was found....I remember a secretary being at the desk too, but she didn't tell me about the alarm or the strip printing." Interview further revealed, "I told (the Nurse Manager) about it the next day....I think (US #1) was unplugging the audible alarms from the monitors. She worked that day (day shift). I feel better about the monitoring now that they fired her."

Interview on 08/25/2010 at 1525 with RN #2 revealed the RN was the charge nurse on 05/24/2010 beginning at 1900. Interview revealed, "When (Pt #11) coded, I was in Room 7033 starting an IV. I heard someone say get the Code cart. When I got in there, she was unresponsive. The next day (the Nurse Manager) asked me about her going asystole at 8:30. He had found the strip. I told him I didn't hear an alarm and the unit secretary had not called me for help before I heard (CNA #1) call for help....The secretary (US #7) told me she told (RN #1) about the asystole. (RN #1) said she didn't (tell her)." Interview further revealed, "The rhythm strip automatically prints when it detects a lethal rhythm. I should have been called." Interview confirmed that the cardiac rhythm strip printed at 2034 warning of asystole and the Code Blue was not initiated until 2052 (18 minutes later).

Interview on 08/26/2010 at 0850 with US #7 revealed "I don't remember (Patient #11). We are supposed to notify the nurse that is assigned to the patient immediately when we hear a beep go off on the monitors. We are to look at the monitor and if we hear a beep, we're supposed to call the nurse and tell her what we see and what the strip says. If the nurse doesn't respond in 2 to 5 minutes, we are supposed to notify the charge nurse." Interview further revealed, "I don't remember this Code". Interview further revealed that US #7 has had no discussion with anyone in the facility about the 18 minute gap between the time the rhythm strip showed asystole for Patient #11 and the time the patient was found by the nursing assistant to be unresponsive.

Interview on 08/25/2010 at 1410 with Physician #1 revealed he was Patient #11's physician. Interview revealed, "I saw her before I left that evening, sometime between 6 and 7 (pm). She was alert and oriented and showed no signs of distress....I was shocked when they called me that she was coding....The next morning I reviewed the record and saw the cardiac rhythm strips. I was mad. I brought down the roof....I talked to (name of director of clinical services) about this....I was so upset....I looked at the strip and it didn't make sense. It was flat-lined way before they found her unresponsive. I wondered what happened during that time." Interview further revealed, "She was unresponsive after this. She suffered severe brain injury because of no oxygen to the brain for 18 minutes. Yes, she was injured....The family did not request an autopsy so I don't know exactly what happened. I just know that she was severely injured due to lack of oxygen to the brain.

Interview on 08/26/2010 at 0845 with the Nurse Manager revealed, "I was made aware of the 18 minute gap on June 3 (10 days after the incident involving Patient #11)....I talked with (RN #1) and she said she didn't hear an alarm when Patient #11 coded." Further interview revealed nursing staff should immediately respond to any lethal cardiac arrhythmia or asystole. Interview confirmed the cardiac monitor continuously printed strips, indicating the monitor alarmed, that showed asystole (absence of cardiac activity) for Patient #11 on 05/24/2010 from 2034 until 2052, when nursing staff responded and assessed the patient and the Code was initiated. Interview confirmed the record showed the patient was in asystole for 18 minutes before nursing staff responded to and assessed the patient. Further interview revealed, "We realized on June 1 that somebody was tampering with the audible alarm plug. I didn't check the plug until June 3 and they were not unplugged at that time." Interview revealed staff reported to the Manager they had seen Unit Secretary (US) #1 unplug the monitor alarm cables on occasion, so that the monitor alarms were not audible. Interview revealed the Manager checked the schedule for 05/24/2010 and found that US #1 had worked during the dayshift. Interview revealed the Manager closely observed US #1 and on 06/13/2010 "we caught her unplugging the cables and fired her". Further interview revealed US #7 was on duty and monitored the cardiac telemetry monitors on 05/24/2010 at 2034, when the monitor alarmed and showed that Patient #11 was in asystole. Interview revealed the monitor still alarmed visually (flashed on the screen) even when it was muted or the cable was unplugged. Interview revealed US #7 had not been counseled regarding the incident.

