HospitalInspections.org

Based on observation, interview, record review and policy and procedure review, it was determined the Governing Body failed to ensure care was provided in a safe setting for patients that were returned to restraints after having been released (A169); failed to ensure orders for restraints were obtained from the physician (A173); failed to monitor restrained patients (A175); failed to ensure Nursing Services followed the physician's order for continuous cardiac telemetry monitoring (A395); failed to ensure a Registered Nurse documented changes in the patient's cardiac rhythm and notified the physician (A395); and failed to ensure a Registered Nurse validated the patient's cardiac rhythm every shift for patients ordered to receive cardiac monitoring (A395). The failed practices caused harm to Patient #6 and the likelihood of potential harm for any or all patients in restraints and/or on continuous monitoring.

Based on clinical record review, interview and policy review it was determined the Facility failed to provide care in a safe setting. Clinical record review revealed the Facility failed to assure new restraint orders were written when a patient was returned to restraints after having been released for 3 (#4, #15 and #16) of 9 (#1, #4, #6-#8, #10, #11, #15, and #16) restrained patients. See A169

Clinical record review, policy review and interview revealed the Facility failed to ensure orders for restraints were obtained from the physician per policy and procedure for 2 (#4 and #16) of 9 ( #1, #4, #6-#8, #10, #11, #15 and #16) restrained patients. See A173

Clinical record review, interview and policy review revealed the Facility failed to monitor restrained patients as required by Facility policy for 4 (#4, #10, #15 and #16) of 9 (#1, #4, #6-#8, #10, #11, #15 and #16) restrained patients. See A175.

Based on observation, interview, clinical record review and policy and procedure review, although 24 hour nursing care was provided, it was determined a Registered Nurse did not assure the physician's order for continous cardiac telemetry monitoring was provided for 3 (#5, #6 and #14) of 11 (#1, #2, #4-#7, #11, #12 and #14-#16) patients; failed to assure a Registered Nurse documented changes in the patient's cardiac rhythm and failed to notify the physician of changes in the cardiac rhythm for 4 (#1, #2, #6, #7) of 11 (#1, #2, #4-#7, #11, #12 and #14-#16) patients; and failed to ensure a Registered Nurse validated the patient's cardiac rhythm every shift for patients ordered to receive cardiac monitoring for 11 of 11(#1, #2, #4-#7, #11, #12 and #14-#16) patients. The failed practice placed the patients at risk of not receiving care when entering a critical cardiac rhythm. The failed practice caused harm to Patient #6 and had the likely potential to affect all patients ordered to be placed on continuous cardiac telemetry monitoring. See A395.

Based on interview, clinical record review and policy review, it was determined the Facility failed to ensure new restraint orders were written when a patient was returned to restraints after having been released for three (#4, #15 and #16) of nine (#1, #4, #6-#8, #10, #11, #15 and #16) restrained patients. The failed practice did not ensure the physician assessed the patient to determine continued need for restraints. Findings follow:

A. Review of the clinical record of Patient #4 revealed the following:
1) An order for restraints was written on 10/25/13. The Restraint Order/Assessment Sheet, dated 10/25/13, revealed the areas checked under Clinical Justification For Restraint Use were Unable to understand the need for treatment; Unable to understand the seriousness of condition; and poor judgment. Under the area titled Please Check Less Restrictive Intervention Attempted, Yet Not Successful, Observed, Or Reported, By Patient-Care Services Staff the following areas were checked: Reorient/educate; Diversional Tubes; Frequent toileting; Ask family for suggestions; Bed/chair alarm; Provide diversional activities; Reposition; PRN medications; and other was checked but there was no documentation as to what other was to be. Under Type Of Restraint the area checked was Left upper extremity: wrist and Right upper extremity wrist. The Restraint Order/Assessment Sheet was signed by the physician and dated 10/25/13 and timed 4P.

Patient #4 was released from restraints from 0800 through 1200. A new order was not written before Patient #4 was returned to restraints at 1300.

