All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer).
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Observations:
Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined the facility failed to document rhythm strips of monitored patient per facility policy for one of three medical records reviewed (MR7), and failed to document telemetry battery changes of telemetry patients two of three medical records reviewed (MR7 and MR9).
Findings include:
Review on June 5, 2024, at 2:00 PM, revealed a policy, "Bedside Monitoring System Policy #60.3.3.07 POL-5423719", which indicated, "... 1. General Monitoring information. ... Batteries will be changed every 24 hours. ... Documentation of the rhythm strips will be done every 4 hours in critical care units and every 8 hours in other areas. ... An alarm history review is completed by the nurse at the end of every shift. ... For monitored patients, documentation of cardiac rhythm includes strip, patient name, room number, date, time, lead, heart rate, ... QRS duration QT interval ... Quarterly monitoring will be done by Clinical Engineering Department and results will be reported to the Patient Safety Committee. ...".
Review of MR7 on June 7, 2024, at approximatley 11:00 AM, revealed that the patient was admitted to the hospital on May 25, 2024, at 0100. Further reviewed revealed that he patient was transferred to 5 west from the emergency department at 1218, and required stenting to the left anterior descending artery. Continued review revealed that MR7 was placed on the cardiac monitor on May 24, 2024, at 23:00, and that nursing staff failed to document the QT and QRS waves on May 26, 2024, at 7:00 PM, on May 27, at 7:00 PM, and on May 28, 2024, at 2:00 PM.
Review of MR7 on June 5, 2024, at approximately 11:00 AM, revealed no documentation that the telemetry batteries were changed every 24 hours, as per facility policy.
Review of MR9 on June 5, 2024, at approximately 11:30 AM, revealed that the patient was admitted to the hospital on May 28, 2024, at 2:50 PM with a chief complaint of confusion. The patient was admitted and was placed on a telemetry monitor. Further review of MR9 revealed no documentation that the telemetry batteries were changed every 24 hours as per facility policy.
During an interview on June 7, 2024, at 11:45 AM, EMP1 confirmed the above findings. .
| | Plan of Correction - To be completed: 06/20/2024
The Chief Nursing Officer is responsible for all corrective actions and ongoing compliance associated with this element of performance.
Which member(s) of leadership have been involved in the corrective action and are maintaining ongoing involvement with this change?
Leaders involved include the Chief Nursing Officer, Director of Nursing, Director of Professional Development and Education, Telemetry Nurse Manager and IT Informatics RN.
Please describe how the above leadership involvement is helping to support compliance with this element of performance in the future.
The leadership team advocated for change in the EMR to support documentation compliance of battery changes. The team also developed single points lessons to educate staff on proper documentation of rhythm strips and battery changes. The leadership will be conducting audits to assess compliance and provide feedback to frontline staff members to ensure patient safety.
What analysis was completed to ensure not only the noncompliant issue was corrected (surface/high level resolution), but also any underlying reasons for the failure were addressed as well?
Analysis of the EMR was completed for battery change and rhythm strip documentation. There was no standard location to document battery changes or rhythm strips interpretation in the EMR.
Corrective actions taken:
The leadership team requested the addition of a battery changed line in the EMR in the cardiac monitoring section. This was approved and implemented on 6/20/2024.
A single point lesson was developed to educate staff on the standard location to document rhythm interpretation.
Ensuring Sustaining Compliance:
The telemetry Nurse Managers will audit 30 telemetry strips for correct documentation per the bedside monitoring system policy. Documentation elements includes the rhythm strip is posted with patient's name, room number, date, time and heart rate. Electronic documentation of the lead, PR interval, QRS duration and QT interval, high and low limit settings, strip interpretation and symptoms that the patient may have with change in rhythm and daily change of batteries.
Auditing will be completed monthly.
The telemetry Nurse Managers or designee will audit 30 charts per month for policy compliance of rhythm strip documentation and battery changes. The manager will review monthly until compliance is >90% for three (3) consecutive months.
Results of the audit will be reported out monthly by the Director of Nursing or designee at the Performance Improvement Oversight Committee.
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