HospitalInspections.org

Based on medical record review, document review, and interview, the facility failed to ensure care was provided in a safe setting (A144).

Based on medical record review, document review, and interview, the facility failed to ensure care was provided in a safe setting for two of 19 patients identified as high risk that received services in Ridgeway Tower (Patient #1 and #5). The sample was 10 medical records reviewed. The total hospital census was 476.

Findings include:

1. Review of the medical record for Patient #1 revealed an Emergency Department (ED) attending physician note dated 03/06/23. The assessment revealed the patient presented to the hospital by helicopter emergency medical services (EMS) after they were called to her facility for hypotension and bright red blood per rectum. Upon arrival she had a facial droop and some dysarthria, more altered. She was noted to be hypotensive with a blood pressure (BP) of 98/52. The patient was otherwise maintaining well with weakness noted to her lower extremities. Workup was going to be done for hematology and stroke. In the ED the patient was normotensive. She was alert and oriented and moves all extremities. She did have some bruising noted to the back of her neck.

Review of the fall risk assessment dated 03/06/23 revealed a Morse Fall Risk Score of 85 (high fall risk). The fall risk assessment revealed the areas that triggered the high fall risk score included history of falling, secondary diagnoses, gait/transferring and mental status. Under musculoskeletal she had full movement to her bilateral upper extremities and limited movement to her bilateral lower extremities. Neuro Assessment revealed her level of consciousness was alert, oriented to person, follows simple commands, clear speech, bilateral pupils round and reactive to light, and weakness dorsiflexion to her right and left foot.

Review of a physical therapy (PT) assessment dated 03/07/23 revealed the patient had impaired bed mobility, impaired transfers, impaired balance, impaired activity tolerance, impaired gait, impaired safety awareness, and the prognosis was good. The patient was supine in bed upon arrival for PT eval. Presents below baseline level of mobility requiring max assist of two for supine to sit and max assist of one for sit to stand. She is limited by impaired balance and impaired cognition. She would benefit from continued inpatient PT to address strength, balance, endurance and functional mobility. The PT assessment also revealed bed mobility for supine to sit maximum assistance of two people, head of bed elevated, and sit to supine maximum assist of two people head of bed flat. Additional comments revealed the patient had a posterior lean in sitting and standing. Position after therapy handoff is call light needs to be within reach, bed alarms and alarms status is activated and interfaced with the call system.

Review of a nursing note dated 03/08/23 at 8:38 PM revealed the patient care assistant (PCA) notified the registered nurse (RN) that the patient had fallen and was found down next to the bottom of the bed laterally. The charge nurse and physician were at the bedside, vitals assessed, the patient was alert and oriented and blood was noted on the back of her head. The physician ordered a computed tomography (CT) scan STAT.

Review of a physician note dated 03/08/23 at 10:54 PM revealed radiology confirmed there is a right intracerebral hemorrhage with minimal midline shift. The patient has been accepted to Neuro Intensive Care Unit (ICU) by the team and will be transferred.

Review of the adverse event log dated 03/08/23 revealed the patient was found down next to the foot of the bed, laterally with a head laceration. The PCA came out of the room and notified the nurse that the patient had fallen. Rapid response was called. The patient was transferred to CT at the main hospital by mobile care.

The description of the adverse event that was completed by the manager revealed the bed exit alarm was at 7:39 PM and the alarm was canceled at 7:41 PM (one minute and 50 seconds) and at 7:45 PM staff emergency was called and canceled at 7:46 PM (25 seconds). The PCA went into the room, placed the patient back in bed, left the room to find someone to help pull her up, alarm was not placed back on the patient and she was found on the floor with a head laceration. The CT scan showed left front parietal lobe intraparenchymal hemorrhage, left temporal lobe contusions, left temporal and right parietal traumatic subarachnoid hemorrhage, subdural hematoma and right scalp laceration

Review of the Rapid Root Cause Analysis (RCA) - Fall revealed the bed alarm was placed, Patient #1 was situated back in bed, PCA needed assistance to pull Patient #1 up. Instead of using the call light and waiting for help in the room, the PCA left the room and did not reset bed alarm. Patient #1 fell out of bed. When the PCA arrived back to the room the PCA found the patient on the floor and rapid response was called.

