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Based on observation, interview, and record review, the facility failed to:
- Promptly identify and correct deficiencies of inaudible alarm systems (cardiac telemetry monitoring, pulse oximetry monitoring, and patient call light monitoring) which were designed to alert nursing staff that assistance was necessary. This had the potential to affect all patients within the facility.
- Provide effective nursing supervision, and therefore failed to provide a safe environment for one patient (#5) of four patients observed with tracheostomies (a surgical opening in the neck to provide easy access to the windpipe) who was confused, unable to speak, and unable to use the patient call light system to alert nursing staff to his needs.
- Appropriately monitor, recognize, and respond in a timely manner to monitor alarms for one (#5) of fourteen patients who were being monitored by telemetry (continuous monitoring of the heart rate) and pulse oximeter (a finger clip that measures oxygen level), which resulted in Patient #5 receiving insufficient oxygenation for ten minutes and also resulted in him being placed on a ventilator (a machine which moves air in and out of the lungs to assist breathing). These failures had the potential to affect all patients who received telemetry or oxygenation monitoring.

The severity and cumulative effect of these systemic practices resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 482.23 Condition of Participation: Nursing Services.

The facility census was 24.


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Based on observation, interview and record review the facility failed to respond in a timely manner to monitor alarms for one (#5) of ten patients who were being monitored by telemetry (continuous monitoring of the heart rate) and one (#5) of 14 patients who were being monitored by pulse oximeter (a finger clip that measures oxygen level), which resulted in Patient #5 receiving insufficient oxygenation for ten minutes and also resulted in him being placed on a ventilator (a machine which moves air in and out of the lungs to assist breathing). The facility census was 24.

Findings included:

1. Record review of the facility's Policy Number 60019 " Government and Accreditation - Sentinel Event, " dated 08/29/11, showed the following direction:
- Sentinel Event - Any unexpected occurrence involving death or serious physical or psychosocial injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
- Such events are called "Sentinel" because they signal the need for immediate investigation and response.
- PROCEDURE:
- Coworkers are to report suspected sentinel events or near miss events immediately to their manager. A report is to be submitted
- The manager is to notify the Chief Quality Officer (CQO) or the Administrator On-Call who may consult with the Sentinel Event Task Force.
- If it is determined a sentinel event has occurred the CQO or designee may notify the President CEO who may voluntarily report the sentinel event to the Joint Commission (JC).
- The Sentinel Event Committee (SEC) will commission a team to perform a thorough and credible review of the event. A root cause analysis will be completed with the finds, and action plan submitted to the SEC for approval within 45 calendar days of the sentinel event.

Record review of an untitled facility document provided to surveyors on 11/29/11 showed the following direction:
- Adverse Event - An adverse event is an inappropriate, undesirable and usually unanticipated event. It is any negative event or situation which was not anticipated, even if there is no injury to the patient. This includes near misses.
- Sentinel Event Examples:
- Any patient death, paralysis, coma or other major permanent loss of function associated with a medication error, operative or postoperative complications, or delay in treatment.
- Any "near miss."
- An in-depth review of the event will be conducted through a process, called "root cause analysis." The purpose of the analysis is to understand how and why the event occurred and to prevent the same or similar event from occurring in the future.

2. Record review of Patient #5's medical record showed the following:
The History and Physical (H&P) dated 11/16/11 showed the patient was admitted to the facility on 11/16/11 at 5:30 PM for continuing respiratory care following neck surgery which involved placement of metal rods and pins, and placement of a tracheostomy (a surgical opening in the neck to allow direct access to the windpipe) at another hospital. Diagnoses on admission included respiratory failure and mild memory loss.
- Admission Orders dated 11/16/11 at (time illegible) showed the following:
- Oxygen: High Humidity
- Titrate (adjust) FIO2 (the fraction of inspired oxygen in a gas mixture) to keep SPO2 (Saturation of Peripheral Oxygen - a measurement of the amount of oxygen being carried by red blood cells, which indicates how well the patient is breathing and how well blood is being pumped throughout the body) over 92%
- Continuous Pulse Oximetry
- Aspen collar (a plastic device that stabilizes the neck) at all times
- The nursing Patient Admission Assessment dated 11/16/11 at 5:30 PM showed that the nurse identified the patient's barriers to learning as: unable to comprehend, disoriented/confused, lack of memory, lack of motivation, anxiety/depression. It also showed the patient was oriented to person only and was restless and confused at night.

