HospitalInspections.org

Based on record review and interview, the hospital failed to:

A. Ensure patient # 1 and 4 were free from injury after procedure for 2 of 20 records reviewed. This failed practice resulted in the death of patient # 1 and # 4 having acute fractures of the right 4th and 5th ribs. (See Tag A - 0144)

B. Ensure competent care was provided for patients to prevent harm for 2 (Patient # 1 and 4) of 20 records reviewed. This failed practice resulted in patient # 1 not receiving adequate neuro checks and receiving general endotracheal anesthesia after head injury; and patient # 4 didn't receive adequate respiratory assessments after rib fractures. (See Tag A - 0145)

Based on record review and interview, the hospital failed to provide adequate staff intervention to decrease the risk of falls for 2 (Patients #1 and 4) of 5 records reviewed (Patients #1, 2, 3, 4, and 21) for patients experiencing a fall during their hospital stay.

This failed practice resulted in injuries for Patients #1 and 4 and had the potential to result in injuries for Patients #2, 3, and 21 due to lack of safety awareness of staff.

Findings:

A policy titled "Fall Prevention" listed factors to be considered that could increase a patient's risk of falling, including:

1. Age- 60 to 69 years of age;
2. History of falls;
3. Medications- including antihypertensives, diuretics, benzodiazepines, and narcotics;
4. Mobility- dependence on assistance with transfers and ambulation; and
5. Cognition- altered awareness of the environment and lack of understanding of one's physical and cognitive limitations.

The policy stated all hospital personnel are responsible for minimizing risk of falls for patients.

Patient #1

A form titled "History and Physical" dated 11/23/17 included the following information:

1. The patient was 65 years old;
2. General appearance was described as "somnolent"; and
3. The patient was diagnosed with hepatic encephalopathy, and required monitoring for acute changes in neurological functioning.

The "Admission Assessment Adult" dated 11/23/17 at 1:19 pm showed the patient had history of multiple falls within the previous 6 months and was deemed high risk for falls.

In the section labeled "Adult Physical Assessment" dated 12/08/17 at 7:00 am (approximately 2.5 hours prior to the fall), Staff Z documented the the patient had "severe weakness" and required assistance or supervision for mobility.

On 12/08/17 at 9:36 am, the patient underwent a procedure in IR to place a tunneled dialysis catheter. Documentation in physician notes showed at 9:45 am, the patient rolled herself off the procedure table and hit the floor, sustaining a laceration above her left eye. The patient was sent to surgery for a pre-planned EGD. The patient's condition deteriorated and subsequent CT imaging revealed a subdural hemorrhage. The patient was placed on comfort care measures and expired the same day at 8:08 pm. See A-395.

Patient #4

A form titled "History and Physical" dated 09/13/16 included the following information:

1. The patient was 70 years old; and
2. The patient's regular medications included furosemide (a diuretic) and metoprolol (an antihypertensive).

On 09/14/16 at 9:46 am, the patient underwent an attempted cardiac catheterization in the CV lab. The patient was given sedation and narcotic pain medication. At 10:37 am, the patient sat up and fell from the procedure table, hitting the floor. A subsequent CXR revealed acute fractures of the right 4th and 5th ribs. See A-395.


Staff Interviews 12/29/17

At 9:05 am, Staff D stated at the time of Patient #1's fall, no one person was designated to ensure a patient could not fall during a procedure, but the hospital had since designated the technician as the person responsible.

At 9:40 am, Staff G stated Staff BB had released the velcro strap holding Patient #1 to the procedure table prior to the hospital bed being positioned against it. Staff G stated he/she was walking away from the table when the patient fell, and was unsure where all staff were positioned at the time (except Staff H, who was at the head of the table.) When asked who was responsible to ensure patient safety while on the table, Staff G stated a nurse should be in the room at all times.

