HospitalInspections.org

Based on record review and interviews, the Off-Site Campus did not meet the Condition of Nursing Services because: 1) the Off-Site Campus failed to ensure that: 1) one of one patients (Patient #46), with a history of ventricular fibrillation (a condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles, making them quiver rather than contract. Ventricular fibrillation is the most commonly identified arrythmia in cardiac arrest patients), was placed on telemetry monitoring (remote monitoring of cardiac activity via a monitor) as ordered by Nurse Practitioner #1.

Please refer to the Statement of Deficiency (SOD) # OM5212, dated 7/11/12

Findings include:

1. The Admission Face Sheet indicated that Patient #46 was admitted to the Off-Site Campus in May, 2012.

a. The History and Physical (H&P), dictated 5/13/12 at 6:14 A.M., indicated that Patient #46 ' s medical history was significant for: morbid obesity, diabetes, end-stage renal failure requiring hemodialysis, high blood pressure, cardiac stent placement, deep vein thrombosis and obstructive sleep apnea. The H&P indicated that on 3/27/12, Patient #46 underwent an elective surgical repair of an abdominal fistula that also resulted in a small bowel resection. The H&P indicated Patient #46 suffered from post surgical complications that included ventricular fibrillation resulting in cardiopulmonary resuscitation and respiratory failure requiring intubation and mechanical ventilation. The H&P indicated that Patient #46 had a prolonged stay in the Intensive Care Unit during which time a tracheostomy was performed and a feeding tube was placed to provide nutrition. The H&P indicated that on 5/12/12, Patient #46 was discharged to the Off-Site Campus for continued medical care.

b. The H&P, dictated 5/13/12, indicated that the assessment and plan included plans for Patient #46 to be started on telemetry monitoring.

c. The Physicians Orders, dated 5/13/12 at 5:57 A.M. included an order to start telemetry monitoring as soon as possible.

d. The Surveyor interviewed Nurse #3 (assigned to Patient #46 from 5/12/12 at 7:00 P.M. until 5/13/12 at 7:00 A.M.) on 7/11/12 at 7:00 A.M. Nurse #3 said that she could not implement Patient #46 ' s telemetry order because there were no telemetry units available. Nurse #3 said she told the covering Nurse practitioner (NP #1) that there were no telemetry units available. Nurse #3 said that NP #1 told her to have the next shift, due in at 7:00 A.M., address the telemetry unit shortage. Nurse #3 said she gave report to Nurse #2 at 7:00 A.M., and told Nurse #2 that available telemetry units would have to be triaged to determine if any unit could be discontinued for use by Patient #46..

e. The Surveyor interviewed Nurse #2 on 7/11/12 at 8:20 A.M. Nurse #2 said she told the Unit Coordinator to let her know when a telemetry unit became available. Nurse #2 said she did not speak to the covering Hospitalist about the need for a telemetry unit because she thought NP #1 told him in report about Patient #46 ' s telemetry order not being filled. Nurse #2 said that when she left the Off-Site Campus at 7:00 P.M.; a telemetry unit was still not available.

f. The Surveyor interviewed Nurse #4, assigned to Patient #46 on 5/13/12 as of 7:00 P.M. Nurse #4 said Patient #46 was not started on telemetry monitoring because there was no unit available. Nurse #4 said Patient #46 was in bed all evening. Nurse #4 said she saw Patient #46 at 9:45 P.M. when she passed medications and released Patient #46 ' s wrist restraints and again at a later time (time uncertain) when she pulled up Patient #46 ' s covers. Nurse #4 said that at 11:45 P.M., she was across the hall from Patient #46's room putting another patient to bed when Certified Nurse Aide (CNA) #10 asked her for assistance to pull Patient #46 up in bed. Nurse #4 said that CNA #10 went to Patient #46's room and found Patient #46 unresponsive.

g. The Transfer Summary, dated 5/14/12 and dictated by NP #2, indicated that cardiopulmonary resuscitation was started. The transfer Summary indicated that defibrillator pads (placed on the patients chest and connected to the defibrillator which allow the staff to view cardiac rhythms and are used to provide shocks if the defribrillator identifies the need for shocks) were not located on top of the Code Cart with the defibrillator and could not be located during resuscitation efforts.

h. The Transfer Summary indicated that Patient #46 was transferred to a tertiary care hospital in critical condition.

i. The Surveyor interviewed NP #2 on 7/10/12 at 7:10 A.M. NP #2 said Patient #46 was pronounced dead at the tertiary care hospital.