Review of nursing and respiratory therapy documentation showed the following:
- Nursing: On 11/16/11 at 10:00 PM the patient was noted to be disoriented and removed his oxygen device and telemetry leads. The patient was redirected and educated regarding the importance of leaving his oxygen on. The call light was placed within reach of the patient and the nurse documented that the patient would be monitored frequently.
- Nursing: On 11/17/11 at 12:20 AM the patient was noted to be anxious, restless and agitated. A notation at this time indicated the patient was having pain, which was documented as "ache," and the patient was given pain medication. Documentation at 1:20 AM showed the patient was "resting."
- Nursing: On 11/17/11 at 4:00 AM, the patient was documented as "resting," and level of consciousness was documented as "normal." A notation was made that the patient denied pain.
- Respiratory: On 11/17/11 at 5:23 AM, the therapist wrote, "Patient removed his HHTP (High Humidity T-Piece - A "T" shaped apparatus which is used to deliver oxygen via tracheostomy). The patient was not in respiratory distress (having difficulty breathing), and desaturation (reduction of oxygen level) was not noted."
- Nursing: On 11/17/11 at 6:00 AM, the patient was documented as "resting." There was no documentation to indicate the patient was in pain, and no documentation that the patient was anxious, restless or agitated.
- Nursing: On 11/17/11 at 7:35 AM Staff K, RN, responded to an audible monitor alarm in Patient #5's room. The patient was unresponsive with agonal (a gasping type of respiration, usually preceding death) breaths, and noted he appeared cyanotic (a purplish, blue color) and was diaphoretic (sweating). The nurse observed that the patient's oxygen was disconnected from the tracheostomy, his telemetry leads were not connected, and his pulse oximeter reading was 45%. (Oxygen saturation levels are considered "normal" at 95%-100%. http://www.mayoclinic.com/health/hypoxemia/MY00219) She was able to palpate (feel through the skin) a pulse. Staff K immediately began mechanical ventilation with an Ambu bag (a self-inflating bag used during resuscitation to assist with breathing), and noted rapid improvement of his oxygen saturation level. His telemetry leads were reconnected, and his cardiac rhythm was noted to be atrial fibrillation (also known as "A fib" - quivering movement of the upper part of the heart). Staff K contacted Respiratory Therapy for assistance, and notified the patient's physician, Staff U, who came to assess the patient. The patient's nurse, Staff HH, also responded to the patient's bedside.
- Nursing: On 11/17/11 at 7:34 AM (NOTE: Time discrepancy noted. Time documented here came from nursing documentation.) Staff HH, RN, entered the patient's room to find Staff K, RN, ventilating Patient #5 with an Ambu bag. The pulse oximeter showed 93%, with a heart rate of 80, and a cardiac rhythm of atrial fibrillation. Staff HH noted that the patient's initial blood pressure (BP) reading was high (not documented), but noted it was within normal limits after the first five minutes. Occasional agonal breathing was noted. The patient was placed on a ventilator by Respiratory Therapy per order of Staff U. The patient was noted to be unresponsive to painful stimulation.
- Respiratory: On 11/17/11 at 7:56 AM, Respiratory Therapy was called to the patient's room by nursing staff, and placed the patient on a ventilator due to low oxygen levels. The patient was given 100% oxygen (O2) by nurses, and the patient's oxygen saturation level elevated to 100%.
- Nursing: On 11/17/11 at 10:30 AM the patient opened his eyes and was able to follow simple commands and nodded his head to questions.

