HospitalInspections.org

Based on medical record review, interview and review of policy and procedures the facility failed to ensure patient rights were followed, failed to ensure injuries of "unknown origin"were investigated, failed to ensure fall intervention were identified on admission, failed to ensure post fall assessments were completed, failed to ensure a physician order was obtained for the use of a restraint, and failed to ensure 15 minutes checks were completed according to policy and procedure (A0144). The cumulative effect of this deficient practice prohibits the facility from ensuring patients receive care in a safe setting.

Based on medical record review, interview and review of policy and procedures the facility failed to ensure patient rights were followed for two patients (#5 and #8) of two patients medical records reviewed whom had injuries of "unknown origin"; three patients (#1, #2, and #3) of 11 patients medical records reviewed were highest fall risk, four patients (#4, #5, #6 and #8) of 11 medical records reviewed were high fall risk, one patient (#7) of 11 medical records reviewed was moderate fall risk and one patient (#9) of 11 medical records reviewed was low fall risk and lacked fall interventions on admission; two patients (#5, and #7) of nine medical records reviewed with falls there was no post fall assessment, one patient (#5) of one medical record reviewed had a geri-chair without a physician order, and two patients (#5 and #8) of 11 medical records reviewed did not have 15 minutes checks completed. The facility census was 29 patients.

Findings include:

1. Review of the medical record for Patient #5 revealed he/she was admitted to the facility for agitation and impulsive behavior on 12/10/16 at 5:26 PM from an extended care facility. Patient #5's diagnosis was dementia with behavioral disturbance.

The psychiatric admission fall risk assessment dated 12/10/17 revealed Patient #5 was a high fall risk. There were no interventions marked on the fall risk assessment to be implemented. The admission orders also revealed Patient #5 had orders for every 15 minute checks.

Review of the nursing progress note for 12/10/16 revealed at 8:15 PM Patient #5 was found lying on the floor in Patient #5's room. Patient #5 stated "I hit my head" and blood was noted. Further review of the progress note revealed Patient #5 was sent to the emergency department (ED) on 12/10/16 for treatment and returned back to the hospital at 10:45 AM. Line of site (LOS) was implemented per nursing judgement and gripper socks were provided to Patient #5. A nursing reassessment note dated 12/11/16 revealed Patient #5 was in a geri-chair. There was no assessment or physician's order for the restraint. There was no documented evidence a post fall assessment was completed.

Further review of the medical record revealed Patient #5 was in line of site (LOS) post fall on 12/10/16 through 12/15/16. On 12/16/16 the LOS was discontinued. There was no documented evidence why the LOS was discontinued on 12/16/16. The LOS was then implemented again on 12/17/16 through 12/21/16.

Review of the "patient observation" forms for Patient #5 revealed the 15 minute checks and line of site (LOS) for 12/11/16 at 10:45 PM, 12/16 16 at 5:45 PM, and 12/18/16 from 11:15 PM through 11:45 PM contained no initials by the staff to show the 15 minute checks were completed including line of site (LOS).

Further review of the medical record for Patient #5 revealed there were no nurses or psychiatric progress notes for 12/14/16. The only documentation for 12/14/16 was a behavioral health technician (BHT) note. The documentation for the BHT note revealed Patient #5 was anxious, yelling, moaning out in pain and became combative with care. There was no nursing documentation found regarding the patient's behaviors. The medical record medication sheet revealed on 12/14/16 at 1:13 AM Patient #5 was given Tylenol 650 milligrams for right wrist pain, 12/14/16 at 3:40 AM Norco 5/325 milligrams for right wrist pain, and on 12/14/16 at 4:14 PM Norco 5/325 milligrams was given for generalized pain. Review of an order for an X-ray for 12/14/16 revealed right wrist and chest X-ray due to Patient #5's complaint of pain. The conclusion of the X-ray report for 12/16/16 revealed a displaced distal ulnar fracture about two centimeters from the wrist joint.

