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Based on record review and interview, the hospital failed to ensure:

I. RN's communicated delays in performing CT Scan/ MRI for two (Patients # 1 & 2) of two geriatric psychiatric patients who fell and subsequently sustained injuries.

This failed practice resulted in delays in performing 1 CT Scan (Patient #1) and 1 MRI (Patient #2) of 6 CT Scan / MRI ordered and had the potential to delay treatment to geriatric psychiatric patients who fell and subsequently sustained injuries.

II. a safe patient care environment was provided that minimized falls for 10 patient (Patient # 3, 8, 13, 21, 24, 25, 26, 27, 28, 29) of a sample of 20 geriatric psychiatric patients from 01/2017 - 10/2017.

This failed practice resulted in 42 patient falls from 01/2017 -06/2017, a "fall rate" of 16.99 in 01/2017 and 24.55 in 06/2017 (the "fall rate goal" was three), and had the potential to increase the risk of fall and injury for 450 inpatient geriatric psychiatric patients per month.

Findings:

I. Delay of CT Scan / MRI
A. Policies
A review of the policy titled, "Critical Results / Value and Critical Test (date 03/16)" showed critical radiology test to include, but not limited to new cerebral hemorrhage, and CT of Brain for stroke. The policy documented timelines for reporting results, but failed to provide guidelines for the timeliness for performing the test.

A review of the policy, titled "Fall Risk Assessment and Prevention (date 11/16)" documented the attending physician should be notified of the fall to determine evaluation / treatment. The policy did not define the timeliness of when a CT Scan or MRI should be performed once ordered.

B. CT Scan
A review of Patient # 1's medical record showed on 06/09/17, at 6:20 pm, the patient fell, the CT Scan was ordered at 6:22 am, and the CT Scan was not performed until 9:34 am (3 hours later). The CT Scan showed an acute 4mm subdural hematoma (bleed between the skull and the brain). No documentation was found as to why the CT was delayed and the medical record showed no documentation to the physician or administration notified of the delay

C. MRI
A review of the medical record for Patient #2 showed a MRI Scan was not performed in a timely manner and MRI service was not available until two days after the physician's order.

On 09/16/17 (Saturday), between 5:59 pm- 6:56 pm, Staff G requested a MRI of the Head, for the Patient #2's deterioration in condition after hitting her head during a fall on 09/14/17. Patient #2 had an acute onset of an inability to move her right side extremities, and the was told the hospital was not able to do MRI until Monday (2 days later). On 09/16/17, Patient #2 was transferred to a higher level of care for stroke due to an acute infarction.

D. Interview

On 10/20/17 at 10:31am, Staff D and Staff J reviewed the medical records for Patient #2. Staff D stated she did not know why the staff did not contact supervisors to coordinate MRI for Patient #2 as the hospital had other options to get the test performed timely.

II. Falls
A. Tour
On 10/17/17 at 9:59 am, during a tour of the geriatric psychiatric unit, multiple patients were seen utilizing walkers and wheel chairs with and without assistance. Each patient room had beds that had bed alarms.

B. Policies
A review of a policy titled: "Fall Risk Assessment and Prevention (date 11/16)" defined the program's purpose was to reduce patient falls and/or if the patient does fall, prevent injury from the fall. The policy failed to specifically address the special needs of the geriatric psychiatric population. The policy documented "intentional falls" were not fall events and should not be counted in fall statistics, and failed to acknowledge that patients can be injured during an intentional fall.

C. Leadership
A review of hospital document titled, "Quality Council (dated 05/11/17)" showed Staff D reported meeting with nursing and leadership to address each fall on the geriatric psychiatric unit. Staff D reported most falls were occurring on the geriatric psychiatric unit, and the falls had been increasing, and the action plan documented was to "continue to monitor"

A review of hospital document titled, "Medical Operation Committee (dated 07/11/17)" showed the Patient Safety fall rate (per 1000 patient days) as "not applicable", and within the same document in a section titled, " Core Measures" showed falls and trauma for mental health unit as 2 falls with 1 of the falls resulting in trauma.