Record review of Facility Records Related to the Event:
Record review of a report dated 11/29/11 at 2:52 PM, showed the following:
At 7:35 AM (on 11/17/11), Staff K, RN, heard (the) pulse oximeter alarming in (room) 1205. Staff K reported that she did not see anyone at the nurse station. She entered and found (the) patient with O2 and EKG (telemetry) leads disconnected. Staff K reported the patient had agonal breathing with an O2 level of 45% and a palpable pulse. She called for help and immediately began artificial respiration with an Ambu bag. Respiratory Therapy staff, Staff U (the patient's physician), and Staff HH (the patient's nurse) responded. When Staff U arrived at bedside, he reported suctioning a mucous plug from the patient's lungs and the patient's oxygen saturation levels rose to 100%. Patient placed on ventilator. Patient remains in A fib (baseline - the patient's rhythm before the event occurred).

During an interview by conference call on 11/30/11 at 3:50 PM Staff W, Patient Safety Manager, and Staff X, Director of Patient Safety, stated that they were contacted by Staff A, Director of Nursing, and Staff J, Administrator on 11/17/11 and the incident with Patient #5 was reported. Staff X stated that after receiving the verbal report of the incident on 11/17/11, they did not initiate any action until notifying the Director of Quality to initiate a root cause analysis on 11/22/11.

Record review of hand written documentation reportedly recorded by Patient Safety staff during a telephone conversation on 11/17/11 (no time documented) with Staff J, Administrator, and Staff A, Director of Nursing regarding this incident showed that staff heard the alarm sound in the patient's room. They went to the patient's room and found the patient with the O2 off. The patient was dusky and had agonal breathing. Staff called for help and provided artificial respiration with the Ambu bag. Oxygen saturations were (elevated to) 89-100% and the patient was placed a ventilator for assistance. Approximately 2? hours later respiration was "appropriate." The patient was not in restraints. He was a new admission 11/16/11 and had a history of needing restraints.

Record review of the initial RCA meeting minutes held 11/28/11 from 2:00 PM to 4:00 PM included the following:
- The patient was being monitored by eICU (see explanation below), but (there was concern that) they might not see changes (in a patient's condition) and (they) had no audible alarms.
- There were no real time alarms at the Central Station (a work station near the lobby from which two nursing units are angled. This work station is at an equal distance from each unit nursing station and is staffed by a Unit Secretary), and there was a question of whether the Unit Secretary notified staff that alarms were sounding at the Central Station.
- The patient's pulse oximeter was set to alarm when the oxygen level was less than 87% saturation.

During an interview on 11/30/11 at 11:20 AM, Staff V, Executive Director of TeleMed Services for this facility, stated the facility was part of a healthcare system which provided telemedicine technology for patients throughout their network of hospitals. (Telemedicine involves the exchange of medical information from one site to another via electronic communications to assist with patient monitoring and improve patients' health status. These systems had the ability to monitor patient's vital signs - defined as blood pressure, pulse and respiration; monitor cardiac rhythm and oxygenation levels; and included the capability of videoconferencing with the nursing staff and the patient through the use of a camera wired into the specially equipped patient room.) Staff V stated this facility had ten patient rooms that were set up for telemedicine, but only six of the ten rooms were capable of videoconferencing. These specially equipped rooms were referred to as eICU (electronic Intensive Care Unit) and provided an additional level of monitoring by nurses and physicians 24 hours a day/7 days a week for patients receiving that service. eICU was integrated at this facility approximately one year ago. Staff V stated that facility nurses had primary responsibility for monitoring and providing care for patients in these rooms, but could request the assistance of eICU staff by pushing a button within the specially equipped eICU rooms. eICU staff could then turn on a camera in the patient's room and rotate it to directly observe the patient, could speak directly with nursing staff or the patient from their remote location, and were able to zoom in with the camera to the extent that they could observe readings on monitors within the room.

During an interview on 11/30/11 at 2:10 PM, Staff U stated that a physician's order was not required to place a patient on eICU monitoring. Staff U stated that after nursing assessment, a nurse could initiate eICU monitoring if she needed assistance monitoring the patient.