Review of a nursing reassessment note dated 12/18/16 revealed patient #5 stated "you don't understand how terrified I am". "Paranoid of staff/potential harm" complains of generalized pain. Patient #5 was comforted/distracted from fears by singing church hymns with staff.

Interview with Patient #5's durable power of attorney (DPOA) on 01/24/17 at 10:00 AM revealed when he was at the hospital with Patient #5 on 12/12/16 he held her right hand and Patient #5 did not complain of pain. The DPOA also revealed there was no bruising on Patient #5's arm. The DPOA revealed on 12/16/16 he received a phone call in regard to Patient #5's fracture and Patient #5 was sent to the hospital for an orthopedic consult. Further interview with the DPOA revealed when he was with Patient #5 at the hospital on 12/16/16 there was black and blue bruising from Patient #5's right elbow down to her fingers and a skin tear on her arm. The DPOA also revealed the physician told the DPOA the bruising on Patient #5's arm happened after 12/10/16, which was after Patient 5's fall.

Interview with Staff A on 01/24/17 at 11:25 AM revealed there was no incident report or a completed investigation of Patient #5's wrist fracture. Staff A revealed he/she did the investigation but did not have the information on the investigation form. The investigation was completed by Staff A on 01/27/17 (during the survey) and provided for review.

2. Review of the medical record for Patient #8 revealed Patient #8 was a 97 year old transferred from an extended care facility (ECF) and admitted on 12/08/16 with a chief complaint of schizophrenia. The patient had a past psychiatric history of anxiety and a past medical history of dementia, hypertension, and hypothyroidism.

Review of Patient #8's nursing assessment upon admission for 12/08/16 revealed bruises to the left upper extremity (large hematoma) and on both hands. Review of pictures of the patient upon admission revealed a hematoma to the left upper extremity and both hands and the pictures of the patient's face revealed no bruises at the time of admission. The patient was given a fall level risk score of 19, which is rated high, but no fall risk interventions were marked on the patient's assessment sheet. The nursing assessment also stated, "patient denies pain...patient has large hematoma to left upper extremity forearm and hand...patient is alert with confusion...patient is uncooperative agitated and combative."

Review of a nursing reassessment note dated 12/09/16 revealed Patient #8 was on every 15 minute checks for safety, but the patient lacked evidence of 15 minute checks on 12/10/16 at 10:15 PM, 10:30 PM, 10:45 PM, and 11:00 PM. Documentation was also missing for the 12/12/16 at 9:45 PM 15 minute check.

Review of a "event investigation" report revealed that on 12/09/16 Patient #8 had an X-Ray of the left upper extremity related to extensive left arm bruising with no fracture and bruising of the peri-orbital right eye. There was no documentation an investigation had been completed until 01/25/17 (during the survey) revealing documentation as follows: Patient #8 returned to the behavioral unit on 12/10/16 at 4:30 PM with a fractured elbow; on 12/11/16 the patient was isolative to her room and depressed; on 12/12/16 at 1:10 PM the patients left arm was bruised to the fingertips, had bruising to both eyes and stated she had pain all over.

Review of the patient's discharge summary from the hospital for 12/10/16 revealed the patient was diagnosed with an elbow fracture and head injury. Both of these are injuries of "unknown origin."

An interview with the DON on 01/25/17 at 2:25 PM confirmed no evidence of a fall at the facility, and the patient developed a bruise to the right side of the forehead within 24 hours of admission to the facility. The DON also confirmed the bruise to the patient's right side of the forehead was from an injury of "unknown origin." There was no confirmation or investigation for the elbow fracture of "unknown origin."

3. Review of two patients (#5 and #7) of 11 medical records reviewed did not have a post fall reassessment.
Patient #7 fell on 09/11/16 and developed a hip fracture and Patient #5 fell on 12/10/16 and hit the back of her head.

