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Based on medical record review, interview, observation, and review of policies and procedures, the hospital failed to ensure no heart rate alarm parameters will be set above 120 or below 60 without a specific physician's order in accordance with hospital Cardiac Monitoring policy. This affected seven patients (Patient #2, #3, #4, #5, #6, #7, #8) of ten patients reviewed. The cumulative effect of these systemic practices resulted in a risk to the health and safety of all 36 patient's.

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Based on medical record review, interview, observation, and review of policies and procedures, the hospital failed to ensure no heart rate alarm parameters will be set above 120 or below 60 without a specific physician's order in accordance with hospital Cardiac Monitoring policy. This affected seven patients (Patient #2, #3, #4, #5, #6, #7 and #8) of ten patients reviewed. The hospital reported a census 36 patient's.

Findings include:

Review on 02/28/17 at 2:20 PM of the Cardiac Monitoring Policy #201-21-008.8, effective date of March 1998 and revised Dec 2015, on page three of five, under Section E. Alarm Parameter(s): number 4. revealed, "No heart rate parameters will be set above 120 or below 60 without a specific physician's order. No heart rate parameters will ever be set above 150 or below 40."

1. Record review of Patient #2's Cardiac Monitoring Log revealed between the period of 01/13/17 at 8:00 PM to 01/16/17 at 8:00 PM the high heart rate parameter was set between 130 bpm and 140 bpm. According to current policy on cardiac monitoring any HR parameters set above 120 bpm or below 60 bpm should have been ordered by the physician. The record lacked evidence of a physician order for the high HR parameter to be set above 120 as stated in current policy.


2. Record review of Patient #5 revealed the patient was admitted to the hospital on 09/03/16 for Acute Respiratory Failure and Pneumonia. Review of Patient #5's Cardiac Monitoring Log revealed between the period of 09/13/16 at 12:00 AM to 09/21/16 at 4:00 PM the high HR parameter was set at 150 bpm. From 09/21/16 at 8:00 PM until 09/23/16 at 3:00 AM the high HR parameter was set at 125 bpm. There was no physician's order for this change in alarm parameters.


3. Record review of Patient #8 revealed the patient was admitted to the hospital on 05/16/16 for Chronic Respiratory Failure. Review of Patient #8's Cardiac Monitoring Log revealed from 05/16/16 at 9:20 PM to 05/26/16 at 8:00 AM the high HR parameter was set at 125 bpm. From 06/01/16 at 8:00 AM to 06/04/16 at 1:00 AM the high HR parameter was set at 135 bpm. From 06/05/16 at 12:00 AM to 06/06/16 the high HR parameter was set at 130 bpm. There was no physician's order for this change in alarm parameters.

Interview on 02/28/17 at 11:10 AM Staff A stated/confirmed according to current policy on cardiac monitoring any HR parameters set above 120 bpm or below 60 bpm should have been ordered by the physician.


4. Patient #3 was admitted to the facility on 01/03/17 at 10:30 PM with a medical history that included acute respiratory failure and intraventricular hemorrhage. The admission orders revealed the attending physician ordered cardiac monitoring for the patient.

According to the Cardiac Monitoring log the patient was placed on the telemetry monitor at 11:03 PM. The alarm parameters were set at a high rate of 120 beats per minute and a low rate of 60 beats per minute.

On 01/04/17 at 8:00 AM the high alarm parameter was changed to 130 beats per minute while the low alarm parameter remained at 60 beats per minute. On 01/05/17 at 8:00 AM the high alarm parameter was increased to 140 beats per minute while the low parameter remained 60 beats per minute. The alarm settings remained at 140 and 60 until 01/14/17 at 8:00 AM. The high parameter remained 140 and the low was decreased to 55 beats per minute. On 01/16/17 at 8:00 PM the high alarm setting was increased to 150 beats per minute and the low alarm setting was increased from 55 to 65 beats per minute. The next day, on 01/17/17, at 8:00 PM the high and low alarm parameters were decreased from 150 to 140 and 65 to 55. The low alarm setting was decreased to 50 beats per minute while the high alarm remained 140 at 08:00 AM on 01/18/17. The high and low alarm settings were decreased on 01/18/17 at 4:00 PM. The high alarm was decreased from 140 to 120 beats per minute and the low alarm setting was decreased from 50 to 40 beats per minute. The low alarm setting was increased from 40 to 60 on 01/22/17 at 12:00 PM while the high alarm setting remained at 120. The high and low alarm parameters of 120 and 60 remained until the patient was discharged to a skilled nursing facility on 02/23/17 at 3:40 PM. The medical record lacked documentation that the alarm parameter changes were ordered by a physician.


5. Patient #4 was transferred from another facility on 10/27/16 at 5:00 PM. The patient was found to be in cardiac arrest at the dentist's office on 10/04/16 and a coronary artery bypass grafting surgery was performed on 10/11/16. Cardiac monitoring was ordered for the patient on admission. The alarm parameters were set at a high rate of 130 and a low rate of 50 on 10/27/16. The high alarm parameter was increased from 130 to 150 on 11/01/16 at 8:00 AM while the low parameter remained 50. This change in the cardiac monitor alarm parameters remained at 150 and 50 until it was discontinued when the patient was transferred to another facility with worsening condition. The medical record lacked documentation that the increase of the high alarm parameter was ordered by a physician.


6. Patient #6 was admitted to the facility on 10/07/16 at 3:06 PM. Patient #6 had a history of large cell lung cancer and was admitted for management of respiratory failure. Cardiac monitoring was ordered. The alarm parameters were set at a high rate of 140 and a low rate of 50. On 10/08/16 at 12:00 PM the alarm parameters were changed. The high limit was increased from 140 to 155 and the low was increased from 50 to 55. On 10/09/16 at 8:00 AM the high alarm limit was decreased from 155 to 145 but the low limit remained 55. There was no physician order for this change noted in the medical record. The high limit was decreased from 145 to 140 on 10/18/16 at 8:00 AM. The low limit was decreased from 55 to 50 on 10/22/16 at 8:00 AM. The Cardiac Monitoring log on 11/01/16 at 8:00 AM revealed the high alarm limit was increased from 140 to 150 while the low limit alarm remained 50. The medical record lacked documentation of a physician's order for any of the changes in the alarm settings.

7. Patient #7 was admitted to the facility on 01/19/17 at 5:00 PM. The attending physician's history and physical indicated the patient was admitted for ventilation weaning. Cardiac monitoring was ordered. The high alarm limit was set at 120 and the low alarm limit was set at 40. On 01/19/17 at 8:00 PM the log revealed the high alarm limit was increased from 120 to 170 beats per minute, which was above the 150 beats per minute limit that even a physician's order won't allow. The low limit remained 40. The high and low parameters remained at 170 and 40 until 01/20/17 at 8:00 AM. The high parameter was decreased from 170 to 145 and the low was increased from 40 to 50. There was no physician's order for this change in alarm parameters.

Staff A was interviewed on 03/01/17 at 9:50 AM. It was confirmed that Patient #3, #4, #6 and #7 lacked documentation of a physician order to change the high and low parameters of the cardiac monitor as required by facility policy.