HospitalInspections.org

Based on interview, record review and a review a facility documentation, the facility failed to ensure the supervision and evaluation of nursing care for each patient concerning compliance with physician orders for the use of telemetry in one of three sampled patients. (#1)

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the Emergency Department on 9/9/25 at 9:33 AM. A physician note of 9/9/25 at 1:02 PM read: "Patient states that he is feeling more than fine today and does not have any acute concerns. The majority of this history is obtained from the sheriff's as well as his daughter. . . . At this time she states he is no longer combative but continues eloping. She states he eloped several times a day and she is not strong enough to always bring him back home. . . " Also: "At this juncture, no interventions / medications are indicated. Findings and disposition communicated with patient, who is agreeable to observation." Also: "Patient will be admitted for further workup and care.

A nurse's note of 9/9/25 at 3:56 PM read: "Patient transferred: From room E47 to room OTF (off the floor)."

A nurse's note of 9/9/25 at 4:10 PM (just over 10 minutes after the prior nurse indicated a transfer of the patient) read: "Patient arrived on unit AOX1 to self only with no signs of distress.

Physician orders of 9/9/25 at 8:35 PM read: "Telemetry Monitoring 24 hours TIA. . . . Frequency: Routine until discontinued 09/09/25 8:35 PM - 24 hours." Also: Indication for 24 hour hour telemetry: TIA, Can the patient be off telemetry for activities (including therapy, ambulation, off-unit procedures, showers, bathroom)? No." Also: "Notify provider for change in rhythm."

Regarding the above mentioned telemetry order of 9/9/25 at 8:35 PM , the Central Monitoring Unit Communication and Escalation Log indicated that the patient was placed on telemetry at 9:06 PM on 9/9/25.

The Central Monitoring Unit Communication and Escalation Log indicated the following at 4:10 PM on 9/10/25: "Leads off / patient confused." It indicated under the column RN (Registered Nurse) Notification Name: "(Staff member RN -1)." It was therefore documented that the patient was effectively removing his leads due to a state of confusion.
On 9/23/25 at approximately 2:30 PM, she stated that the patient was not put back on the leads after the patient removed them. She stated there was no evidence of the physician having been notified of the discontinuation of telemetry for this patient. She stated that they did uncover telemetry concerns in their investigation, but they did not pertain to physician notification of an inability to maintain telemetry.

Thus, there was no evidence of physician notification regarding the inability to maintain leads on the patient as alluded to in policy (for rhythm changes).

On 9/23/25 at 12:40 PM, RN-1 (who worked on 9/10/25 from 6:47 AM to 8:27 PM) stated that when she started the shift, the patient's leads were off (text below reveals they were ordered on 9/9/25). She stated she was told by the night nurse that he was not on telemetry because he was refusing. She said she spoke to the daughter at some point, who said that the patient did not want all the cords. The RN stated that she did not notify the MD regarding this.

The patient eloped from the facility on 9/10/25 at approximately 6:20 PM.

A review of facility policy Telemetry Monitoring revealed the following: "Notify physician of dysrhythmias, changes in rhythm, . . . or changes in clinical condition. Document assessments, physician notifications, and interventions in the electronic medical record." When telemetry is discontinued: Notify the Central Monitoring unit." As indicated above, the physician had not been notified. When the leads were unattached, there was no way to know whether or not the patient had any rhythm changes.