On 10/20/2017 at 10:30 am, Staff D stated she did not know why the Medical Operation Committee had documented the fall safety rate for the geriatric psychiatric unit as not applicable.

A review of hospital document titled, "Medical Operation Committee (dated 09/11/17)" showed the Patient Safety fall rate (per 1000 -patient days) as "not applicable", and within the same document in a section titled, " Core Measures" showed falls and trauma as zero.

D. Quality Plan
A review of a document titled, "OUMC Edmond ALC [Autumn Life Center-Behavioral Geriatric Psychiatric unit] showed 42 patient falls occurred from 01/2017 -06/2017, with a "fall rate" of 16.99 in 01/2017 and 24.55 in 06/2017, and a "fall rate goal" of three. It failed to include statistics of injuries from falls or define how the fall rate was derived.

A review of a document titled, "Autumn Life Fall Prevention Action Plan 08/17" showed a fall action plan to include conducting literature search regarding fall best practices, focusing efforts to eliminate the patient's ability to turn off the bed alarm, implementing the "Post Fall Huddle Form", reviewing videos capturing falls to look for improvement opportunities, and reviewing post fall documentation for compliance.

A review of a documents titled, "ALC Post Fall Huddle Form dated 08/16/17 to 10/12/17" showed 16 patients falls (Patient #3, 8, 13, 21, 24, 25, 26, 27, 28, & 29).

On 10/20/2017 at 10:30 am, Staff D, Vice President of Nursing, stated the "ALC Post Fall Huddle" form was created to gather fall information for quality improvement. Staff K stated the hospital had not compiled or analyzed the data.

This data of the 16 falls showed three (Patient # 21, 25, & 27) of the 10 geriatric psychiatric patients involved in falls had fallen multiple times during their hospitalization:
*Patient #21: fell on 10/07/17 and 10/12/17,
*Patient #25: fell on 10/06/17 and 10/07/17, and
*Patient #27: fell on 09/23/17 and 09/30/17.
A review of this data showed 9 of 16 falls involved patients with impaired mobility, 6 of 16 falls involved patients who used assistive devices, such used walkers and wheel chairs, 6 of 16 falls involved patients who had received benzodiazepine medication (a psychoactive drug primarily used for anxiety) within two hours of the fall, 6 of 16 falls involved patients who fell from bed with working bed alarming, and the patients' average age was 80 years old. The hospital failed to consider patients' mobility, medication, and ages in their 08/17 Fall Prevention action plan.

E.. Patients with Injury
A review of Patient # 1's medical record showed the patient fell and hit head on wall on 06/09/17 at 6:20 am on the geriatric psychiatric unit. Although the CT Scan was ordered on 06/09/17 at 6:22 am, it was performed at 9:30 am, and showed an acute subdural hematoma. On 06/10/17 at 10:00 am a repeat CT no changes.

A review of Patient #2 medical record showed the patient rocked herself back and forth in a wheelchair until it fell over and the patient landed on her face on 09/14/17 when on the geriatric psychiatric unit. On 09/16/17, Patient #2 was transferred to a higher level of care for stroke due to an acute infarction. This patient's fall with injury failed to be documented on the "ALC Post Fall Huddle Form dated 08/16/17 to 10/12/17".

On 10/20/2017 at 10:30 am, Staff D stated she participated in reporting general statistics of stroke to the Quality Committee, but failed to review the specific nursing care provided to the patients involved.
The (Refer to Tag A-0395)

F. Patient with Delayed Implementation of Safety Care Plan

A review of the medical record for Patient #13 showed on 08/16/17 at 11:45 pm, Patient #13 fell out of bed on floor, and hip x-rays showed no injury.

On 08/17/17 at 2:43pm, Staff G ordered a safety attendant at all times. On 08/21/17, Patient #13 was assigned an attendant.

Based on record review and interview, the hospital failed to ensure:

a. RNs assessed and monitored post-fall patients according to policy and standards of practice, and communicated changes in neuro checks for two (Patients # 1 & 2) of 2 geriatric psychiatric patients who fell and subsequently sustained injuries.