2. Please refer to A-0396 regarding the Off-Site Campus failure to ensure that fall prevention identifiers were implemented for 2 of 4 randomly selected patients, Patient #47 and Patient #50.

3. Please refer to A-0397 regarding the Off-Site Campus's failure to ensure that: 1) the nurse/patient staffing ratio on the 5/13/12 evening shift was scheduled at safe ratio to meet patients' needs, 2) registered/licensed nursing staff, without evidence of telemetry certification training were assigned to care for telemetry patients and were signing off on telemetry strips printed during their shift and 3) personnel assigned to monitor the master telemetry board, which displayed telemetry patients' cardiac rhythms, were nursing personnel who were qualified to monitor telemetry patients and detect abnormal heart rhythms.

Based on observation, record review and interviews, the Off-Site Campus failed to ensure that: 1) fall prevention interventions were implemented on 5/12/12 when Patient #46 was identified as a fall risk and 2) fall prevention identifiers were implemented for 2 of 4 randomly selected patients (Patient #47 and Patient #50.

Findings included:

1. The Admission Nursing Assessment (Assessment), dated 5/12/12 at 4:42 P.M. indicated that Patient #46 was alert and oriented with periods of confusion. The Assessment indicated that heart sounds were normal. The Assessment indicated that Patient #46 was assessed for fall risk and scored a 13, placing him/her at risk for falls.

a. The Off-Site Campus's Policy/Procedure titled Fall Prevention indicated that patients assessed with a score greater than or equal to 10 were to have bed/chair alarms and a low bed provided to prevent falls.

b. The Surveyor interviewed the nurse (Nurse #2) who performed Patient #46's initial fall assessment on 7/11/12 at 8:20 A.M. Nurse #2 said that she did not implement the bed alarm or low bed because Patient #46 was alert and oriented and was not trying to get out of bed.

c. The Change of Condition Note, dated 5/13/12 at 2:20 A.M. indicated that Patient #46 had an unwitnessed fall out of bed. The Change of Condition Note indicated that Patient #46 did not injure him/her self and was transferred back to bed via mechanical lift and staff assistance.

d. The Surveyor interviewed the nurse assigned to Patient #46 at the time of his/her fall (Nurse #3) on 7/11/12 at 7:40 A.M. Nurse #3 said that after Patient #46 had fallen, she implemented fall prevention measures including a bed alarm and a low bed.


2. The Surveyor conducted a tour of the Off-Site Campus on 7/10/12 at 9:05 A.M. and with the Director of Quality and the Unit Manager present. The Director of Quality said that they used yellow magnets placed on the door frames to the patient rooms to identify patients assessed as at risk for falls.

a. Observation made during the tour indicated that Patient #47 and Patient #50 did not have a yellow magnet.

b. Review of Patient #47 ' s Fall Risk Assessment, dated 7/6/12, indicated that Patient #47 scored a 12 and was at risk for falls.

c. Review of Patient #50 ' s Fall Risk Assessment, dated 7/2/12, indicated that Patient #50 scored a 21 and was at high risk for falls.

Based on observation, review of Assignment Sheets, Staffing Guide and Schedules, education histories, and job descriptions and interviews, the Off-Site Campus failed to ensure that: 1) the nurse staffing ratio on the evening shift of 5/13/12 was at a safe level to meet the patients' needs, 2) registered/licensed nursing staff, with evidence of telemetry certification training were assigned to care for telemetry patients and signed off on telemetry strips printed during their shift and 3) personnel assigned to monitor the master telemetry board, which displayed telemetry patients' cardiac rhythms, were nursing personnel qualified to monitor telemetry patients and detect abnormal heart rhythms.

