HospitalInspections.org

Based on review of documentation and interview, the facility failed to protect and promote each patient's rights when the facility failed to properly assess and reassess its patients for injury and ongoing illness resulting in Patient #1 being transferred to a higher-level of care with a Hgb of 5.7 due to a GI bleed and extensive bruising to her lower extremities (Cross Refer A0144).

Based on review of documentation and interview, it was determined that the facility failed to provide care to its patients in a safe setting.

Findings were:

Patients' Rights Handbook stated in part "You have the right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs, and promotes respect and dignity for each patient. You also have the right to appropriate treatment in the least restrictive appropriate setting available consistent with the protection of the patient and the protection of the community ...You have the right to be free from mistreatment, abuse, neglect, and exploitation."

Facility policy entitled "Fall Assessment/Re-assessment and Precautions" stated in part
"Inpatient:
1.All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall, or change in mobility status, and/or every 7 days if identified as "at risk for falls."
2.In the event of a fall occurrence, patients will be re-assessed, and additional fall prevention interventions will be implemented.
3.The Registered Nurse (RN) utilizing the Fall Risk criteria on the Fall Risk Assessment Tool, will assess/reassess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated."

Patient # 1 fell at the facility 4 times during her stay (5/8/23 at 8:00 pm, 5/15/23 at 2:37 pm, 5/18/23 at 9:05 am, and 5/18/23 at 10:00 pm). Skin checks were documented after each fall; however skin checks all stated that skin was intact with no bruising. On 5/21/23, patient # 1 had a change in mental status and was transferred to the ED for evaluation. The ED documented extensive bruising on the patient's legs and hips.

Review of the medical record of patient # 1 revealed 6 skin assessments. Nothing was noted but "dry skin." Per the Director of Nurses during an interview on 5/23/23, all patients had skin assessments weekly and post falls. She said that the patients were taken to a private area and their entire skin was fully assessed. She stated that patient # 1 was incontinent so staff had to assist with changing the diaper/pull-up. She stated that staff would have reported any rectal bleeding.

On 5/21/23, patient # 1 was transferred to the ED for assessment after a change in mental status. She was found to have a Hgb of 5.7 due to a GI bleed and extensive bruising to her lower extremities. Her diagnosis was shock with hypovolemic and/or septic shock.

Nursing daily physical assessments and post fall assessments were found to be inadequate. These findings were revealed to the Administrator and to the Director of Nurses on 5/25/23.

Based on review of documentation and interview, it was determined that the facility failed to properly assess and reassess its patients for injury and ongoing illness.

Findings were:

Facility policy entitled "Fall Assessment/Re-assessment and Precautions" stated in part
"Inpatient:
1. All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall, or change in mobility status, and/or every 7 days if identified as "at risk for falls."
2. In the event of a fall occurrence, patients will be re-assessed, and additional fall prevention interventions will be implemented.
3. The Registered Nurse (RN) utilizing the Fall Risk criteria on the Fall Risk Assessment Tool, will assess/reassess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated."

Review of the medical record of patient # 1 revealed 6 skin assessments. Nothing was noted but "dry skin." Per the Director of Nurses during an interview on 5/23/23, all patients had skin assessments weekly and post falls. She said that the patients were taken to a private area and their entire skin was fully assessed. She stated that patient # 1 was incontinent so staff had to assist with changing the diaper/pull-up. She stated that staff would have reported any rectal bleeding.

On 5/21/23, patient # 1 was transferred to the ED for assessment after a change in mental status. She was found to have a Hgb of 5.7 due to a GI bleed and extensive bruising to her lower extremities. Her diagnosis was shock with hypovolemic and/or septic shock.

Daily physical assessment was found to be inadequate. These findings were shared with the Director of Nurses and the Administrator on 5/25/23.