Based on hospital policy review, staff interview, job description review, medical record review, staffing sheet review, and physician interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to immediately evaluate and assess a patient when cardiac monitor warning alarms activated due to the absence of cardiac activity for 1 of 9 sampled patients on a cardiac monitor (#11).

The findings include:

Review of the hospital's policy, "Continuous Cardiac Monitoring (Telemetry)", revised 05/2010, revealed "...It is the policy of XX hospital to ensure that cardiac monitoring is: ...2)once initiated, surveillance is consistently maintained by qualified staff; and 3) management of clinical changes related to cardiac monitoring, including response to emergencies by the interdisciplinary care team are consistent and timely...."

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed the unit secretaries (US) monitor the cardiac telemetry monitors. Interview further revealed, "The unit secretaries should know what lethal cardiac rhythms are, like v-tach (ventricular tachycardia), v-fib (ventricular fibrillation) and asystole (absence of cardiac activity). The alarm is audible and the light flashes on the monitor. The rhythm strip also prints automatically when there's a problem." Interview revealed the rhythm strip automatically begins to print whenever a lethal cardiac rhythm or asystole is detected. Interview revealed the secretary should alert the patient's nurse when a lethal cardiac rhythm or asystole is detected on the cardiac monitor and the nurse should immediately evaluate and assess the patient.

Review of the hospital's policy, "Assessment and Reassessment", revised 05/2010, revealed "...Nursing...B. Reassessment...Additional reassessment will also be conducted and documented in the following circumstances: a) With any change in medical condition or status b) Code Blue (cardiac/respiratory life-threatening emergency)...."

Review of the hospital's job description for a Registered Nurse (RN), revised 11/2008, revealed "...JOB SUMMARY...He/She is responsible for the overall direction and supervision of all patient care during his/her shift....SUMMARY OF ESSENTIAL JOB FUNCTIONS...Assess patient's condition...Implement patient care...Knowledge of emergency...procedures...."

Review of the hospital's job description for a Charge Nurse, revised 03/01/2006, revealed "...JOB SUMMARY...Responsible for the overall direction and supervision of all nursing department personnel during his/her shift...."

Closed medical record review of Patient #11 revealed an 80 year-old female admitted on 05/20/2010 from a local community hospital with respiratory failure, status post tracheostomy (airway provided via a tube in the trachea), chronic atrial fibrillation (cardiac arrhythmia), coronary artery disease (heart disease), clostridium difficile colitis (inflammation of the colon), chronic pleural effusion (accumulation of fluid in the lining of the lungs and chest cavity) and severe protein malnutrition. Review of the physician's History and Physical dated 05/20/2010 revealed the patient was alert and oriented on admission. Record review revealed the patient was on a continuous cardiac telemetry monitor. Review of the Patient Care Flow Sheet dated 05/24/2010 at 0730 revealed the patient was alert and oriented with no distress noted. Further record review revealed a cardiac rhythm strip printed on 05/24/2010 at 2034. Review of the cardiac rhythm strip at 2034 revealed "Event: Asystole" automatically printed in the left upper corner of the strip. Further review of the cardiac rhythm strips revealed a strip dated 05/24/2010 at 2051 also noted "Event: Asystole". Record review revealed the first available documentation that the nurse assessed the patient after the monitor alarmed and showed "asystole" was at 2052 (18 minutes after the printed cardiac rhythm strip first indicated asystole), when the nurse noted the patient had no heart rate or blood pressure. Review of the Hospital Code Report Flowsheet dated 05/24/2010 revealed "Time of Arrest 2052". Further review of the Code Flowsheet revealed chest compressions, mechanical ventilations, and cardiac drugs (Epinephrine and Dopamine) were started at 2052. Review of the Code Flowsheet revealed the first documentation the patient had a heart rate was at 2100 (8 minutes after Code started and 26 minutes after the printed cardiac rhythm strip first indicated asystole). Review of RN #1's notes dated 05/24/2010 at 2052 revealed, "Pt (patient) found unresponsive 0 pulse 0 resp (respirations) pupils fixed and dilated...2115 family @ bedside requested...pt to be full code...." Record review revealed at 2109 the patient was placed on a mechanical ventilator (artificial life support). Further review of the record revealed the patient remained unresponsive and on the ventilator until her death on 06/04/2010, after the family requested the patient be removed from life support and signed for a "Do Not Resuscitate" form.