2) An order for restraints was written on 11/07/13. The Restraint Order/Assessment Sheet, dated 11/07/13, revealed the areas checked under Clinical Justification For Restraint Use were Unable to understand the need for treatment; Unable to understand the seriousness of condition; and Potential for dislodging tubes. Under the area titled Please Check Less Restrictive Intervention Attempted, Yet Not Successful, Observed, Or Reported By Patient-Care Services Staff the following areas were checked: Reorient/educate; Diversional Tubes; Secure lines and tubes; Ask family for suggestions; Exercise/Out of bed; Reposition; and PRN Medications. The area checked under Type of Restraint was Left upper extremity wrist and Right upper extremity wrist. The Order was dated 11/07/13 at time 1200 and signed by (Named)ACNP.

Patient #4 was removed from restraints from 1700 through 2300. A new order was not written before Patient #4 was returned to restraints at 2400.

3) Findings were confirmed by the Chief Nursing Officer on 12/09/13 at 1425.

B. Review of the clinical record of Patient #15 revealed the following:

1) An order for restraints was written on 11/16/13. The Restraint Order/Assessment Sheet, dated 11/16/13, revealed the areas checked under Clinical Justification For Restraint Use were: Unable to understand the need for treatment; Unable to understand the seriousness of condition; Potential for dislodging tubes; and Poor judgment. Under the area titled Please Check Less Restrictive Intervention Attempted, Yet Not Successful, Observed, Or Reported By Patient-Care Services Staff the following areas were checked: Diversional Tubes; Secure lines and tubes; and Reposition. The area checked under Type of Restraint was Left upper extremity wrist and Right upper extremity wrist. The Order was dated 11/16/13, signed by physician and no time was documented.

Patient #15 was released from restraints from 0900 through 1600. A new order was not written before Patient #15 was returned to restraints at 1700.

2) Findings were confirmed by the Chief Nursing Officer on 12/09/13 at 0935.

C. Review of the clinical record of Patient #16 revealed the following:

1) An order for restraints was written on 11/11/13. The Restraint Order/Assessment Sheet, dated 11/11/13, revealed the areas checked under Clinical Justification For Restraint Use were: Unable to understand the need for treatment; Unable to understand the seriousness of condition; Potential for dislodging tubes; and Poor judgment. Under the area titled Please Check Less Restrictive Intervention Attempted, Yet Not Successful, Observed, Or Reported By Patient-Care Services Staff the following areas were: Reorient/educate; Diversional Tubes; Secure lines and tubes; Reposition; and PRN medications. The area checked under Type of Restraint was Left upper extremity wrist and Right upper extremity wrist. The Order was dated 11/11/13, signed by (Named) APN and timed 1300.

Patient #16 was released from restraints from 0800 through 1700. A new order was not written before Patient #16 was returned to restraints at 1800.

2) Findings were confirmed by the Chief Nursing Officer on 12/05/13 at 1530.

D. Review of policy number R02-N titled Restraints and Seclusion revealed ...page 5 under Orders to Initiate Restraint...Orders for restraints must be renewed on a daily basis...If a patient is removed from restraint before the current order expires and must be returned to restraints a new physician order is required...

Based on interview, clinical record review and policy review, it was determined the Facility failed to obtain a Physician's order when placing a patient in restraints for 2 (#4 and #16) of 9 (#1, #4, #6-#8, #10, #11, #15 and #16) restrained patients. The failed practice resulted in the likelihood of patients being unnecessarily restrained and affected Patients #4 and #16. Findings follow.

A. Review of Nurse's Notes for Patient #4 revealed restraint monitoring documentation without a restraint order on the following dates:
1) 0700 on 11/01/13 through 0600 on 11/02/13
2) 0700 on 11/06/13 through 0600 on 11/07/13
3) 0700 on 11/10/13 through 0100 on 11/11/13
4) 1900 on 11/13/13 through 0300 on 11/14/13
5) Findings were confirmed by the Chief Nursing Officer on 12/09/13 at 1425.

