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Based on policy review, medical record reviews, staff assignment reviews, staff interviews and observations, the hospital staff failed to maintain patient safety by not ensuring all telemetry (heart monitoring) tracings were validated and cosigned by a nurse for 8 of 13 patients (Patients #4, #2, #3, #7, #10, #11, #12 and #13).

Findings included:

Review on 11/15/2017 of the hospital's policy, "TELEMETRY, ALARMS, PRIORITIZATION" revised 7/2010 revealed, "Purpose: To clarify telemetry monitoring requirements, ensure patient safety, and provide guidelines to prioritize telemetry when demand exceeds capacity. Indications for Telemetry: ...Alarm Settings ...Monitor Techs/Telemetry Techs (MT/TT) 1. ...2. Strips may be interpreted by a MT/TT or telemetry-competent staff member (Charge Nurse, Assigned Nurse or RT); however, all rhythm strips analyzed by a MT/TT must be validated and cosigned by the assigned RN 'Registered Nurse' or Charged Nurse that is telemetry competent. ...Alarms, Analysis, Documentation and Notification 1. ...9. A rhythm strip will be analyzed and posted at a minimum of every shift. All rhythm interpretations will be validated by a monitor competent RN and so noted by signing the telemetry strip. ..."

1. Closed medical record review on 11/14/2017 revealed on 07/14/2017, Patient #4, a 57 year-old was admitted for respiratory failure. Review of admission orders revealed Physician #9 orders included telemetry (heart monitoring). On 08/09/2017 at 2009, a telemetry tracing was posted, analyzed and interpreted. Review failed to reveal the charge nurse or the assigned nurse validated and cosigned the telemetry tracing.

Review on 11/15/2017 of the staff assignment sheets revealed on 08/09/2017, night shift (7p-7a), Patient #4 nursing care was assigned to Nurse #3, Charge Nurse was assigned to Nurse #4 and telemetry monitoring was assigned to Monitor Tech #7.

Interview on 11/14/2017 at 1937 with Nurse #4 revealed on night shift, at about 2200, the MT would obtain telemetry tracings for each patient on telemetry; in which, would be signed by the nurse if the nurse agreed with the telemetry analysis. Interview revealed Nurse #4 was aware of the hospital's telemetry monitoring requirements.

Interview with medical record review on 11/15/2017 at 1354 with Monitor Tech #7 revealed on 08/09/2017, the staff member worked night shift (7 pm-7 am). Interviewee revealed the telemetry tracing dated 08/09/2017 at 2009 was their analysis and interpretation occurring for that shift. Interviewee revealed Nurse #3 nor Nurse #4 validated and cosigned the telemetry tracing. Interview revealed the hospital staff failed to maintain patient safety.



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2. Open medical record review on 11/15/2017 revealed on 11/01/2017, Patient #10, an 82 year-old was admitted for ventilator-dependent respiratory failure (patient is relying on the breathing machine to breath). On 11/01/2017 at 1307, a nurse signed telemetry strip without documentation of telemetry interpretation (the acknowledgement of measurements for the heart muscle contraction and relaxation timing); 11/01/2017 at 1721, no nurse signature; 11/02/2017 at 0740, no nurse signature authentication; on 11/10/2017 at 0714, no nurse signature authentication; 11/13/2017 at 0833, no nurse signature authentication nor interpretation of telemetry strip and on 11/14/2017 there was no nurse signature authentication.

Interview on 11/15/2017 at 1420 with Nurse #11 revealed the MT was permitted to interpret the telemetry strip; however, it was required that a nurse verify the interpretation name and measurements with signature/date and time which were required to authenticate the strip by a licensed personnel. Nurse #11 reviewed the missing interpretation and signatures during an observation by this surveyor.

Observation on 11/15/2017 at 1500 with Nurse #11 it was stated that as part of the hand off of Nurse to Nurse communication the patient's rhythm and I & O (input and output) should be discussed as part of the process of informing the oncoming nurse caring for the patient. Nurse #11 acknowledged that this should be done routinely and was not done as part of these records.

3. Open medical record review on 11/15/2017 revealed on 10/26/2017, Patient #11, a 75 year-old was admitted for acute hypoxic respiratory failure and acute renal insufficiency (patient's kidneys not function well). On 10/26/2017 at 2327 there was no nurse signature for the telemetry strip; 10/27/2017 at 0749, no nurse signature; 10/30/2017 at 0743, no nurse signature; 11/04/2017 at 1149, no telemetry interval mapping; 11/06/2017 at 0943, no nurse signature; 11/08/2017 at 2224, no telemetry interval mapping; 11/10/2017 at 0107, no telemetry interval mapping and 11/13/2017 at 0834, no nurse signature or telemetry interval mapping.