Review of the staffing sheet for 05/24/2010 revealed RN #2 was the assigned charge nurse, RN #1 was assigned to Patient #11, CNA #1 (Certified Nursing Assistant) was assigned to Patient #11, and the Unit Secretary from 1500 until 2300 was Unit Secretary #7.

Interview on 08/26/2010 at 0830 with CNA #1 revealed the CNA was assigned to Patient #11 on 05/24/2010 beginning at 1900. Interview revealed, "I check on my patients every 30 minutes. I was making my rounds and went into her room. Her face looked pale and I knew something was wrong. She was in room 2 so I called for help. The nurses came in then and started working on her."

Interview on 08/25/2010 at 1650 via telephone with RN #1 revealed the nurse was Patient #11's assigned primary nurse on 05/24/2010 beginning at 1900. Interview revealed the RN remembered Patient #11 and was at the desk charting when she heard a call for help. Interview revealed, "I didn't hear any alarms and the secretary didn't tell me about an alarm. I reviewed her (Patient #11's) strips after the code and I couldn't understand why the time difference in the monitor strip and when she was found....I remember a secretary being at the desk too, but she didn't tell me about the alarm or the strip printing." Interview further revealed, "I told (the Nurse Manager) about it the next day....I think (US #1) was unplugging the audible alarms from the monitors. She worked that day (day shift). I feel better about the monitoring now that they fired her."

Interview on 08/25/2010 at 1525 with RN #2 revealed the RN was the charge nurse on 05/24/2010 beginning at 1900. Interview revealed, "When (Pt #11) coded, I was in Room 7033 starting an IV. I heard someone say get the Code cart. When I got in there, she was unresponsive. The next day (the Nurse Manager) asked me about her going asystole at 8:30. He had found the strip. I told him I didn't hear an alarm and the unit secretary had not called me for help before I heard (CNA #1) call for help....The secretary (US #7) told me she told (RN #1) about the asystole. (RN #1) said she didn't (tell her)." Interview further revealed, "The rhythm strip automatically prints when it detects a lethal rhythm. I should have been called." Interview confirmed that the cardiac rhythm strip printed at 2034 warning of asystole and the Code Blue was not initiated until 2052 (18 minutes later).

Interview on 08/26/2010 at 0850 with US #7 revealed "I don't remember (Patient #11). We are supposed to notify the nurse that is assigned to the patient immediately when we hear a beep go off on the monitors. We are to look at the monitor and if we hear a beep, we're supposed to call the nurse and tell her what we see and what the strip says. If the nurse doesn't respond in 2 to 5 minutes, we are supposed to notify the charge nurse." Interview further revealed, "I don't remember this Code". Interview further revealed that US #7 has had no discussion with anyone in the facility about the 18 minute gap between the time the rhythm strip showed asystole for Patient #11 and the time the patient was found by the nursing assistant to be unresponsive.

Interview on 08/25/2010 at 1410 with Physician #1 revealed he was Patient #11's physician. Interview revealed, "I saw her before I left that evening, sometime between 6 and 7 (pm). She was alert and oriented and showed no signs of distress....I was shocked when they called me that she was coding....The next morning I reviewed the record and saw the cardiac rhythm strips. I was mad. I brought down the roof....I talked to (name of director of clinical services) about this....I was so upset....I looked at the strip and it didn't make sense. It was flat-lined way before they found her unresponsive. I wondered what happened during that time." Interview further revealed, "She was unresponsive after this. She suffered severe brain injury because of no oxygen to the brain for 18 minutes. Yes, she was injured....The family did not request an autopsy so I don't know exactly what happened. I just know that she was severely injured due to lack of oxygen to the brain."