At 10:15 am, Staff H stated he/she was at the head of the bed, saw Patient #1 lift her shoulders and right knee and was unable to reach the patient before she fell from the table. When asked who was responsible to ensure patient safety during a procedure, Staff H stated the nurse must be able to leave the room, and it was the technician's responsibility to be next to the patient or make sure someone was next to the patient.






37859

Based on record review and interview, the hospital failed to ensure quality care was provided for patients to prevent neglect for 2 (Patient # 1 and 4) of 20 patient records reviewed.

This failed practice resulted in the death of patient # 1 and rib fractures for patient # 4.

Findings:

See Tag A -0144.

Based on record review and interview, the hospital failed to:

A. Ensure an RN performed physical assessments to identify new problems for 2 (Patients #1 and 4) of 2 records reviewed for patients experiencing a fall and subsequent injury during their hospital stay. This failed practice resulted in neurological injury and death for Patient #1, and compromised respiratory status for Patient #4 due to inadequate physical assessments following a fall with injury. See A-395.

Based on record review and interview, the hospital failed to ensure an RN performed physical assessments to identify new problems for 2 (Patients #1 and 4) of 2 records reviewed for patients experiencing a fall and subsequent injury during their hospital stay.

This failed practice resulted in neurological injury and death for Patient #1, and compromised respiratory status for Patient #4 due to inadequate physical assessments following a fall with injury.

Findings:

A policy titled "Assessment/Reassessment" stated patient reassessments were considered ongoing and would be triggered by changes in a patient's condition. The policy further detailed unit-specific requirements for patient assessments, including the following:

1. In Medical/Surgical/Telemetry Units, an RN would perform a reassessment following any physician-ordered changes in care, and following a change in the patient's physical condition. The reassessment would be based on factors including the medical diagnosis and nursing diagnosis.

2. For patients undergoing surgical and/or invasive procedures, a pre-operative assessment of the patient's condition would be conducted and documented in the electronic record, with any "variations" being reported to anesthesia, surgeons, and other physicians as appropriate.

3. For patients in Recovery (including PACU, CV Lab, and Radiology), the patient would be reassessed every 5 minutes for a minimum of 15 minutes and the plan of care would be revised based on assessment findings.

Patient #1

The patient was admitted to the hospital from 11/23/17 to 12/08/17. On 12/08/17 at 9:36 am, the patient underwent a procedure in IR to place a tunneled dialysis catheter. Documentation in physician notes included the following:

1. At 9:45 am, the patient rolled off the procedure table and hit the floor, sustaining a laceration above her left eye;

2. At 10:00 am, the patient was taken for a CT exam of the head. The CT identified no acute findings, except left periorbital edema; and

3. At 10:00 am, the patient was examined by a physician. The physician's report stated the patient complained of right face and nasal pain, and mental status was documented as "...alert and oriented and was at her baseline when comparing mental status prior to procedure."

Documentation in nursing notes showed no nursing assessments were completed following the fall with head injury.

At 10:55 am, the patient was taken to surgery holding for a previously scheduled procedure (EGD). Documentation in nursing notes during the time period prior to surgery included the following:

1. At 11:14 am, Staff O (an RN providing care for the patient prior to surgery) documented the patient's mental status as "awake" and the physician was discussing the patient's DNR status with family at the bedside;

2. At 11:25 am, Staff L (an RN from endoscopy) documented the patient was brought to the OR with a swollen and bruised left eye and a bloody nose. Documentation stated the physicians and director were aware of the patient's condition; and

3. On a form titled "Anesthetic Record" dated 12/08/17 at 11:11 am, Staff M documented the patient was vomiting (a potential sign of elevated intracranial pressure) in surgery holding.
There was no documentation of a neurological assessment completed or any changes noted in the patient's mental status.

