HospitalInspections.org

Based on staff interviews, facility document review and patient record review the facility failed to have an effective governing body to ensure that the facility protected and promoted patient rights, ensure that the facility has a effective Quality Assurance and Performance Improvement (QAPI) program, and failed to provide Nursing Services to ensure patient safety. For this reasons, the Condition of Governing Body was found to be out of compliance

Findings:

Reference A 0115: Based on staff interview, facility document review and patient record review the facility failed to ensure for 1 of 5 patients, (patient #1) that patients receive care in a safe environment. Failure to protect the patient from an unsafe environment places patients at risk of physical and psychosocial harm.

Reference A 0263: Based on staff interviews, facility document reviews and patient record review the facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program that evaluated the safety and effectiveness of a newly expanded call bell system. Failure to effectively evaluate the safety and effectiveness of the call bell system has placed patients at risk of falls with injury and death.

Reference A 0385: Based on staff interviews, facility document review and patient record review the facility failed to provide nursing supervision for 1 of 5 patients, (patient #1) to ensure timely reassessment and the development of appropriate nursing interventions in order to provide timely care to meet the patient's care needs. Failure to provide nursing care based on a timely reassessment places patients at risk of not receiving care and services to prevent injury or harm.

Based on staff interview, facility document review and patient record review the facility failed to ensure for 1 of 5 patients, (patient #1) that patients receive care in a safe environment. Failure to protect the patient from an unsafe environment places patients at risk of physical and psychosocial harm.

Findings:

Reference to A 0144. Based on observations, staff interviews and document review the facility failed to ensure that a consistent process was in place for 3 of 5 Medical Units in order to ensure that call bells are answered within a time frame to meet the patients needs. Failure to answer the patients call bells within the timeframe to meet the patient's individual needs places them at risk for physical and psychosocial harm.

Based on observations, staff interviews and document review the facility failed to ensure that a consistent process was in place for 3 of 5 Medical Units in order to ensure that call bells are answered within a time frame to meet the patients needs. Failure to answer the patients call bells within the timeframe to meet the patient's individual needs places them at risk for physical and psychosocial harm.

Findings:

Review of patient #1's medical record revealed that the patient was transferred to this facility on 03/20/2010 and admitted to the Bone Marrow Transplant Unit for the treatment of new onset Acute Myeloid Leukemia, (AML). The patient's past medical history included significant left hip pain, status post (s/p) left shoulder replacement. On 03/21/2010 the physician ordered Morphine ER Tab (tablet) SR 15 milligrams (mg) by mouth (PO) twice daily, at 0900 (9:00 AM) and 2100 (9:00 PM) for pain. Additionally the physician ordered on 03/20/2010 Oxycodone Tab 5 mg-10 mg PRN (as needed), PO every 4 hours for moderate pain. Review of the medical record revealed that starting on 03/25/2010 and continued thru 03/29/2010 the patient experienced diarrhea daily. On 03/30/2010 the patient's gastrointestinal (GI) status was evaluated at 14:23 (2:23 PM) as within defined limits except, no nursing note was found in the medical record to explain what except means. Review of the medical record for patient #1 revealed that on 03/30/2010 at 08:10 (8 :10 AM) reported a, "critical" low result for Platelet Count of 5.0 for the patient. The patient received two transfusions of leuko-reduced, irradiated pooled platelets. The first transfusion started at 11:15 and was transfused without incident. The second transfusion was started at 14:57 and at 16:30 (4:30 PM) the patient developed a transfusion reaction that manifested as Rigors and a mildly elevated temperature. The patient's physician was notified, orders were received and the patient was treated with Demerol 25 mg intravenous (IV) at 16:40 and again Demerol 25 mg IV at 16:50, Benadryl 50 mg IV at 16:50 and hydrocortisone 100 mg IV at 16:55. The patient's vital signs were taken after the transfusion was stopped, again in 17 minutes and repeated at 17:22 (5:22 PM) and 17:58. Review of the nursing note at 17:58 revealed, "Pt. feels better no more rigors noted. Sitting on bed ready to take [his/her] food. " At 20:45 (8:45 PM) the vital signs had returned to the pre-transfusion levels.
Review of the daily nursing assessments for patient #1 revealed that consistently from the day of admission to discharge from the Bone Marrow Unit the patient's gait was evaluated as unsteady. Review of the evaluation of the fall risk for patient #1 revealed that the patient was classified as, "High Risk for Falls". Review of the patient's fall risk score revealed that on the 03/28 and 03/29/2010 the patient had a Mores Scale score of 35. When the patient evaluated on 03/30/2010 the Mores score was 75, indicating that the fall risk of the patient had significantly increased from the previous two days. Review of the medical record did not reveal that the patient's care plan for fall prevention were evaluated or changed to reflect the patient's significantly high likelihood of falling. Review of the medical record revealed that the fall assessment was performed prior to the reaction to the platelet transfusion. Further review of patient #1's medical record, for this date (03/30/2010) revealed that at 2100 (9:00 PM) the patient received a Morphine 15 mg Extended Release tablet for pain management and an Ambien 10 mg for insomnia.
Review of the patient call bell log for the Bone Marrow Unit for 03/30/2010 revealed that at 21:20:35 (9:20 PM and 35 seconds), the patient press the call bell (Call Set) for assistance. The Unit Ward Clerk answered the call bell (Call Clear) at 21:20:47, opened the intercom (Intercom Activate)at 21:20:47 and spoke to the patient. The report revealed that the intercom/call bell system was terminated (Intercom Deactivated) with the patient at 21:20:65.