Interview on 08/26/2010 at 0845 with the Nurse Manager revealed, "I was made aware of the 18 minute gap on June 3 (10 days after the incident involving Patient #11)....I talked with (RN #1) and she said she didn't hear an alarm when Patient #11 coded." Further interview revealed nursing staff should immediately respond to any lethal cardiac arrhythmia or asystole. Interview confirmed the cardiac monitor continuously printed strips, indicating the monitor alarmed, that showed asystole (absence of cardiac activity) for Patient #11 on 05/24/2010 from 2034 until 2052, when nursing staff responded and assessed the patient and the Code was initiated. Interview confirmed the record showed the patient was in asystole for 18 minutes before nursing staff assessed the patient. Further interview revealed, "We realized on June 1 that somebody was tampering with the audible alarm plug. I didn't check the plug until June 3 and they were not unplugged at that time." Interview revealed staff reported to the Manager they had seen Unit Secretary (US) #1 unplug the monitor alarm cables on occasion, so that the monitor alarms were not audible. Interview revealed the Manager checked the schedule for 05/24/2010 and found that US #1 had worked during the dayshift. Interview revealed the Manager closely observed US #1 and on 06/13/2010 "we caught her unplugging the cables and fired her". Further interview revealed US #7 was on duty and monitored the cardiac telemetry monitors on 05/24/2010 at 2034, when the monitor alarmed and showed that Patient #11 was in asystole. Interview revealed the monitor still alarmed visually (flashed on the screen) even when it was muted or the cable was unplugged. Interview revealed US #7 had not been counseled regarding the incident.

Based on policy review, job description review, staff interview, observation, and personnel file review, the hospital failed to ensure qualified and competent staff continuously supervised cardiac telemetry monitors for 7 of 7 staff that supervised cardiac telemetry monitors (Unit Secretary #7, #6, #1, #2, #4, #3, and #5.

The findings include:

Review of hospital policy, "Continuous Cardiac Monitoring (Telemetry)", revised 05/2010, revealed "...STAFF ORIENTATION, COMPETENCY REQUIREMENTS, AND COMPETENCY VALIDATION... 1....b. Cardiac Rhythm interpretation...If utilized, monitor technicians are required to satisfactorily complete a cardiac rhythm interpretation course and pass a written cardiac rhythm interpretation test administered by the education department of XX hospital. c. Competency must be demonstrated and documented within 90 days of initial hiring and annually thereafter. Telemetry technicians will not be allowed to monitor rhythms without the presence of another competent staff member until competency has been validated. d. All documentation related to orientation and competency validation will be maintained in the employee's education and human resource file...."

Review of the hospital's job description for a Unit Secretary (US), revised 03/01/2006 revealed "JOB SUMMARY Under the supervision of the Nurse Manager and/or Director of Clinical Services, assists in planning, organizing, implementing and evaluating the activities occurring in the nursing station by performing clerical and receptionist duties and maintaining the physical environment of the area...." Review of the job description revealed no evidence that the Unit Secretary's "Essential Job Functions" included monitoring cardiac telemetry monitors. Review of the job description revealed no documented evidence that the Unit Secretary's "Abilities Required" included cardiac telemetry monitor competency.

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed the unit secretaries monitor the cardiac telemetry monitors. Interview further revealed, "The unit secretaries should know what lethal cardiac rhythms are, like v-tach (ventricular tachycardia), v-fib (ventricular fibrillation) and asystole (absence of cardiac activity). The alarm is audible and the light flashes on the monitor. The rhythm strip also prints automatically when there's a problem." Interview revealed the rhythm strip automatically begins to print whenever a lethal cardiac rhythm or asystole is detected. Interview further revealed, "They should notify the nurse when an alarm goes off."

