HospitalInspections.org

Based on staff interview and record review the hospital failed to provide ongoing supervision and accountability for 1 applicable patient and failed to ensure the safety and well being for all patients. (Patient #1) Findings include:

During the initial weeks of hospitalization from 6/23/10 through 7/22/10, Patient #1 had left their hospital room, exited the nursing unit, wandered the hospital and walked off the hospital campus to smoke without the provision of an escort for supervision. During hospitalization, the patient demonstrated challenging behaviors to include belligerence, agitation, intimidating verbal and physical threats towards staff on several occasions and was often non compliant with medication administration. Nursing note dated 7/19/10 at 1300 states "Per attending.......Patient is not allowed to leave the unit without assistance d/t high safety risk---patient insists to go outside to smoke....". However, before and after this note, the patient frequently left the hospital and as noted in nursing note from 7/16/10 at 2045 "RN informed pt. s/he is not allowed to smoke on hospital grounds, and s/he would have to leave campus......Will call security if pt does not return within 30 minutes". Despite the patient's behavioral issues and threats, the hospital did not provide a security escort for this individual as h/she wandered the hospital and patient units. Per interview on 2/22/11 at 10:28 AM, the Director of Patient Safety stated "We cannot have 1:1 security escorts for every patient that
wants to walk around". On 7/22/10 during one of the patient's unescorted walks within the
facility, the patient sustained a fall with injury. Per the Director of Patient Safety the hospital
was unable to identify direct cause for the fall, but it was confirmed the patient was not provided a security escort and/or supervision at the time of the incident. In addition, there was no definitive plan in place to ensure the patient's safety or the safety of others when Patient #1 wandered in and out of the hospital and exited the hospital campus to smoke.

Based on staff interview and record review, physical restraints were implemented on Patient #1 with no indication for their use or evidence of prior attempts at less restrictive measures to meet the patient's clinical needs or to protect the safety of the patient. Findings include:

1. Per review on 2/23/11, Patient #1 was admitted to the Medical Intensive Care Unit (MICU) on 6/24/10. The patient arrived to MICU intubated, requiring the assistance of a respirator for breathing. The patient was placed in a bed with 4 siderails up and soft wrist restraints were applied to prevent the patient from interfering with the enforceable tube (breathing tube). Per nursing progress note dated 6/24/10 at 1145 Patient #1 was extubated, breathing sufficiently on their own. Soft restraints were removed, but side rails remained up. At 0200 on 6/25/10 a nursing progress note states: "loud bang heard from room, upon entering Pt. found on floor, all 4 side rails remain up in bed. Confused conversation, oriented to person only, MAE (moving all extremities) on command, without sensorimotor deficits. Needed assistance of 4 to get back to bed, legs weak and unable to bear weight. Repositioned back to bed, vital signs stable, physical assessment done, vest posey applied.......". Per review of the Fall Prevention Policy - Adult Inpatient (published 03/21/2008), states: "Consider using two upper siderails to assist with bed mobility and safe egress. Note that four side rails up does not prevent falls and is a restraint if patient can initiate bed exit." Although the patient had demonstrated s/he was able to exit the bed, the 4 side rails continued to be used. There was no evidence of reassessment to determine justifications for the continued use of 4 side rails.

The hospital's policy "Restraints Medical, Surgical and Behavioral Health Indications on Non-Psychiatric Units" (published 04/08/2010) states "the choice of restraints should always be the least restrictive method possible and based on the patient's assessed needs." Record review revealed there was no assessment or documentation by nursing staff that described the need for, or implementation of, physical restraints as the least restrictive measure to assure the physical safety of the patient nor was a specific behavior demonstrated and/or documented that warranted both a vest posey and 4 side rails. Alternatives such as a bed alarm or sitter were not attempted. The patient remained restrained in a vest posey until 1400 on 6/25/10 even while up in a chair during a physical therapy evaluation.

In addition, although the hospital policy allows an RN to initiate the use of a restraint when an MD/LIP (Licensed Independent Practitioner) is not immediately available, the record does not specifically reflect notification of an MD/LIP for the initiation of the vest posey and 4 side rails at 0200 on 6/25/10. A signed order for the use of the restraints was not documented until 0703 on 6/25/10. The noncompliance by the MICU nurse with hospital policy related to restraint use was confirmed by the Director of Nursing Education on the morning of 2/23/11.