Interview with the Unit Ward Clerk on 04/06/2010 at 3:17 PM revealed that the Unit Clerk worked full time on the unit and worked 3 evening shift and 2 days shift per week. Interview with the Unit Clerk revealed that she remembered patient #1, as she was working the evening of 03/30/2010 and had answered the patient's call bell prior to the patient's fall. The Unit Clerk stated that the patient had used the call bell to request assistance to go the bathroom and that she told the patient that she would tell his/her nurse. The Unit Clerk then turned the call bell/intercom off and wrote on a posted note that the patient needed assistance to go the bathroom and gave the note to the nurse. According to the Unit Clerk, the nurse was at that nursing station at the time and was on the telephone. The Unit Clerk further stated that the nurse acknowledged the note and left the nursing station heading in the direction of patient #1's room.

Interview with patient #1's nurse on 04/06/2010 at 2:32 PM revealed that at 9:00 PM the patient requested a sleeping pill, stating that he/she was tired, but could not sleep. The nurse was asked about the patient care plan, the nurse stated that the patient needed assistance for going to the bathroom. The nurse further stated that the patient had in the past gotten up out of bed without asking for assistance. Continued interview with the nurse revealed that she neither heard the patient call for assistance nor that the Unit Clerk gave her a note or told her that the patient needed assistance.

Review of the medical record throughout the admission to the Bone Marrow Unit revealed the patient to be Alert and Oriented to person, place and time and cooperative with the staff. The medical record did not reveal that at any time the patient had gotten out of bed without assistance.

Interview with the Unit Manager on 04/02/2010 at 4:00 PM revealed that a nurse, (not the patient's assigned nurse), was at the nursing work station outside of patient #1's room when at approximately 21:25 (5 minutes after the patient had called for assistance) she heard a thump coming from patient #1's room. The nurse went in the room and found the patient on the floor in the bathroom. According to the Unit Manager, the nurse went to the hallway and called for help. The patient's assigned nurse was in the hall and responded.