Interview on 08/24/2010 at 1700 with the clinical educator revealed a class was held for the unit secretaries on 02/19/2010. Interview further revealed, "The unit secretaries have no clinical background." Interview further revealed the class was a 1 hour class and no post-test was given. Interview further revealed, "I did not feel they were competent to interpret cardiac monitors after this class. I discussed this with (the Director of Clinical Services) and his response was 'I want them trained'. I told him they were not competent to read rhythms and he said again, 'I want them trained'. I have had multiple discussions with him about this. They started watching the monitors on February 20th, the day after the class. Before that, the nurses were responsible for watching their patients' monitors".

1. Observation of nursing station desk on 08/24/2010 at 1305 revealed a centralized nursing station with telemetry monitors at the far left of the desk. Observation revealed US #7 was stationed in chair at the desk in front of the cardiac telemetry monitor. Observation revealed the continuous cardiac tracings of 11 patients were visible on the monitor screen.

Further observation of nursing station desk on 08/25/2010 at 0920 revealed US #7 was stationed in chair at the desk in front of the cardiac telemetry monitor. Observation revealed the continuous cardiac tracings of 10 patients were visible on the monitor screen. Interview with US #7 during the observation revealed the secretary was watching the monitor tracings and was supposed to notify the nurse if the monitor alarmed and showed asystole, ventricular tachycardia, or ventricular fibrillation. Observation revealed no other staff were watching the monitors.

Review of the personnel file for US #7 revealed a hire date of 05/09/2008. File review revealed the secretary was also a certified nursing assistant. File review revealed the secretary attended the "Telemetry Alarm Safety" class on 02/19/2010. File review revealed no documented evidence of a competency validation for cardiac telemetry monitoring or a written cardiac rhythm interpretation test.

Interview on 08/24/2010 at 1700 with the clinical educator confirmed there was no competency validation and no written cardiac rhythm interpretation test for US #7. Interview revealed, "The only training I've given the unit secretaries was a one hour class."

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed, "We are not following our policy for who can monitor the cardiac telemetry monitors."

Interview on 08/26/2010 at 0845 with the Nurse Manager revealed there had been an incident on 05/24/2010 at 2034 when asystole (absence of cardiac activity) showed on Patient #11's cardiac monitor strip and nursing staff did not respond and assess the patient until 2052 (18 minutes later). Interview revealed, "I talked with (the nurse - RN #1) and she said she didn't hear an alarm when Patient #11 coded." Interview revealed the cardiac monitor continuously printed strips, indicating the monitor alarmed, that showed asystole for Patient #11 on 05/24/2010 from 2034 until 2052, when nursing staff responded and assessed the patient and the Code was initiated. Further interview revealed US #7 was on duty and assigned to monitor the cardiac telemetry monitors on 05/24/2010 at 2034, when the monitor alarmed and showed that Patient #11 was in asystole. Interview revealed US #7 had not been counseled regarding the incident.

Interview on 08/26/2010 at 0850 with US#7 revealed, "I have had a 1 hour class. That training is not adequate." Further interview revealed when the secretary arrived to work on the morning of 08/26/2010 there was a nurse assigned to watch the monitors at the desk. Interview revealed, "I was happy and relieved this morning when I was told the nurses would be watching the monitors now."

2. Observation of the nursing station desk on 08/24/2010 at 1330 revealed the monitors were being watched by the receptionist (US #6). Interview with the receptionist during the observation revealed "I'm relieving the unit secretary for lunch. I use to be a unit secretary so I've been trained on the monitors."

Review of the personnel file for the receptionist (US #6) revealed a hire date of 04/06/2009. File review revealed the secretary attended the "Telemetry Alarm Safety" class on 03/05/2010. File review revealed no documented evidence of a competency validation for cardiac telemetry monitoring or a written cardiac rhythm interpretation test.

Interview on 08/24/2010 at 1700 with the clinical educator confirmed there was no competency validation and no written cardiac rhythm interpretation test for US #6. Interview revealed, "The only training I've given the unit secretaries was a one hour class."

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed, "We are not following our policy for who can monitor the cardiac telemetry monitors."

