HospitalInspections.org

Based on record review and interviews the hospital failed to ensure that all State laws were met as required. (Patient identifier is #1.)

Findings Include:
Review of Title XI Hospitals and Sanitaria Chapter 151 Residential Care and Health Facility Licensing Adverse Events reporting System Section 151:38 Hospitals and Ambulatory Surgical Centers Required to Report Adverse Events. - I. "Any hospital or ambulatory surgical center licensed pursuant to this chapter shall report to the commissioner the occurrence of any of the adverse health care events described in subparagraphs (a)-(f) as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The report shall be filed in a format specified by the commissioner and shall identify the facility but shall not include any identifying information for any of the health care professionals, facility employees, or patients involved... (e) (5) Patient death or serious disability associated with the use or lack of restraints or bedrails while being cared for in a facility."

Review of the New Hampshire Code of Administrative Rules Chapter He-P Residential Care and Health Facility Rules indicates the following:

PART He-P 802 Rules for Hospitals:

"He-P 802.03 Definitions:..

(h) "Adverse event" means a negative consequence of care that results in unintended injury which may or may not have been preventable, and which is listed in RSA 151:37.

(u) " Department " means the New Hampshire department of health and human services, at 129 Pleasant St, Concord, NH 03301...

He-P 802.14 Duties and Responsibilities of All Licensees.

(q) Licensees shall, in accordance with He-P 802.15:

(1) Report all adverse events to the department as required by He-P 802.15(a)-(c);

He-P 802.15 Adverse Event Reporting.

(a) Pursuant to RSA 151:37, the hospital administrator or designee shall report to the department the following adverse events:


(a)(e) Environmental events including:

(5) Patient death or serious disability associated with the use or lack of restraints or bedrails while being cared for in a facility.

(b) If the hospital suspects an adverse event occurred, the hospital administrator or designee shall send a report to the department in electronic or paper format, within 15 days, including:

(1) Hospital information;

(2) Patient information;

(3) Event information; and

(4) Type of occurrence as listed in (a) above.

(c) For events reported in (b) above the hospital shall within 60 days provide the department:

(1) An analysis that includes the type of harm and contributing factors; and

(2) A corrective action plan that includes what corrective actions are planned, who is responsible for implementation, when the action will be implemented and what measurements will be used to evaluate the corrective action plan or the justification for not implementing a corrective action plan if the hospital determines that one is not required.

He-P 802.16 Organization and Administration.

(b) Each hospital shall have a full time administrator who:

(2) Shall be responsible to the governing body for the daily management and operation of the hospital including:
h. Ensuring development and implementation of hospital policies and procedures on:
6. Adverse event reporting; and

i. Notifying the department, directly or through delegation, as specified in He-P 802.15 of any adverse event involving a patient ... "


Review of Patient #1 medical record on 8/10/11 reveals a daily Progress/Narrative note written by Staff E, RN, (Registered Nurse) dated 6/11/11 indicates at approximately 11:30 p.m. Patient #1 was left on toilet alone. Staff F, LNA (Licensed Nurses Aide) heard noise. Resident #1 was found on back leaning towards left side with head up. Resident #1 complaining of left leg pain and crying out. Resident #1 head placed on pillows while waiting for ambulance.

Interviews on 8/10/11 with Staff A, Chief Operations Officer, Staff C, Director Quality and Risk Management revealed that Patient #1 was sent to a local hospital emergency department and revealed Patient #1 sustained a fracture of the left femur. Staff A and C confirmed that a report was not submitted as required per the requirements of Adverse Event Reporting System.

Based on review of medical records, interviews with hospital staff, and review of hospital policies and procedures, it was determined that the hospital failed to ensure a patient at risk for falling receives care in a safe setting for 1 patient in the investigation survey. (Patient identifier is: #1.)

Findings include:

Review of Patient #1's medical record on 8/10/11 reveals that Patient #1 was admitted late afternoon of 6/10/11 from acute hospital with diagnoses including multiple falls, knee/ back pain and hypertension.
Documentation reveals that Patient #1 was identified as a fall risk with a Morse Falls Score on admission of 115 (45 and above = High risk).

Review on 8/10/11 of the facility "Fall Prevention Program Policy and Procedure" last revised 6/10 includes the following:

Patient's who score greater than 45 on the Modified Morse Fall Assessment are considered high risk for falls and require strict fall precaution measures implemented:
1. Re-orient patient to the environment, time, place and person as frequently as needed.
2. Assure supervision and assistance are provided with elimination, transfers and ambulation.
5. Do not leave patient unattended in the bathroom.

Patient #1's medical record reveals documentation dated 6/11/11 indicating that Patient #1 sustained an unwitnessed fall in the bathroom around 11:15 p.m. Patient #1 was transferred to local hospital for evaluation. Daily progress/narrative note dated 6/12/11 at 4:45 a.m. reveals that the local hospital informed facility that Patient #1 was being admitted with a left femur fracture.

Review of the facility rapid response documentation form dated 6/11/11 23:30 indicates that Patient #1 was left in bathroom on toilet alone. LNA (licensed nursing assistant) heard noise. Patient #1 was found lying on back leaning towards the left side with head up. Patient #1 had unwitnessed fall, complaining of left leg pain and crying out.

During interview on 8/10/11 with Staff C, risk management Staff C revealed documentation of a discussion with Staff F, LNA . Staff F had indicated putting Patient #1 on the toilet and that Patient #1 would wait for help and not get up. Staff F then went outside of Patient #1's room to call for another staff to answer another light and heard Patient #1 fall. Staff F entered the bathroom to find Patient #1 on the floor. Staff F indicated that Patient #1 reported that Patient #1 didn't get up but collapsed and slid to floor.

Review of documentation by Staff C dated 7/8/11 reveals a response to Patient #1's family regarding their concerns. Staff C indicates in the response that an evaluation was done on whether all appropriate fall prevention measures were in place to prevent such an incident from occurring. The LNA used poor judgment in deciding to leave Patient #1 unattended in the bathroom.

Based on record review and interview the facility failed to ensure that nursing notes, reports of treatment and other information necessary to monitor the patient's condition is documented in 1 patient record. (Patient identifier is: #1.)

Findings include:

Review of Patient #1's medical record on 8/10/11 reveals a physician order dated 6/11/11 at 4:15 a.m. to monitor patient and call if diastolic blood pressure is over 100 and to continue every two hour vital signs. Review of Patient #1's medical record reveals no documented evidence of the every two-hour blood pressure monitoring scheduled for 4:00 p.m., 6:00 p.m., 8:00 p.m. and 10:00 p.m. on 6/11/11.

During an interview on 8/10/11 with Staff A, Chief Executive Officer and Staff C, Quality Risk Manager, Staff A and C were unable to locate documented evidence of Patient #1's blood pressure monitoring on 6/11/11 at 4:00 p.m., 6:00 p.m., 8:00 p.m. and 10:00 p.m.