During an interview on 11/29/11 at 2:06 PM, Staff B, Director of Quality, stated he was unofficially notified of a "near miss" in this facility on 11/17/11 during a hallway conversation at another facility. He stated that this was not considered a "sentinel" event because the patient didn't die, and "near miss" events would not require immediate investigation. Staff B stated that the Patient Safety Department "owns" the RCA process, and an RCA is not initiated until or unless directed by the Patient Safety Department.

During an interview on 11/30/11 at 10:00 AM Staff B stated that he was briefed about the incident by the Patient Safety Department on 11/22/11, and was told that the facility Administrator and Director of Nursing notified the Patient Safety Department of the incident on 11/17/11. He stated that he was notified that RCA was required on 11/22/11 but did not begin an investigation until 11/28/11 (11 calendar days after the incident, and 5 calendar days after being informed that investigation was necessary) due to the Thanksgiving holiday. Staff B stated that there was no standard timeframe for initiation of investigations or initiation of the RCA process, and stated he did not appreciate the gravity of the situation until he started doing the RCA.

During an interview on 11/29/11 at 2:55 PM, with Patient #5's family members, the following statements were made:
- A family member stated that during the admission process at the facility, the family informed the staff that the patient was unable to use the call light. A family member stated they placed the call light in the patient's hand and asked him to press the call light and he was unable to do so.
- A family member stated they told the staff that the patient often grabbed his lines because he was trying to find the Yankauer (a tool used to suction secretions from the mouth).
- A family member stated that he called the nursing station on 11/17/11 at about 5:00 AM to check on the patient. No one answered so he called another family member to notify him/her that he was unable to reach a nurse.
- A family member stated that he/she then called the facility and spoke with Staff FF, RN, regarding the patient's condition. The family member stated Staff FF told him/her that he had tried to pull his humidifier (warmed and moisturized oxygen) off during the night but was doing "OK."

During an interview on 11/29/11 at 2:15 PM, Staff A, Director of Nursing (DON) stated that soon after she entered the building on 11/17/11, she was told that patient #5 had pulled his O2 and telemetry leads off, resulting in decreased oxygen saturations in the 40's and the patient was placed on a ventilator.

During an interview on 11/30/11 at 4:15 PM Staff J, Administrator, stated that she was informed of the incident of Patient #5 the morning of 11/17/11. Staff J and Staff A, Director of Nursing, reported the incident to the Patient Safety Department by phone, but did not document this notification.

During an interview on 11/30/11 at 9:41 AM, Staff K, RN, stated that on the morning of 11/17/11 Staff HH (the patient's nurse) was in the med room preparing medications for administration. Staff K stated that she had been in another patient's room with the door shut, and did not hear any alarms until she opened the door to the patient's room. When she came out of that patient's room, she heard an alarm going off directly across the hall. She said no one else was at the desk or in the hallway. She stated that she entered the patient's room and saw the telemetry leads were on the floor and the oxygen tubing was on the floor. She noticed the patient had agonal breathing, then looked at the monitor and saw that the O2 saturation was registering in the 40% range. Staff K was able to palpate a pulse at the groin and began artificial respiration using an Ambu bag. She yelled for help and another nurse came in to assist with resuscitation efforts. She said the patient's O2 saturations started to rise. Respiratory Therapy then entered the room and placed the patient on a ventilator. At that same time, the patient's physician, staff U, entered the room and assessed the patient.

During an interview on 11/30/11 at 2:10 PM, Staff U, the patient's physician, stated the following:
- After entering the patient's room during this incident, Staff U suctioned the patient and removed a mucus plug the size of a pea. He stated he believed the mucus plug to be the cause of the patient's breathing difficulties and the reason that the patient was pulling at his tubes. Staff U reviewed the patient's data from the eICU monitors after the incident, and the data showed that the patient had been in the range of 40% oxygenation for 10 minutes. When questioned whether Patient #5 would have any permanent damage from this event, Staff U stated that he thought there would be no long term consequences, and stated the patient's functional status had returned to his pre-incident level of function.