3. Review of the personnel file for US #1 revealed a hire date of 07/2006. File review revealed no documented evidence of a competency validation for cardiac telemetry monitoring or a written cardiac rhythm interpretation test. File review further revealed a disciplinary action record dated 06/16/2010 "failed to monitor the telemetry equipment on 06/13/2010, Terminated 06/16/2010".

Interview on 08/24/2010 at 1700 with the clinical educator confirmed there was no competency validation and no written cardiac rhythm interpretation test for US #1. Interview revealed, "The only training I've given the unit secretaries was a one hour class."

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed, "We are not following our policy for who can monitor the cardiac telemetry monitors."

Interview on 08/26/2010 at 0845 with the Nurse Manager revealed staff reported to the Manager they had seen Unit Secretary (US) #1 unplug the monitor alarm cables on occasion, so that the monitor alarms were not audible. Interview revealed the Manager checked the schedule for 05/24/2010 and found that US #1 had worked during the dayshift. Interview revealed the Manager closely observed US #1 and on 06/13/2010 "we caught her unplugging the cables and fired her".

4. Review of the personnel file for US #2 revealed a hire date of 12/05/2005. File review revealed the secretary was also a certified nursing assistant. File review revealed the secretary attended the "Telemetry Alarm Safety" class on 02/19/2010. File review revealed no documented evidence of a competency validation for cardiac telemetry monitoring or a written cardiac rhythm interpretation test.

Interview on 08/24/2010 at 1700 with the clinical educator confirmed there was no competency validation and no written cardiac rhythm interpretation test for US #2. Interview revealed, "The only training I've given the unit secretaries was a one hour class."

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed, "We are not following our policy for who can monitor the cardiac telemetry monitors."

Interview on 08/24/2010 at 1720 with US #2 revealed, "I've been looking after the monitors for a year and a half. I have been told to notify the nurses if the alarm sounded and if the heart rate was less than 50 and greater than 100, no 80." Interview further revealed, "We didn't have any classes until Spring of this year. I think something happened with patient care so they decided to have a class....I would like to know exactly what I'm looking at it." Further interview revealed US #2 did not think that she was competent to supervise the monitors.

5. Review of the personnel file for US #4 revealed a hire date of 04/05/2010. File review revealed the secretary was also a certified nursing assistant. File review revealed no documented evidence that the secretary has attended the "Telemetry Alarm Safety" class. File review revealed no documented evidence of a competency validation for cardiac telemetry monitoring or a written cardiac rhythm interpretation test.

Interview on 08/24/2010 at 1700 with the clinical educator confirmed there was no competency validation and no written cardiac rhythm interpretation test for US #4. Interview revealed, "The only training I've given the unit secretaries was a one hour class."

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed, "We are not following our policy for who can monitor the cardiac telemetry monitors."

6. Review of the personnel file for US #3 revealed a hire date of 05/20/2009. File review revealed the secretary attended the "Telemetry Alarm Safety" class on 02/19/2010. File review revealed no documented evidence of a competency validation for cardiac telemetry monitoring or a written cardiac rhythm interpretation test.

Interview on 08/24/2010 at 1700 with the clinical educator confirmed there was no competency validation and no written cardiac rhythm interpretation test for US #3. Interview revealed, "The only training I've given the unit secretaries was a one hour class."

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed, "We are not following our policy for who can monitor the cardiac telemetry monitors."

7. Review of the personnel file for US #5 revealed a hire date of 05/20/2008. File review revealed the secretary attended the "Telemetry Alarm Safety" class on 02/19/2010. File review revealed no documented evidence of a competency validation for cardiac telemetry monitoring or a written cardiac rhythm interpretation test.

Interview on 08/24/2010 at 1700 with the clinical educator confirmed there was no competency validation and no written cardiac rhythm interpretation test for US #5. Interview revealed, "The only training I've given the unit secretaries was a one hour class."

Interview on 08/25/2010 at 1020 with the Director of Clinical Services (DCS) revealed, "We are not following our policy for who can monitor the cardiac telemetry monitors."

