HospitalInspections.org

Based on facility policy, medical record review and interview, the facility failed to ensure the Registered Nurse provided accurate assessments and ensured all patients' needs were met appropriately for 2 of 3 (Patients #1 and #3) sampled patients.

The findings included:

1. Review of the facility's "Fall Prevention Guidelines" policy revealed, "...Guidelines: Using the Morse Fall Scale, a patient's fall risk will be assessed...Morse Fall Scale...
History of Falling Immediate or Within Last 3 Months...Yes = 25 IF patient has falled during this hospitalization...has immediate history of falls within the past 3 months or is current admission related to fall due to seizure/dizziness/falls/syncopal episodes or other diagnosis...Unknown = 25 if patient is unable to answer and no family available...
Dx [Diagnosis] /Problem That Increases Fall Risk...Yes = 15 Does the patient have more than one active dx or problem? Ex. stroke, Parkinson's, Multiple Sclerosis, lower extremity injuries, severe obesity, leg ulcers, peripheral vascular disease, severe arthritis, vision problems, and others...
Use of Ambulatory Aid...crutches, cane, walker = 15 if the patient uses...cane or a walker...
Gait/Transferring...Impaired/Weak = 20...cannot walk without assist...wheelchair; score according to gait used at transfer...
Mental Status...Forgets limitations/confused/impulsive = 15
Score...0 indicates no risk for falls...< [less than] 25 indicates a low risk for falls...25-45 indicates a moderate risk for falls...> [greater than] 45 indicates a high risk for falls..."

Review of the facility's "Back Injury Prevention" policy revealed, "...Establish consistent patient lifting and transfer method that enusures the safety of both patient and employee...Procedure... Patient cooperation, functional ability, and goals/outcomes are to be considered when establishing a plan for lifting and transferring. Safe patient lifts and transfers involve a planned, systematic, deliberate approach that solicits the patient's assistance as much as possible..."

2. Medical record review revealed Patient #1 presented to the DED on 2/22/18 with the complaint of falling at home. The patient arrived via ambulance.

Review of the DED triage note at 6:44 PM revealed RN #1 documented the patient arrived via EMS with the complaint of "FALL AT HOME FROM STANDING..." and "Psych Concerns: No." The patient was alert, oriented to person, place and time; the patient complained of acute pain at a level of 10, with 10 being the worst possible pain. At 6:47 PM RN #1 documented, "Pt was walking in room...when she tripped over feet and fell face forward onto floor striking bed on way down...states struck head/face/legs and abdomen...upon admit has pain to left lower ext that radiates up left leg, pain to LLQ abdomen. Pain to left shoulder, pain to left arm, pain to head, right toe...Pt has hematoma to left lower extremity..."

At 6:47 PM RN #1 documented the patient's fall risk assessment to be "Low Risk...< [less than] 25..." RN #1 documented the following:
"History of Falling...Within Last 3 Months...No...Dx [Diagnosis] /Problem That Increases Fall Risk...No...Use of Ambulatory Aid...None, bedrest, wheelchair, nurse...Gait/Transferring...Normal, bedrest, immobile...Morse Fall Risk Score: 0..."
The patient's fall assessment was inaccurate and did not reflect the patient's current fall status (the reason she was presenting to the DED), Multiple diagnoses/problems that increase fall risk, use of all ambulatory aid devices, home oxygen use and gait/transferring status.

At 6:55 PM RN#1 documented as of 2/22/18 at 6:55 PM the patient's Social History included, "...disabled...lives alone...oxygen, walker/cane, wheelchair, hospital bed, bsc..."

At 6:59 PM the physician saw the patient and documented, "...Acute pain of left shoulder; Acute pain of right foot; Left-sided chest wall pain; Left leg pain; Morbid obesity..." The physician documented the medical history active problems to include Arthralgia, Migraines, Diabetes, Congestive Heart Failure, Angina, Gout, Hypertension, Hypothyroid, Atrial Fibrillation and Obesity. The physician's note included "...disabled...lives alone...oxygen, walker/cane, wheelchair, hospital bed, bsc...Psychiatric: Cooperative, appropriate mood & [and] affect, normal judgment..." At 10:40 PM the physician discharged the patient with the dianoses of "Acute pain of left hsoulder...Acute pain of right foot...Left leg pain...Morbid Obesity...Chronic Superficial femerol VT [Venous Thrombosis]..."

The nursing documentation revealed on 2/23/18 at 2:24 AM RN #2 documented, "Pt refused to attempt to get into van despite being transported home via van in the past. Call placed to Tenncare to update...and they will send authorization to EMS for BLS unit. Call placed to EMS to update..."
On 2/23/18 at 4:57 AM RN #2 entered a note for further explaination of the patient's refusal to take the medic van transportation home. RN #2 documented, "Pt's Tenncare arranged medic van arrived to transport pt back to residence. RN to room to assist pt into wheelchair but pt refused to get into wheelchair, stated she cannot walk. Pt stated she wanted an ambulance for transport back to residence...RN explained to pt that her insurance arranged the current form of transport. Multiple RNs at bedside to assist pt into wheelchair. Pt became aggressive and combative, yelling and hitting nursing staff. Pt assisted into wheelchair but still combative and yelling at staff...Charge nurse, security, and [police department] at bedside..."