Review of the medical record for patient #1 revealed a nursing note, written by the patient's nurse on 03/30/2010 at 21:40 (9:40 PM), "patient fell around 21:25, found on floor, PA [named Physician Assistant] aware and informed assessed pt. (patient) made orders. Made patient comfortable on bed vital signs check. Cold compress applied to pt's right temporal area and right wrist. Continue to monitor". Review of a physician progress note dated 03/30/2010 at 9:20 PM revealed, "Pt fell in bathroom, hit right side of face, right shoulder and right wrist. Pt ambulated to bathroom without assistance prior to fall. Distressed secondary to fall/pain confused. Right max face, right temple, right orbit with large hematoma, right shoulder hematoma, right wrist hematoma with extensor surface deformity." Review of the nursing note revealed that at 21:30 patient #1's vital signs were obtained along with the following comment from the nurse, "Vital signs taken after pt. fell in the bathroom. Pt. alert and aware at the time of the incident. PA [named Physician Assistant] aware and informed. Orders made in the chart. Pt. vital signs monitored every 15 minutes". Review of the patient's medical record did not reveal that vital signs were taken at 21:45 or any other times before being transferred off the Unit. Review of the medical record did not reveal that the nurse had performed any neurological checks on the patient after the fall. Review of nursing note dated 03/30/2010 at 22:00 (10:00 PM) revealed the following entry, "Nurse with the pt. Pt. asked for nausea [medication]. Nurse took Zofran 4 mg IV and trying to get pt. aware, nurse notice that pt. become unresponsive. Nurse called PA and call code blue." Further review of patient #1's medical record revealed the patient was placed on ventilator and transferred to the Neurological Intensive Care Unit (ICU). After consultation with patient #1's family the patient was removed from the ventilator and expired on 03/31/2010.

Review of the call bell system reveals that the system has the capability of being placed in a reminder mode that after 5 minutes the system will remind the Unit Clerk or any staff at the nursing station if the call bell is not turned off in the patient's room. The system also allows the Unit Clerk to assign the call to any staff member, usually the patient's nurse or Patient Care Technician (PCT). When the room is assigned to a specific staff a light outside the patient's room will light in a color that is specific to the staff. For example a red lights indicates it is for the patient's nurse. The light will flash red until the nurse enters the room and the system senses a locator device that the nurse wears. After the nurse enters the room the light will turn to a solid red. When the nurse is done assisting the patient and leaves the room the light will automatically turn off. One of the advantages of the system is all of the staff can see a flashing light and know that the patient needs assistance.

Interview on 04/06/2010 at 3:17 PM with the Unit Clerk for the Bone Marrow Transplant, who was on duty the night patient #1 fell on 03/30/2010 ,revealed that the reminder system is not used and that she will generally call the nurse on their telephone or in this case give them a note.

Interview with the day shift Unit Clerks (2 clerks) for the Bone Marrow Transplant Unit on 04/06/2010 at 10:20 AM revealed that, "We do not turn the system off, it goes off when the nurse leaves the room." Review of the patient call bell log for the Bone Marrow Unit on 03/30/2010 revealed the reminder system was not used, on that unit, for a single patient who used their call bell.

Review of the Call Bell logs for 4 additional units, that have the same call bell system and organizational structure as the Bone Marrow Unit, revealed that two (11-5 Neurosurgery) utilizes the reminder function routinely, one (8 east) utilizes the system frequently but has frequent long gaps where the system is not being utilized and like the Bone Marrow Unit, 6 west does not utilized the system.

Interviews with the Unit Clerks from all five units revealed that all had been trained on the call bell system, but none knew of any policy and procedures relating on how the system is to be used and if utilizing the reminder function is required.

Interview with a Quality Manager on 04/06/2010 at 10:30 AM revealed that the facility has not developed or implemented policy and procedures related to the call bell system. Additionally, the facility has not developed any quality measures to monitor the effectiveness of the call bell system.

Interview on 04/06/2010 at 9:40 AM with the Nurse Manager for the Bone Marrow Transplant Unit revealed that following the fall of patient #1 an incident report was started and that a preliminary investigation was also initiated. When asked if any actions were identified that needed to be immediately implemented to prevent a reoccurrence; the Nurse Manager stated no actions were implemented to prevent a reoccurrence of the incidence. Follow-up interview with the Nurse Manager on 04/06/2010 at 3:30 PM revealed that there were no actions identified following the incident that needed to be taken to prevent other patients from experiencing the same incident.

Based on staff interviews, facility document reviews and patient record review the facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program that evaluated the safety and effectiveness of a newly expanded call bell system. Failure to effectively evaluate the safety and effectiveness of the call bell system has placed patients at risk of falls with injury and death.

