HospitalInspections.org

Based on medical record review, incident reports and interview with staff members, it was determined that the hospital did not provide nursing care to each patient, in accordance with the patient's needs. The involved patients resided in the swing bed (long term care) portion of the Critical Access Hospital. For five patients who fell in the facility the physicians and family members were not routinely called and notified of the falls. One patient had an undiagnosed injury and under treated pain for 5 days. Patient identifiers: 1, 2, 3, 6, 7.
Findings include:
PATIENT 1
1. Medical Record Review for patient 1 revealed the following information:
Patient 1 was a 66 year old female who was admitted to the (swing bed) portion of the hospital, with the following diagnoses: Brain injury due to lack of oxygen, stroke, and difficulty swallowing.
Review of the nurse's notes revealed the following information:
On 11/9/14, at 4:10 pm, the nurse documented that the CNA found the patient on the floor. The patient stated that she did not hit her head.
On 11/13/14, at 4:00 pm, the nurse documented on the pain portion of the patient assessment form that the patient was complaining of pain in the left lower chest area and the patient stated that it was penetrating in nature.
On 11/13/14, at 5:25 pm, the nurse documented on the pain portion of the patient assessment form that the patient was complaining of pain in the left lower chest area. The patient rated the pain as a 4 on a scale of 10. The patient stated that the pain was aching and dull in nature.
On 11/14/14, at 2:48 pm the nurse documented that the patient complained of pain under her left rib. The patient had informed the nurse that the pain had started the previous day after the patient's shower. The nurse documented that there were no reports indicating the patient had fallen. The nurse gave the patient ibuprofen after which the patient still had pain but stated that the pain was not as bad. The nurse notified the patient's physician.
On 11/15/14, the nurse documented that the patient complained of left sided rib pain. The nurse documented that the area was " extremely" tender to touch. The nurse notified the physician's assistant on duty in the emergency department. The patient was medicated for pain with Ibuprofen and the nurse documented that the patient had minimal relief if any. A chest X-Ray was done which confirmed rib fractures. The patient was given an injectable pain medication. The nurse documented that the patient had relief from the medication. This was 5 days after the last recorded fall.
2. Review of a document dated 11/15/14, written by the hospital's social worker revealed the following:
"On Thursday 11/13, the TRT (Therapeutic Recreational Therapist) reported to me that she had observed (patient 1) last evening 11/12 and she stated (patient 1) said she was in pain. The TRT stated she reported (patient 1's) pain to the Staff nurses and the clinical coordinator. I met with (Patient 1) on Friday 11/14 and she said she was still having pain and she had not been given any new medications for her pain. I spoke with the RN on duty and she stated she would contact the doctor regarding the pain. I came into the SNF this morning at 8:30 am, and asked the nurse if (patient 1) had been given any additional pain medications. She said she had not checked yet. She said we are giving her Tylenol and Ibuprofen. I met with (patient 1) and she reported that she was still in pain and she had only the regular stuff. She became tearful and said it really really hurts. I spoke with the nurse and told her that (patient 1) said she has pain and was crying. The nurse said 'I just saw her a little while ago and she wasn't crying. What did you do to make her cry'. I notified my supervisor of the situation."
2. Patient 1's incident reports were reviewed and revealed the following information:
An incident report dated 11/9/14, at 7:30 am, documented that the patient 1 was found on the floor at the bedside. The staff member assisted patient 1 back to bed. The staff member documented that there were no injuries. Patient 1 was described as restless and confused and thought she needed to go to the bathroom. The portion of the incident report which documents that the physician and family members were informed of the fall was blank.
An incident report also dated 11/9/14, at 2:15 pm, documented that patient 1 was found on the floor at the side of the bed. The nurse put her bed alarm on and assisted her back to bed. The report indicated that there were "No apparent injuries". The nurse documented that patient 1 was very restless and the patient stated she needed to go to the bathroom. The nurse documented that there were no injuries found. The portion of the form indicating the physician and family had been informed of the fall was blank.
An incident report dated 11/10/14, at 2:45, documented that the staff member heard beeping from the bed alarm. The incident report indicated that it took no longer than 3 seconds to get to the patient. The patient was on the floor and complained that her bottom hurt. Patient 1 was assisted to bed and cleaned up. There was no indication on the incident report that the physician or a family member was notified of the fall.
Patient 2
1. Review of patient 2's medical record revealed the following information:
The 98 year old male patient was admitted to the swing bed portion of the hospital on 9/1/14, with diagnoses of high blood pressure, history of gunshot wound of the head, and urinary tract issues.
Review of the nurse's progress notes revealed the following information:
On 10/7/14, at 9:58 pm, the nurse documented that patient 2 had lifted his "seat" up as if to stand up but then leaned forward to grab something out of his night stand drawer. This was according to the nurses aide's report. The aide called the nurse to the room to assist in getting him into his wheelchair. The patient denied any pain or discomfort at the time of the nurse's assessment. The aide and the patient both stated that he had not hit his head. Patient 2 exhibited a normal level of consciousness and his vital signs were within normal limits.