Review of the "ED Nursing Discharge Summary" revealed at 2:39 AM RN #2 documented, "...Patient Left ED: 2/23/18 02:25 [2:25 AM]...Mode of Discharge: Stretcher..." The Discharge Instructions provided to Patient #1 revealed, "...Continue all activities unless the activities cause more pain...During periods of severe pain, bed rest may be helpful. Lay or sit in any position that is comfortable..."

In an interview on 5/15/18 at 8:05 AM, in the conference room, Security Officer (SO) #1 stated a call was received on a combative and confused older female in the Emergency Department. She didnt want to leave the ED. SO #1 stated she was on the bed in the ED; ED staff and Security held each side and eased her to the wheelchair. SO #1 stated the patient eventually left when an ambulance arrived. SO #1 stated he did not remember if the police department came or if they threatened to take the patient to jail.

In a telephone interview on 5/15/18 at 2:35 PM RN #2 stated, "...I told her [Patient #1] we called someone to get her a medic van. She [Patient #1] said she needed an ambulance. I got staff to help get her in the wheelchair and she started yelling, swinging and scratching..." RN #2 stated the patient said she couldn't walk because her "foot and ankle hurt too bad to put weight on it..." RN #2 stated they later called an ambulance to take her home per stretcher.

In a telephone interview on 5/15/18 at 3:25 PM Patient #1 stated, "...I told them I can't get up and walk. I told them I had to have an ambulance. They started pulling on me and it hurt. I kept telling them to stop, that it was hurting. I started yelling and jerking to try to get them to stop. I didn't realize until it was over that I had hit someone, when the nurse said why did you hit that nurse. They were laughing when they left me..."

In a telephone interview on 5/15/18 at 4:45 PM SO #3 stated Patient #1 was "upset about her transport. She said she couldn't stand up for that transport because her feet were hurting too bad. She was not combative with me and when the ambulance got there to take her, she was fine."

There was no documentation the Registered Nurse appropriately assessed the patient's transfer/ambulation ability and pain related to being transported home via van, when the patient informed the nurse she required an ambulance.

3. Medical record review revealed Patient #3 presented to the DED on 3/29/18 at 5:04 PM via ambulance with the complaint neck pain.

Review of the pre-arrival summary report given at 3:59 PM via EMS revealed the patient was being tranported with intractable head and neck pain, and left arm numbness.

Review of the DED triage revealed at 5:14 PM RN #3 documented the patient presented with neck pain.

At 5:24 PM RN #3 documented the patient's fall risk assessment to be "Low Risk...< [less than] 25..." RN #1 documented the following:
"History of Falling...Within Last 3 Months...No...Dx [Diagnosis] /Problem That Increases Fall Risk...No...Use of Ambulatory Aid...Crutches, cane, walker...Gait/Transferring...Normal, bedrest, immobile...Morse Fall Risk Score: 15..."
The patient's fall assessment was inaccurate and did not reflect the patient's fall status from 2 days ago or the fall the patient had just sustained after arrival to the ED.

Review of an ED occurence report revealed the patient arrived per EMS, was assisted off the stretcher and requested to go to the bathroom. The patient ambulated to the bathroom without assistance and approximately 4 minutes later was noted to be sitting on the floor with her left shoulder leaning against the wall. The report further revealed an attempt to assist the patient to a standing position, using a lift under her left arm/shoulder. The patient stated that she could not move the left arm because it was numb and was asisted off the floor using the right arm and shoulder.

In an interview on 5/14/18 at 4:30 PM in the conference room, RN #3 verified he assisted the patient off the bathroom floor on 3/29/18. RN #3 stated as soon as she arrived, Patient #3 requested to go to the bathroom. RN #3 stated EMS let the stretcher down and the patient ambulated to the bathroom. RN #3 stated a few minutes later she was on the bathroom floor. RN #3 stated, "Went to get her up by the right arm and she said you can't use that arm. So I assisted her hips over...got her up with my arm under her left arm pit, assisted her to stand and walked her back to her room."

Review of the physician's ED note at 6:04 PM revealed, "...The patient presents with neck injury and pain...sustained a fall a couple of days ago...has been experiencing more pain in her neck, left knee, and arm. Her left arm has also been numb since then. She has a history of an extensive cervical susion and has chronic pain..."

There was no documentation the Registered Nurse assessed the patient for an appropriate lift procedure to assist the patient from the floor.