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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on interviews and document review, the facility failed to ensure all staff who were assigned to work on the orthopedic surgical floor were trained in order to care for patients with specific post-operative precautions for safety with transfers and bed mobility. This failure was identified in 1 of 3 medical records of patients who underwent total hip replacement surgeries (Patient # 2).

Based on interviews and document review, the facility failed to ensure all staff who were assigned to work on the orthopedic surgical floor were trained in order to care for patients with specific post-operative precautions for safety with transfers and bed mobility. This failure was identified in 1 of 3 medical records of patients who underwent total hip replacement surgeries (Patient # 2).

Findings include:

Facility policy:

The Nursing Service Staffing policy purpose was to give direction to nursing units regarding the use of staffing resources. The policy read it was the Staffing Coordinator, Shift Specialty Coordinator, and House Supervisors responsibility to serve as a liaison in floating staff to other units. Additionally, all associates were required to float to other units based on documented clinical competence, skill and patient care needs. The policy read staffing assignments were to be adjusted based on the judgement of the registered nurse (RN) in charge to provide special patient care needs depending on the patient's condition and to ensure the patient care needs were met.

1. The facility failed to ensure nursing staff had been educated on posterior hip precautions when caring for Patient #2. Subsequently, during Patient #2's transfer from the bed the patient suffered further injury after being moved by untrained staff.

a. A medical record review was conducted for Patient #2 who was admitted to the orthopedic surgical floor following a total hip arthroplasty (hip joint replacement) (THA) on 6/26/19.

On 6/26/19 Patient #2 had an order by the provider for hip precautions (avoidance of certain movements of the hip to protect the joint from dislocation). These precautions included not to bend the hips greater than 90°, no crossing legs and no rotation of the feet inwards.

On 7/3/19 Patient #2 was being transferred out of bed by Certified Nursing Assistant (CNA) #3 and RN #4 when the patient experienced a loud pop and sudden severe pain. Review of the x-ray results from 7/3/19 at 11:07 p.m., revealed one of the cerclage bands broke and the patient sustained a fracture to her lesser trochanter (a small protrusion off the femoral shaft where ligaments and tendons attach).

b. On 11/6/19 at 9:38 a.m., an interview was conducted with RN #4 who worked in the site based float pool (staff members who rotated through a single hospital to different units based on staffing needs). RN #4 who transferred Patient #2 on 7/3/19 stated she had worked on the orthopedic surgical unit but had not received any training specific to patients on the unit or additional training from Physical Therapy (PT) and Occupational Therapy (OT) regarding orthopedic precautions. Additionally, she stated she had not had any orientation shifts on the orthopedic surgical unit prior to caring for patients on the unit.

Review of the orthopedic surgical unit's orientation packet given to full time staff contained a patient checklist which provided guidance for the Care of Fractured Hips Before Surgery and Care for Total Hip after Surgery, guidance for staff to follow when patients required hip precautions and change in weight bearing status' and included a quick reference guide for the RN's which specified the orthopedic precautions.

The facility was unable to provide any evidence which indicated RN #4 had received the above training, to include the care for a patient who had undergone a total hip surgery and hip precautions/weight bearing status.

c. On 11/7/19 at 8:37 a.m., an interview was conducted with RN #8 who had cared for Patient #2 as the primary RN on 7/3/19. RN #8, who was also not a permanent staff member on the unit, stated she also had not received any training related to the care of orthopedic patients and special precautions prior to working on the unit.

Similarly to RN #4, the facility was unable to provide evidence RN #8 had received training and orientation to the orthopedic surgical unit.

d. An interview was conducted with RN Educator #6 (Educator #6) on 11/6/19 at 1:07 p.m. Educator #6 stated she was responsible for the orientation and education of permanent nursing staff to the orthopedic surgical unit. Educator #6 said all new CNA's and RN's hired to the orthopedic surgical unit were required to attend special training which reviewed orthopedic precautions and definitions of different weight bearing status'. Additionally, Educator #6 stated all new hires met with PT or OT for two to four hours for additional orthopedic specific training.

e. An interview was conducted with Clinical Nurse Educator #9 (Educator #9) on 11/7/19 at 9:33 a.m. Educator #9 stated she was responsible for the orientation of staff members to the site based float pool. Educator #9 said the orientation for the site based staff members included general hospital orientation followed by two days of orientation on each of the floors they would work on. Educator #9 stated the site based float pool staff were informed of the access to the tip sheets for each unit, however, she was unable to verify the staff reviewed or utilized these tip sheets.

Educator #9 stated there was no specific document which identified orientation and education of the site based float pool staff specific to the specialized needs and precautions of the orthopedic surgical unit.

f. On 11/7/19 at 10:23 a.m., an interview was conducted with Director of Inpatient Services (Director #10). Director #10 stated, orthopedic surgical patients were a specialized type of patient and a float nurse should have basic knowledge in regards to transferring patients, but if there were additional questions, the staff member would be expected to speak up.

Director #10 was unable to provide any evidence RN #4 and RN #8 had received training specific to orthopedic surgical patients prior to caring for patients on the unit.