B. Review of Nurse's Notes for Patient #16 revealed restraint monitoring documentation without a restraint order on 11/21/13 from 0700 through 2100. Findings were confirmed by the Chief Nursing Officer on 12/05/13 at 1530.

C. Review of policy and procedure number R02-N titled "Restraints and Seclusion" revealed Any physician of the active Medical Staff or Licensed Practitioner may issue an order for restraint. Orders for restraints must be renewed on a daily basis. The order for a restraint may never be written as a standing order or on an as needed bases (PRN).

Based on review of personnel records, policy and procedure review and interview, it was determined the Facility failed to assure 3 (#1, #4, and #6) of 8 (#1-#8) Registered Nurse (RN) personnel had documentation of annual restraint training. It could not be assured RN #1, #4 and #6 were knowledgeable in restraint application, monitoring and assessment. The failed practice had the potential to affect any patient with restraints. The findings were:

A. On 12/09/13, personnel files for 8 (#1-#8) RN staff revealed RN #1, #4 and #6 lacked documentation of annual in-service training that included restraint application, monitoring and assessment. RN #1 had a hire date of 04/17/08; RN #4 had a hire date of 09/20/11 and RN #6 had a hire date of 09/11/12.

B. The CNO (Chief Nursing Officer) reviewed the personnel files and online training of RN #1, #4 and #6 and confirmed 12/09/13 at 1300 there was no evidence of current training for restraint use.

C. In an interview with the CNO on 12/09/13 at 1305, she stated that employees, "should have completed the annual restraint training by their hire date".

D. Review of Clinical Services Policy and Procedure, #R02-N as provided by the CNO on 12/04/13 revealed "Staff Training- Registered Nurses are trained in the assessment of restraint need, the restraint order process, time frames for and processes of reassessments. Staff with direct patient care is trained in alternatives to restraints, applying restraints, monitoring restrained patients and releasing patients from restraints. Training is provided in initial orientation and annual in-service training including the practical application of principles and the use of various restraint devices to minimize danger to patients and staff."

Based on observation, interview, clinical record review and policy and procedure review, although 24 hour nursing care was provided, it was determined Nursing staff failed to follow the physician's order for continuous cardiac telemetry monitoring for 3 (#5, #6 and #14) of 11 (#1, #2, #4-#7, #11, #12 and #14- #16) patients; failed to ensure a Registered Nurse documented changes in the patient's cardiac rhythm and failed to notify the physician of changes in the cardiac rhythm for 4 (#1, #2, #6, #7) of 11 (#1, #2, #4-#7, #11, #12 and #14- #16) patients; and failed to ensure a Registered Nurse validated the patient's cardiac rhythm every shift for patients ordered to receive cardiac monitoring for 11 of 11(#1, #2, #4-#7, #11, #12 and #14- #16) patients. The failed practices placed the patients at risk of not receiving care when entering a critical cardiac rhythm. The failed practice caused harm to Patient #6 and had the likely potential to affect all patients ordered to be placed on continuous cardiac telemetry monitoring. The findings follow:

A. Review of Patient #6's clinical record on 12/09/13 revealed a 43 year old female patient admitted for End Stage Renal Disease, scalp wound, buttock wound, anemia, deconditioning and blindness. The patient was alert and responsive on admission. Review of the clinical record revealed the following:
1) 11/22/13 - Admission Orders signed by the physician at 1500 revealed, "Telemetry: Yes."
2) 11/26/13 - 24 Hour Patient Record and Plan of Care revealed, "Telemetry" was blank. At 2000 under "Alarms" it was documented "Ordered but not available" for telemetry. There was no evidence why Patient #6 was not placed on continous cardiac telemetry monitoring as ordered by the physician. There was no evidence the physician discontinued the telemetry monitoring. There was no evidence the physician was notified there were no telemetry monitors available.

