HospitalInspections.org

Based on review of facility documents, personnel files (PF), and staff interview (EMP), it was determined that the facility failed to ensure that patients requiring telemetry monitoring were monitored by trained, qualified nursing staff on the third floor telemetry and medical surgical unit.

Findings include:

Review on December 21, 2011, of the facility's "Telemetry Monitoring Utilization" policy, last reviewed October 2011, revealed "Policy Statement: The role of cardiac monitoring in the patient care delivery system has dramatically expanded for many reasons. There is no single set of guidelines that can anticipate all possible clinical situations, therefore the ultimate decision to utilize or not to utilize cardiac monitoring remains the responsibility of the physician. According to the American College of Cardiology, there are several guidelines that must apply to the use of cardiac monitoring in all clinical settings: a. Adequate human surveillance of the monitors 24 hours per day; b. Trained, qualified personnel assigned to monitor surveillance ..."

Review on December 21, 2011, of the facility's "Electrophysiologic Monitoring: Hardwire and Telemetry" policy, last reviewed October 2011, revealed "Purpose: To continuously assess activity for those patients requiring arrhythmia detection and recognition. Policy Statement: Cardiac monitoring provides a continuous graphic picture of cardiac electrical activity. Cardiac monitoring is provided via a telemetry system. Cardiac rhythms are continuously monitored by qualified telemetry staff. ..."

Review on December 21, 2011, of PF15 revealed the facility hired this employee on September 12, 2011, and that PF15 received Basic ECG (electrocardiography a test used to record the electrical activity of the heart) on November 21, 2011.

Review on December 21, 2011 of the facility's 24 hours Administrative Report sheet dated November 12, 2011, revealed patients were admitted that required telemetry monitoring.

Review on December 21, 2011, of the facility's Daily Assignment sheet dated November 12, 2011, revealed that PF15 worked as the second registered nurse for that shift.

Review on December 21, 2011, revealed that PF11 performed the function for telemetry monitoring from 8:00 PM to 11:00 PM. The facility was unable to provide documentation that trained, qualified personnel performed the function of telemetry monitoring from 3:00 PM to 8:00 PM

Interview with EMP1 and EMP2 on December 21, 2011, at approximately 4:00 PM confirmed that PF15 functioned as the second registered nurse on November 12, 2011, and that PF15 did not receive Basic ECG training until November 21, 2011. Further interview with EMP1 and EMP2 confirmed the facility was unable to provide documentation that trained, qualified personnel performed the function of telemetry monitoring from 3:00 PM to 8:00 PM.

Based on review of facility documents, observation and staff interview (EMP), it was determined that the facility failed to ensure the security of medical records for four of four applicable medical records (MR1, MR2, MR3 and MR4).

Findings include:

Review on December 20, 2011, of the facility's "Location and Security of Medical Records" policy, last approved June 2011, revealed "Policy: It is the policy of this facility that medical records be maintained in a secure and confidential manner. Areas housing health information shall be restricted to authorized personnel only and these areas will be locked at all times. ... The Health Information Management Department will be responsible for ensuring the security of medical records and /or reports against loss, tampering, and unauthorized access. Procedure: The Health Information Management Department will ensure receipt of all original medical records after discharge of the patient from the hospital. ... Medical records will be maintained within the Health Information Management Department and the department will remain locked 24 hours a day for security purposes. ... Hospital staff members shall not maintain original records in their departments. ..."

Observation on December 21, 2011, at approximately 1:30 AM revealed an unlocked, unsecured, and unmonitored room identified by EMP1, EMP2 and EMP3 as the physician's lounge on the third floor medical surgical unit. Further observation of the physician's lounge revealed MR1's closed medical record on the coffee table and faxed orders for medications and treatments for MR2, MR3 and MR4 on the countertop.

Interview with EMP1, EMP2 and EMP3 on December 11, 2011, at approximately 1:30 AM confirmed that the physician's lounge on the third floor medical surgical unit was unlocked, unsecured, and unmonitored; that the physician's lounge was accessible to unauthorized personnel; that MR1's medical record was on the coffee table; and, that faxed orders for medications and treatments for MR2, MR3 and MR4 were on the countertop. Further interview with EMP1, EMP2 and EMP3 confirmed it is the facility's policy that all patients' medical records must be maintained in a locked and secured manner.