Findings:

Reference to 0316. Based on staff interview, facility record review and patient record review the facility failed to evaluate the safety and effectiveness and develop policy and procedures for the new patient call bell system following the remodeling and expansion of patient care settings. Failure to develop policy and procedures for new or expanded call bell system and to evaluate the effectiveness and safety of that system, places patients at risk of not receiving care and services to prevent falls with injury or death.

Based on staff interview, facility record review and patient record review the facility failed to evaluate the safety and effectiveness and develop policy and procedures for the new patient call bell system following the remodeling and expansion of patient care settings. Failure to develop policy and procedures for new or expanded call bell system and to evaluate the effectiveness and safety of that system, places patients at risk of not receiving care and services to prevent falls with injury or death.

Findings:

Review patient #1's medical record revealed that the patient was admitted on 03/20/2010 and to the Bone Marrow Transplant Unit for the treatment of new onset Acute Myeloid Leukemia, (AML). Review of the daily nursing assessments for patient #1 revealed that consistently from the day of admission to discharge from the Bone Marrow Unit the patient's gait was evaluated as unsteady. Review of the evaluation of the fall risk for the patient revealed that the classified as "High Risk for Falls". Review of the patient's fall risk score revealed that on the 03/28 and 03/29/2010 the patient's had a recorded Mores Scale score of 35. When patient #1 was evaluated on 03/30/2010 the Mores score was 75, indicating that the patient's fall risk had significantly increased from the previous two days. Review of the medical record did not reveal that the patient's care plan for fall prevention were evaluated or changed to reflect the patient's significantly high likelihood of falling. Review of the medical record revealed that the fall assessment was performed prior the reaction to the platelet transfusion. Further review of the medical record revealed that at 2100 the patient received a Morphine 15 milligrams (mg) Extended Release tablet (tab) for pain management and an Ambien 10 mg for insomnia.

Review of the patient call bell log for the Bone Marrow Unit on 03/30/2010 revealed that at 21:20:35 (9:20 PM and 35 seconds) the patient press the call bell (Call Set) for assistance. The Unit Ward Clerk answered the call bell (Call Clear) at 21:20:47, opened the intercom (Intercom Activate)at 21:20:47 and spoke to the patient The report revealed that the intercom/call bell system was terminated (Intercom Deactivated)with the patient at 21:20:65.

Interview with the Unit Ward Clerk on 04/06/2010 at 3:17 PM revealed that the Unit Clerk worked full time on the unit and worked 3 evening shift and 2 days shift per week. Further interview with the Unit Clerk revealed that she remembered patient #1 as she was working the evening of 03/30/2010 and had answered the patient's call bell prior to the patient's fall. The Unit Clerk stated that the patient had used the call bell to request assistance to go the bathroom and that she told the patient that she would tell his/her nurse. The Unit Clerk then tuned the call bell/intercom off and wrote on a posted note that the patient needed assistance to go the bathroom and gave the note to the nurse. The Unit Clerk stated that the nurse was at the nursing station at that time and was on the telephone. The Unit Clerk stated that the nurse acknowledged the note and left the nursing station heading in the direction of the patient's room.

Interview with the patient's nurse on 04/06/2010 at 2:32 PM revealed that at 9:00 PM the patient requested a sleeping pill, stating that he/she was tired, but could not sleep. The nurse was asked about the patient care plan the nurse stated that the patient needed assistance for going to the bathroom. Continued interview with the nurse revealed that the nurse stated that she had not heard the patient call for assistance and that the Unit Clerk did not give her a note or tell her that the patient needed assistance.

Interview with the Unit Manager on 04/02/2010 at 4:00 PM revealed that a nurse, (not the patient's assigned nurse), was at the nursing work station outside of patient #1's room when at approximately 21:25 (5 minutes after the patient called for assistance ) she heard a thump coming from patient #1's room. The nurse went in the room a found the patient (pt.) on the floor in the bathroom. The nurse went to the hallway and called for help. The patient's assigned nurse was in the hall and responded.