3) 11/28/13 - 24 Hour Patient Record and Plan of Care revealed, "Telemetry" was blank. At 0800 under "Alarms" it was documented "N/A" for telemetry.
4) 11/28/13 - Nurse's Notes at 1100 revealed, "Arrived in patient's (Patient #6) room. She was unresponsive. No pulse and chest compressions begin (began). Code Blue and RRT (Rapid Response Team) called @ this time. Dr. (named) paged, orders received. Dr. (named) on floor for Code."
5) 11/28/13 - Code Blue Record at 1100 revealed there was "No pulse" and at 1120 "ST (Sinus Tachycardia) (heart) rate 60-110".
6) 11/28/13 - Patient #6 was placed on telemetry.
7) 11/29/13 - Physician Progress Note revealed, "Unresponsive. Rhythmic jaw/shoulder jerking - myoclonus vs. Sz (seizure) activity. A/P (Assessment/Plan): Resp. (Respiratory) Failure; S/P (status post) arrest; Probable anoxic brain injury; probable new onset Sz."
8) 11/30/13 - Nurse's Note at 0800 revealed, "Unable to arouse. Pupils do not react. Left eye blind."
9) 11/30/13 - Electroencephalogram report revealed, "This is a markedly abnormal EEG recording due to persistent generalized bursts of polyspike and wave and sharp activity with a burst suppression pattern. The findings indicate severe cerebral insult. The pattern is likely representing status epilepticus; however, severe hypoxic brain damage can result in such pattern."
10) 12/02/13 - Electroencephalogram report revealed, "This is an abnormal EEG recording due to irregular slowing seen diffusely indicating diffuse brain dysfunction that is not specific regarding possible etiology."
11) 12/05/13 - 24 Hour Patient Record and Plan of Care at 1100 revealed, "Code Blue called. No pulse. Chest compressions began. 1 amp of Atropine. BP (Blood Pressure) 67/19, NS (Normal Saline) bolus started. Dr. (named) paged. Spoke to (named) patient's daughter. She wants her mom to remain a full code. 1145 Patient's HR (heart rate) 103, BP 140/80. Patient (#6) was coded 5 times from 1100 am until Code was called (stopped) by Dr. (named) @ 1300." There was no documented evidence of the Code Blue event that occurred on 12/05/13 from 1100 to 1300.
12) 12/05/13 - Record of Death form revealed Patient #6 expired at 1300.
13) The findings were confirmed in an interview with the Chief Nursing Officer on 12/09/13 at 1245.

B. Observation of the telemetry monitor on 6East on 12/04/13 at 0925 to 1015 revealed a total of 15 patients on telemetry. Observation on 12/04/13 from 0925 to 1015 revealed the following:
1) Patient #5's telemetry monitor was alarming "Leads Off " from 0925 to 1015. Monitor Technician #1 at 0925, stated she had notified the Registered Nurse taking care of Patient #5. At 0940 Registered Nurse #2, who caring for Patient #5, stated he was aware of the alarm. He stated he had checked the leads but Patient #5 needed a new telemetry monitor. At 1010, Registered Nurse #2 stated he had "issues" with the telemetry monitor since he started his shift at 0720. He stated he had not notified the physician about the telemetry not working. Patient #5 was off the monitor when Surveyor #1 left the floor at 1015. Review of Patient #5's clinical record on 12/04/13 revealed the patient was ordered for telemetry and was admitted for wound care. The patient was oriented on admission. There was no order to discontinue telemetry.

2) Patient #14's telemetry monitor was alarming "Leads Off" from 0925 to 1015. In an interview with Monitor Technician #1 at 0925, she stated she had notified the Registered Nurse taking care of Patient #14. On 12/04/13 at 0945, Patient #14 was observed up in a chair in his room and stated to Surveyor #2 that he was not in pain. Registered Nurse #1, who was caring for Patient #14, on 12/04/13 at 1000, stated she was aware Patient #14's telemetry was alarming "Leads Off" and stated "Yes I've checked the (telemetry) unit and it's not working and we don't have another one to replace it right now. I've got a patient going home at 1030 and I plan on using that one."
3) Patient #14 was a 69 year old admitted to the facility on 11/12/13. Clinical record review 12/04/13 revealed his past medical history included "coronary artery disease, peripheral vascular disease with stents in his coronaries and his lower extremities". Admission orders included telemetry.
4) On 12/04/13 at 1000 clinical record review revealed there was no physician order to discontinue the use of the telemetry.

