HospitalInspections.org

Based on record review and interview, the hospital failed to ensure treatment plans were updated to include identified problems for two (Patients #2 and #4) of twenty patients.

This failed practice has the likelihood to result in patients receiving no or delayed therapeutic treatment and quality care.

A review of a policy titled "Treatment Planning" read in part, "The goals in developing an individualized and comprehensive treatment plan are to focus attention on the person admitted as a unique individual; to assist staff in understanding the needs of the individual receiving treatment...The plan identifies problems, needs...and defines the actions of the staff...Treatment plan updates will be completed...every seven days for the first two months.

Patient #2

A review of a document titled "Treatment Plan" dated 04/24/20 showed the patient's admission date was 04/09/20 and showed no update to include a problem or need related to a fall.

A review of a document titled "Progress Note(s) Report" dated 04/19/20 showed the patient fell on 04/19/20 at approximately 10:10 PM.

On 09/08/20 at 12:59 PM, Staff R reviewed the medical record for Patient #2 and stated the following:
1. The treatment plan was not updated to include a problem, goals or interventions related to the patient's fall.
2. Falls were to be included on treatment plans to ensure staff knew what to do care for the patient in a safe manner and prevent future falls.

Patient #4

A review of documents titled "Treatment Plan" dated 07/30/20 and 08/06/20 showed the patient's admission date was 07/15/20 and did not show an update to include a problem or need related to a fall.

A review of a document titled "Progress Note(s) Report" dated 07/27/20 showed the patient fell on 07/27/20 at approximately 5:00 PM.

On 09/08/20 at 2:20 PM, Staff R reviewed the medical record for Patient #4 and stated the treatment plan should have been updated to include a problem related to a fall.

Based on record review and interview, the hospital failed to ensure care was provided in accordance to the hospital's written instruction for two (Patients #2 and #3) of twenty patients.

This failed practice has the likelihood to place patients at risk of receiving care inconsistent with the hospital's standards of care, thereby leading to a poor health outcome.

A review of a policy titled "Fall Prevention" read in part, "AFTER A CONSUMER FALLS...Check vital signs. Assess the consumer's level of pain. Assess leg lengths to be sure they are even. Check feet to determine any rotation. Assess the consumer's range of motion of upper and lower extremities. Assessments by the RN should include any changes in skin color, edema...Document in the medical record: consumer appearance at time of discovery, location, consumer response to event, results of assessment...Registered Nurse: completes fall assessment/re-assessment."

A review of a policy titled "Vital Signs and Weights" read in part, "Complete vital signs, Blood Pressure (B/P), Pulse (P), Respirations (R), and Temperature (T), will be taken as ordered by the Physician and/or as indicated by the Registered Nurse."

Patient #2

A review of the medical record showed the patient fell and complete vital signs were not obtained by facility staff per policy. Documentation showed no respirations and temperature were obtained upon discovery of the fall or that a post-fall assessment was completed.

A review of a document titled "Progress Note(s) Report" dated 04/19/20 at 10:51 PM showed the following:
1. Patient was found on floor on 04/19/20 at approximately 10:10 PM after having slipped on some liquid
2. Blood pressure 82/60 manually and heart rate 105

On 09/04/20 at approximately 1:00 PM, Staff E reviewed the medical record for Patient #2 and stated vital signs were to include blood pressure, pulse, respirations and temperature.

On 09/08/20 from 12:36 PM to 12:59 PM, Staff R reviewed the medical record for Patient #2 and the Fall Prevention policy and stated no post-fall assessment was completed and any fall was to have one.

Patient #3

A review of the medical record showed patient had a witnessed fall on 08/26/20 at approximately 2:30 PM. Documentation did not show the location of the fall or a post-fall assessment of pain, even leg lengths, feet rotation, range of motion, change in skin color or edema.

A review of documents titled "Progress Note(s) Report" dated 08/26/20 showed the patient was transported by ambulance on 08/26/20 at approximately 2:50 PM to Norman Regional Hospital and returned at approximately 6:30 PM with new orders to treat a fractured distal fibula.

On 09/08/20 at 11:15 AM, Staff R reviewed the medical record for Patient #3 and the Fall Prevention policy and stated the following:
1. There was no documentation to show if the patient hit her head or any other body parts during this fall
2. There was no documentation to show any other physical assessment besides the patient's pupils
3. There was no documentation of a post-fall assessment
4. Policy was not followed