HospitalInspections.org

Based on document review and interview, the facility failed to ensure patients have the right to receive care in a safe setting for 1 of 10 (patient 1) patient medical records reviewed.

Findings:

1. Policy #I-A.9, Patient Rights and Responsibilities, revised/reapproved 7/16, indicated patients have the right to humane care and protection from harm.

2. Review of patient 1's medical record on 7/27/16 at approximately 1306 hours indicated a wheelchair was used by the patient as an assistive device and the Patient Education Record lacked documentation of wheelchair safety education being provided to the patient. Admission Orders indicated fall precautions were ordered. Nurses Note dated 7/14/16 at 0515 hours indicated patient was up in a wheelchair after a.m. care and being propelled out to the dayroom by staff when patient fell face forward on to the floor. Patient was bleeding from a small gash to the right forehead and bleeding from the nose.

3. Review of grievances indicated there was one grievance filed for patient 1 related to an incident that happened 7/14/16 at 0515 hours. Patient was being pushed in a wheelchair by a C.N.A. to the day room and while in motion the patient fell face first out of the wheelchair. Patient was observed on the floor bleeding from the right side of their forehead and nose, extensively.

4. Staff 4 (Registered Nurse) was interviewed on 7/27/16 at approximately 1442 hours and confirmed the patient was in a wheelchair and fell from the wheelchair 7/14/16 at 0515 hours sustaining injuries.

Based on document review and staff interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to lack of educating patients on wheelchair safety; lack of documenting precaution types; and lack of notification of family/legal guardian of a fall with injuries for 1 of 1 (patient 1) medical records reviewed.

Findings:

1. Policy #II-A.9, Fall Risk Identification and Precautions, revised/reapproved 4/14, indicated patients should be educated in wheelchair safety and fall precautions will be documented on the patients Q15 minute observation form.

2. Policy #III-B.11, Incident Reports, revised/reapproved 11/14, indicated family/legal guardian should be notified of an incident regardless of whether or not injuries were sustained.

3. Review of patient 1's medical record on 7/27/16 at approximately 1306 hours indicated a wheelchair was used by the patient as an assistive device and the Patient Education Record lacked documentation of wheelchair safety education being provided to the patient. Admission Orders indicated fall, assault and aspiration precautions were ordered. The Patient Observation Monitoring form dated 7/13/16 at 1745 hours for observations every 15 minutes indicated staff were to circle the precaution type, but nothing was circled. Nurses Note dated 7/14/16 at 0515 hours indicated patient was up in a wheelchair after a.m. care and being propelled out to the dayroom by staff when patient fell face forward on to the floor. Patient was bleeding from a small gash to the right forehead and bleeding from the nose.

4. Review of incident reports/complaints/grievances indicated there was one grievance filed for patient 1 related to an incident that happened 7/14/16 at 0515 hours. Patient was being pushed in a wheelchair by a C.N.A. to the day room and while in motion the patient fell face first out of the wheelchair. Patient was observed on the floor bleeding from the right side of their forehead and nose, extensively. The patient's FM1 was not documented as being notified of the fall.

5. Staff 4 (Registered Nurse) was interviewed on 7/27/16 at approximately 1442 hours and confirmed the patient was in a wheelchair and fell from the wheelchair 7/14/16 at 0515 hours sustaining injuries. Nursing staff normally documents wheelchair safety education on the Nursing Admission Database and this was not documented for patient 1 as required by facility policy and procedure. Also, patient's family/legal guardian was not notified of the fall as required by facility policy and procedure.

6. Staff 3 (Certified Nursing Assistant) was interviewed on 7/27/16 at approximately 1420 hours and confirmed fall, assault and aspiration precautions were ordered for the patient on 7/13/16 at 1745 hours, but were not circled on the Patient Observation Monitoring form on 7/13/16 as required by facility policy and procedure.

Based on document review and staff interview, nursing staff failed to develop and keep the nursing care plan current related to requesting a physical therapy/occupational therapy (PT/OT) evaluation for 1 of 1 (patient 2) medical records reviewed.

Findings:

1. Policy #II-E.4, Scope of Services for Rehabilitation Therapy Services, revised/reapproved 1/16, indicated as an integral part of the interdisciplinary team, rehabilitation therapists will assist each patient in maximizing their potential to the extent that it enables them to return to a lower level of care, or to achieve their most practical level of functional independence. Rehabilitation services are available two days per week and based on patient needs. The therapy department will provide treatment as the patients clinical needs dictate per physicians orders.

2. Policy #III-A.7, Content of the Medical Record, revised/reapproved 3/14, indicated on pg. 3, point:
A. 14, reassessments are conducted at predetermined and regular intervals or whenever a change in the patient's condition requires his or her re-evaluation. The results of all reassessments are documented in the medical record along with actions and outcomes resulting from the reassessment, including revisions of the treatment plan.
B. 15, clinical observations of the interdisciplinary care givers, along with the medical diagnosis, provide the structure for planning and evaluating the effectiveness of care. Discipline-specific assessments and clinical observations are combined in care planning sessions to present as complete a picture of the whole person as possible so that effective interventions can be identified.

3. Review of patient 2's medical record on 7/27/16 at approximately 1306 hours indicated on admission the patient's mobility status was transfer with assist, weakness and assistance with activities of daily living. FM1 met with the Social Worker on 6/6/16 at 1545 hours to discuss patient's progress with PT/OT. The Social Worker explained PT/OT was not a service provided at the facility, but an evaluation could be ordered if FM1 requested it and FM1 stated they thought the patient came to this facility to get intensive PT/OT. The MR lacks documentation that a PT/OT evaluation was done. The Multidisciplinary Plan of Care lacked actions, outcomes or revisions to the treatment plan related to PT/OT.

4. Staff 2 (Director of Nursing) was interviewed on 7/27/16 at approximately 1600 hours, and confirmed the facility does provide PT/OT services two days per week based on a patients needs per physicians orders and the information given to FM1 by the Social Worker was false. A PT/OT evaluation should have been ordered and added to the Multidisciplinary Plan of Care as an action and revision to the treatment plan after FM1 spoke to the Social Worker and expressed a desire for the patient to receive PT/OT services.