Review of a Neuro ICU note dated 03/08/23 revealed the patient was admitted to Neuro ICU under neurosurgery for head injuries.

Review of a neurocritical care resident progress note dated 03/09/23 titled, Medical Orders for Life-Sustaining Treatment Discussion, revealed the patient was with worsening neurologic examination after a fall. She has a deteriorating Glasgow Coma Scale (used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients). It was discussed with family that she may need intubation for airway protection if her current trajectory continues. The family wa son their way to the hospital to discuss code status and understand that staff will proceed with intubation if needed.

Interview with Staff H on 03/21/23 at 3:38 PM revealed on 03/08/23 a post fall huddle was completed with the nursing staff right after Patient #1 fell. Risk management, Patient Safety, patient safety officers (physicians), and Accreditation then reviewed the incident where it would be determined if the incident met the sentinel event definition. The incident did and then a Rapid RCA was completed. The Rapid RCA was sent out to the unit leaders on 03/13/23 and the response was completed by the unit leaders on 03/14/23. The next step was to meet with the unit leadership to go over any immediate action items and then education would be provided. The education had not been scheduled yet.

Interview with Staff G on 03/22/23 at 11:30 AM, in the presence of the Interim Unit Manager for Ridgeway Tower, revealed she went to the patient's room because the bed alarm was sounding. The patient was at the foot of the bed and she sat the patient at the side of the bed with her feet dangling. The PCA went to get help because she could not get the patient pulled up in bed. The PCA stated she thought she turned the bed alarm on before she left the patient's room. She stated she could not find any help and when she went back into the patient's room she was on the floor and the back of her head was bleeding. The PCA turned on the call light and asked for rapid response. The bleeding stopped on it's own.

Interview with Staff I on 03/22/23 at 11:33 AM revealed the fall did cause a decline in Patient #1's condition. He stated that over the course of the year Patient #1 had been declining related to her dementia. She had increased falling at the nursing home. She was admitted here and she had declined from her UTI, but then with the fall and the trauma she was worse. By report prior to the fall the patient was verbal with confusion. Patient #1 intermittently needed assistance with feeding in general. She now had nasogastric tube and she will have to have a feeding tube.

2. Review of the medical record for Patient #5 revealed she was admitted through the ED on 03/15/23 with a diagnosis of altered mental status, highly suspicious for infection, and a urinalysis (UA) suggestive of UTI. The final diagnosis was sepsis due to UTI. In the ED the patient's fall risk score was a 50 (high fall risk). On 03/16/23, the patient had a fall risk score a 60 with high fall risk interventions put in place.

A PT eval on 03/21/23 revealed minimal assistance with sit to stand, patient unwilling to attempt forward or lateral steps at edge of bed due to reports of pain.

A nursing progress note dated 03/23/23 at 4:53 AM revealed Patient #5 was found on the floor by her bed. Patient #5 states she slid to the bottom of the bed and was trying to get up. Vitals were stable, and the bed alarm was put on. Patient #5 had a skin tear to her elbow and was educated on the need to use her call light for assistance. A chest and shoulder X-ray were both negative.

Review of the fall prevention audit smart bed technology and alarm compliance for Patient #5 revealed on 03/23/23 the bed alarm was on at 4:00 PM, at 8:00 PM there was no indication whether the bed alarm was on or off, and at 10:00 PM the bed alarm was off until Patient #5 was found on the floor in her room between 2:00 AM and 4:00 AM.

Interview with the Staff C on 03/23/23 at 12:31 PM regarding Patient #5 revealed when the nurse rounded at 2:00 AM, Patient #5 was asleep. A new admission came up around 4:00 AM and Patient #5 was found on the floor by Emergency Medical Services (EMS) while they were going down the hall. The nurse was informed at this time. The bed alarm was not on. The patient was put back to bed and the bed alarm was put on.

Interview with Staff C on 03/23/23 at 1:45 PM revealed the fall prevention audit, smart bed technology and alarm compliance revealed at 10:00 PM Patient #5's bed alarm was not on and that was why the alarm was not sounding when Patient #5 was found on the floor in her room. She stated the fall happened between 2:00 AM and 4:00 AM which was when the bed alarm was put back on.

This deficiency represents non-compliance investigated under Substantial Allegation OH00141259.