Observation on 11/15/2017 with Nurse #11 it was stated that as part of the hand off of Nurse to Nurse communication the patient's rhythm and I & O should be discussed as part of the process of informing the oncoming nurse caring for the patient. Nurse #11 acknowledged that this should be done routinely and was not done as part of these records.

Interview on 11/15/2017 at 1420 with Nurse #11 revealed the MT was permitted to interpret the rhythm strip; however, it was required that a nurse verify the interpretation name, measurements with signature/date and time are to accompany the strip. Nurse #11 revealed the missing interpretation and signatures.

4. Open medical record review on 11/15/2017 revealed on 11/03/2017, Patient #12, a 70 year-old was admitted for volume overload (a back up of bodily fluids) and wounds on the lower legs. On 11/04/2017 at 0019 there was no nurse signature for the telemetry strip, 11/10/2017 at 0107 there was no nurse signature nor telemetry interval mapping and 11/13/2017 at 0834 no nurse signature authentication.

Observation on 11/15/2017 with Nurse #11 it was stated that as part of the hand off of Nurse to Nurse communication the patient's rhythm and I & O should be discussed as part of the process of informing the oncoming nurse caring for the patient. Nurse #11 acknowledged that this should be done routinely and was not done as part of these records.

Interview on 11/15/2017 at 1420 with Nurse #11 revealed the MT was permitted to interpret the rhythm strip; however, it was required that a nurse verify the interpretation name, measurements with signature/date and time are to accompany the strip. Nurse #11 revealed the missing interpretation and signatures.

5. Open medical record review on 11/15/2017 revealed on 10/17/2017, Patient #13, an 81 year-old was admitted for Acute respiratory failure. On 11/11/201717 at 1858 there was no nurse signature for the telemetry strip, 11/13/201717 at 0834 there was no nurse signature nor interval mapping for the telemetry strip and 11/13/2017 at 2037 there was no interval mapping of the telemetry strip.

Observation on 11/15/2017 with Nurse #11 it was stated that as part of the hand off of Nurse to Nurse communication the patient's rhythm and I & O should be discussed as part of the process of informing the oncoming nurse caring for the patient. Nurse #11 acknowledged that this should be done routinely and was not done as part of these records.

Interview of Personnel #11 on 11/15/2017 at 1420 it was stated that the MT was permitted to interpret the rhythm strip; however, it was required that a nurse verify the interpretation name, measurements with signature/date and time are to accompany the strip. Nurse #11 revealed the missing interpretation and signatures.


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6. Open medical record review on 11/14/2017 revealed on 11/10/2017, Patient #2, a 69 year-old was admitted for infection of the inner lining of the heart. Review revealed documented telemetry strips starting on admission 11/10/2017 at twice daily intervals through the survey dates. Two telemetry strips dated 11/10/2017 at 1643 labeled "New admit strip" and on 11/13/2017 at 0824 revealed no nurse signature for verification of telemetry interval mapping (the measurement of the heart muscle reaction during blood flow).

Interview on 11/14/2017, at 1500 with Nurse #11 revealed that telemetry was monitored by "techs and" that "all tech are NAs (nursing assistants)." Continued interview revealed that the techs printed and reviewed strips "at least once" during each shift. The nurse for the patient "reviews and verifies the techs readings." Further interview revealed that "strips are printed and reviewed at least once a shift."

Interview on 11/14/2017 at 1937 with Nurse #4 revealed the registered nurse responsible for signing off on telemetry strips each shift.

7. Open medical record review on 11/14/2017 revealed on 10/24/2017, Patient #3, a 63 year-old was admitted for respiratory failure with low oxygen levels. Review revealed telemetry strips from admission, through the survey dates. Further review revealed the following: 11/03/2017 at 0828 no telemetry interval mapping and no nurse signatures indicating a nurse review of telemetry strip; 11/05/2017 at 0928 no interval mapping; 11/13/2017 at 0828 no interpretation initials for tech review strips; 11/09/2017 and 11/09/2017 no time on telemetry strip; 10/30/2017, 11/03/2017 at 1928, 11/04/2017 at 1928, 11/05/2017 at 0928 and 2023, 11/09/2017 at 2023 no nurse signature/date/time for review of interpretation. Further review revealed that on 11/08/2017 there was no documentation of telemetry strips.