At 11:51 am, the patient was taken to the PACU. Documentation in nursing notes during the time period in recovery included the following:

1. At 11:51 am, Staff X (an RN providing care in PACU) documented "Noted dressing on RT side of head and above eye from fall...PT is sedated. Smiple [sic] mask at 4 6 liters.";

2. At 1:21 pm, Staff X documented "Left oral airway in place...PT is still unresponsive falling [sic] the fall pre op...in IR...";

3. At 2:05 pm, Staff Y (an RN providing care in PACU) documented "Late entry...PT does not respond to stimulation...Dr. (omitted) said after IR PT was this non responsive." Documentation stated report was called to the Medical-Surgical RN at 12:30 pm; and

4. At 12:57 pm, Staff Z (an RN providing care in the Medical-Surgical Unit) documented report was called, in which the patient was described as nonverbal and nonresponsive. Staff Z questioned why the patient would be returned to the Medical-Surgical Unit in that condition, and was told "...patient has been that ways [sic] from IR that the DR has already saw [sic] patient and OK for her to come back to the floor."
There was no documentation of a neurological assessment completed in PACU following the mental status change.

At 1:14 pm, the patient was taken to the Medical-Surgical floor. Staff Z documented the patient had an oral airway in place, a bandage to her left eye, and did not respond to verbal or tactile stimuli. Staff Z notified the charge nurse and physician. The patient was subsequently transferred to the ICU approximately 1:25 pm.

At approximately 1:45 pm, Staff AA (an RN providing care in ICU) documented the patient was placed on BiPAP 100%, patient was not awake and not responsive, and the patient's right pupil was dilated to 6 mm and not responsive to light (a sign of brain damage). The left pupil was not assessed due to swelling of the eye.

At 2:36 pm, CT exam showed a subdural hemorrhage with midline shift and herniation (intracranial bleeding causing pressure on the brain.) The attending physician advised the family the patient would need to be intubated and sent for neurosurgical evaluation immediately. The family declined these interventions and the patient was placed on comfort care measures. The patient expired at 8:08 pm.

Patient #4

The patient was admitted to a Medical-Surgical Unit from 09/13/16 to 09/20/16. On 09/14/16 at 9:46 am, the patient underwent an attempted cardiac catheterization in the CV Lab. Documentation of the procedure included the following:

1. At 9:46 am, the patient was placed on the procedure table;

2. At 9:57 am, staff placed a foam "head positioner" and "Posey limb straps" on the patient;

3. At 10:15 am, the patient was given Versed (a benzodiazepine used for sedation) IV 1 mg and Fentanyl (a narcotic pain medication) IV 50 mcg;

4. At 10:34 am, the patient was agitated and requested to stop the procedure (the procedure was halted); and

5. At 10:37 am, the patient sat up and fell off the cath table, hitting the floor. The patient was immobilized with a backboard and cervical spine collar and taken for CT and XR exams.

A chest XR done 09/14/16 at 10:50 am revealed acute right 4th and 5th rib fractures, not previously seen on images obtained 09/13/16.

A document titled "Family Med Progress Note" dated 09/14/16 at 1:00 pm stated the patient was unable to take deep breaths because of pain. Oxygen saturation at that time was 97% on 2L O2 by NC. Under the heading "Assessment", the diagnosis of rib fractures was included, with the instructions "Nursing instructed to assess for breath sounds q2h."

On the same titled document dated 09/15/16 at 8:45 am, documentation stated the patient demonstrated decreased respiratory effort and reported body movement was very painful. The most recent documented oxygen saturation reading was 09/15/16 at 7:00 am, a suboptimal reading of 93% on 3L O2 by NC. Under the heading "Assessment", the diagnosis of rib fractures was included, with the instructions "Nursing instructed to assess for breath sounds q2h."

A document titled "Cardiology Progress Note" dated 09/15/16 at 1:37 pm stated the patient complained of right rib pain that became worse with inhaling and body movement. The most recent documented oxygen saturation reading was 09/15/16 at 7:00 am, a suboptimal reading of 93% on 3L O2 by NC.

A review of nursing notes from 09/14/16 at 1:00 pm through 09/15/16 at 6:00 pm showed nursing staff did not perform respiratory assessments every 2 hours as instructed.

