Immediate Jeopardy at Pocono Hospital

By Walter F. Roche Jr.

State surveyors officially declared patients at a Pennsylvania hospital were in "immediate jeopardy" two times over a two day period because physician ordered cardiac monitors for critically ill patients were not being monitored.
The details of the July visit to the 237 bed Lehigh Valley-Pocono Hospital are spelled out in a report just made public by the state Department of Health.
The hospital, the report states, "failed to ensure that patients were provided continuous telemetry monitoring for 36 of 36 patients requiring physician ordered monitoring."
In fact a review of patient records at the East Stroudsburg, facility found multiple cases in which monitors recorded critical changes in a patient's heart condition which produced no response from hospital staff.
Federal regulations define immediate jeopardy as a situation in which actions or in-actions by hospital employees "placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death."
Once a declaration is issued, health providers are required to respond immediately.
According to the report the state survey team declared the first immediate jeopardy at 2:06 p.m. on July 15. That was just 41 minutes after they arrived at the hospital. At 2:46 p.m. the survey team rejected the hospital's first plan of correction. A second plan of correction was submitted at 4:06 p.m. but it also was rejected. A third plan of correction was submitted at 5:22 p.m. and it was accepted at 6:30 p.m.
The immediate jeopardy was back in place at 11:25 a.m. the next morning when surveyors once again found that telemetry monitors were not being continuously monitored.
It was finally lifted at 2:20 p.m. on July 16.
The teams' review of records showed one case in early July when a patient experienced 14 beats of ventricular fibrillation recorded on a monitor, but there was no response from staffers. No vital signs were taken and the physician was not informed, according to the report.
Ventricular fibrillation, the report states, is "considered the most serious cardiac rhythm with the potential to cause cardiac arrest."
Another patient experienced atrial fibrillation, but again there was no response by hospital staff
During the review team's time at the hospital they observed that in three of four cases patients experienced changes in heart rhythms but no staffers responded, even when one of the monitors was alarming.
The corrective action plan finally accepted and put in place by the hospital calls for non-nursing personnel being assigned to constantly monitor all monitors but only after they are educated on the proper procedures.
"They (non nurse personnel) may not be in charge of monitoring," the plan states, adding that monitoring will be their only assignment and they are not to perform other duties.
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