HospitalInspections.org

Based on document review and interview, the facility failed to follow their policy and procedure to ensure staff promptly notified a patient's representative of an incident/occurrence in one (1) instance (Patient # 10).

Findings include:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, indicated that every patient who enters the hospital for care has rights, and he/she may exercise these rights while hospitalized. The patient has the right to have their family and/or agent, when appropriate, be informed of their care, "including unanticipated outcomes". This policy was last revised in 09/2021.

2. Review of the hospital policy titled, "Fall Prevention Program", PolicyStat ID 9827537, indicated the nurse must notify all applicable parties including...POA (power of attorney)/Guardian and/or patient's family as part of the post fall procedure. This policy was last revised in 05/2021.

3. Review of Daily Nursing Narrative dated 11/29/2021 at approximately 2:00 pm, indicated patient # 10 slid onto his/her bottom on floor with his/her head on wheelchair seat.

4. In interview on 12/29/2021 at 3:45 pm with administrative staff member A # 3 (Corporate Quality Improvement), confirmed the medical record (MR) lacked documentation that the POA/Guardian had been notified after the fall incident.

Based on document review and interview, the facility failed to follow their staffing nursing plan matrix for one (1) of three (3) patient care units reviewed. (Unit 100)

Findings include:

1. Review of the facility policy, "Nursing Staffing Plan", PolicyStat ID 8818485, indicated the DON (Director of Nursing) would be accountable to ensure a sufficient number of qualified staff are on duty at all times to provide patients with quality care. The facilities staffing patterns are built from "historical trends, benchmark data and practice guidelines". This policy was last revised in 01/2020.

2. Review of the facilities staffing matrix for the 100 unit, indicated the unit should have staffed (days and nights) three (3) nurses for a patient census of seventeen (17) to twenty-four (24) and four (4) nurses for a patient census of twenty-five (25) to twenty-eight (28).

3. Review of the facilities staffing matrix for the 100 unit, indicated the unit should have staffed (days and nights) three (3) nursing aides for a patient census of seventeen (17) to twenty-four (24) and four (4) nursing aides for a patient census of twenty-five (25) to twenty-eight (28).

4. Review of the "staffing pattern worksheet" provided by the facility, indicated the 100 unit was short staffed on the following days/nights:
A. On 11/25/2021 the patient census was twenty-three (23). On days there were two (2) nurses staffed. The staffing matrix indicated there should have been three (3) nurses staffed. On nights there was one (1) nurse and one (1) aide staffed. The staffing matrix indicated there should have been three (3) nurses and three (3) aides staffed.
B. On 11/26/2021 the patient census was twenty-four (24). On days there were two (2) nurses and one (1) aide staffed. The staffing matrix indicated there should have been three (3) nurses and three (3) aides staffed. On nights there were two (2) nurses and one (1) aide staffed. The staffing matrix indicated there should have been three (3) nurses and three (3) aides staffed.
C. On 11/27/2021 the patient census was twenty-four (24). On days there were two (2) nurses staffed. The staffing matrix indicated there should have been three (3) nurses staffed. On nights there were two (2) nurses and two (2) aides staffed. The staffing matrix indicated there should have been three (3) nurses and three (3) aides staffed.
D. On 11/29/2021 the patient census was twenty-five (25). On days there were two (2) nurses and two (2) aides staffed. The staffing matrix indicated there should have been four (4) nurses and four (4) aides staffed. On nights there was one (1) nurse and two (2) aides staffed. The staffing matrix indicated there should have been four (4) nurses and four (4) aides staffed.
E. On 11/30/2021 the patient census was twenty-five (25). On days there were two (2) nurses and two (2) aides staffed. The staffing matrix indicated there should have been four (4) nurses and four (4) aides staffed. On nights there was one (1) nurse and two (2) aides staffed. The staffing matrix indicated there should have been four (4) nurses and four (4) aides staffed.
F. On 12/01/2021 the patient census was twenty-four (24). On days there were two (2) aides staffed. The staffing matrix indicated there should have been three (3) aides staffed. On nights there was one (1) nurse staffed. The staffing matrix indicated there should have been three (3) nurses staffed.
G. On 12/02/2021 the patient census was twenty-five (25). On days there were two (2) nurses staffed. The staffing matrix indicated there should have been four (4) nurses staffed. On nights there was one (1) nurse and three (3) aides staffed. The staffing matrix indicated there should have been four (4) nurses and four (4) aides staffed.
H. On 12/03/2021 the patient census was twenty-four (24). On days there were two (2) nurses and one (1) aid staffed. The staffing matrix indicated there should have been three (3) nurses and three (3) aides staffed. On nights there was one (1) nurse and one (1) aide staffed. The staffing matrix indicated there should have been three (3) nurses and three (3) aides staffed.
I. On 12/04/2021 the patient census was twenty-three (23). On days there were two (2) nurses staffed. The staffing matrix indicated there should have been three (3) nurses staffed. On nights there was one (1) nurse and two (2) aides staffed. The staffing matrix indicated there should have been three (3) nurses and three (3) aides staffed.

