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Based on a review of facility documents, medical records (MR) and employee interview(EMP), the facility staff failed to adhere to the hospital policies and procedures regarding telemetry in five of five medical records (MR2, MR3, MR4, MR5, and MR6)

Findings include:

On June 24, 2025, a review of POL-7657421, Bedside and Telemetry Monitoring (Last Approved: 6/2/2025; Last Revised: 6/2/2025) was completed and revealed the following: C. Monitored Units: 1. On arrival, initiation of monitoring, change in care giver, and any time patient comes on/off monitor, (i.e. transport/ bathing) the monitor tech will verify patient name, room number, pack number, and order for monitoring. If there is not an order contact the nurse to obtain an order from the provider. The monitor tech will check daily for an order for continuous cardiac monitoring and notify the nurse if an order is needed. 2. The nurse will take the telemetry pack to the patient, apply the electrodes and the monitor pack. The Nurse will call the monitor tech to make sure the rhythm is visualized. The RN will physically look at pack and verify box number with monitor tech. The monitor tech will document on log sheet and nurse will document box number in EPIC. a. During each assigned handoff or when the patient is off the floor for procedures/testing, the RN shall validate the telemetry box number matches the monitor tech log. Confirmation shall be documented within EPIC under the complex cardiac assessment flow sheet by the RN. 3. A monitor tech will be assigned to watch the central monitors on each shift. A registered nurse may rotate to this position. The staff member assigned to monitor telemetry may not leave the monitors unattended at any time. Coverage will be provided for breaks and lunch... 5. For each patient the monitor tech will document in Epic under the complex cardiac assessment time, lead, heart rate, PR interval, QRS duration, QT interval and strip interpretation every 12 hours (0730 and 1930) ...6. The bedside nurse: a. Will analyze and review the interpretation and measurements done by the monitor tech and document. b. Will document the rhythm and rate with vital signs. c. Will document if there are cardiac symptoms d. The nurse will also document if the rhythm was reviewed with the monitor tech. this is located under the complex cardiac assessment " EKG strip reviewed " and choose " with monitor tech. "

On June 24, 2025, a review of open medical records on Unit 5C was completed and revealed the following:

On May 21, 2025, MR2 was transferred from the ICU to Unit 5C and ordered telemetry monitoring. There was no documentation, upon transfer, at 01:41, of the telemetry box number. On May 23, 2025, at 10:00 PM, the monitor tech failed to document PR interval, QRS duration, and QT interval, per facility policy. On May 24, 2025, there was no rhythm strip located in MR2 for the shift commencing at 1930.

On June 22, 2025, MR3s telemetry was discontinued and re-ordered at 1603 on June 23, 2025. On June 23, 2025, at 1834 and 1931, it is noted that the telemetry box number was not documented with the reapplication of the telemetry monitor. On June 24, 2025, at 0900, the telemetry box number was entered into MR3, 13.5 hours after re-application.

On June 23, 2025, MR4was transferred from the intensive care unit to Unit 5C. Telemetry was ordered. On June 23, 2025, at 1929, the telemetry pack number was not documented, per policy. However, it was documented that MR4 was on a bedside monitor. On June 24, 2025, at 0730, neither the lead nor telemetry pack number was documented. MR4 was documented to be on a bedside monitor, at this time. On June 24, 2025, at approximately 12:15 PM, EMP3 was asked if Unit 5C had beside monitoring capability. EMP3 stated that the unit did not have bedside capability- only telemetry.

On June 14, 2025, MR5, admitted for a NSTEMI, arrived to Unit 5C at 1311 with an order for telemetry. At 1327, the monitor tech and the RN failed to document the telemetry pack number. On June 14, 2025, at 2057, the monitor tech failed to document the telemetry pack number. The RN documented at 1342, 2015, and 2339 and failed to document the telemetry pack number per hospital policy. The telemetry pack number was not documented in the medical record until June 18, 2025 at 0155, approximately 3.5 days after admission.

Lead of the telemetry tracing for MR5 was not documented by the monitor tech on June 15, 2025 at 0729 and 2101; June 16, 2025, at 0730 and 2316; June 17, 2025, at 0729 and 2000; and June 18, 2025 at 0730 and 2342.

On June 21, 2025, MR6 was admitted to Unit 5C with a diagnosis of bradycardia and ordered telemetry. Lead(s) of the telemetry tracing for MR6 was/were not documented by the monitor tech on June 22, 2025 at 0729 and 2134; June 23, 2025, at 0732 and 1932; and June 24, 2025, at 0730.

On June 24, 2025, the above findings were confirmed with EMP2 between 11:30 AM and 1:30 PM.