This failed practice resulted in a delay of care for Patient #2 and potentially resulted the worsening conditions of 2 (Patient #1 & 2) of 2 geriatric psychiatric patients whose post-fall CT scans showed stroke and subdural hematoma (blood collection between the skull and surface of the brain), and had the potential to affect all head injury patients involved in the 42 falls from 01/2017 -06/2017. (Refer to Tag A-0395)

b. a safe patient care environment was provided that minimized falls for 10 (Patient # 3, 8, 13, 21, 24, 25, 26, 27, 28, 29) of a sample of 20 geriatric psychiatric patients from 01/2017 - 10/2017.

This failed practice resulted in 42 patient falls from 01/2017 -06/2017, a "fall rate" of 16.99 in 01/2017 and 24.55 in 06/2017 (the "fall rate goal" was three), and had the potential to increase the risk of fall and injury for 450 inpatient geriatric psychiatric patients per month. (Refer to Tag A-144)

Based on record review and interview, the hospital failed to ensure:

I. RNs assessed and monitored post-fall patients according to policy and standards of practice, and communicated changes in neuro checks for two (Patients # 1 & 2) of 2 geriatric psychiatric patients who fell and subsequently sustained injuries.

This failed practice resulted in a delay of care for Patient #2 and potentially resulted the worsening conditions of 2 (Patient #1 & 2) of 2 geriatric psychiatric patients whose post-fall CT scans showed stroke and subdural hematoma (blood collection between the skull and surface of the brain), and had the potential to affect all head injury patients involved in the 42 falls from 01/2017 -06/2017 on the geriatric psychiatric unit.

II. RNs' were responsible for accuracy of mental health technicians' patient assessments for three (Patients # 13, 20, & 23) of four geriatric psychiatric patients who received one-time doses of medication for agitation and aggression from a total sample of 20 patients.

This failed practice resulted in the potential for mental health technicians' 15 minute check sheet assessments to be inaccurate and to miscommunicate the behavioral conditions of patients at 15 minutes intervals.

Findings:
I. Assessment, Monitoring and Communication of Changes in Status

A. Policies & Quality
A review of the policy titled, "Fall Risk Assessment and Prevention (date11/16) -Post Fall Interventions" documented nursing actions as follows:
*Take vitals prior to moving patient,
*Complete post fall assessment / reassessment every 15 minutes x4 hours, then every 1 hour x4 hours, (a 5 hour post evaluation) or until discharged,
*Patients with any open or closed head injury should receive neuro checks every 15 mins x4, then every 1 hour x4 hours (a 5 hour post evaluation) , and
*Notify the patient's attending physician for further evaluation / treatment.

A review of policy titled "Assessment and Reassessment" showed assessment of the patient was to provide the right care at the time it is needed and make appropriate and timely decisions regarding patient care or treatment needs. Assessments in the geriatric mental health unit were performed every eight hours or more often if the needed based on patient condition.

A review of policy titled, "Documentation of Inpatient Nursing Care (date 01/17)" documented each patient will have an assessment documented by a RN every shift (12 hours) or more often as patient condition warrants ...charting is done by exception method. The policy documented any assessments in which the patient was not "within designated parameters" should have an explanation in the narrative section of the note.

A review of policy titled "Assessment of Patients" showed any deviations of assessment findings from listed norms require further documentation. Normal neurological findings include but not limited to: awake, alert, responding appropriately and oriented times four (time, place, person and situation).

A review of a document titled, "Autumn Life Fall Prevention Action Plan 08/17" showed a fall action plan to include, but not limited to, reviewing post fall documentation for compliance.

A review of policy titled "Emergency Response and Resuscitation" showed the Rapid Response Team could be initiated by hospital personnel for any non-ICU patient exhibiting acute clinical changes.

B. Interviews
On 10/18/17 at 9:02 am, Staff J stated nurses were instructed to write details in the "comment" section for any system assessment that were not within defined parameters. Staff J stated the EMR program contained neurology assessment templates for documenting assessments, such as level of consciousness, pupil check, facial symmetry, evaluate orientation, evaluate tongue movement, sensitivity to touch and check for numbness or lack of movement, grasp strength and motor skills and balance. Staff J stated the neuro check templates were not used on the geriatric psychiatric unit and the nursing staff had not been training to use it.