Following the fall on 09/14/16 at 10:37 am, respiratory assessments were performed at 5:55 pm (over 7 hours after the fall), 7:00 pm and 10:00 pm. There was no documentation regarding the rib fractures or the effects of pain on respirations. The patient's depth of respirations was documented as "normal". There was no oxygen saturation level documented in the assessments.

On 09/15/16, nursing notes included the following documentation:

1. At 9:33 am, nursing staff documented "Unable to lie flat, SOB with exertion". There was no documentation regarding the rib fractures and pain. The depth of respirations was documented as "normal". There was no documentation of oxygen saturation level at that time.

2. At 4:33 pm, nursing staff documented the patient's respiratory rate was elevated at 24 per minute, oxygen saturation had decreased to 85% (level below 90% is considered hypoxic) on 4L O2 per NC, and the patient reported pain level 7 out of 10 for right rib pain.

3. The next respiratory assessment was performed at 6:00 pm. The oxygen delivery method was changed to BiPAP. Oxygen saturation was documented as 95% at 5:58 pm following the change.

Staff Interviews 12/29/17

At 10:15 am, Staff H (involved in care of Patient #1 when the fall in IR occurred) stated he/she did not perform a neurological assessment after the fall and did not witness any staff perform a neurological assessment. When asked if there was a protocol for neurological checks, Staff H stated "probably" but he/she was a "procedure nurse" and did not do neurological checks.

At 11:45 am, Staff A stated nursing assessment policies and protocols are the same for all areas of the hospital (including procedure areas), and the hospital standards of practice were based on Lippincott standards (a commonly used nursing reference).

At 12:20 pm, Staff I (involved in care of Patient #1 in surgery) stated the patient demonstrated AMS prior to the fall, and asked a family member if the patient was at baseline mental status prior to surgery; the family member reported she was. Staff I stated he/she was not told the patient was vomiting in holding, and this would have been "a flag" for a neurological problem.

At 1:55 pm, Staff J (involved in the care of Patient #1 in surgery) stated he/she overheard staff saying the patient fell, and was not told any details about the fall; he/she was also not told the patient was vomiting in holding, and that should have been a concern to the staff in holding due to the recent head trauma.

At 2:15 pm, Staff K (involved in the care of Patient #1 in surgery) stated the patient was not moving or responding to anything when brought to the OR, and he/she was not told the patient had fallen.

At 2:20 pm, Staff L stated he/she was told the patient had fallen, and had witnessed the patient "dry heaving" in holding. Staff L did not perform a neurological assessment, and stated he/she was unsure where that would be documented in the EMR.

Staff Interviews 01/02/18

At 10:05 am, Staff A stated nursing staff have the option of entering free text in a patient's EMR if they do not know where to document assessment of a particular system.

At 11:00 am, Staff O (involved in the care of Patient #1 in surgery holding) stated patient orientation is assessed in surgery holding prior to the procedure. With regard to Patient #1, Staff O stated Staff R had performed the actual patient assessment while he/she was reviewing paperwork; but his/her own observations were that the patient was awake and nonverbal. Staff O reported being told that the patient was sedated from the procedure in IR. (There was no documentation the patient was given any medications for sedation during the procedure.)

At 12:15 pm, Staff Q (the patient's attending physician) stated he/she was notified of the fall, the CT results, and the injury to the left eye, but did not know the patient was taken to surgery immediately afterward. Staff Q stated the patient should have had neurological examinations done by physician and nursing staff, and the procedure should have been halted. When asked if nursing staff should have started 15 minute checks, Staff Q stated 15 minute neuro checks would not be expected, but the nurse should have performed a neurological assessment.

At 12:30 pm, Staff R (involved in the care of Patient #1 in surgery holding) stated he/she did not get report on the patient, was only told the patient was coming from IR. When asked if anything about the patient was different, Staff R reported the patient had a swollen eye without a bandage and a bloody nose. Staff R stated the patient was awake and "mouthing" responses to her sister, but did not actually speak; the patient's sister answered any questions and gave consent for the procedure.