HospitalInspections.org

Based on interview and document review the hospital was found to be out of compliance with the Condition of Participation for Nursing Services CFR 482.23. The hospital failed to provide nursing services according to patient needs for 1 of 10 patients (Patient #1) reviewed for nursing services when his call light was not answered and he attempted to get up independently, fell and fractured his arm as a result of the fall. Refer to deficiency issued at A-0392.

Based on interview and document review the hospital failed to have adequate numbers of licensed and unlicensed staff to provide nursing care to all patients as needed for 1 of 10 patients reviewed, Patient #1, (P-1), when his call light went unanswered, he attempted to get up independently and fell, P-1 suffered a fracture as a result of the fall. Findings include:

Hospital medical record review revealed P-1 was admitted to the hospital on 10/7/2013. P-1's emergency room record dated 10/7/13 was reviewed and revealed P-1 was admitted with intracerebral hemorrhage, coagulopathy and seizure. P-1 had left sided paralysis as a result of a stroke 4 years prior. P-1 had a history that included benign prostatic hyperplasia. At the time of admission P-1 had an indwelling urinary catheter. P-1 was admitted to the neurological intensive care unit (neuro-ICU).

A physical therapy note dated 10/8/13 was reviewed and revealed P-1 was able to transfer with the assistance of one person and was unable to stand without assist and was therefore a fall risk.

P-1's cognitive assessment dated 10/11/13 was reviewed and revealed P-1 was cognitively in tact.

P-1's fall risk assessment dated 10/11/13 revealed P-1 was assessed as a high fall risk with nursing interventions including red slipper socks, visual reminder (door sign), communication of fall risk to staff, patient and family education, assistive devices available, high/low bed, frequent visualization, physical therapy consult, return demonstration of call light use, pharmacist review of medications, room closer to desk, safe patient moving, sensory aides on when awake, stay within arms reach during toileting, utilize non pharmacological sleep aides, and verbal agreement to use call light before getting out of bed.

Documentation indicated that P-1 was transferred from the ICU to the neuro ICU Step Down Unit on 10/12/13.

A hospital document identified as an incident report log (undated) for P-1 was reviewed and revealed on 10/12/13 all RNs assigned to this neuro step down unit unit were in rooms assisting other patients. P-1 needed to use the urinal and put on his call light. The patient stated he was not able to wait for help, so the patient attempted to use the bathroom on his own. The patient stood up and fell at the side of his bed. The patient landed on his buttocks and hit his head against the bedrail.

P-1's x-ray report dated 10/12/13 at 2:46 p.m. was reviewed and revealed a nondisplaced fracture of the left humerus.

Registered Nurse (RN)-F, the nurse caring for P-1 on 10/12/13, was interviewed on 1/30/14 at 9:56 a.m. and stated P-1 had been transferred to the neuro-ICU step-down unit prior to her arrival on 10/12/13. RN-F stated staff use the sign out report and face to face report to communicate about patient needs from shift to shift and from unit to unit. RN-F had received the sign out report and face to face report and was made aware of P-1's needs related to falls risk. P-1 was using a urinal to void independently. The morning of 10/12/13 RN-F was busy in another patient room when she heard an alarm sound. She went to P-1's room to investigate and found P-1 on the floor next to the bed. When queried related to why the urinal was not within reach of P-1, RN-F stated she did not know why. RN-F stated that she was told by family later that day that P-1 was not using his upper body normally. RN-F stated that an x-ray was ordered that afternoon and revealed P-1 had a fracture.

P-1's family member (FM)-E was interviewed on 1/28/14 at 12:30 p.m. and stated P-1 had recently had his catheter discontinued. P-1 told her that on 10/12/13 he had put his call light on because he had to use the urinal and no one responded for 10 - 15 minutes. FM-E stated P-1 had urinary urgency and has to use the bathroom at least every hour and a half. P-1 stated he could not wait and got up to use the urinal and he fell. FM-E stated that P-1 is admitted to this hospital regularly and the nurses often get busy in other patient rooms and cannot answer call lights in a timely manner.

RN-G, Patient Care Manager for the neuro-ICU step down unit was interviewed on 1/29/14 at 10:10 a.m. and stated that she investigated the incident by speaking with P-1 and his wife. RN-G stated that P-1 stated he put his call light on and waited 10-15 minutes with no response. P-1 stated he got up on his own, because no one responded to the call light, and fell. RN-G stated she spoke with RN-F's care manager about the incident but no other investigation had been completed related to this fall. RN-G stated that the neuro-ICU step down unit has been seeing higher acuity patients since the new neuro-ICU opened. RN-G stated staff members have approached her regarding the staffing concerns and the hospital has implemented changes including increased staffing hours and hourly rounding.

Quality and Patient Data Services employee, (QP-C) was interviewed on 1/28/14 at 8:45 a.m. QP-C stated that the hospital's root cause analysis investigation (RCA) system would routinely be implemented related to a fall such as this. QP-C stated an RCA had not been completed for this fall because she had not been made aware that P-1 experienced a fracture as a result of the fall until this investigator questioned hospital staff about the fall.

RN-V, Patient Care Supervisor responsible for the neuro-ICU step-down unit, was interviewed on 1/24/14 at 1:10 p.m. RN-V stated that the unit has seen a change in the patient population since the opening of the new neuro-ICU. RN-V stated the hospital has implemented many changes on the unit as a result of this change. The changes implemented have included increasing nursing hours, ongoing fall risk assessments and odd hour rounding (so patients are rounded on every hour).

The hospital policy titled Fall Prevention: Inpatient and dated January 2014 was reviewed and revealed under:
1: Evaluation: A fall risk score based on the Hendrich Fall Risk Model is calculated and documented as part of the admission process and every shift.
3.e. It is recommended that someone be with the patient at risk of falling during toileting and that toilet rounding occurs at regular intervals.