5. Review of the "Daily Census Sheet" provided by A # 1 (Chief Executive Officer-CEO), indicated the facility had vacancies for eleven (11) full time equivalent (FTE's) and/or 440 hours available for registered nurses (RN's). There were three and a half (3.5) FTE's and/or 140 hours available for a licensed practical nurse (LPN) and eight and a half (8.5) FTE's and/or 340 hours available for aides.

6. In interview on 12/29/2021 at approximately 4:40 pm with administrative staff member A # 1, confirmed the staffing data was correct on the staffing pattern worksheet and the policy/staffing matrix was the most current up to date version.

Based on document review and interview, the registered nurse failed to ensure care in a safe setting, complete an admission fall risk assessment and failed to ensure neurological checks and an incident report were completed post patient fall in one (1) instance (Patient # 10).

Findings include:

1. Review of the hospital policy titled, "Fall Prevention Program", PolicyStat ID 9827537, indicated all patients presenting for admission would be assessed for the level of fall risk during the nursing admission assessment. The nurse should initiate neurological checks on the patient who had hit their head or was suspected of hitting their head and maintain the neurological checks conducted in the patient's chart (medical record-MR). An incident report should have been submitted through the electronic system. This policy was last revised in 05/2021.

2. Review of the hospital policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, indicated to have the right to receive care in a safe setting. This policy was last revised in 09/2021.

3. Review of the hospital policy titled, "Incident Reports", PolicyStat ID 8824000, indicated an incident report should be completed in the system by the end of the shift in which the incident occurred but no later than twenty-four (24) hours from the time the event occurred. This policy was last revised 01/2020.

4. The Incident Report log for November 2021 lacked any documented incidents for patient # 10.

5. Review of patient # 10's MR indicated the following:
A. The patient was admitted on 11/26/2021.
B. The Daily Nursing Narrative dated 11/29/2021 at approximately 2:00 pm, indicated patient # 10 slid onto his/her bottom on the floor with his/her head on wheelchair seat.
C. The Provider Order Form dated 11/29/2021 at 3:00 pm, indicated the provider wrote an order for "neuro checks per unwitnessed fall protocol" and strict fall precautions-bed/chair alarm at all times.
D. The MR lacked any previous orders for fall precautions and or the fall risk nursing admission assessment.
E. The MR lacked documentation of neurological checks performed by the nurse.

6. In interview on 12/29/2021 at approximately 3:45 pm with administrative staff member A # 3 (Corporate Quality Improvement), confirmed the MR lacked neurological checks that should have been performed per provider order and an incident report should have been completed related to the patient's fall.

7. In interview on 12/29/2021 at approximately 4:22 pm with administrative staff member A # 4 (Director of Social Services), confirmed the MR lacked documentation related to the admission fall risk assessment.

Based on document review and interview, the Registered Dietitian failed to place an order recommendation for a nutritional supplement in a timely manner which resulted in a delay of care, failed to ensure the patient was weighed upon admission and weekly per facility policy for one (1) of ten (10) patients reviewed (Patient # 10).

