HospitalInspections.org

Based on document review and interviews the facility failed to ensure that a Registered Nurse (RN) was evaluating the care needs and health status of 1 (Patient #1) of 7 patients whose medical records were reviewed. The facility also failed to follow their own policy regarding Nursing Documentation.

This deficient practice placed all patients at risk for the likelihood of harm and possibly subsequent death by not ensuring a nursing assessment was completed after exposure to fire.



Findings include:


A review of the document titled, "Incident Report" dated 6/28/2021 and timed 9:38 AM by Staff #1 was as follows:

" ...Staff member smelled something burning, opened pt.'s door-bed was on fire, staff removed pt. from bed, put out fire. No injury to pt. or staff. Fire dept responded ..."

Further review revealed Patient #1 was seen by Staff #12 on 6/28/2021 via telemed. No time was documented on the record.


A review of the document titled, "PROGRESS NOTE" dated 6/28/2021 by Staff #12 was as follows:

" ...The patient was seen this morning. This morning, he is noted to be anxious, irritable, argumentative, and agitated. I encouraged the patient to comply with treatment. He is willing to comply with treatment and staff reported that he was trying to set his mattress on fire ..."


A review of the document titled, "Interdisciplinary Notes" by Staff #13 dated 6/28/2021 at 4:03 PM was as follows:

" ...6/28: Patient tried to set his bed on fire this morning. His d/c was cancelled because of that. He did take his medications today.

OBJECTIVE:
T-97.0
HR-70
RR-16
BP-148/71

PHYSICAL EXAM:
LUNGS: Breath sounds clear bilaterally without rales, rhonchi, or wheezing.
NEUROLOGICAL: Paralyzed R arm. Patient uses a walker ..."


A review of the Observation Check Sheet/Graphic Flowsheet revealed Vital Signs were taken at 6:00 AM and 6:00 PM on 6/28/2021 by the MHT (Mental Health Tech).


A review of the "Daily Nurse Note" on 6/28/2021 at 2:10 PM by Staff #4 revealed no documentation of the fire that was started by Patient #1.

Staff #4 confirmed the patient assessment was conducted at 2:10 PM but no vital signs were taken at that time. The nursing assessment was completed 4 hours after Patient #1 was removed from Room 8 after the fire.


An interview was conducted with Staff #4 on 7/2/2021 after 10:00 AM. Staff #4 was asked how often nursing assessments are completed. Staff #4 stated, "We do patient assessments once a shift and the MHT's (Mental Health Techs) do the vital signs once a shift unless they are ordered by the doctor to do them more frequently." Staff #4 was asked if an assessment was completed on Patient #1 after he was removed from the room where the fire was started. Staff #4 replied, "The patient had no complaints and there was no visible injuries at the time he was removed from the room."


A review of the document titled, "INCIDENT STATEMENT SHEET" dated 6/28/2021 at 9:38 AM by Staff #4 was as follows:

" ...I ran down the hallway and saw black smoke coming out of Room #8. I went into the room where I saw Staff #8. Black smoke was seen in Room #8 and mattress was smoldering, soon afterwards, the fire alarm was triggered. Code Red Room #8 was announced over the intercom three times. Staff were moving patients out to the patio and doing a head count. All exits were covered by staff immediately. The unit census was 17 and 17 patients were accounted for. No injury noted ..."

An interview conducted with Staff #7 confirmed no documented assessment of Patient #1 was completed before 2:10 PM by Staff #4. Staff #7 stated, "We should have completed and documented a full Nursing assessment with vital signs and system assessment findings after incident and we failed to do so. I documented a nurses note that related to the contraband search of Patient #1. I did not document an assessment of Patient #1 other than he was in no distress and had no visible injuries."


A review of the Multi-Disciplinary Note by Staff #7 on 6/28/2021 at 9:45 AM confirmed the above.


An interview was conducted with Staff #6 on 7/2/2021 after 11:00 AM. Staff #6 was asked if any staff that assisted Patient #1 were assessed following the fire incident on 6/28/2021. Staff #6 replied, "I completed an assessment on Staff #8 to make sure he did not suffer from any smoke inhalation after he removed Patient #1 from the room during the fire." Staff #6 was asked, why would you complete an assessment on the staff and not on Patient #1? Staff #6 stated, "We should have completed and documented the assessment on Patient #1. I'm sure the nurses did an assessment on Patient #1, but I see that nothing was documented."


A review of the facility policy titled, "DOCUMENTATION" Policy Number NSG-02, with a revision date of 2/01/2021 was as follows:

" ...POLICY:
Inpatient nursing personnel document patient's progress every shift, incorporating the elements of the nursing process and patient's treatment goals and progress within the patient's medical record.

PROCEDURE: Inpatient:

Routine:
RN and/or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) documents all extraordinary occurrences and special needs (i.e. falls, etc) in the multidisciplinary progress notes and documents any notifications or issues reported to the physician or non-physician practitioner (NPP), as applicable. The daily nurse note is only for daily assessment and expected daily occurrences ..."




Staff #1, #2, #3, #4, #6, and #7 confirmed the above findings.