4. Review of the medical record for three patients (#1, #3, and #10) of seven medical records reviewed were assessed as highest fall risk, three patients (#4, #5 and #8) of seven medical records reviewed were high fall risk, and one patient (#9) of seven medical records reviewed was low fall risk. There was no evidence fall risk interventions were put into place.

Review of the policy and procedure for "Falls Prevention and Monitoring" policystat ID: 2115816 revealed in order to reduce the risk of patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions including routine every 15 minute observations, and proper fitting non-skid footwear. High risk for falls included re-evaluate daily and interventions to be individualized to patient's needs. Interventions post fall included patient will be assessed for injury as well as reason for fall, medical practitioner will be contacted by the charge nurse to determine course of treatment after a patient has fallen, family or legal guardian will be notified, incident report will be completed and submitted to the PI director after a patient has fallen, and patient falls risk reassessed and appropriate interventions implemented.

Review of the policy and procedure for "Incident Reporting" policy ID: 2764310, origination: 01/20/13, last approved 09/20/16 included any accident, unusual occurrence involving patients is to be be reported timely and in the approved format. Reports are to be made by the staff first aware and/or most knowledgeable about the situation and is to be used to report events or occurrences not consistent with the routine operation of the hospital that has resulted in an injury to a patient. Upon completion of the incident report, direct the original report to the risk manager where further routing or notification shall be evaluated and performed.

Review of the policy and procedure for "Level of Observation" policystat ID: 2638931 originated 07/13 included in order to maintain patient safety line of site (LOS) all patients are monitored at minimum once in every 15 minute block of time. The registered nurse will assess the patient at minimum of two times per day and document in the progress note. The assessment will include the need for continued LOS observation.

Review of quality assurance performance improvement (QAPI) revealed there were QAPI meeting minutes monthly. The meeting minutes identified the falls as Class 1 but there was no documented evidence in the quality assurance action plans for the injuries of "unknown origin"or any other falls identified. There was a fall graph from June 2016 to December 2016 which identified there was 106 falls. The falls for January 2017 were not identified on the graph.

An interview with Staff A on 01/25/17 at approximately 2:40 PM and Staff A, Staff B, and Staff C on 01/27/17 at approximately 4:40 PM during the exit conference confirmed this deficient practice.


29731

Based on medical record review, interview and review of policy and procedures the registered nurse failed to investigate falls and injury of unknown origin, failed to supervise staff to ensure policy and procedures were followed for injuries of "unknown origin", failed to have fall interventions identified on admission, failed to ensure patients had post fall assessments, and failed to ensure a physician order was obtained for a geri-chair (A0386). The cumulative effect of this deficient practice prohibits the facility from ensuring patients' nursing needs are met.

Based on medical record review, interview and review of policy and procedures the facility failed to ensure injuries of unknown origin were investigated (Patients #5 and #8); failed to ensure interventions were identified and implemented on admission (Patients #1, #3, #4, #5, #8, #9, and #10); failed to ensure post fall assessments were completed (Patient #5); and failed to ensure physical restraints were not applied without a physician's order (Patient #5). The facility census was 29 patients.

Findings include:

1. Review of the medical record for Patient #5 revealed Patient #5 was assessed as a high risk for falls. There were no interventions marked on the fall risk assessment to be implemented.

Review of the nursing progress note for 12/10/16 revealed at 8:15 PM Patient #5 was found lying on the floor in Patient #5's room. Line of site (LOS) was implemented per nursing judgement and gripper socks were provided to Patient #5. A nursing reassessment note dated 12/11/16 revealed Patient #5 was in a geri-chair. There was no assessment or physician's order for the restraint. There was no documented evidence a post fall assessment was completed.

Further review of the medical record for Patient #5 revealed an order for an X-ray for 12/14/16 revealed right wrist and chest X-ray due to patient #5's complaint of pain. The conclusion of the X-ray report for 12/16/16 revealed a displaced distal ulnar fracture about two centimeters from the wrist joint.