Call Lights, Telemetry, and Alarm System
Observation on 11/28/11 at 3:00 PM showed a patient call light mounted approximately five feet from the door outside of each patient room. When the light was turned on, it indicated that the patient in the room was in need of assistance. Lights were observed to light up, but there were no audible alarms to indicate the light was turned on.

During an interview on 11/29/11 at 10:33 AM, Staff A, Director of Nursing, stated that the call light alarms were turned off on the nursing units because the alarms disturbed patients. Staff A stated that when a patient pressed the call light button, a light went on outside the patient's room and the patient's room number simultaneously appeared on a monitor screen at the Central Station, which was approximately 125 feet from each nursing station. The call light was answered by the Unit Secretary at the Central Station, the Unit Secretary would ask the patient what was needed, and would then relay the patient's request by phone to the patient's primary nurse. If the nurse did not answer the phone, a message was left. When the Unit Secretary hung up the receiver after talking to the patient, the call light would disappear from the monitor at the Central Station, and the light outside the patient's room would turn off.

Observation during the interview showed that some call lights were not visible from the nursing station or unit hallway, because the hallway at the end of each nursing unit was shaped like a "T." One patient room was positioned at each side of the T, obstructing those wall-mounted patient call lights from visualization unless observed from the end of the hallway. (Two rooms were obstructed from visualization on the "Lilac" hall, and one room was obstructed from visualization on the "Rose" hall.)

During an interview on 11/28/11 at 3:15 PM, Patient #1 stated that at times, she had to wait 30-45 minutes before her call light was answered. She stated she thought the facility provided good care, but the delay in answering call lights concerned her.

During an interview on 11/30/11 at 8:35 AM, Staff B, Director of Quality, stated that the facility had been aware for a year that the call light system needed work because audible alarms for call lights could not be heard on the nursing unit. Staff B stated that the facility did not wish to do a costly replacement or conversion of the current call light and alarm systems because the facility was considering a move to a new facility.

Observation on 11/28/11 at 3:30 PM showed a telemetry monitor mounted near each nursing station at a height of approximately six feet. The telemetry monitor screens were difficult to read when standing within two feet of the monitor. There were no audible alarms on these monitors to alert staff to abnormal cardiac rhythms, and nursing staff were not observed to observe the telemetry monitor.

During an interview on 11/28/11 at approximately 3:30 PM, Staff CC, RN, "Lilac" Hall, stated that telemetry monitors were mounted on both nursing units, but that patients receiving telemetry were rarely placed on the "Lilac" Hall. Staff CC stated that patients receiving telemetry monitoring were placed on the "Rose" Hall - which was used primarily for patients on respirators and those requiring close monitoring. (eICU is also located within a patient room on the "Rose" Hall.)

During an interview on 12/02/11 at 2:10 PM, Staff K, RN, "Rose" Hall, stated that she had difficulty viewing rhythms on the telemetry monitor outside of the nursing station, and stated there were no audible alarms on the monitor itself to alert staff to a rhythm change.

During an interview on 12/01/11 at 08:55 AM, Staff B, Director of Quality, stated that when Patient #5's pulse oximeter monitor alarmed on 11/17/11, it wasn't audible at the Central Station where the Unit Secretary sat. He stated that the previous Director of Nursing made the decision to turn off all audible alarms at the Central Station because they disturbed visitors sleeping in the lobby area at night. This included the alarms for call lights, telemetry monitors, and pulse oximeters.

During an interview on 12/02/11 at 9:30 AM, Staff B stated that audible pulse oximeter alarms in patient rooms were also set at a volume of 50% at the time of the event. The decision to set the volume at 50% loudness was also made by the previous Director of Nursing, who had left employment nine months prior to the survey. Staff B stated that the facility had restored all patient room alarms to 100% during the night of 12/01/11. Staff B also stated that the facility did not have currently the capability of making overhead pages (the facility occupied space on the lower level of a nursing home, and the nursing home did not allow paging), but was attempting to negotiate use of the paging system to prevent potential problems of nursing staff not responding quickly to alarms.