On 10/19/14, the nurse documented that patient was heard yelling. He was found on the floor. Patient 2 did not use his call light. A post fall assessment was completed; the pupils of the eyes were described as equal and reactive to light and accommodation. The nurse documented that patient 2 had no apparent injuries and the patient denied pain. A chair alarm was put in place to aid in the prevention of future falls.
On 12/10/14, the nurse documented that patient 2 was found on the floor beside his bed. He was lying on his left side. The floor was wet with urine. Patient 2 denied any pain or injuries. There was no visible evidence of bruising, swelling or redness. Patient 2 stated he had to go to the bathroom really bad. The patient's daughter was notified of the fall.
On 1/1/15, an aide documented that she found patient 2 getting out of bed. The aide documented that she redirected the patient to lie back down and wait for breakfast. The aide documented that she advised patient 2 that if he continued to try to get up alone "we would have to put the leg straps back on".
There was no evidence that the physician was notified of any of the above falls.
Incident Report Review
Review of the hospital's adverse incident reports revealed the following information:
Patient 3
The incident occurred on 11/22/14 at 4:00 am. The incident report description indicated that the staff member heard the bed alarm and found patient 3 was on the floor in a sitting position with the patient's arm on the bed keeping the alarm activated. The patient did not complain of pain and there were no marks indicating injuries on the body. Patient's vital signs were stable. The portion of the report which would indicate the physician and family member were notified was blank.
The incident occurred on 11/25/14 at 5:10 am. The incident report documented that patient 3 slid to the floor from the side of the low bed. Patient 3 was sitting next to bed finishing the slide to the floor as the aide walked into the room. The aide who witnessed the fall stated the patient did not hit his head. The patient was put back to bed. A post fall assessment was completed. The incident report documented that the physician was not notified of the fall. The portion of the form indicating whether patient 3's family was notified was blank.
Patient 6
Review of an incident report dated 11/19/14, at 12:00 am, documented that the staff member was walking down the hallway when patient 6 hollered. The staff member entered the room and found the patient on the floor. No injury was noted. There was no change in mental status. Patient 6 was assisted back to bed. The bed alarm was on. There was no indication on the incident report that the physician was notified of the fall. The documentation indicated that patient 6' s family would be notified in the morning.
Patient 7
Review of an incident report dated 11/25/14, at 7:25 pm, documented that patient 7 was stepping backwards and caught her walker on the chair and tipped over onto her left side. Patient 7 denied hitting her head. She was helped back to the chair. The nurse documented that patient 7 denied any pain. The nurse documented that patient 7 had abrasions on the left lower knee. The abrasions were cleaned with antiseptic, antibiotic ointment and bandages were applied. The incident report indicated that the physician was not notified "not needed". The incident report indicated that the patient's family or friend was not informed "not needed".
Staff Interviews
An interview was conducted with the hospital's social worker on 1/6/15 at 10:50 am.
The social worker stated that patient 1 had arrived at the hospital unresponsive but soon regained consciousness. The patient 1 was unstable when out of bed and fell several times. The social worker stated that patient 1 was confused and would get out of bed unassisted. The nursing staff had placed a bed alarm on the patient (the alarm would sound when the patient attempted to get up). The social worker stated that the recreational therapist came to her and told her that patient 1 was crying with pain when she went to take her to an activity. Patient 1 refused to go to the activity. The social worker checked in on the patient and the patient stated that she had pain in her rib area. The social worker stated that she went to the nurse on duty and informed her that patient 1 was having pain and the nurse informed the social worker that patient 1 had Tylenol ordered for pain. The nurse told the social worker she would try to get her something stronger. The social worker checked back with patient 1 the next day and found her crying with pain. The social worker then checked to see if the patient had an order for the stronger pain medication. The social worker stated that nothing new had been ordered for pain. The social worker went to the nurse again and told her the patient was crying with pain. The social worker stated that the nurse asked the social worker what the social worker did to make the patient cry. The social worker stated that finally that patient 1's pain was addressed when another nurse was on duty and notified the physician. The social worker stated that patient went to the emergency room the next day and was found to have fractured ribs. The patient then received a stronger pain medication.
The social worker stated that patient 1's daughter who lived out of stated called and was concerned that the family members were not being informed about patient 1's falls.
An interview was conducted with the director of nurses on 1/7/15.
The director of nurses stated that the social worker did come to her and tell her that patient 1 was complaining of pain. The director of nurses stated that she was notified of the problem with the patient's pain control sometime during the time frame of 11/19 to 11/21. The director of nurses stated that she did not know the specific date that she found out. The involved nurse was placed on leave for a week without pay and put on a corrective action plan. The director of nurses acknowledged that there had been other nursing staff on duty (night shift) during the 5 days after the patient fell and fractured her ribs. The director of nurses stated that patient was on ibuprofen and tyenol for pain. None of the nursing staff who were involved with patient 1's care between 11/9/15 and 11/14/15, addressed patient 1's increased pain. The director of nurses stated that she had talked with patient 1 on occasion during her stay and had not seen the patient in distress. There was no evidence that patient 1 was evaluated by a physician and no X-ray was done to diagnose patient 1's rib fractures until 11/14/15.