Findings include:

1) The Assignment Sheet, dated 5/13/12 from 7:00 P.M. to 11:00 P.M., indicated that the Off-Site Campus had a census of 35 patients.

a. Review of the Off-Site Campus 's staffing guide (a grid that identifies the nurse/CNA to patient ratio based on patient census) indicated that for a census of 35 patients, the recommended staffing ratio was 6 registered/licensed nurses and 5 CNAs.

b. Review of the Staffing Schedule, dated 5/13/12 from 7:00 P.M. to 11:00 P.M., indicated that the following nursing staff were scheduled: a nursing supervisor, a unit coordinator, 4 registered nurses (1 of which was agency), 3 licensed practical nurses (2 of which were agency), and 4 certified nurse aides (CNA). The Staffing Schedule indicated that 1 CNA was crossed out, 1 CNA did not show and 1 CNA called out sick.

c. The Off-Site Campus scheduled 1 mid-level staff, either a nurse practitioner or physician assistant to be present on-site from 7:00 P.M. until 7:00 A.M. On 5/13/12, Nurse Practitioner (NP) #2 was scheduled to work.

d. Review of the Assignment Sheet, dated 5/13/12, 7:00 P.M. to 11:00 P.M., indicated that the Off-Site Campus ended up with the nursing supervisor, the unit coordinator, 3 registered nurses (no indication as to what happened to the 4th nurse), 3 licensed practical nurses and 1 CNA (CNA #9).

e. The Surveyor interviewed: 1) the NP #2 on 7/10/12 at 7:10 A.M, 2) Nurse #2 on 7/11/12 at 8:20 A.M., 3) Nurse #4 on 7/11/12 at 9:30 A.M. and 4) CNA #9 on 7/11/12 at 6:45 A.M. NP #2, Nurse #2, Nurse #4 and CNA #9 all said that on the evening of 5/13/12, the Off-Site Campus was not sufficiently staffed and/or was considered unsafe.

2) The Surveyor reviewed the Assignment Sheets from 6/26/12 to 7/10/12 and randomly selected 22 nurses (19 registered nurses and 3 licensed practical nurses) assigned to patients requiring telemetry monitoring and requested the education history for the 22 nurses.

a. Review of the education history (a electronic printout of the individual's education over several years) indicated that: 1) 5 of 22 nurses (including the 2 licensed practical nurses) attended telemetry certification training, 2) 3 of 22 nurses took the Monitor Tech Exam (a one hour exam) without attending a training program, 3) 3 of 22 nurses took an electrocardiogram exam for registered/licensed nurses without evidence of prior training and 4) 3 of 22 nurses attended a 16 hour critical care course that focused on critical care , but not on telemetry monitoring.

b. On 3/20/12, a Back to Basics Telemetry Review (2 hours) was offered and attended by one sampled registered nurse and 1 sampled licensed practical nurse. The review did not include a competency exam to demonstrate certification.

c. The Surveyor interviewed the Clinical Nurse Educator on 7/11/12 at 8:35 A.M. The Clinical Nurse Educator said that she just started the position in March, 2012 and prior to that, there were several nurses in the Clinical Nurse Educator position. The Clinical Nurse Educator said that the Corporation who owned the Off-Site Campus had developed a telemetry exam and it was up to the Nurse Educators to develop a telemetry certification program.

d. The Surveyor asked the Clinical Nurse Manager to review the selected sample of nurses' personnel/education files to determine if there was additional telemetry training that had not been entered into their education history.

e. The Clinical Nurse Educator said that there was no additional telemetry certification training.

