Mixed Med/Surg unit with tele not being watched

NewEastCoastRN · Jun 24, 2004

I work on a telemetry unit where I can have up to 5 patients at a time, all on monitors. We do not have anyone watching the monitors, we just check them when the alarm goes off. Never been a problem.

movealong · Jun 25, 2004

I worked on a larger tele floor, we had 25 patients or so. Each was on a monitor. And yes, we did have a watcher. Of course the patients were more acute on this floor.

We also had to run off strips q4hours and post them in the chart, along with the very basics: rate, PR, QRS intervals, etc. You might want to consider running strips and placing them in the charts if you don't do this already. That way you would at least have something to show what rhythm the patient was in most of the time, if something should go wrong. It might also make a more effective tool to go to management with if you capture some abnormals, like longer runs of back to back PVCs, or a patient bradying down, whatever.... It would back up the need for a watcher.

Consider the settings for the alarms. If you don't have a watcher, make sure the alarms aren't set at any high ends.

bellehill, RN · Jun 26, 2004

I have had 7 patients with 4 of them on tele. We don't have a tech, we just watch it ourselves. Wait for an alarm and glance at the screen when you walk by. Always run a strip at the beginning of your shift and if anything changes. No problem!

Tweety, BSN, RN · Jun 26, 2004

I've worked in a similar unit. Once the alarm went off, we all were busy and the patient was in a critical situation. I was off the unit at the time and my coworkers..., well let's just say I left that unit.

Also you never know when a subtle change may occur like a rhythm switch from sinus to afib, or st segment changes. The alarm doesn't always ring for those.

It's dangerous. But what can you do?

Trauma Columnist · Jun 26, 2004

Oh my goodness!!! Am I Pollyanna??? No monitor for tele patients?? Then why have them on tele??? In our hospital we have tele and a dedicated monitor. We also what is called remote tele - the pt wears a monitor but it is monitored somewhere else in the hospital but still continuously monitored. Is this the standard of care??? I have not worked a floor in many years - I work in the ER - but we have a monitor too.

Stryker · Jun 27, 2004

Thank you for all of your inputs...I'm wondering are there any laws or standards of practice which specifically state its ok for telemetry to not be watched continously. Or visa versa, that telemetry is to be monitored at ALL times. Couldn't this be a potentially disastrous situation?? Wouldn't a Telemetry nurse be responsible if a rhythm was not detected by the computer and a pt in worse case scenario died as a result of a rhythm not being detected???? Any input would be appreciated.

BSN, shift lead

movealong · Jun 27, 2004

Truthfully, I would have to research the legal implications to be able to answer your questions. I would be uncomfortable with the situation personally. IMHO, telemetry means being monitored, and to me, that is worthless if a patient wears a monitor and nobody is watching the monitors. I mean, what's the point?

Anyway, my personal view is colored by the fact the patients I cared for telemetry were quite ill. Everyone usually had dopamine, dobutamine, heparin drips going.

If I were you, I'd start researching the issue in ernest.

pickledpepperRN · Jun 27, 2004

This is NOT OK. The state DHS will cite your hospital. The JCAHO should be notified too.

Here is a thread regarding a similar situation:

https://allnurses.com/forums/showthread.php?t=49763&page=3&pp=10

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And from the newspaper:

nurses failed to adequately examine the patients

November 8, 2003 - Times Headlines

Hospital Blamed in 2 Deaths

By Tracy Weber and Charles Ornstein, Times Staff Writers

A state report finds that one King/Drew patient's heart stopped and another ceased breathing without anyone noticing.

Nurses and other employees at Martin Luther King Jr./Drew Medical Center botched the care of two women who died there this summer, failing in one case to notice that a patient's heart had slowed and stopped over 45 minutes, according to a state report released Friday.

Inspectors from the California Department of Health Services found that nurses failed to adequately examine the patients and that some apparently had never been taught to use new bedside monitors at the hospital. In addition, one nurse lied about performing crucial tests ordered by a doctor, the report said.

In both women's cases, a technician assigned to watch a central monitor displaying patients' vital signs was also given other duties. It is unclear if anyone was watching the monitor when the technician was away or when the women needed emergency attention, state health inspectors said.

Los Angeles County, which owns King/Drew, has reassigned the technician while it conducts its own investigation and has changed the rules so monitor technicians may do nothing but watch the monitors. County officials also reported a nurse to the state nursing board for documenting care that was not provided to one of the women, said Laura Sarff, director of quality improvement for the county Department of Health Services.