Observation on 12/01/11 at 4:20 PM, after alarms were restored to full volume (100%) showed that pulse oximeter alarms in a patient room directly opposite the "Rose" Hall nursing station could be heard up to three patient rooms away if room doors were left wide open. However, when the door to a patient room three doors away was closed, the alarm could not be heard at all.

During an interview on 12/02/11 at 2:10 PM, (after alarms were restored to full volume) Staff K, RN, "Rose" Hall, stated that pulse oximeter alarms were audible inside patient rooms, but stated she could not hear pulse oximeter alarms in rooms three to four patient rooms away.

During an interview on 12/02/11 at approximately 2:20 PM, both Staff K, RN, and Staff HH, RN, stated that until the monitor alarms were turned to full volume, they had not realized how soft the alarms were and how hard they were to hear. Staff K stated that in general, she thought the alarms were louder than before.

During an interview on 12/01/11 at 9:55 AM, Staff EE, Unit Secretary, stated that visual monitor alarms went off "all the time" at the Central Station. When the visual alarms went off, the Unit Secretary was to phone the unit nursing station to inform the nurses of a patient alarm or of a patient need. In addition to answering unit call lights and relaying patient requests to the nursing unit, the Unit Secretary's responsibilities included monitoring telemetry rhythms and relaying abnormal rhythms to nursing staff, monitoring pulse oximeter alarms and relaying data to the nursing staff, answering and transferring incoming phone calls, transcribing physician orders, setting up patient appointments outside the facility, and completing laboratory requisitions. Staff EE stated that sometimes she was overwhelmed by the volume of work and activity level at the Central Station, but that she had gotten "used to it." Staff EE stated that she could hear pulse oximeter alarms in the first few room on each patient hall but could not identify what rooms the alarms were originating from. Staff EE said that if she saw an abnormal cardiac rhythm on the telemetry monitor and could not reach someone on the ward by phone, she would leave her work station to locate nursing staff or check on the patient herself. When questioned regarding the safety of other patients if she abandoned her work station, Staff EE stated, "Well, I can't just ignore a flat line!" Staff EE did not indicate whether another staff member would be asked to assume the Unit Secretary duties in her absence.

During an interview on 11/30/11 at 1:46 PM, Staff R, eICU Nurse, stated that she remotely monitored telemetry for up to 36 Medical Intensive Care Unit patients at another facility in addition to monitoring patients at this facility. Staff R stated the eICU used visual alarms when monitoring telemetry and pulse oximeter levels, and stated there were no audible alarms. Staff R also stated that when she noticed an abnormal cardiac rhythm at this facility and couldn't reach as nurse or the alarm continued, she would occasionally leave her work station and would check on the patient herself. When questioned regarding the safety of other patients she was monitoring if she abandoned her work station, Staff R stated that she would notify staff within another eICU to watch her monitors in her absence.

Clarification from Staff B, Director of Quality, by email on 12/15/11 at 5:40 PM stated, "The process at the time of (Patient #5's) event was the charge nurse was notified by the (eICU) nurse if a problem was observed with a patient. There was not a written policy in place on this, but it was what they were trained to do."

During an observation and interview on 12/02/11 at 4:45 PM, Staff II, eICU nurse demonstrated how she monitored patients by use of the monitor board within eICU. The monitor panel (of approximately eight computer screens) showed multiple screens with cardiac rhythms; multiple screens contained written info about various patient's diagnoses, vital signs, etc.; and one screen showed Patient #5 resting in bed. To the right of the monitor panel were a series of small lights approximately the size of an eraser head. Staff II stated that when the lights were lit, the eICU nurse had to determine which patient the alarms referred to and then respond by turning the room camera toward the patient and observing whether the patient appeared to be in distress. Staff II stated that on 12/02/11, she was monitoring 32 patients at another facility, and five patients at this facility.

During an interview on 11/30/11 at 2:05 PM, Staff DD, Executive Director of Critical Care, stated the first alarm that should have alerted nursing staff to a problem with Patient #5 was the bedside telemetry and pulse oximeter alarms. The second alarm that should have alerted staff was the visual monitor alarms at the Central Station manned by the Unit Secretary. The third alarm that should have alerted staff was the visual alarm in the eICU.

