HospitalInspections.org

Based on review of facility documents and interview with staff (EMP) it was determined that the facility failed to ensure that care was provided in a safe setting (A-0144) by failing to follow adopted policy to notify the registered nurse that a patient's telemetry monitor alarmed in one of one patient (PT1).


Findings include:
Review of "Administration Policy and Procedure Number: P01-A Subject: Patient Rights Issue Date: 10/01/2023 ... Purpose: ... 1. A patient has the right respectful care given by competent personnel. ... 6. The patient has the right to expect emergency procedures to be implemented without unnecessary delay. 7. The patient has the right good quality care and high professional standards that are continually maintained and reviewed. ... 16. The patient has the right to expect good management techniques to be implemented within the hospital considering effective use of the time of the time of the patient and to avoid the personal discomfort of the patient. ... ."

Review of "Clinical Services Policy and Procedure Number: T05-N Subject: Telemetry, Alarms, Prioritization ... Revised Date: ... 04/01/24 ... Purpose: ... Monitor Techs/Telemetry Techs (MT/TT) ... Any new dysrhythmia or change in rhythm will be captured on a strip, interpreted, and the house Supervisor/Nursing Supervisor notified. ... 2. Telemetry alarms will be set appropriately and be 'On' at all times. NO One May Suspend An Alarm For Any Reason ... ."

"Select Medical-LTACH Division Job Description Title: Telemetry Technician Department: Clinical Services ... Revised: 9/9/2021 Job Summary The Telemetry Technician assumes responsibility for continuously watching and ensuring appropriate and timely responses to alarms. The Telemetry Technician identifies basic rhythms lethal rhythms, and artifact, maintains EKG monitor alarms, and responds to all alarms as needed. ... 11. Continuously observes all monitors assigned and responds to alarms promptly and appropriately, up to and including calling a Rapid Response Team. 12. Immediately notifies Charge Nurse or appropriate RN of significant changes in rhythm. ... ."

Review of the '"Unit Based Competencies: Telemetry Tech" revealed a "General Overview of hospital functions, 'Key Functions' to include: ... observes monitors assigned and responds to alarms promptly, immediately notifies the Charge Nurse or appropriate RN of significant changes, ... etc."



1) Review of facility investigation revealed the Registered Nurse (RN) assessed the patient at 8:00 PM when the patient answered basic questions with head nod, was repositioned twice within the next hour and then subsequently, upon entering the patient's room at 9:55 PM with requested medication, the RN and nurse aide found the the patient not breathing and without a pulse.

Continued review of facility investigation revealed the telemetry technician did not notify the RN that the patient had been off telemetry monitor for approximately forty minutes prior to the code.

Interview with EMP1 on July 8, 2024, at approximately 1:45 PM confirmed that the telemetry technician failed to notify the RN that the patient was off the monitor and silenced the alarm.