C. Observation on 12/05/13 from 1348 to 1351 revealed Monitor Technician #1 was in the Medication Room retrieving paperwork. No one was observed at the desk observing telemetry monitors.

D. In an interview with Monitor Technician #1 on 12/04/13 at 0940 she stated she also did Unit Secretary work besides monitor technician duties; stated she "has to do what she has to do to accommodate the nurses"; stated she doesn't sit and directly observe the monitors, she is "attuned" to sounds when monitoring the monitors. A nurse was observed asking Monitor Technician #1 to assist with processing lab work. The Monitor Technician was observed answering telephone calls, processing physician orders, answering the call lights at the nurse's station and looking up physician telephone numbers on the computer.

E. On 12/04/13 at 1025 the Chief Nursing Officer and Charge Nurse #1 were interviewed. It was confirmed at the time of the interview that the facility had a total of 15 telemetry units available for use and three DataScopes (for bedside use) and one was a rental. The Chief Nursing Officer stated that if they ran out of telemetry units they would use a DataScope at the bedside, which does not register on the monitor with the telemetry. The observation would be at bedside with someone assigned for bedside continuous observation.

F. On 12/04/13 at 1035 the Materials Manager confirmed there were no additional telemetry units available in Materials Management.

G. Review of Patient #1's clinical record on 12/05/13 revealed the following:
1) 09/20/13 - Admission Orders at 1830 revealed, "Telemetry: Yes".
2) There was no evidence a Registered Nurse validated the Monitor Technician's interpretations of the rhythm strips.
3) Code Blue Record dated 09/22/13 at 1330 revealed, "Initial Cardiac rhythm and rate: Paced rhythm 88". There was no evidence of a rhythm strip to identify the change in the patient's cardiac rhythm to correlate with the Code Blue Record.
4) Code Blue Record dated 10/17/13 at 1246 revealed, "Initial Cardiac Rhythm and rate" was blank. At 1246 the patient had no pulse. There was no evidence of a rhythm strip to identify the change in the patient's cardiac rhythm to correlate with the Code Blue Record. Patient #1's time of death was 1304.
5) The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1445.

H. Review of Patient #2's clinical record on 12/05/13 revealed the following:
1) Admission Orders dated 09/05/13 revealed, "Telemetry: Yes".
2) There was no evidence a Registered Nurse validated the Monitor Technician's interpretations of the rhythm strips.
3) On 09/09/13 at 1742 rhythm strip documentation revealed the patient had a rhythm change. Rhythm strip dated 09/09/13 at 1742 revealed, "Notified of arrhythmia @ 1830" and was signed by a Registered Nurse. Nurses note dated 09/09/13 at 1830 revealed, " Notified of 12 beat V-Tach (ventricular tachycardia) done @ 1742. Pt (patient) asymptomatic @ this time." The time from the change in the rhythm change to the Registered Nurse's notification was 47 minutes.
4) The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1230.

I. Review of Patient #4's clinical record on 12/09/13 revealed the following:
1) Admission Orders dated 10/23/13 revealed, "Telemetry: Yes ".
2) There was no evidence a Registered Nurse validated the Monitor Technician's interpretation of the rhythm strips.
3) The findings were confirmed in an interview with the Chief Nursing Officer on 12/09/13 at 1425.

J. Review of Patient #5's clinical record on 12/04/13 revealed the following:
1) Admission Orders dated 12/03/13 revealed, "Telemetry: Yes".
2) There was no evidence of telemetry strips in the clinical record. There was no evidence the physician was notified the patient was not placed on telemetry per the physician's order.
3) The findings were confirmed in an interview with the Charge Nurse on 12/04/13 at 1520.