Based on policy review and observation the hospital failed to ensure nursing staff identified a patient per policy prior to the administration of medications for 1 of 2 observed medication passes (Patient #3).

The findings include:

Review of current hospital policy entitled, "Medication Administration Policy" dated 02/2010 revealed, "This policy provides guidelines for medication administration in a safe manner following established policies and procedures with the right patient, medicine, dose, route, time and documentation....Ask patient to state name if able and check patient's identification bracelet before giving a medication...."

Observation of a medication pass on 08/25/2010 at 0925 revealed a registered nurse (RN #3) administered medications to the patient in room 7033 (Patient #3). Observation revealed the nurse did not check the patient's identification bracelet prior to giving medications to the patient.

Interview on 08/25/2010 at 0930 with RN #3 revealed the nurse did not check the patient's identification bracelet to verify the identity of the patient. Interview revealed, "I've had him for 2 weeks."


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Interview on 08/26/2010 at 1215 with the Nurse Manager revealed a nurse must check a patient's identification band to verify the patient's identification prior to giving the patient medication. Interview revealed RN #3 did not follow the hospital's policy for medication administration.

Based on staff interview, medical record review, Staff Meeting Minutes review, and Charge Nurse Meeting Minutes review, the hospital failed to implement actions to ensure staff immediately evaluated and assessed patients when cardiac telemetry monitor alarms activated and warned of the absence of cardiac activity.

The findings include:

Interview on 08/25/2010 at 1020 with the director of clinical services revealed the unit secretaries monitor the cardiac telemetry monitors. Interview further revealed "the unit secretaries should know what lethal cardiac rhythms are, like v-tach (ventricular tachycardia), v-fib (ventricular fibrillation) and asystole (absence of cardiac activity). The alarm is audible and the light flashes on the monitor. The rhythm strip also prints automatically when there's a problem." Interview revealed the rhythm strip automatically begins to print whenever a lethal cardiac rhythm or asystole is detected. Interview revealed the secretary should alert the patient's nurse when a lethal cardiac rhythm or asystole is detected on the cardiac monitor and the nurse should immediately evaluate and assess the patient.

Closed medical record review of Patient #11 revealed an 80 year-old female admitted on 05/20/2010 from a local community hospital with respiratory failure, status post tracheostomy (airway provided via a tube in the trachea), chronic atrial fibrillation (cardiac arrhythmia), coronary artery disease (heart disease), clostridium difficile colitis (inflammation of the colon), chronic pleural effusion (accumulation of fluid in the lining of the lungs and chest cavity) and severe protein malnutrition. Record review revealed the patient was continuously on a cardiac telemetry monitor. Review of the cardiac rhythm strip at 2034 revealed "Event: Asystole" automatically printed in the left upper corner of the strip. Further review of the cardiac rhythm strips revealed the next strip dated 05/24/2010 at 2051 also noted "Event: Asystole". Record review revealed the first available documentation that the nurse assessed the patient after the monitor alarmed and showed "asystole" was at 2052 (18 minutes after the printed cardiac rhythm strip first indicated asystole). Review of the record revealed a Hospital Code Report Flowsheet dated 05/24/2010. Review of the Code Report Flowsheet revealed "Time of Arrest 2052." Further review revealed the patient had no heart rate and blood pressure at 2052. Review of RN (Registered Nurse) #1's notes dated 05/24/2010 at 2052 revealed, "Pt (patient) found unresponsive 0 pulse 0 resp (respirations) pupils fixed and dilated..." Record review revealed at 2109 the patient was placed on a mechanical ventilator (artificial life support). Further review of the record revealed the patient remained unresponsive and on the ventilator until her death on 06/04/2010, after the family requested the patient be removed from life support.