C. Record Review
The following were the medical record reviews of assessments and monitoring for two (Patient #1 & 2) of two geriatric psychiatric patients after falls involving a head injury:

Patient #1
On 06/07/17, Patient #1, 92 years, was admitted to the geriatric psychiatric unit, with diagnoses of major neurocognitive disorder (dementia) with psychosis and other medical conditions, and had daily documented symptoms of aggressive and agitated behavior. The EMR documented the patient was on anticoagulant therapy of aspirin for the condition of atrial fibrillation and cardiac stents, which potentially made her more susceptible to bleed.

On 06/09/17 at 6:20 am, the patient fell and hit her head on the wall. Staff G ordered a CT Scan of Head to be done by phone at 6:22 am; however, approximately 3 hours later, at 9:34am, the CT Scan was performed. The CT results were available at 10:00 am, and showed an acute 4mm subdural hematoma.

On 06/09/17 at 6:10 pm, Staff M, RN, documented "neuro checks completed all day", and described the patient's "right pupil slightly greater than left", but failed to notate the patient had cataract surgery on her right eye, and failed to clarify with the physician if the pupil assessment was a change and significant. Staff M failed to document a full neuro check assessment. From 6:10 pm to 2:23am no neuro checks documented. Patient #1 had vital signs documented only twice at 6:20 am and 7:36 pm.

On 06/10/17 at 2:23 am, Staff M documented neuro check were performed every 2 hours were within normal limits (wnl) except right pupil slightly sluggish, which was a change in pupil reactivity, because prior assessments had described pupil size only. Staff M failed to clarify with the physician if the pupil assessment was a change and significant. Staff M documented at 3:02 am: no change in neuro checks, at 5:57am neurochecks remain wnl, right eye remains restricted/sluggish, answered questions appropriately, and at 7:48am up for breakfast, neuro checks wnl, and except right eye sluggish. Staff W documented at 8:00 am, 10:00 am, 12:00 am, 14:00 am, 16:00am neuro check wnl.

On 06/10/17 at 9:50 am, Staff G documented: " in spite of the staff's observation of aggressive behaviors last night, particularly when trying to put her in bed, this morning the patient has been calmer, this is the first time I have seen the patient to be calm. Needs to be further observation" and ordered a repeat CT Scan, which showed no changes.

On 10/20/17 at 10:15 am, Staff J stated Staff M should have contacted the physician regarding the pupil finding and should have followed the policy.

Patient #2 On 09/13/17 at 1:27 am, Patient #2, 74 year, was admitted to the geriatric psychiatric unit with diagnosis of anxiety and psychosis, and a history of somatic complaints. A review medical record showed Patient #2 fell on 09/14/17, and on 09/16/17 was subsequently diagnosed with an ischemic stroke and transferred to ED and a higher level of care. Staff N, an internist, documented Patient #2 was awake and alert, and able to answer some questions.

On 9/13/17 at 1:27am, Staff M described Patient#2 as follows: alert: oriented x 4 (name, location, date/time, and circumstances), normal conversation, up with assistance, transfers moderate assist, unsteady gait, ,handgrips weak, general weakness, right arm has abnormal movements.
On 09/13/17 at 12:45am results of a CT Scan of Head (ordered on admission for involuntary movement right arm) showed no acute intracranial hemorrhage or large territorial infarct ...likely chronic small vessel ischemic disease.

On 09/14/17 at approximately 7:15 pm Patient #2 began rocking her wheelchair side to side until it fell over onto the patient. Staff S documented the patient fall, the patient was mildly confused, and did not document any post-fall neuro checks for 09/14/17. On 10/20/17 at 10:31 am, Staff J and Staff F found no documentation that neuro checks had been performed. The CT Scan showed "Hyper density w/in left basal ganglia appears slightly less prominent, could be related to hyperglycemia and correlation with serum glucose levels, if patient remains symptomatic further f/u w/ add'l (additional) imaging could be performed."
On 09/14/17 at 5:34 pm documentation showed the patient required two staff to assist her to ambulate.