According to facility documents, there was no response to the room monitor alarms until 10 minutes had passed, which indicated there had not been an attempt by the Unit Secretary or the eICU nurse to contact nursing staff and alert them to a problem with Patient #5.

As evidenced by investigation during this survey:
- Nursing staff were unable to hear the telemetry and oxygen and pulse oximeter alarms, and were not aware that the alarms were set at 50% volume.
- The facility discovered during their initial review of Patient #5's "near miss" event that eICU alarms were not audible.
- The Unit Secretary at the Central Station on 11/17/11 was unable to provide any information regarding Patient #5's "near miss."
- The facility questioned why the Unit Secretary did not alert nursing staff, but had not completed their investigation.
- There is conflicting evidence regarding whether or not Patient #5 was being monitored by eICU staff at the time of the "near miss" event.
- eICU staff did not alert nursing staff to check on Patient #5, and could not recall anything about the event. The eICU nurse could not provide any information regarding how long the patient was without oxygen when questioned by nursing staff at the time of the event.

The Immediate Jeopardy was abated by the following actions implemented or initiated on 12/01/11:
- A monitor technician or registered nurse with training in interpretation of cardiac rhythms was assigned to monitor and respond to telemetry and pulse oxygenation monitors at the Central Station. Duties of the position included:
- Posting cardiac rhythm strips in a binder (daily) for each patient receiving telemetry. This sheet would become part of the patient's permanent medical record.
- Maintenance of a log documenting when primary care nurses were contacted, the reason for the call, and a cardiac rhythm strip at the time of the call. This sheet would become part of the patient's permanent medical record.
- The audible alarm for decreased oxygen saturation was turned on at the Central Station and adjusted at a volume of 100%. (The alarms were previously turned off.)
- The volume of the GE monitors (monitors which are hard-wired into specific patient rooms) in patient rooms was increased to 100%. (They were previously set at 50%.) The GE alarms had the capability of being turned down to 80% volume, but were labeled with a notation that "Alarm volume must remain at 100%." An education plan regarding monitor alarm changes was developed, with a training completion date of 12/09/11.
- Random checks of the bedside pulse oximeter monitors was initiated 12/02/11, with a plan to continue monitoring until the next state survey process and subsequent revisit surveys. The charge nurse (a nurse assigned to oversee nursing care for a specific nursing unit or shift) or designee would perform these checks, and data would be monitored through the performance improvement program. The checks would occur twice daily on all patients with GE monitors. The random check logs would be maintained by the charge nurse and monitored by the Director of Nursing on Monday, Wednesday and Friday.
- A respiratory therapist or registered nurse would document oxygen saturation levels at the Central Station every 30 minutes for each patient receiving pulse oximetry until all corrective actions were fully implemented, and documentation would then be done every three hours per current policy. This sheet would become part of the patient's permanent medical record.
- Hourly rounding (visits to patient rooms to visually assess a patient) of patients on the "Rose" hall by nursing staff was implemented at 7:00 PM on 12/02/11. Registered nurses would complete the rounding on odd hours, and personal care assistants (nurse aides) would complete the rounding on even hours. A clinical supervisor would be responsible for daily audits of rounding documentation, and the Director of Nursing would audit the documents Monday, Wednesday and Friday.

Improvement in process:
- A new work flow for answering call lights and responding to alarms. Staff training was initiated on 12/02/11.
- A plan to implement overhead paging, with an anticipated completion date of 12/09/11.
- A plan to assign a "sitter" (a nursing assistant or other trained healthcare professional who is stationed within a patient's room for close observation of the patient) upon admission to patients who had a history of agitation, or were exhibiting that behavior at the time of admission. Initiation of a sitter would not require a physician order, and continued use of a sitter would be determined through nursing assessments.
- A "telemetry monitor technician" position was being implemented, with the responsibility of observing telemetry monitors and responding to abnormal cardiac rhythms by notifying nursing staff.


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