Review of the medical record for patient #1 revealed a nursing note by the patient's nurse on 03/30/2010 at 21:40 stating that, "patient fell around 21:25, found on floor, PA [named Physician Assistant] aware and informed assessed pt. made orders. Made patient comfortable on bed vital signs check. Cold compress applied to pt's right temporal area and right wrist. Continue to monitor". Review of a physician progress note dated 03/30/2010 at 9:20 PM revealed, "Pt fell in bathroom, hit right side of face, right shoulder and right wrist. Pt ambulated to bathroom without assistance prior to fall. Distressed secondary to fall/pain confused. Right max face, right temple, right orbit with large hematoma, right shoulder hematoma, right wrist hematoma with extensor surface deformity." Review of nursing note dated 03/30/2010 at 22:00 which states, "Nurse with the pt. Pt. asked for nausea [medication]. Nurse took Zofran 4 mg IV and trying to get pt. aware, nurse notice that pt. become unresponsive. Nurse called PA and call code blue." According to patient #1's medical record, the patient was placed on ventilator and transferred to the Neurological Intensive Care Unit (ICU). After consultation with patient #1's family the patient was removed from the ventilator and expired on 03/31/2010.

Review of the call bell system reveals that the system has the capability of being placed in a reminder mode that after 5 minutes the system will remind the Unit Clerk or any staff at the nursing station if the call bell is not turned off in the patient's room. The system also allows the Unit Clerk to assign the call to any staff member, usually the patient's nurse or Patient Care Technician (PCT). When the room is assigned to a specific staff a light outside the patient's room will light in a color that is specific to the staff. For example a red lights indicates it is for the patient's nurse. The light will flash red until the nurse enters the room and the system senses a locator device that the nurse wears. After the nurse enters the room the light will turn to a solid red. When the nurse is done assisting the patient and leaves the room the light will automatically turn off. One of the advantages of the system is all of the staff can see a flashing light and know that the patient needs assistance.

Interview on 04/06/2010 at 3:17 PM with the Unit Clerk for the Bone Marrow Transplant, who was on duty the night patient #1 fell on 03/30/2010, revealed that the reminder system is not used and that she will generally call the nurse on their telephone or in this case give them a note.

Interview with the day shift Unit Clerks (2 clerks) for the Bone Marrow Transplant Unit on 04/06/2010 at 10:20 AM revealed that, "We do not turn the system off, it goes off when the nurse leaves the room." Review of the patient call bell log for the Bone Marrow Unit on 03/30/2010 revealed the reminder system was not used, on that unit, for a single patient who used their call bell.

Review of the Call Bell logs for 4 additional units, that have the same call bell system and organizational structure as the Bone Marrow Unit, revealed that two (11-5 Neurosurgery) utilizes the reminder function routinely, one (8 east) utilizes the system frequently but has frequent long gaps where the system is not being utilized and like the Bone Marrow Unit, 6 west does not utilized the system.

Interviews with the Unit Clerks from all five units revealed that all had been trained on the call bell system, but none knew of any policy and procedures relating on how the system is to be used and if utilizing the reminder function is required.

Interview on 04/06/2010 at 9:40 AM with the Nurse Manager for the Bone Marrow Transplant Unit revealed that following the fall of patient #1 an incident report was started and that a preliminary investigation was also initiated. When asked if any actions were identified that needed to be immediately implemented to prevent a reoccurrence; the Nurse Manager stated no actions were implemented to prevent a reoccurrence of the incidence. Follow-up interview with the Nurse Manager on 04/06/2010 at 3:30 PM revealed that there were no actions identified following the incident that needed to be taken to prevent other patients from experiencing the same incident.

Interview with a Quality Manager on 04/06/2010 at 10:30 AM revealed that the facility had selected to use in the newly constructed south towers, the same call bell system utilized in the north towers. The Quality Manager stated that the facility did not develop any or implemented new policy and procedures related to the expanded call bell system and that prior to the expansion policy and procedures retaliating to how and when to utilize the system functions did not exist .
Additionally, the facility has not developed any quality measures to monitor the effectiveness and safety of the call bell system, even though the company who develop the system has an employee in the facility on a daily basis.

Based on staff interviews, facility document review and patient record review the facility failed to provide nursing supervision for 1 of 5 patients, (patient #1) to ensure timely reassessment and the development of appropriate nursing interventions in order to provide timely care to meet the patient's care needs. Failure to provide nursing care based on a timely reassessment places patients at risk of not receiving care and services to prevent injury or harm.

