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Based on a review of medical records, facility's policies and procedure, and staff interviews it was determined that the facility failed to have a Governing Body that had oversight of the facility's nursing services to execute PA #1's order for a diagnostic test (computerized tomography of the head), on 8/25/18 at 1:55 a.m., following a fall for Patient #1. This failure resulted in harm to Patient #1 whose potentially serious brain condition was undetected. Patient #1 expired on 08/27/18 at 03:06 a.m.

Findings:-

Cross refer A-0385 as it relates to the failure of the facility's nursing services to execute PA #1's order for a diagnostic test (computerized tomography of the head), on 8/25/18 at 1:55 a.m., following a fall for Patient #1. This failure resulted in harm to Patient #1 whose potentially serious brain condition was undetected. Patient #1 expired on 08/27/18 at 03:06 a.m.

Cross refer A-0115 as it relates to the failure of the facility to protect and promote the right of a patient to receive care in a safe environment.

Based on review of facility's policies, patient records and staff interviews , it was determined that the facility failed to maintain a patient's right to receive care in a safe setting for Patient #1. PA #1 ordered computerized tomography of the head on 8/25/18 at 1:55 a.m., following a fall for Patient #1. The facility's nursing services failed to execute the order. This failure resulted in harm to Patient #1 whose potentially serious brain condition was undetected for several hours. Patient #1 expired on 08/27/18 at 03:06 a.m.

Findings:

Cross refer A-0043 as it relates to the failure of the facility to have a Governing Body that had oversight of the facility's nursing services to follow credential staff's orders, and for the Governing Body to protect and promote a patient's right to care in a safe setting.

Cross refer A-0385 as it relates to the failure of the facility's nursing services to execute PA #1's order for a diagnostic test (computerized tomography of the head), on 8/25/18 at 1:55 a.m., following a fall for Patient #1. This failure resulted in harm to Patient #1 whose potentially serious brain condition was undetected. Patient #1 expired on 08/27/18 at 03:06 a.m.

Based on a review of facility's policies, patient records, and staff interviews, it was determined that the facility's nursing services failed to execute PA #1's order for a diagnostic test (computerized tomography of the head), on 8/25/18 at 1:55 a.m., following a fall for Patient #1. This failure resulted in harm to Patient #1 whose potentially serious brain condition was undetected. Patient #1 expired on 08/27/18 at 03:06 a.m.

Cross-reference A-0115 as it relates to the failure of the facility to protect and promote each Patient #1's right to care in a safe setting.

Cross refer A-0043 as it relates to the failure of the facility to have a Governing Body that had oversight of the facility's nursing services to follow credential staff's orders, and for the Governing Body to protect and promote a patient's right to care in a safe setting.

Review of Patient #1's medical record revealed that he was admitted from another facility on 08/25/18 at 1:00 a.m. with a diagnosis of decompensated liver cirrhosis (a disease that involves loss of liver cells and irreversible scarring of the liver) to the facility's Hepatology service for organ transplant recommendation. The medical history and physical revealed that Patient #1's comorbidities (presence of other illnesses) included fourteen (14) years of daily alcohol abuse, anasarca (generalized body swelling) hypertension (elevated blood pressure) and psoriasis (a chronic skin condition that causes the rapid buildup of skin cells).

Further review of the record revealed that Patient #1 was alert to name, had hand tremors and an unsteady gait.
The record also revealed that on 8/25/18 at 1:05 a.m., Patient #1 was found face-down on the floor in his room. A code MET (Medical Emergency Treatment) was conducted at 1:06 a.m. on 8/25/18.
The Physician Assistant (PA) #1 ordered a computerized tomography scan of the head on 8/25/18 at 1:55 a.m.

The medical record further revealed that Patient #1 remained confused and frequently attempted to get out of bed. The registered nurse (RN #3) remained at Patient#1's bedside.

A nursing event note on 8/25/18 at 2:51 p.m. by RN #4, the day shift nurse, revealed that the computerized tomography (CT) of the head that had been ordered by PA #1 on 8/25/18 at 1:55 a.m. could not be performed due to Patient #1's agitation and restlessness. The record further revealed that a bedside abdominal ultrasound (sonic viewing) was performed on Patient #1 at 2:00 p.m. on 8/25/18.