Interview on 11/14/2017, at 1500 with Nurse #11 revealed that telemetry was monitored by "techs and" that "all tech are NAs (nursing assistants)." Continued interview revealed that the techs printed and reviewed strips "at least once" during each shift. The nurse for the patient "reviews and verifies the techs readings." Further interview revealed that "strips are printed and reviewed at least once a shift."

Interview on 11/14/2017 at 1937 with Nurse #4 revealed the registered nurse responsible for signing off on telemetry strips each shift.

8. Closed medical record on 11/14/2017 revealed on 10/10/2017, Patient #7, a 71 year-old was admitted for respiratory failure and difficulty swallowing. Review revealed that on 10/27/2017 at 1913 there was no telemetry interval mapping and no nurse signature indicating a nurse review of telemetry strip; 10/26/2017 at 0819, 10/26/2017 at 2117 and 10/29/2017 at 1927 no interpretation initials for tech review strips; 10/26/2017 10/28/2017, and 10/29/2017 no nurse signature/date/time indicating review of tech interpretation.

Interview on 11/14/2017, at 1500 with Nurse #11 revealed that telemetry was monitored by "techs and" that "all tech are NAs (nursing assistants)." Continued interview revealed that the techs printed and reviewed strips "at least once" during each shift. The nurse for the patient "reviews and verifies the techs readings." Further interview revealed that "strips are printed and reviewed at least once a shift."

Interview on 11/14/2017 at 1937 with Nurse #4 revealed the registered nurse responsible for signing off on telemetry strips each shift.

Based on policy review, medical record reviews, incident report review, medication report reviews and staff interviews, the hospital staff failed to demonstrate safe administration of medication by not obtaining a physician order prior to dispensing and administering a medication to 1 of 13 (Patient #4) from the night cabinet.

Findings included:

Review on 11/15/2017 of the hospital's policy, "DRUG DISTRIBUTION WHEN PHARMACY IS CLOSED" revised 10/2015 revealed, "PURPOSE: A system is needed by which nurses may obtain medications for new orders, missing doses, and wasted doses after the pharmacy is closed. POLICY STATEMENT: Medications will be available, as approved by the Pharmacy and Therapeutics Committee, for after-hours use when the pharmacy is closed. These supplies will be accessible to authorized persons in a "night cabinet". PROCEDURE: 1. A locked cabinet, automated dispensing system, or other locked storage site is stocked with an appropriate supply of selected medications for authorized use by non-pharmacists for initiating medication orders. For purposes of this Policy and Procedure, these sites are referred to as "the nigh cabinet". 2. ...6. A pharmacist must review all medication orders written after the pharmacy is closed within 24 hours. If drugs were removed from the night cabinet pursuant to these orders, the pharmacist must verify that the correct product was used. Discrepancies will be documented on an incident report. ..."

Closed medical record review on 11/14/2017 revealed on 07/14/2017, Patient #4, a 57 year-old was admitted for respiratory failure. On 08/10/2017 at 0430, Nursing flowsheet review revealed Physician #14 was notified, gave orders for Narcan intravenously and Narcan was administered when ordered. Physician Orders revealed on 08/10/2017 at 0500, Physician #14 gave a telephone/verbal order to Nurse #4 for Narcan (reversal medication). Code Blue (medical emergency) record review revealed from 0515 to 0543 (28 minutes), no documentation of Narcan administration. Further review revealed at 0522, 0535 and 0542, Sodium Bicarbonate (antacid) was 1 of 3 medications administered during the medical emergency. Review revealed Patient #4 did not survive the medical emergency and the time of death was pronounced at 0546. Review failed to reveal how much Narcan was administered and an order for 1 of 3 Sodium Bicarbonate administered.

Review on 11/14/2017 of the incident report revealed on 08/10/2017 at 1516, The Pharmacist reported a medication related incident secondary to medications removed from the night cabinet and drugs administered without orders nor charted. The incident date and time was 08/10/2017 at 0450 which involved two medications: Narcan and Sodium Bicarbonate. Review revealed the incident underwent review and it was determined all staff should adhere to policies when removing medications from the night cabinet and when administering medications.

Review on 11/15/2017 of the Pharmacy night cabinet log revealed at 0450/0500, Narcan and Sodium Bicarbonate were removed from the night cabinet. Review revealed no dates were associated with the times of medication removal.

Review on 11/15/2017 of the MAR (Medication Administration Record) revealed from 07/14/2017 to 08/10/2017 (28-days), revealed no documentation that Narcan nor Sodium Bicarbonate were scanned and administered to Patient #4.

