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Based on observation, medical record review, and staff interview, the facility failed to protect the patients' right to receive care in a safe setting by having a qualified, dedicated staff member assigned to visualize the telemetry monitors; which could potentially affect all telemetry patients.

Findings include:

During the opening conference on 3/24/15 with the administrator, he/she revealed the facility had thirty (30) private rooms; that fifteen (15) contained cardiac monitors, but all thirty (30) potential patients could be on telemetry monitoring if ordered.

Interview with ward secretary #3 on 3/24/15 at 10:00 AM at the nurse's station revealed that he/she received EKG recognition training annually; that only patients with orders were placed on a telemetry monitor; that the charge nurse, RN, or respiratory therapist (RT) could watch the telemetry monitors if needed for breaks, and, that his/her responsibilities included:
· Admitting patients in the computer
· Placing order in computer
· Stuffing charts with necessary paperwork
· Thinning charts as needed
· Answering call lights via intercom
· Answering the phone
· Paging nurses or nursing assistant (NA) to respond to patient call light needs
· Watching telemetry monitors
· Obtaining and posting patient cardiac monitoring strips in charts every 8 hours
· Alerting nurses for changes in cardiac rhythms

During a facility tour on 3/24/15 at 12:15 PM with the Director of Patient Care, it was observed that ward secretary #3 was sitting at the nurse's station where the cardiac monitors were located, and was performing various tasks, such as answering call lights via intercom, paging staff regarding patient needs, answering the telephone, and, checking patient medical records.

Interview with MD #8 on 3/24/15 at 1:30 PM at the nurse's station revealed that reasons for ordering telemetry monitoring on patients included diagnosis of ischemic cardiomyopathy, (a weakness in the muscle of the heart due to inadequate oxygen delivery to the heart muscle)ESRD (end stage kidney disease), history of cardiac arrest (heart attack), low potassium, electrolyte imbalance, and ejection fraction (fraction of outbound blood pumped from the heart with each heartbeat; with normal being 55% to 75%) of less than 30%. The physician explained that the MD must order telemetry, and that if telemetry had not been ordered, the nurses sometimes contacted the MD to ask of the patient needed telemetry.

Interview with ward secretary #3 on 3/25/15 at 2:10 PM in the conference room revealed that he/she also worked in the critical care unit; it was difficult to account for percentages of time spent on his/her required tasks; that he/she was provided with a list of the patients who were unable to speak; if a telemetry monitor lead was off (as indicated by telemetry monitor), the unit secretary contacted the NA to re-attach; if there was a problem/change with the patient's rhythm, the unit secretary contacted the assigned nurse (even if the monitor did not alarm), and would phone the MD as instructed by the nurse. The unit secretary went on to explain that he/she never left the telemetry monitors unattended.

Based on medical record review and policy review, the facility failed to assure that orders for restraints be signed by the ordering physician each calendar day as directed by their policy for two (2) of ten (10) medical records reviewed (#s 3 and 6).

Findings include:


Review of ten (10) medical records revealed:
· Patient #3, a 68 year old male patient, admitted on 1/17/15 with diagnosis of pulmonary edema and respiratory failure; had restraints ordered 1/25-2/11/15.
2/2/15 the restraint order was not signed
2/3/15 order signed 2/14/15
2/9/15 order signed 2/15/15
2/10/15 order signed 3/10/15
· Patient #6, a 75 year old female patient, admitted on 2/2/15 with diagnosis of pulmonary edema and respiratory failure; had
2/7-2/10/15 restraint orders signed on 2/11/15
2/14/15 at 2:52 AM order, signed on 2/16/15 at 7:45 PM

Review of policy # LTACH ID NSG 013, Restraints, effective 06-2011, last review 05-2013, revealed physician/LIP would evaluate the patient in person within 24 hours and complete a written order for restraints; continued use of restraint beyond 24 hours is based on patient examination by the ordering physician/LIP and a written order each calendar day

The Director of Patient Care acknowledged the above findings on 3//25/15 at 5:00 PM during the closing conference.