On 8/25/18 at 2:05 p.m., Patient #1 was found unconscious. A code MET notification was initiated at 2:05 p.m. The Code MET team began to arrive in Patient #1 ' s room at 2:07 p.m. Patient #1 was intubated and transferred to the intensive care unit on 8/25/18 at 3:10 p.m.
A computed tomography (CT) of the head was completed at 5:22 p.m. on 8/25/18. The CT revealed a subfalcine herniation (a displacement of the brain). Patient #1's condition continued to decline, and he was admitted to Hospice care on 08/26/18. Patient #1 expired on 08/27/18 at 03:06 a.m.

A review of the facility ' s Policies and Procedures revealed the following:

Delivery of Patient Care via the Nursing Process, effective date 07/08/2015, revealed that the policy's scope addressed all nursing staff across acute and ambulatory care environments. The policy statement is defined as the method of delivering patient care is determined by the department leadership based on resources and patient population. It must be patient-centered, directed by a professional nurse, be appropriate to both the patient and context of care, and involve patient assessment; development and implementation of a nursing plan of care, and evaluation of the outcomes of care. The policy further revealed that a registered nurse (RN) will assess each patient's needs for nursing care at the time of admission, at the beginning of each nursing shift but not less than every 12 hours, at transfer to another level of service, and at discharge.

Patients will be assessed more frequently as their conditions warrant, as identified by standards of care or protocol, and/or as indicated by a physician or nursing order. Nursing care is planned and delivered through collaboration with physicians and other members of the healthcare team so that the plan of care is consistent with the therapies of other disciplines involved in the patient's care. The nurse assigned to the patient is responsible and accountable for implementing physician and nursing orders. Event notes which describe patients' response to untoward events or describe significant changes in condition are documented as needed.

Falls Prevention and Management: Adult Population, effective 05/1/12018. Revealed that the policy's purpose was to provide identification and ongoing assessment of patients who were at risk of falling, to provide resources for staff to implement fall safety intervention and to educate patient /families about fall prevention. The policy further revealed that the RN conducts and documents fall risk factors on admission, every shift, transfer and after a fall occurs.

Patient's Rights & Responsibilities, effective (no date) revealed that the policy's scope applied to all facility's patients and the purpose was to establish guidelines for patient care that recognizes each patient as an individual with unique healthcare needs, values, and cultural perspective. The policy statement revealed that all patients can participate in the development and implementation of his/her plan of care, know who is responsible for coordinating his/her care, receive considerate and respectful care without discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression, as well as source of payment for care and expect his/her care to be given with regard to his/her safety, in a safe setting and, receive appropriate assessment and management of pain.

An interview with RN #3 on 09/26/18 at 4:57 p.m., in the Administrative Conference Room revealed that she had been employed at the facility for seven (7) months. RN #3 stated that she recalled Patient #1 who was transferred from another facility to the current facility on 8/25/18 during her shift at night. RN #3 stated that she received a transfer report from the transferring facility, which indicated that Patient #1 was alert and oriented but unsteady on his feet. Upon admission to the floor, Patient #1 was assisted by the paramedics to a standing position from the stretcher and onto a scale. RN #3 recalled that Patient #1 was answered simply questions and complied with simple commands. RN #3 stated that shortly Patient #3 was admitted and in bed, she instructed Patient #1 not to move and left the room to use the bathroom. While RN #3 was in the bathroom, she heard a Code MET (Medical Emergency Team) notification on the facility's public-address system. RN #3 stated that Patient #1 had been found lying face down on the floor and about six or seven staff members log-rolled Patient #1 onto a blanket and placed him back in bed. RN #3 recalled that the Physician Assistant (PA #1) assessed Patient #1 and ordered computerized tomography (CT) scan of the head. RN #3 stated that upon the completion of the code MET Patient #1 was awake, calm, alert to his name, but kept attempting to stand up to "to check on his truck". RN #3 stated that thereafter, she remained by Patient #1's bedside for the duration of the night shift. RN #3 stated that her co-workers assisted with caring for RN#3 ' s other patients while she sat with Patient #1. RN #3 further stated that she asked PA #1 if Haldol (a medication that decreases psychosis) or Diazepam (medication that decreases anxiety) could be given to Patient #1 due to his agitation. No medication order for either Haldol or Diazepam was received from PA #1.
RN #3 did not have an answer for why the CT scan of the head ordered by PA #1 on 8/25/18/ at 1:55 a.m. was not done.