Findings:

Reference A 0396. Based on staff interview and record review the facility failed to ensure that for 1 of 5 patients' records reviewed (Patient #1) to perform timely reassessment and develop nursing interventions to provide timely care to meet the patient's care needs. Failure to provide nursing care based on a timely reassessment places patients at risk of not receiving care and services to prevent injury or harm.
Reference A 0404. Based on staff interviews and record review the facility failed for 1 of 5 patients, (patient #1) to assess the need for and the effectiveness of medications administered. Failure to assess the appropriateness of a medications and the effectiveness of medications places patients at risk of medications not being effective or of medications causing injury or death.

Based on staff interview and record review the facility failed to ensure that for 1 of 5 patients' records reviewed (Patient #1) to perform timely reassessment and develop nursing interventions to provide timely care to meet the patient's care needs. Failure to provide nursing care based on a timely reassessment places patients at risk of not receiving care and services to prevent injury or harm.

Findings:
Review of patient #1's medical record revealed that the patient was transferred to this facility on 03/20/2010 and admitted to the Bone Marrow Transplant Unit for the treatment of new onset Acute Myeloid Leukemia, (AML). The patient's past medical history included significant left hip pain, status post (s/p) left shoulder replacement. On 03/21/2010 the physician ordered Morphine ER Tab (tablet) SR 15 milligrams (mg) by mouth (PO) twice daily, at 0900 (9:00 AM) and 2100 (9:00 PM) for pain. Additionally the physician ordered on 03/20/2010 Oxycodone Tab 5 mg-10 mg PRN (as needed), PO every 4 hours for moderate pain. Review of the medical record revealed that starting on 03/25/2010 and continued thru 03/29/2010 the patient experienced diarrhea daily. On 03/30/2010 the patient's gastrointestinal (GI) status was evaluated at 14:23 (2:23 PM) as within defined limits except, no nursing note was found in the medical record to explain what except means. Review of the medical record for patient #1 revealed that on 03/30/2010 at 08:10 (8 :10 AM) reported a, "critical" low result for Platelet Count of 5.0 for the patient. The patient received two transfusions of leuko-reduced, irradiated pooled platelets. The first transfusion started at 11:15 and was transfused without incident. The second transfusion was started at 14:57 and at 16:30 (4:30 PM) the patient developed a transfusion reaction that manifested as Rigors and a mildly elevated temperature. The patient's physician was notified, orders were received and the patient was treated with Demerol 25 mg intravenous (IV) at 16:40 and again Demerol 25 mg IV at 16:50, Benadryl 50 mg IV at 16:50 and hydrocortisone 100 mg IV at 16:55. The patient's vital signs were taken after the transfusion was stopped, again in 17 minutes and repeated at 17:22 (5:22 PM) and 17:58. Review of the nursing note at 17:58 revealed, "Pt. feels better no more rigors noted. Sitting on bed ready to take [his/her] food. " At 20:45 (8:45 PM) the vital signs had returned to the pre-transfusion levels.
Review of the daily nursing assessments for patient #1 revealed that consistently from the day of admission to discharge from the Bone Marrow Unit the patient's gait was evaluated as unsteady. Review of the evaluation of the fall risk for patient #1 revealed that the patient was classified as, "High Risk for Falls". Review of the patient's fall risk score revealed that on the 03/28 and 03/29/2010 the patient had a Mores Scale score of 35. When the patient evaluated on 03/30/2010 the Mores score was 75, indicating that the fall risk of the patient had significantly increased from the previous two days. Review of the medical record did not reveal that the patient's care plan for fall prevention were evaluated or changed to reflect the patient's significantly high likelihood of falling. Review of the medical record revealed that the fall assessment was performed prior to the reaction to the platelet transfusion, but the patient was not reassessed after the transfusion reaction.
Further review of patient #1's medical record, for this date (03/30/2010) revealed that at 2100 (9:00 PM) the patient received a Morphine 15 mg Extended Release tablet for pain management and an Ambien 10 mg for insomnia. Review of the medical record did not reveal that the patient was evaluated at the time for the presents of pain or was re-evaluated for the effectiveness of the pain medication, after administration of the Morphine.
Review of the patient call bell log for the Bone Marrow Unit for 03/30/2010 revealed that at 21:20:35 (9:20 PM and 35 seconds), the patient press the call bell (Call Set) for assistance. The Unit Ward Clerk answered the call bell (Call Clear) at 21:20:47, opened the intercom (Intercom Activate) at 21:20:47 and spoke to the patient. The report revealed that the intercom/call bell system was terminated (Intercom Deactivated) with the patient at 21:20:65.