Interview with Staff A on 01/24/17 at 11:25 AM revealed there was no incident report or a completed investigation of Patient #5's wrist fracture. Staff A revealed he/she did the investigation but did not have the information on the investigation form. The investigation was completed by Staff A 01/27/17 (during the survey) and provided for review.

2. Review of Patient #8's nursing assessment upon admission for 12/08/16 revealed bruises to the left upper extremity (large hematoma) and on both hands. Review of pictures of the patient upon admission revealed a hematoma to the left upper extremity and both hands and the pictures of the patient's face revealed no bruises at the time of admission. The patient was given a fall level risk score of 19, which is rated high, but no fall risk interventions were marked on the patient's assessment sheet.

Review of a "event investigation" report revealed that on 12/09/17 Patient #8 had an X-Ray of the left upper extremity related to extensive left arm bruising with no fracture and bruising of the periorbital right eye. There was no documentation an investigation had been completed until 01/25/17 (during the survey) revealing a fractured elbow.

3. Review of the medical records for seven patients (#1, #3, #4, #5, #8, #9 and #10) of 11 medical records reviewed did not have fall interventions marked on the admission nursing assessment form.

Review of quality assurance performance improvement (QAPI) revealed there were QAPI meeting minutes monthly. The meeting minutes identified the falls but there was no documented evidence in the quality assurance action plans for the injuries of "unknown origin"or any other falls identified. There was a graph for December 2016 which identified there was 106 falls.

Review of the policy and procedure for the "director of nursing", DON-06/2013 revealed the DON reports to the chief executive officer (CEO). The policy for the DON included, oversees the operations of the nursing department, including the delivery of nursing services, actively participates in the performance improvement and risk management programs, manage the daily operations of nursing services, monitor unit functioning through direct observation of patient care and review of medical record documentation, oversees nursing services documentation to ensure it meets hospital policy and regulatory standards, and actively participates in performance improvement activities as approved through quality council.

Review of the policy and procedure for "Incident Reporting" policy stat ID: 2764310, origination: 01/20/13, last approved 09/20/16 included any accident, unusual occurrence involving patients is to be reported timely and in the approved format. Reports are to be made by the staff first aware and/or most knowledgeable about the situation and is to be used to report events or occurrences not consistent with the routine operation of the hospital that has resulted in an injury to a patient. Upon completion of the incident report, direct the original report to the risk manager where further routing or notification shall be evaluated and performed.

Review of the "Falls Prevention and Monitoring" policystat ID: 2115816 revealed in order to reduce the risk of patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions including routine every 15 minute observations, and proper fitting non-skid footwear. High risk for falls included re-evaluate daily and interventions to be individualized to patient's needs. Interventions post fall included patient will be assessed for injury as well as reason for fall, medical practitioner will be contacted by the charge nurse to determine course of treatment after a patient has fallen, family or legal guardian will be notified, incident report will be completed and submitted to the PI director after a patient has fallen, and patient falls risk reassessed and appropriate interventions implemented.

Review of the policy and procedure for "Class 1 Events" policystat ID: 2751447 originated 01/2013 revealed the purpose of a class 1 event is to provide guidelines for communicating, investigating and acting upon class 1 events. The definition of a class 1 event is the policy applies to events that meet the following criteria including emergency room transfer due to serious injury, fall with significant injury and any event which is not included above, but which Staff A believes analysis/reporting is appropriate. Review of an additional attachment "B" revealed emergency room transfer due to serious injury includes any medical emergency where serious harm to the patient results regardless of cause. Class 11 events included medical event/injury not classified elsewhere.

An interview with Staff A on 01/25/17 at approximately 2:40 PM and Staff A, Staff B, and Staff C on 01/27/17 at approximately 4:40 PM during the exit conference confirmed the deficient practice.



29731