An interview with PA #1 (Physician Assistant) on 09/27/18 at 08:30 a.m., in the Administrative Conference Room, revealed that he had been employed at the facility for twenty-five years (25). He stated that he was initially made aware of Patient #1 on 8/25/18 when he responded to the code MET where Patient #1 was found lying face-down on the floor. PA #1 stated that prior to responding to the code MET.
PA #1 stated that when he entered Patient #1's room, Patient #1 was prone (face down), head turned to the right, awake, moving all four (4) extremities, had no visible lacerations or contusion, no raccoon eyes (discoloration around the eyes indicative of a skull fracture) or Battle's sign (discoloration behind the ear indicative of a skull fracture). PA #1 recalled that Patient #1 weighed over 300 pounds and was logged rolled onto a blanket and placed back into the bed. PA #1 stated that he examined Patient #1 and found him oriented to person and month, but not to day or place. Patient #1 exhibited no outward signs of trauma. PA #1 stated that he/she was under the impression that Patient #1 was being admitted to the transplant service and therefore placed medical orders per standard protocol, including the computerized tomography (CT) of the head. PA #1 stated that he checked intermittently for the CT results. PA #1 stated that he did not recall any conversation with RN #3 about medications to aid Patient #1's agitation. PA #1 stated that he re-evaluated Patient #1 multiple times throughout the night on 8/25/18, and was made aware that Patient #1 had fallen an additional couple of times but found that Patient #1's orientation had improved.

An interview with RN #4 on 09/27/18 at 10:45 a.m., in the Administrative Conference Room, revealed that she has been employed at the facility since 1992. She recalled Patient #1 who had been under her care on 8/25/18 on the day shift. Patient #1 had been sitting on a bedside chair and was attempting to stand up. Patient #1 was very confused and remained confused for the duration under he was under RN #4's care. Patient #1 was then placed in bed with two (2) side rails up. RN #4 further stated that she and other staff took turns in monitoring Patient #1.
RN #4 also recalled that she called the computerized tomography (CT) department twice on 8/25/18 in an attempt to complete the outstanding CT order for Patient #1. CT personnel asked RN #4 if Patient #1 was alert and oriented. RN #4 answered, no. The CT personnel responded that if Patient #1 was confused, a physician would have to accompany Patient #1 to complete the CT. RN #4 stated further that Patient #1 was given Lactulose (medication used to decrease ammonia from the blood), and a portable ultrasound was performed on Patient #1. After the foregoing treatments, RN #4 went to render hygienic care to Patient #1 and found Patient #1 unresponsive. RN #4 initiated a code MET notification. Patient #1 was intubated and transferred to the Intensive Care Unit.

An interview with Staff #5 (Chief Quality Officer) on 09/27/18 at 11:15 a.m., in the Administrative Conference Room revealed that the facility ' s risk managers have done a deep dive chart review and are currently gathering more details regarding the incident with Patient #1. Staff #5 further stated that chart documentation regarding sedation versus risks will be viewed and the first Root Cause Analysis meeting is scheduled for 10/04/18 at 08:00 a.m.

A review of three (3) personnel files (2, 3, and 4) revealed that all contained evidence of current licensure, department orientation, annual competency, and health exams.
A review of one (1) credentialing file (Employee #1) revealed current licensure, insurance, appointment, privileges, and peer reviews.

Review of nine (9) additional medical records (# 2, 3, 4, 5, 6, 7, 8, 9, and 10) revealed that all patients had signed consent forms and Patient Rights and responsibilities. All nine (9) had evidence of clinical assessments and re-assessments, appropriate diagnostic-specific treatment plans and completed medication administration records.