Interview on 08/25/2010 at 1720 with the Quality Manager revealed, "I reviewed the incident on 06/14/2010 due to the patient's death. I review all patient deaths." Interview revealed the Manager found that the monitor had alarmed at 2034 on 05/24/2010 to alert staff the patient was in asystole. Interview revealed the Manager was concerned that it took 18 minutes of asystole before staff responded to the patient. Interview revealed the Manager did not know if the alarm was audible, but she knew it was at least visual because the cardiac strips were automatically printed. Interview revealed the Manager discussed her findings with the Nurse Manager and the Director of Clinical Services (DCS). Interview revealed, "(The DCS) said they were having some problems with staff muting the alarms and they were not always audible. He called the company....They found the alarms were off." Further interview revealed, "They (the Nurse Manager and the DCS) reported back to me they had talked with the nurses and disciplined the secretary."

Interview on 08/26/2010 at 1040 with the Director of Clinical Services revealed the Director contacted the monitor company on 06/01/2010 to have them remotely check the monitor system to see if there was a problem with the alarms. Interview revealed the company confirmed there was no problem with the alarms and the alarms were properly functioning on 05/24/2010. Interview revealed the company said an unplugged cable at the audible alarm would not cause an error message nor would it affect the visual alarm. Interview revealed the Director had the company set the monitor system so that only he could mute alarms and make any changes to the monitor settings, including alarm parameters and the alarm mute function. Interview revealed on 08/05/2010 there was another incident when the monitor did not audibly alarm to alert staff to a lethal cardiac rhythm. Interview revealed staff immediately responded to the patient per protocol and the patient had a positive outcome. Interview revealed the Director called the monitor company, again, on 08/05/2010 and the company sent a representative onsite to check the monitors the same day. Interview revealed the company representative found the monitors had been muted. Interview revealed the Director instructed the company that only he should be able to make any changes to the monitor settings, including muting alarms. Interview revealed the company again adjusted the monitors so that the Director had the only passcode to make adjustments, such as muting alarms. Interview revealed the Director had no documentation that alarms had been checked for proper functioning since 08/05/2010, when they were found by the monitor company representative to be muted.

Interview on 08/26/2010 at 0845 with the Nurse Manager revealed, "I was made aware of the 18 minute gap on June 3 (10 days after the incident involving Patient #11)....I talked with (RN #1) and she said she didn't hear an alarm when Patient #11 coded." Further interview revealed nursing staff should immediately respond to any lethal cardiac arrhythmia or asystole. Interview confirmed the cardiac monitor continuously printed strips, indicating the monitor alarmed, that showed asystole (absence of cardiac activity) for Patient #11 on 05/24/2010 from 2034 until 2052, when nursing staff responded and assessed the patient and the Code was initiated. Interview confirmed the record showed the patient was in asystole for 18 minutes before nursing staff assessed the patient. Further interview revealed, "We realized on June 1 that somebody was tampering with the audible alarm plug. I didn't check the plug until June 3 and they were not unplugged at that time." Interview revealed staff reported to the Manager they had seen Unit Secretary (US) #1 unplug the monitor alarm cables on occasion, so that the monitor alarms were not audible. Interview revealed the Manager checked the schedule for 05/24/2010 and found that US #1 had worked during the dayshift. Interview revealed the Manager closely observed US #1 and on 06/13/2010 "we caught her unplugging the cables and fired her". Further interview revealed US #7 was on duty and monitored the cardiac telemetry monitors on 05/24/2010 at 2034, when the monitor alarmed and showed that Patient #11 was in asystole. Interview revealed the monitor still alarmed visually (flashed on the screen) even when it was muted or the cable was unplugged. Interview revealed US #7 had not been counseled regarding the incident. Further interview revealed the Manager had discussed monitor alarms and the expected response to them during staff meetings and charge nurse meetings since the incident occurred. Interview revealed the Manager had no documentation available to show that staff had been re-educated regarding monitor alarms or response to lethal cardiac arrhythmias.

Review of Staff Meeting Minutes and Charge Nurse Meeting Minutes revealed no documentation staff were educated to issues with monitor alarms or response to lethal cardiac arrhythmias since the incident on 05/24/2010, when the cardiac monitor alarmed and showed that Patient #11 was in asystole for 18 minutes before nursing staff responded and assessed her.