After being questioned by officials, the nurse has failed to show up for work again, Sarff said.

Cynthia Millage, whose mother, Robbie Bilbrew, was one of the patients whose care was criticized in the state report, said Friday that the findings didn't surprise her, because she had her own concerns about the treatment at the time.

"But it just hurts me to think about it," Millage said. "It hurts me a lot to even talk about it."

Since the women's deaths, July 4 and July 15, the county's investigation has focused largely on potential problems with a new monitoring system that was installed in late June. In September, hospital officials disconnected the $411,000 system, in part because nurses said that they were worried it wasn't reliable and that it hadn't alerted them to the two women's distress.

The state report did not address whether the system itself failed, but raised questions about the staff's training and mistakes made in using the monitors.

In one case, an incorrect identification code was entered into the computer, meaning the patient's vital signs did not show up on the central monitoring system. As a result, the central alarm didn't sound when her condition changed, staff members told the state inspectors.

The woman, Sonia Lopez, 33, had stopped breathing when a physician discovered her at 6:27 a.m. June 30. Although she was resuscitated, she died July 4.

Ana Lopez, Sonia's sister, said that even if her sister's monitor was hooked up incorrectly, someone should have noticed that she had stopped breathing.

"Why didn't they check?" Lopez asked.

In the case of Bilbrew, 52, state inspectors zeroed in on the lack of documented care and contradictions in the records.

On the afternoon before her death, a doctor ordered respiratory therapy to keep the level of oxygen in her blood high. But the nurse assigned to Bilbrew did not document her oxygen levels, nor did it appear the therapy had been provided, inspectors found.

Bilbrew's cardiac monitor records show that her heart rate began to slow at 5 a.m. July 15. By 5:08, her heart rate indicated that she was near death, and at 5:27, her heart stopped. According to her chart, however, cardiopulmonary resuscitation was not started until 5:45. Bilbrew was pronounced dead at 6:35 a.m.

The state report indicated that a doctor had ordered numerous tests on Bilbrew, including blood work and a chest X-ray, to be done at 2 a.m. "Staff interviews revealed the [nurse] never ordered the tests, although the [nurse] had signed the orders as completed," the state report said.

The state found other discrepancies: A nurse wrote on Bilbrew's chart that she was checked at 5:30 and "was in no acute distress." By that time, actually, her heart had stopped.

The nurse also indicated that at 6 a.m., the patient was given routine oral and IV medications. The state inspectors said, however, that at the time, the patient "had no IV in place."

The hospital had planned to release Bilbrew to a skilled nursing facility that day, and had written on her chart that she was "ready" to be discharged, according to the state.

After the deaths, county officials said they had introduced additional training for the staff on using the monitors and the need to both perform and document procedures ordered for patients.

"There was a breakdown in the management of patient care in that unit," said John Wallace, county health department spokesman.

The state report does not carry any immediate penalties for the hospital, but county officials must quickly draft and implement a plan to correct the violations. Inspectors have the option of requesting a full-blown survey of the hospital's problems by the U.S. Centers for Medicare and Medicaid Services, which could lead to sanctions against the hospital, including loss of federal funds.

It is the latest in a series of problems for King/Drew, in Willowbrook just south of Watts. The hospital must shut down its radiology and surgery doctor-training programs in June because of serious deficiencies. And county officials have put a new management team in place to help the hospital restore fiscal order.

In addition, the county continues to investigate why the new monitoring system was purchased in the first place.

The system is set up so a central station receives information from bedside monitors tracking the blood pressure, heart rate, blood oxygen level and temperature of up to 60 patients.

The monitors' manufacturer, Welch Allyn Inc., has stood behind the equipment. But its own investigation in August found physical damage to the central monitoring unit at King/Drew that could have caused its speakers to malfunction in one of the cases, company officials said.

Relatives of both women said Friday that they had never been told by King/Drew staff that anything but unavoidable medical problems led to the deaths. But even before the state report, they said, they had their suspicions about the quality of care. Their requests for basic services such as clean sheets and baths were ignored by nurses, they said.

"I knew they weren't taking care of my mom. I knew it," Cynthia Millage said.

pickledpepperRN · Jun 27, 2004

http://www.latimes.com/news/local/l...-home-headlines

January 30, 2004

By Charles Ornstein and Tracy Weber, Times Staff Writers

Report Assails Hospital Lapses

U.S. inspectors find that King/Drew nurses were ordered to lie and key drugs weren't given. Criminal inquiries could be launched.