Interview with the Unit Ward Clerk on 04/06/2010 at 3:17 PM revealed that the Unit Clerk worked full time on the unit and worked 3 evening shift and 2 days shift per week. Interview with the Unit Clerk revealed that she remembered patient #1, as she was working the evening of 03/30/2010 and had answered the patient's call bell prior to the patient's fall. The Unit Clerk stated that the patient had used the call bell to request assistance to go the bathroom and that she told the patient that she would tell his/her nurse. The Unit Clerk then turned the call bell/intercom off and wrote on a posted note that the patient needed assistance to go the bathroom and gave the note to the nurse. According to the Unit Clerk, the nurse was at that nursing station at the time and was on the telephone. The Unit Clerk further stated that the nurse acknowledged the note and left the nursing station heading in the direction of patient #1's room.

Interview with patient #1's nurse on 04/06/2010 at 2:32 PM revealed that at 9:00 PM the patient requested a sleeping pill, stating that he/she was tired, but could not sleep. The nurse was asked about the patient care plan the nurse stated that the patient needed assistance for going to the bathroom. The nurse further stated that the patient had in the past gotten up out of bed without asking for assistance. Continued interview with the nurse revealed that she had not heard the patient call for assistance and that the Unit Clerk did not give her a note or tell her that the patient needed assistance.

Review of the medical record throughout the admission to the Bone Marrow Unit revealed the patient to be Alert and Oriented to person, place and time and cooperative with the staff. The medical record did not reveal that at any time the patient had gotten out of bed without assistance.

Interview with the Unit Manager on 04/02/2010 at 4:00 PM revealed that a nurse, (not the patient's assigned nurse), was at the nursing work station outside of patient #1's room when at approximately 21:25 (5 minutes after the patient had called for assistance) she heard a thump coming from patient #1's room. The nurse went in the room and found the patient on the floor in the bathroom. According to the Unit Manager, the nurse went to the hallway and called for help. The patient's assigned nurse was in the hall and responded.

Review of the medical record for patient #1 revealed a nursing note, written by the patient's nurse on 03/30/2010 at 21:40 (9:40 PM), "patient fell around 21:25, found on floor, PA [named Physician Assistant] aware and informed assessed pt. (patient) made orders. Made patient comfortable on bed vital signs check. Cold compress applied to pt's right temporal area and right wrist. Continue to monitor". Review of a physician progress note dated 03/30/2010 at 9:20 PM revealed, "Pt fell in bathroom, hit right side of face, right shoulder and right wrist. Pt ambulated to bathroom without assistance prior to fall. Distressed secondary to fall/pain confused. Right max face, right temple, right orbit with large hematoma, right shoulder hematoma, right wrist hematoma with extensor surface deformity." Review of the nursing note revealed that at 21:30 patient #1's vital signs were obtained along with the following comment from the nurse, "Vital signs taken after pt. fell in the bathroom. Pt. alert and aware at the time of the incident. PA [named Physician Assistant] aware and informed. Orders made in the chart. Pt. vital signs monitored every 15 minutes". Review of the patient's medical record did not reveal that vital signs were taken at 21:45 or any other times before being transferred off the Unit. Review of the medical record did not reveal that the nurse had performed any neurological checks on the patient after the fall. Review of the medical record revealed that the nurse, utilized a medication order written on 03/20/2010, for Oxycodone Tab 5 mg -10 mg PRN (as needed) PO every 4 hours for moderate pain, to treat the patient's pain associated with the fall.