K. Review of Patient #7's clinical record on 12/05/13 revealed the following:
1) Admission Orders dated 11/27/13 revealed, "Telemetry: Yes".
2) There was no evidence a Registered Nurse validated the Monitor Technician's interpretation of the rhythm strips.
3) Code Blue Record documentation revealed Patient #7 coded on 12/01/13 at 1053, 1515, 1600, 1640, 1700 and on 12/05/13 at 0140. There was no evidence of rhythm strip documentation to correlate with the times the patient coded.
4) The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1335.

L. Review of Patient #11's clinical record on 12/05/13 revealed the following:
1) Admission Orders dated 11/29/13 revealed, "Telemetry: Yes".
2) There was no evidence a Registered Nurse validated the Monitor Technician's interpretation of the rhythm strips.
4) The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1350.

M. Review of Patient #12's clinical record on 12/05/13 revealed the following:
1) Admission Orders dated 11/30/13 revealed, "Telemetry: Yes".
2) There was no evidence a Registered Nurse validated the Monitor Technician's interpretation of the rhythm strips that were in the clinical record.
3) The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1350.

N. Review of Patient #14's clinical record on 12/05/13 revealed the following:
1) Admission Orders dated 11/12/13 revealed, "Telemetry: Yes".
2) There was no evidence a Registered Nurse validated the Monitor Technician's interpretations of the rhythm strips.
3) The findings were confirmed in an interview with the Chief Nursing Officer on 12/09/13 at 1250.

O. Review of Patient #15's clinical record on 12/09/13 revealed the following:
1) Admission Orders dated 11/14/13 revealed, "Telemetry: Yes".
2) There was no evidence a Registered Nurse validated the Monitor Technician's interpretation of the rhythm strips.
3) The findings were confirmed in an interview with the Chief Nursing Officer on 12/09/13 at 0935.

P. Review of Patient #16's clinical record on 12/05/13 revealed the following:
1) Admission Orders dated 10/31/13 revealed, "Telemetry: Yes".
2) There was no evidence a Registered Nurse validated the Monitor Technician's interpretation of the rhythm strips.
4) The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1515.