Nurses at Martin Luther King Jr./Drew Medical Center were ordered to lie about patients' conditions, failed to give crucial medications prescribed by doctors and left seriously ill patients unattended for hours-including three who died-according to a new report by federal health officials.

Government inspectors have now identified five patients who died at King/Drew last year after what were determined to have been grave errors by staff members, and the findings could trigger criminal investigations into possible misconduct by the nurses and their supervisors.

The Jan. 13 report also said hospital officials had failed to fix dangerous lapses in care after promising to do so.

Details in the report suggest that problems at the Los Angeles County-owned hospital in Willowbrook, just south of Watts, are far worse than previously disclosed and that the county faces a daunting task in turning it around.

For instance, inspectors found that nurses had all but ignored 20-year-old Oluchi McDonald, who was suffering from gangrene of the intestines, when he arrived by ambulance March 12. Eighteen hours later, he was found on the floor-where he had fallen unnoticed-in a pool of his own vomit, according to the federal report and an autopsy summary. He could not be revived.

"It's extremely distressing to know that he was rendered invisible," said his mother, Akilah Oliver, a college lecturer in Boulder, Colo., "that his life seemed not to be important to his caretakers."

Four days after McDonald died, another patient suffering from gangrene and other problems died. He was neglected for almost a day, the report said.

Then, in July, two women died when nurses did not notice their conditions were deteriorating, even though they were connected to cardiac monitors, government inspectors found. In December, a fifth patient died under similar circumstances in the same unit, known as 4B, the report said.

Taken together, the deaths and other shortfalls in patient care illustrate the "failure of the hospital to ensure quality health care in a safe environment," said the report by the U.S. Centers for Medicare and Medicaid Services, which oversees federal healthcare funding. The document has not yet been released publicly but was obtained by The Times.

A federal health official familiar with King/Drew, who declined to be identified, said the problems found and the number of questionable deaths were highly unusual.

Nurses told inspectors, for instance, that their supervisors had ordered them to downplay the conditions of critically ill patients to subvert rules requiring that the sickest patients get more nursing care.

In response, officials suspended assistant nursing director Margaret Latham without pay last Friday and had her escorted from the hospital. She could not be reached for comment Thursday.

The county had already suspended the hospital's nursing director without pay and hired an outside firm to run the nursing operation.

"It's criminal," said Supervisor Zev Yaroslavsky, one of five county supervisors responsible for overseeing the hospital, referring to nurses' alleged misconduct. "It's just unbelievable. It's unethical. It's immoral and it's probably illegal."

Officials in the county Department of Health Services said they were preparing cases to be presented to the district attorney's office for possible criminal prosecution. These include "intentional misrepresentation of patient conditions," said Fred Leaf, the agency's chief operating officer.

Leaf said that the department was investigating 20 to 25 cases of misconduct at the hospital and that he expected to discipline employees in coming weeks.

In recent weeks he has spent much of his time at King /Drew, which was founded to provide desperately needed services to South Los Angeles after the 1965 Watts riots and remains one of the few healthcare providers in the area.

If the problems are not corrected, the hospital could lose all federal funding, which accounts for about half its $430-million annual budget. Such a move would be rare, however, and county officials say they are making reforms to avoid that.

"I think you will find that, once they see what we've done, they will be amazed at the extent to which we have taken immediate and decisive action," said Dr. Thomas Garthwaite, director of the county health department.

He cited changes that include closing unit 4B, where at least three of the patients died, and bringing in new managers.

The Jan. 13 report is the latest and most damning in a series of sanctions and citations issued against the hospital since August.

A national accrediting group has revoked King/Drew's ability to train aspiring surgeons and radiologists and has threatened to do the same for trainees in neonatology.

This latest round of inspections was spurred by the deaths last summer of the two women in 4B. Both were supposed to be continuously watched by nurses but were not. State inspectors were so concerned by the events that they asked the federal government to authorize a more extensive review.

During that review, which began in December, inspectors pulled the files of 20 patients and found that eight of them had received inadequate care.

In three of those cases, the patients died.

Inspectors also found serious and unusual ethical breaches that deprived the most critically ill patients of adequate care.