Findings include:

1. Review of the hospital policy titled, "Dietary - Scope of Service", PolicyStat ID 8837251, indicated the dietary program was based on a nutritional assessment of the needs of each individual resident. Standardized methods practiced in the preparation of therapeutic and/or modified diets in accordance with the attending physician's and/or dietitian's orders. This policy was last revised in 01/2020.

2. Review of the hospital policy titled, "Recommendation to Nursing", PolicyStat ID 8837388, indicated the Dietitian would document the diet recommendation on the Provider Order Form for the provider to approve or disapprove the recommendation within 48 hours. This policy was last revised in 01/2020.

3. Review of the hospital policy titled, "Nutrition Risk Data Collection and Assessment", PolicyStat ID 9446948, indicated an overall risk category of zero (0) to two (2) points no/low risk, three (3) to seven (7) points moderate risk and anything greater than eight (8) points would put the patient at high risk. This policy was last revised in 06/2018.

4. Review of the hospital policy titled, "Food Services and Nutritional Balance", PolicyStat ID 8816965, indicated weights would be obtained weekly. This policy was last revised in 01/2020.

5. Review of the hospital policy titled, "Vital Signs and Weight", PolicyStat ID 9908981, indicated all patients would have their weight taken upon admission. This policy was last revised in 07/2021.

6. Review of the medical record (MR) for patient # 10 indicated the following:
A. The Nutritional Risk Data Collection and Assessment dated 11/29/2021 at 8:00 am by A # 9 (Clinical Dietitian), indicated the patient's total points to be fifteen (15) which put the patient at a high overall risk category. The oral nutrition supplement was documented as boost or magic cup.
B. The Provider Order Form dated 12/02/2021 at approximately 11:18 am by the patient's provider, indicated Boost-glucose control three times a day (TID) with meals. Give if less than 75% of meals consumed.
C. The Patient Daily Care Forms indicated on 11/29/2021, 12/01/2021 and 12/02/2021 the patient ate less than 75% of breakfast, lunch and dinner.
D. The MR lacked the admission weight and the weekly weight for the patient.

7. In interview dated 12/29/2021 at approximately 4:00 pm with administrative staff member A # 9, confirmed he/she should have ordered the nutritional supplement on the provider order form on 11/29/2021. It caused a delay in care because "I was off until 12/03/2021. The patient should have had the supplement for those days. It was greater than 48 hours before the provider ordered the nutritional supplement. I pulled the patients admission weight off his/her triage paperwork because the patient had not been weighed upon admission.

8. In interview dated 12/29/2021 at approximately 4:10 pm with administrative staff member A # 1 (Chief Executive Officer-CEO), confirmed he/she should have reached out to another one of their facilities to have a dietitian cover while A # 9 was off. "I missed this".

Based on document review and interview, the facility failed to ensure an outpatient service was completed in one (1) instance. (Patient # 10)

Findings include:

1. Review of the facility policy titled, "Therapy Services - Scope of Service", PolicyStat ID 8818436, indicated to provide speech-language pathology evaluations within twenty-four (24) hours of referral to seventy-two (72) hours to establish goals for treatment. He/she provides assessment and treatment interventions including, but not limited to, patients with swallowing deficits. This policy was last revised in 01/2020.

2. Review of patient # 10's medical record (MR) indicated the Provider Order Form dated 11/29/2021 at 2:30 pm by A # 9 (Clinical Dietitian) had ordered the SLP (Speech Language Pathologist) to perform a swallow evaluation due to the patient reporting difficultly swallowing.

3. In interview on 12/29/2021 at approximately 3:30 pm with ST # 1 (Speech Pathologist), confirmed he/she had received the order, but did not complete the evaluation due to being told the patient wasn't at the facility. "I didn't check to see if the patient was there".

4. In interview on 12/29/2021 at approximately 3:45 pm with A # 3 (Corporate Quality Improvement), confirmed that ST # 1 should have done the swallow evaluation on 12/01/2021 when he/she was at the facility. The patient was at the facility at that time.