3) The Surveyor conducted a tour of the Off-Site Campus on 7/10/12 at 9:05 A.M. with the Unit Manager present. The Unit Manager said that the Off-Site Campus used Monitor Techs, who were also the Unit Coordinators, to observe the Master Telemetry Board located at the Nursing Station. During the tour, the Unit Coordinator was observed to be stationed in front of the Master Board watching the telemetry patients' cardiac activity.

a. Review of the job descriptions and education history for Monitor Techs #4, #5, #6 and #7 indicated that they were hired as either a Unit Secretary and/or a Certified Nurse Aide.

b. Review of the Monitor Technician's job description indicated that, under essential functions, "Monitors telemetry patients by observing telemetry monitors for changes in cardiac rhythms." Under the Summary, it indicated that, "Monitors heart rhythm pattern of patients to detect abnormal pattern variances, using telemetry equipment. Reviews patient information to determine normal heart rhythm pattern, current pattern, and prior variances.

c. The Monitor Technician job description indicated that the Monitor Technician position was under the control and management of the nursing department and reported to nursing managers or supervisors.

d. The Monitor Technician's job description indicated that " Under Knowledge/Skills/Abilities it indicated, "Satisfactory score on EKG interpretation competency test. Ability to accurately identify cardiac rhythms and understand their significance."

e. Review of the telemetry education indicated that Monitor Techs were required to take and pass a 1 hour Monitor Tech Exam, but were not required to attend a training program and per their job description, were required to perform monitoring duties beyond the scope of their practice.

Based on clinical record review of Patient #46 and interview, the Off-Site Campus failed to ensure that: 1) the Off-Site Campus's investigation of the staff's failure to implement telemetry monitoring for Patient #46 was completed in a timely manner and 2) all opportunities for improvement were identified during its investigation of the staff 's failure to implement telemetry monitoring for Patient #46.

Findings include:

Please refer to A-0385 for Patient #46 ' s medical information.

Please refer to A-0397 for information regarding staff training for telemetry monitoring.

1) The Surveyor interviewed the Director of Quality on 7/10/12 and 7/11/12. The Director of Quality said that although an investigation was conducted, the Off-Site Campus had intended to hold an interdisciplinary meeting to determine if all opportunities for improvement had been addressed, but as of the 7/10/12 survey, the meeting did not occur.

2) Review of the Off-Site Campus's investigation of the staff's failure to implement telemetry monitoring for Patient #46 indicated that the investigation did not identify that: 1) staff assigned to monitor and detect abnormal cardiac rhythms did not have adequate qualifications and competence for monitoring telemetry and 2) registered/licensed staff assigned to care for patients on telemetry monitoring had not completed a telemetry certification training program.

Based on record review and interviews, the Off-Site Campus failed to ensure that: 1) corrective actions, developed in response to the Off-Site Campus's investigation of the staff's failure to implement physican-ordered telemetry monitoring for Patient #46, were implemented or followed through for all identified opportunities for improvement.

Findings included:

Please refer to A-0325 for Patient #46's medical information.

1. The Surveyor interviewed the Director of Quality on 7/10/12 and 7/11/12. The Director of Quality said that not all opportunities for improvement identified during the investigation of the staff's falure to implement telemetry monitoring for Patient #46 were addressed because the Off-Site Campus had a 4/30/12 validation survey in the interim and focused on addressing corrective actions in response to deficiencies cited during that survey.

a. The findings identified during the Off-Site Campus's investigation that were not addressed with corrective actions included: 1) The Pre-Admission Assessment did not indicate that Patient #46 required telemetry monitoring, 2) on 5/13/12 at 5:34 P.M., medication was administered to Patient #46 without vital signs recorded to ensure that the medication was within the ordered parameters for administration, 3) The Code Sheet for Patient #46's cardiopulmonary resuscitation was not fully completed and there was no cardiac monitor/automatic external defibrillator strip printed, 4) event reports were not completed for Patient #46's fall or failure to implement telemetry monitoring and 5) Nurse #2's failure to implement fall prevention measures when Patient #46 was initially assessed as a fall risk.

b. The Off-Site Campus had implemented a process to check telemetry orders to ensure that everyone with an order was placed on telemetry monitoring. Audits were conducted on 5/19/12, 5/20/12, 5/22/12 and 5/23/12. No further auditing was not conducted after 5/23/12.