HospitalInspections.org

1. Based on review of medical records, policy and procedure, and staff interview, the facility failed to ensure that a registered nurse evaluate and document the patients cardiac rhythm while under continuous telemetry monitoring every shift per the facility's policy and procedure. The nursing staff also failed to notify the physician for changes in patient cardiac status per the facility's policy and procedure.

The findings include the following:

a. Review of medical records on August 2, 2011 and August 3, 2011 at the facility nurse ' s station revealed that patients receiving continuous cardiac monitoring did not have consistent documentation that a registered nurse reviewed the patient's rhythm strip or notified the physician of changes in cardiac status.

(C17) Rhythm Strip Record revealed the following documentation for August 1, 2011:
8:23am heart rate of 95 Interpretation of strip: sinus rhythm
12:13 pm heart rate of 133 Interpretation of the strip: Sinus tachycardia
No documentation could be found that a registered nurse reviewed the rhythm strips or contacted the patient's physician to notify of the change in cardiac status.
(C18) Rhythm Strip Record revealed on August 1, 2011 the following documentation:
8:23am heart rate of 96 Interpretation of the strip: sinus rhythm with bundle branch block.
2:26pm heart rate of 134 Interpretation of strip: Sinus tachycardia with bundle branch block and premature ventricular contraction
4:29pm heart rate 120 Interpretation of strip: Sinus tachycardia with bundle branch block and premature ventricular contraction
8:05 pm heart rate 114 Interpretation of strip: Atrial Fibrillation.
No documentation could be found that a registered nurse reviewed the rhythm strips or contacted the patient's physician to notify of the change in cardiac status.

b. Review of Policy and Procedure under nursing service. No: MO-19-001 Telemetry Monitoring directs the nursing staff to:
1. Include evaluation of telemetry in shift assessment and document rhythm strips and evaluation every shift in the medical record.
2. Call patient's physician to report any serious rhythm changes or disturbances.

c. Staff interview with the EKG monitor technician on August 2, 2011 at 3:35pm in the facility's Intensive Care Unit revealed that not all patients on continuous telemetry monitoring could be viewed by the technician at one time due to the size of the monitoring screen. The technician stated that he is able to change the screen setting to review the patients that are not able to be seen on the original screen. He states that if a rhythm change occurs the computer will alert him.

Based on review of documentation in 20 medical records and interviews with staff, the facility failed to ensure that all entries in the medical records were completed, dated, timed and authenticated.

Findings:
Review of medical records it was found that 20 of 20 (100%) medical records (MR #1, through 20) were not being promptly completed, physicians ' verbal orders not being dated or timed within 48 hours, discharge summary for MR # 2, 6, 7 and 9 (25%) were not signed and not completed within the 30 days after patients ' discharge, standing admission orders (MR# 15) , informed consent (MR# 14, 16, 17, 18), initial wound care assessment (MR#15) , initial nutritional assessment (MR#15) were not signed by a physician.

b. These records were confirmed in an in-person interview conducted with Staff 1 and 2 Medical Records Coordinators at 11:00 am on August 3, 2011 either staff member could not provided evidence that this requirement was met with these patients ' records.

Based on review of documentation in 20 medical records and interviews with staff, the facility failed to ensure that all verbal orders were dated, timed and authenticated by the ordering practitioner or another practitioner responsible for the care of the patient according to facility Medical Staff Rules and Regulations. In the medical records reviewed 18 of 20 applicable medical records for Solara Hospital McAllen reviewed contained verbal/telephone orders that were not authenticated according to the 48-hour requirement adopted by the hospital Medical Staff.

Findings were:
Review of Medical Records

a. Review of 16 closed medical records and 4 open medical records revealed that 18 out of 20 (90%) patient records reviewed at this facility contained verbal/telephone orders that were not dated, timed, and authenticated by the practitioner within 48 hours of the order.

b. These records were confirmed in an in-person interview conducted with Staff 1 and 2 Medical Records Coordinators at 2:00pm on August 3, 2011 either staff member could not provided evidence that this requirement was met with these patients ' records.