On 09/15/17 no neuro checks were documented. At 6:45pm, Staff T documented " 2-3 person assist, complains of knee pain, did not try to help at all, and stated she can't move her legs, even though she can move when she is in her chair." Patient #2 did not participate in groups throughout the day. At 8:56 pm and 9:31 pm, Staff T described the patient as confused and irritable.

On 09/16/17 at 5:20 am, Staff M documented the patient was tearful, had general weakness, was not able to tolerate laying on her side, her right leg was weaker, and was not walking currently. At 7:56 am, the patient required maximum assistance to get out of bed, and Staff M documented "she cannot even sit up or stand without total assist".
At 09:04 am and 9:40 am, the patient was described as sedated, sleepy, confused, disoriented, and incontinent of bladder. The documentation showed the patient was not able to sit up by self and required maximum assistance to transfer. There was no evidence the physician was notified of these changes in status.
At 2: 36 pm, Staff M documented the patient reported her hand was not moving. No neuro checks were performed, and no physician was notified.

At 5:49 pm, Staff H documented the patient stated "I'm paralyzed", was not able to move her right leg. did have limited movement of her right arm, and the right side of her mouth drews up when she talks. Staff H notified the physicians, Staff G and N. Between 5:59 pm- 6:56 pm, Staff G ordered a MRI of Head due to the patient's acute onset of an inability to move her right side extremities, and the hospital was not able to do MRI until Monday.

At 6:32 pm, Staff N ordered the patient to be discharged to the ED., and a CT Scan of Head which was performed promptly and showed attenuation within the high left frontal lobe concerning an acute infarct and stroke.
At 6:56, Rapid Response (Stroke Team) was called per Staff N's progress note.

On 10/20/17 at 10:31 am, Staff D, Vice President of Nursing stated no leadership/ administrative staff was notified to assist in the coordination of a timely MRI, and stated the hospital had resources. Staff J stated Rapid Response team could be called by any staff for patients with acute health changes. Staff D and Staff J stated nurses were trained to call a "Code Gray" if patients exhibited signs and symptoms of stroke, and stated the rapid response team would be triggered to immediately respond and exam the patient per the stroke protocol. Staff D and Staff J stated the Code Gray forms were paper documents that were scanned into the EMR, but these forms could not be located for Patient #2.

II. Mental Health Technician's (MHT) Assessment
A review of the Oklahoma Board of Nursing guideline titled "Delegation of Nursing Function to Unlicensed Personnel" documented licensed nurses within the scope of their practice are responsible for all nursing care that a patient receives under their direction. Determining the nursing needs of a patient, the plan of nursing actions, implementation of the plan, and evaluation of the plan are essential components of nursing practice.

A review of policy titled "Delegation of Nursing Care (date 04/17)" showed nurses are responsible for all care of patient care.

The medical records for three patients (Patients #18, 20, and 23) who received one time medication injections to reduce aggressive and agitiated behavior were reviewed of a total sample of 20 patients. The patient assessments in nursing notes and the MHT's 15 minute check sheets were compared at the patient received a one-time injection. The patients' behavior were not similarly described.

Patient #18: On 09/10/17 at 2:55 pm was given an one time, "now", injection for agitation, and the nurse documented the patient was very agitated, anxious, and at 3:00 pm wanted to leave. At 3:00 pm, the MHT documented Patient #18 was quiet in the dining room.

Patient #20: On 07/05/17 at 11:22 pm was given an one time, "now", injection for agitation, and the nurse documented the patient was confused and irritable. At 10:30pm -11:30 pm, the MHT documented Patient #20 was quietly, resting in his room.

Patient #23: On 10/11/17 at 6:38 pm was given an one time, "now", injection for agitation and aggression, and the nurse documented the patient was very agitated. At 6:30 pm, the MHT documented Patient #23 was alert and appropriate in the dining room.

On 10/20/17 at 10:31 am, Staff J stated the MHT are responsible for completing the 15 minute check sheets for the geriatric psychiatric patients, and the patient assessments should match nursing assessments.