"Confidential interviews revealed that nursing staff were prohibited from assigning patients a classification of IV," the most critical level of sickness, the report said.

Delays Found

As a result, inspectors said, nurses sometimes struggled to care for four times as many patients as the state allowed. Crucial medications and treatments were often delayed for hours. Nurses also did little to help patients who were in severe pain, according to the findings.

On one shift reviewed by inspectors, nine of the 16 patients should have been classified at the sickest level, which would have required one nurse for every two patients.

One patient was bleeding and required multiple transfusions, five required ventilators to aid their breathing and one of those patients had a temperature as high as 104 degrees, inspectors found. Four more patients were waiting to be admitted from the emergency room.

Yet there were only two registered nurses assigned to the unit-one for every eight patients, according to the report. One less skilled licensed vocational nurse, though not qualified for the task, was left to watch the cardiac monitors. When nursing administrators were asked for help, they told the nurses on duty that no help was available, the report said.

The inspectors also found that the hospital hadn't followed through on pledges to correct problems.

For instance, in November, state health inspectors looking into the two women's deaths in 4B issued a report that cited errors, misconduct, and poor training of nurses. The county promised better training and oversight.

But the death of the man in December under similar conditions showed that those changes were not made, according to federal inspectors.

In fact, the man's family had to tell nurses that something was wrong with him. When nurses went to his room, they found a "flat line" on the cardiac monitor and no heart rate, the report said. He died within hours.

The employee assigned to watch the monitors "had not notified the nurse prior to being alerted by the patient's family" that the man's heart had stopped, according to the report. The Times reported this patient's death last month.

Even after this death, the hospital still did not ensure that employees in 4B were trained to use the monitors or were even paying attention, inspectors found.

When inspectors visited King/Drew on Dec. 23, the nurse assigned to watch the cardiac monitors told them she "did not feel comfortable" with use of the devices. Her employee file also lacked proof that she had been trained to operate them or spot abnormal heart rhythms, the report said.

While inspectors spoke to the nurse, the monitors for all six patients in 4B showed a red X next to the "pulse" read-out.

None of the three nurses in 4B at the time knew the X meant that the alarm, designed to alert them to dangerous dips in patients' heart rates, was off.

While the inspectors were at King/Drew, county officials were in the process of closing 4B until they could ensure that the staff was properly trained.

Last March, in the second of the deaths, the patient arrived at the emergency room with gangrene of his lower leg, pneumonia with a collapsed lung and kidney failure.

Although his temperature was 90.8 degrees, there was no evidence that the nurse gave him a heating blanket, inspectors found. Nor was there any sign that he received the antibiotics or blood products ordered by the doctor to control his infection and blood-clotting problems during the 22½ hours he was in the emergency room, the report said. The man died a short time after being transferred to an inpatient bed, according to inspectors.

'Horrifying' Conditions

Supervisor Gloria Molina said county officials were working as quickly as possible to reverse the "horrifying" conditions at King/Drew.

"We recognize there are huge problems there-huge, huge problems," she said. "They must be resolved, and we need to take some very drastic actions, and those are the actions we're taking today."

Supervisor Yvonne Brathwaite Burke, whose district includes the hospital, said she felt terrible about how the patients died. Given the details of 20-year-old McDonald's death, she said, "It's something that should not happen."

Yaroslavsky said he was particularly troubled that some of the patient care lapses had occurred after county officials took over the day-to-day running of the hospital.

"It was more than a little bit disconcerting that problems were still popping up after all this had been known to us," he said. "And it begs the question: What is going on there today?"

Rapheal · Jun 28, 2004

Our telemetry is always watched. We have very sick patients and I could not work on a floor where I was responsible to monitor telemetry and do patient care. I am constantly on the floor- in patient's rooms. It would be impossible for me to accurately respond to a change in heart rhythm when I am in the middle of something like putting in an NG tube. Not having a telemetry person watch the monitors is way past my comfort zone. But that is just me.

tommycher · Jun 29, 2004

I work on a tele unit, and we have one monitor, but no monitor tech. However, we are required to wear pagers. These pagers have all tele pts programmed into them. If there is a change in heart rate, rhythm, etc. our pager goes off. It shows us all the info, including a picture of the rhythm as it appears on the main monitor. Since we all have the pagers we all run to whatever room the pager is indicating, this is just in case the nurse assigned to the pt with the change is busy. We have never had a problem with this system. We are all responsible for reading and posting the strips for our own pts.