HospitalInspections.org

Based on policy review, medical record review and staff interview it was determined the facility failed to provide care in a safe setting by not ensuring appropriate nursing care for one (1) of ten (10) medical records reviewed (patient #1) after the patient fell in his room. This failure has the potential to adversely impact the care and condition of all patients.

Findings include:

1. The policy "Procedure for Assessment and Documentation of Care for the Hospitalized Patient who Has Experienced a Fall", last reviewed 11/11, was provided for review. The policy states: "Immediately following a fall , the nurse will complete a physical assessment and compare to baseline assessment. Notify physician and family of fall and assessment. Document-Time, Location, patient position, and appearance of fall. Assess every hour times 4 hours-Integumentary, Cardiovascular, and Neurological status". "Report any changes in assessment to physician".

2. Review of the medical record revealed no documentation of the patient's fall or the appropriate physical assessment required by hospital policy. The physician was notified of the patient's fall but no documentation was recorded of the patient's family being notified of the incident.

3. An interview was conducted with the Plastic Surgeon via telephone on 10/10/12 at 1630. He stated that on 10/25/11 at 0630 he was paged by the nursing staff from four (4) south and was told his patient was face down on the floor in his room. He asked if the patient was responsive and the nurse replied she didn't know. He was about one hundred (100) yards from the hospital and ran into the facility and went to four (4) south. The nurses had picked the patient off the floor and were putting him in his bed. He asked the patient what had happened and the patient replied, "I was trying to go to the bathroom and felt dizzy and ended up lying on the floor on my face". The patient was alert and did not have any injuries from the fall. The doctor went out to the nurses station and said "an incident report needs to be done". He stated the nurses walked away from him and he didn't know if an incident report would be done or not. When asked if he had documented about the patient's fall, he stated that he did not document about the incident but should have filed a report about the occurrence.

4. These findings were discussed with the Corporate Director of Regulatory Compliance at 0930 on 10/11/12. She stated "I don't know why this was never documented in the medical record and the appropriate procedures followed for the care of the patient". This is not our expectation of what should be done when an incident occurs with a patient. This has never happened before the staff is very aware of the policy and procedures surrounding patient falls. She concurred with the findings.

Based on policy review, medical record review and staff interview it was determined the facility failed to provide a sterile environment for the surgical procedure of one (1) of ten (10) medical records reviewed (patient #1) by allowing the patient to wear dirty work jeans and socks during the surgical procedure. This failure has the potential to adversely impact the care and condition of all surgical patients.

Findings include:

1. The policy "Procedure For Preparing The Patient For Surgery", last revised 12/11, was provided for review. The policy states: "Secure all personal items or relinquish to family". It is unacceptable to tape jewelry if it can be removed. Dentures should be placed in labeled denture cup and secured or relinquished to family. All personal clothing should be removed except for hospital gown.

2. Review of the OR surgical record revealed the pre-op check list was documented by the validating RN and the OR Circulator before the patient went to surgery. The perioperative record stated, "pants left on patient stated he had money in pocket, OR staff did not remove jeans or verify what change he had in pocket". Documentation on the post anesthesia flowsheet revealed personal items as blue jeans/socks bilaterally.

3. An interview was conducted with the Charge Nurse-OR Circulator on 10/10/12 at 1350. When asked about the specific duties of the OR Circulator , she stated the duties of the circulator is to watch the newer surgeons and residents scrub up before a surgery case, constant surveillance of the surgical suite in maintaining sterility and on the spot correction if contamination is identified. She also stated, the OR Circulator is the last stop before the patient is taken into the surgical suite and they are responsible for checking the pre-op checklist and identifying any problems before surgery.

4. An interview was conducted with the OR Clinical Manager Coordinator on 10/10/12 at 1240. When asked about the expectation for the OR regarding patient's personal belongings, she stated the expectation is that patient's will not be brought to the OR with any personal belongings except for glasses or hearing aids needed for communication purposes. She stated, the OR Circulator is responsible for the aseptic and sterile surveillance of the surgical suite and this incident should not have happened. She concurred with the findings.

Based on policy review, medical record review and staff interview it was determined the facility failed to follow protocol for triage procedures for one (1) of ten (10) medical records reviewed (patient #1) by giving the patient an incorrect triage category. This failure has the potential to adversely impact the care and condition of all patients.

Findings include:

1. The policy "Nursing Triage Categories in the Emergency Department", last reviewed 2011, was provided for review. The policy states: "Triage involves the sorting of injured and ill persons into categories that prioritize them for medical care according to the nature and severity of their injury or illness". Triage acuity determinants will be based on the following parameters: Chief Complaint, Brief past medical history, Signs/symptoms of injury/illness, General overall appearance and vital signs.

2. Review of the ED medical record revealed the patient was given an incorrect triage category upon arrival to the ED. Documentation in the medical record stated the patient was triaged as Category III-Urgent. The patient had sustained an injury to the left hand resulting in a traumatic amputation of a digit which falls under the triage Category II-Emergent. The diagnosis documented in the medical record was "Traumatic Amputation of Finger".

3. These findings were reviewed with the Corporate Director of Regulatory Compliance on 10/11/12 at 0930 and she concurred with these findings.