Q. Based on the process for telemetry rhythm strip documentation, the rhythm strips were to be printed at 0900 and 2100, interpreted, initialed and placed on the Telemetry Mount Strip page in the clinical record.
1) Clinical record review of Patient #1 revealed no rhythm strip documentation at 0900 for 09/21/13, 09/22/13, 10/15/13 and 10/17/13. There was no rhythm strip documentation for 2100 for 09/20/13, 09/21/13, 09/28/13, 09/29/13, 10/06/13, 10/12/13, 10/13/13 and 10/14/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1445.
2) Clinical record review of Patient #2 revealed no rhythm strip documentation at 2100 for 09/07/13, 09/08/13, 09/14/13, 09/15/13, 09/21/13, 09/22/13 and 09/23/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1230.
3) Clinical record review of Patient #4 revealed no rhythm strip documentation at 0900 for 10/23/13, 10/27/13, 10/29/13 to11/01/13, 11/03/13, 11/09/13, 11/10/13, and 11/12/13 to 11/14/13. There was no rhythm strip documentation for 2100 for 10/26/13, 10/27/13, 10/29/13, 11/02/13, 11/03/13, 11/08/13 to 11/10/13, 11/12/13, and 11/13/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/09/13 at 1425.
4) Clinical record review of Patient #5 revealed no rhythm strip documentation for 12/04/13 on admission or 12/04/13 at 0900.
5) Clinical record review of Patient #6 revealed no rhythm strip documentation at 0900 for 11/23/13 to 11/29/13 and 12/01/13 to 12/03/13. There was no rhythm strip documentation for 2100 for 11/23/13 to 11/28/13, 11/30/13 and 12/01/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/09/13 at 1245.
6) Clinical record review of Patient #7 revealed no rhythm strip documentation at 0900 for 12/01/13 to 12/03/13. There was no rhythm strip documentation for 2100 for 11/29/13 to 12/01/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1335.
7) Clinical record review of Patient #11 revealed there was no rhythm strip documentation at 2100 for 11/30/13. There was no rhythm strip documentation for 0900 or 2100 12/01/13 through 12/03/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1350.
8) Clinical record review of Patient #12 revealed there was no rhythm strip documentation at 2100 for 11/30/13. There was no rhythm strip documentation for 0900 or 2100 for 12/01/13 through 12/04/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1350.
9) Clinical record review of Patient #14 revealed no rhythm strip documentation at 2100 for 11/15/13, 11/17/13, 11/19/13, 11/21/13, 11/22/13, 11/23/13, and 11/29/13 to 12/02/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/09/13 at 1250
10) Clinical record review of Patient #15 revealed there was no rhythm strip documentation at 0900 for 11/23/13, 12/01/13 to 12/03/13 and 12/05/13 to 12/08/13. There was no rhythm strip documentation for 2100 for 11/14/13, 11/15/13, 11/17/13, 11/19/13, 11/21/13, 11/22/13, 11/24/13, 11/25/13, 11/29/13 to 12/01/13 and 12/05/13 to 12/08/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/09/13 at 0935.
11) Clinical record review of Patient #16 revealed there was no rhythm strip documentation at 0900 for 11/01/13, 11/09/13, 11/12/13, 11/25/13, 11/26/13, 12/01/13, 12/02/13, and 12/03/13. There was no rhythm strip documentation for 2100 for 11/09/13, 11/10/13, 11/12/13, 11/17/13, 11/19/13, 11/21/13 to 11/24/13 and 11/30/13. The findings were confirmed in an interview with the Chief Nursing Officer on 12/05/13 at 1515.

R. In an interview with Monitor Technician #1 on 12/04/13 at 1350 she stated rhythm strips documentation followed the "Process for Rhythm Changes/Alarms" form. Review of the "Process for Rhythm Changes/Alarms" form provided on 12/04/13 at 1350 revealed, "Print strips via strip printer at 0900 and 2100."

S. Review of the Policy and Procedure "Telemetry, Alarms, Prioritization" on 12/04/13 revealed the following:

"Indications for telemetry: Absolute (must be on telemetry or continuous EKG (electrocardiogram) monitoring): Physician order; Any patient who has developed a significant change in condition; Any patient receiving Critical Drip Therapy; Medical staff approved, hospital protocols; Initiation of any antiarrhythmic therapy.

All EKG strips analyzed by a MT/TT (Monitor Technician/Telemetry Technician) must be validated and cosigned by the assigned RN (Registered Nurse) or Charge Nurse that is telemetry competent. Interpretations are to include heart rate, regularity, PR interval, QRS duration, QT interval, ST segment, QTc, rhythm interpretation, date, time, signature and title.

Any new dysrhythmia or change in rhythm will be captured on a strip, interpreted and the Charge/attending nurse notified. This strip will be placed on the chart.

The Telemetry Tech will notify the Charge Nurse or assigned nurse of a telemetry alarm, a change in rhythm or signal.

24/7 Observation of the telemetry shall be the responsibility of the MT/TT, Charge Nurse, or nurse who has documented competencies via successful completion of EKG education requirements.

The MT/TT or person who is watching telemetry will notify the Charge Nurse or assigned nurse of telemetry alarm and/or a change in rhythm.

A rhythm strip will be analyzed and posted a minimum of every shift. All rhythm interpretations will be validated by a monitor competent RN and so noted by signing the telemetry strip. The rate, regularity, PR interval, QRS duration, QT interval, QTc, ST segment and interpretation will be noted.

An EKG strip will be analyzed and posted for rhythm changes by a telemetry competent RN."