Based on staff interview and record review, after a patient experienced a fall, an adverse patient event report was not completed, as per hospital policy, to ensure such events are measured, analyzed and monitored for patient safety and quality of care for 1 applicable patient. (Patient #1) Findings include:

The opportunity to improve patient safety outcomes specific to the use of restraints and fall prevention did not occur as a result of nursing staff's failure to file a SAFE report (an adverse event report). On 6/25/10 in MICU at 0200 Patient #1 exited their bed while 4 side rails were in use and was found lying on the floor in their room. After the fall, the patient was placed back to bed, the 4 side rails remained up and a vest posey was then applied without any evidence of attempting a least restrictive intervention to prevent further falls or restraint use. The hospital's " Fall Prevention Policy - Adult Inpatient" requires staff to complete specific documentation and reporting after a patient experiences a fall. In addition to completing a "Post Fall Evaluation", the nurse who had found Patient #1 after the fall was also required to complete a SAFE report. The nurse failed to file the SAFE report or complete the process associated with the "Post Fall Evaluation". Per interview on 2/22/11 at 10:30 AM, the Director of Patient Safety confirmed all SAFE reports are sent to the Patient Safety office where events are reviewed. During this process the event is investigated to determine "...if there is anything we could have done differently.......any environmental factors that lead to a fall...human factors, any physical factors". The Director of Patient Safety stated a report of patient event investigations are reported monthly to the Quality Council.. However, due to the omission of the SAFE report specific to Patient #1's fall on 6/25/10, a quality compliance review related to the use of 4 side rails, the use of a vest restraint and the circumstances associated with the fall were not investigated to explore opportunities for improvement.

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Based on staff interview and record review, nursing staff failed to conduct a post fall assessment and a adverse event report, as per hospital policy, for 1 applicable patient who had sustained a fall while hospitalized. (Patient #1) Findings include:

Per record review on 2/22/11 and 2/23/11 a nurse assigned to care for Patient #1 on 6/25/10 in the Medical Intensive Care Unit (MICU) failed to complete a "Post Fall Evaluation" assessment after Patient #1 sustained a fall from their bed at 0200 while 4 side rails remained in the upright position. The hospital's "Fall Prevention Policy - Adult (last reviewed 3/21/08) requires several actions to be initiated by the nurse to include an initial clinical evaluation of the patient after the fall and documenting findings and outcomes using the "Post Fall Algorithms". By not completing the assessment, actions and interventions in response to Patient #1's fall were not initiated. In accordance with hospital policy, notifications to nurse managers was not documented as completed; identification of immediate interventions needed to prevent another fall was not documented as implemented, and the MD section of the Post Fall Algorithm was also not completed . In addition, to not completing the "Post Fall Assessment" the nurse also failed to complete a SAFE report (adverse event report) as required per hospital policy. By not completing the SAFE report, the fall incident was not reviewed as per hospital protocol to include an investigation of the event by the nurse manager and a Patient Safety review was not triggered for Quality Improvement for an evaluation of risk factors. The omission of the Post Fall Assessment and the failure of the nurse to file the SAFE report was confirmed on 2/23/11 at 10:45 AM by the Director of Nursing Education.

Based on staff interviews and record review, nursing staff failed to develop a timely care plan for a patient who was assessed to be at risk for falls and who experienced a fall while hospitalized. (Patient #1) Findings include:

1. Despite being identified to be at high risk for falls upon admission on 6/24/10, Patient #1 experienced a fall on 6/25/10 and it was not until 6/30/10 that a care plan was developed by nursing to incorporate specific fall risk factors and interventions for Patient #1. Per record review, on 6/23/10 Patient #1 was brought to the Emergency Department after being found on the street experiencing multiple seizures. S/he was admitted to the MICU on 6/24/10 and per hospital policy, an assessment for fall risk was conducted using the Hendrich II Fall Risk Assessment tool as per the "Fall Prevention Policy - Adult Inpatient". Due to risk factors including a neurological injury with changes in mental status, generalized weakness and use of antiepileptic medications, Patient #1's high fall risk score from 6/25/10 through 6/30/10 were assessed to be 8 through 12 depending on the patient's daily clinical status. (A score of 5 or above designates a patient as a Level II/higher fall risk requiring additional fall prevention interventions ). When admitted to MICU on 6/24/10 , Patient #1 was placed in a bed with all 4 side rails up. On 6/25/10 at 0200 while all 4 side rails remained up, Patient #1 exited their bed and was found on the floor in their MICU room. The "Fall Prevention Policy" Post Fall Assessment process includes nurse managers or their designee assuring a plan of care exists to address the risk factors and fall precautions are initiated. On the morning of 2/23/11 the Director of Nursing Education confirmed that nursing staff failed to develop and implement a fall risk care plan until 6 days after Patient #1 was identified to be a fall risk..