Review of drug information found in the Geriatric Dosage Handbook, 13th edition copy 2008 by Lexi-Comp on page 1179 revealed for Oxycodone under Warnings/Precautions "Respiratory depressant effects and capacity to elevate CFS pressure may be exaggerated in presence of head injury, other intercranial lesion, or pre-existing intracranial pressure."

Review of patient #1's nursing note dated 03/30/2010 at 22:00 (10:00 PM) revealed the following entry, "Nurse with the pt. Pt. asked for nausea [medication]. Nurse took Zofran 4 mg IV and trying to get pt. aware, nurse notice that pt. become unresponsive. Nurse called PA and call code blue."

Review of a Respiratory note dated 10/31/2010 at 05:58 (5:58 AM) revealed that, "Pt was taken to [computed tomography] where they found a SAH [Subarachnoid hematoma] and then to 4 West".

Further review of patient #1's medical record revealed the patient was placed on ventilator and transferred to the Neurological Intensive Care Unit (ICU). After consultation with patient #1's family the patient was removed from the ventilator and expired on 03/31/2010.

Based on staff interviews and record review the facility failed for 1 of 5 patients, (patient #1) to assess the need for and the effectiveness of medications administered. Failure to assess the appropriateness of a medications and the effectiveness of medications places patients at risk of medications not being effective or of medications causing injury or death.

Findings.

1. Review patient #1's medical record revealed that on 03/30/2010 at 2100 (9:00 PM) the patient received a Morphine 15 mg Extended Release tablet for pain management and an Ambien 10 mg for insomnia. Review of the medical record did not reveal that the patient was evaluated at the time for the presents of pain or was re-evaluated for the effectiveness of the pain medication, after administration of the Morphine.

2. Review of the medical record for patient #1 revealed a nursing note, written by the patient's nurse on 03/30/2010 at 21:40 (9:40 PM), "patient fell around 21:25, found on floor, PA [named Physician Assistant] aware and informed assessed pt. (patient) made orders. Made patient comfortable on bed vital signs check. Cold compress applied to pt's right temporal area and right wrist. Continue to monitor". Review of a physician progress note dated 03/30/2010 at 9:20 PM revealed, "Pt fell in bathroom, hit right side of face, right shoulder and right wrist. Pt ambulated to bathroom without assistance prior to fall. Distressed secondary to fall/pain confused. Right max face, right temple, right orbit with large hematoma, right shoulder hematoma, right wrist hematoma with extensor surface deformity." Review of the nursing note revealed that at 21:30 patient #1's vital signs were obtained along with the following comment from the nurse, "Vital signs taken after pt. fell in the bathroom. Pt. alert and aware at the time of the incident. PA [named Physician Assistant] aware and informed. Orders made in the chart. Pt. vital signs monitored every 15 minutes". Review of the patient's medical record did not reveal that vital signs were taken at 21:45 or any other times before being transferred off the Unit. Review of the medical record did not reveal that the nurse had performed any neurological checks on the patient after the fall. Review of the medical record revealed that the nurse, utilized a medication order written on 03/20/2010, for Oxycodone Tab 5 mg -10 mg PRN (as needed) PO every 4 hours for moderate pain, to treat the patient's pain associated with the fall.

Review of drug information found in the Geriatric Dosage Handbook, 13th edition copy 2008 by Lexi-Comp on page 1179 revealed for Oxycodone under Warnings/Precautions, "Respiratory depressant effects and capacity to elevate CFS pressure may be exaggerated in presence of head injury, other intercranial lesion, or pre-existing intracranial pressure."

Review of patient #1's nursing note dated 03/30/2010 at 22:00 (10:00 PM) revealed the following entry, "Nurse with the pt. Pt. asked for nausea [medication]. Nurse took Zofran 4 mg IV and trying to get pt. aware, nurse notice that pt. become unresponsive. Nurse called PA and call code blue."

Review of a Respiratory note dated 10/31/2010 at 05:58 (5:58 AM) revealed that, "Pt was taken to [computed tomography] where they found a SAH [Subarachnoid hematoma] and then to 4 West".

Further review of patient #1's medical record revealed the patient was placed on ventilator and transferred to the Neurological Intensive Care Unit (ICU). After consultation with patient #1's family the patient was removed from the ventilator and expired on 03/31/2010.