Interview on 11/14/2017 at 1830 with Nurse #3 revealed the personnel remembered Patient #4 as demonstrated by increased requests for pain medication which were associated with moaning. On 08/10/2017, night shift (7p-7a), interviewee revealed the patient was assigned to their Primary nursing care was assignment and at the start of the shift, the patient vital signs were normal despite having a low-grade temperature secondary to developing an infection; in which, the patient was ordered and administered fluids and antibiotics (medication for bacteria). Interviewee revealed prior to the Code Blue, no concerns were reported to Nurse #4 nor did Nurse #4 inquire about the patient. As related to acquisition and administration of Narcan and Sodium Bicarbonate, the interviewee revealed Nurse #4 received the order and administered the medications. Interviewee revealed that medication should not be administered without an order.

Interview on 11/14/2017 at 1937 with Nurse #4 revealed the personnel remembered Patient #4 as demonstrated by difficult to arouse on 08/08/2017, night shift. Interview revealed on 08/09/2017, night shift, the personnel was on duty in a leadership capacity. As related to Narcan and Sodium Bicarbonate for Patient #4, interviewee revealed they received the order from Physician #14 because the patient demonstrated decreased level of consciousness and decrease response to tactile stimulation; in which, Sodium Bicarbonate was obtained from the Code Cart (emergency medication/monitoring equipment) and Narcan was obtained from the night cabinet. Interview revealed ½ amp of Narcan was administered, patient was rolled onto their side, patient vomited and coded (life-saving measures required). Interviewee revealed a Code Blue was called and the on-call Physician, hospital staff and the host hospital Code Blue team responded and assisted with life-saving measures. Interviewee revealed Sodium Bicarbonate was administered during and not prior to the Code Blue. Interview revealed Sodium Bicarbonate was obtained from the code cart and was not administered prior to the Code Blue.

Interview on 11/15/2017 at 0945 with the Pharmacist revealed the personnel was familiar with and had oversight for the night cabinet medication. As related to Sodium Bicarbonate and Narcan dispensed from the night cabinet for Patient #4 revealed on 08/10/2017 at 1516, an incident report was submitted because when the Pharmacy department conducted their daily audit, there were no orders for Narcan nor Sodium Bicarbonate within the patient's medical record nor was there a rapid response form that indicated the medications were administered. And based upon the lack of documentation, the Pharmacy department was unable to determine if the patient received the medication. When the medication discrepancies were identified, they were reported to other members of the hospital leadership team; in which, the discrepancies were "heavily" discussed and investigated. The outcome of the investigation determined to be no medication error occurred and based upon that outcome, no concerns were reported to the Pharmacy Board. Interview revealed Narcan and Sodium Bicarbonate were dispensed from the night cabinet prior to obtaining a physician order.

Interview on 11/15/2017 at 1130 with the Director of Quality Management and the Chief Nursing Officer revealed the Pharmacist created "confusion" by creating an incident report prior to conducting a thorough investigation; at which time, the State Agency consultant informed the interviewees the investigation was not to place blame but to survey the hospital as one entity for the care provided to Patient #4. As related to the incident report interview revealed the report was related to Nurse #3 and Nurse #4 dispensing Narcan and Sodium Bicarbonate from the night cabinet for the patient. As a result of the incident report, the investigation revealed two Sodium Bicarbonate medication packaging were maintained on the Code Cart, indicating the third Sodium Bicarbonate was obtained from another location. Interviewees revealed that Nurse #4 stated the Sodium Bicarbonate was obtained from the Code Cart and administered during the Code Blue interventions for Patient #4. The State Agency consultant informed the interviewees the investigation revealed Narcan and Sodium Bicarbonate were removed prior to the Code Blue. Interview failed to reveal a physician order for 1 of 3 Sodium Bicarbonate administered during a Code Blue.

Telephone interview on 11/16/2017 at 1140 with Nurse #4 served as a follow-up for clarification related to the Code Blue occurring 08/10/2017 at 0515 involving Patient #4. Interview revealed Nurse #17 involved Nurse #4; in that, Nurse #3 needed assistance with the patient. Upon entering the room, Nurse #4 assessed the patient, obtain medication order upon physician notification, obtain after-hours medication and participated in the Code Blue. As related to the physician order for Sodium Bicarbonate, interviewee revealed Physician #14 discussed the administration of Sodium Bicarbonate and the medication was the first med administered during the code. As related to the documentation on the night cabinet sheet interviewee revealed Narcan and Sodium Bicarbonate were dispensed from the after-hours pharmacy on 08/10/2017 at 0450/0500 perspectively for Patient #4 purposes (15-minutes prior to the Code Blue). Interview failed to reveal a physician order for 1 of 3 Sodium Bicarbonate dispensed and administered to a patient and failed to reveal how much Narcan was administered.

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