HospitalInspections.org

Based on policy review, medical record reviews, event report and staff interviews the hospital failed to provide care in a safe setting by failing to institute measures to prevent a fall in 3 of 3 patients (#2, #8, #9), and failed to complete safety checks per hospital policy in 5 of 6 patients (#8, 9, 11, 12, 13).

The findings included:

Review of the hospital policy titled "Fall Prevention (Adult)" last revised 12/13/2021, revealed, "I. Policy: In keeping with the high priority given to patient safety, each inpatient is considered part of our fall prevention plan, which includes assessment of risk utilizing the Morse Fall Scale (MFS) and initiation of appropriate prevention interventions. II. Purpose: To minimize the risk of falls and the severity of injury resulting from falls. III. Procedure: ...Ongoing assessments occur depending on patient status, changes in condition, and if the patient falls. All injuries will be promptly addressed, and post-fall interventions will be implemented...MFS Score: High Risk > 51. Implement High Risk Fall Preventions Interventions. Standard Fall Preventions: Patient rounding per protocol. High Risk Fall Prevention Interventions: All the above, ...Activate fall risk on nurse call system, ...Activate bed alarms using the most appropriate zone setting. (Should always be set to zone 2 or greater) .... Discuss fall risk with family and ask family to remain with the patient. Reassessment: Patients placed on fall risk at the time of admission will remain on fall risk precautions throughout their hospital stay..."

Review of the hospital policy "Nursing Care Standards - Medical Surgical approved 11/23/2020 revealed, " ...This policy addresses the process for multidisciplinary assessment/reassessment of patients at (named facility) on the Medical-Surgical Unit ...VI ...b ...w. Frequent rounding by both nurse and nursing assistant as outlined in the Hourly Rounding policy..."

1. Closed medical record review on 03/08/2022 revealed Patient #2, a 59-year-old female patient admitted on 11/13/2021 with Covid pneumonia and a urinary tract infection. History and Physical dated 11/13/2021 at 0157 by Medical Doctor (MD) #1 revealed "...Plan: The patient was admitted to the telemetry unit with bilateral infiltrates consistent with coronavirus pneumonia...Past History: Acute arthritis (sudden onset of joint inflammation and pain), Acute respiratory failure with hypoxia (inability of the respiratory system to meet the body's oxygenation, and ventilation requirements), Anxiety, Breast Ca (cancer), CAD (coronary artery disease), CHF (congestive heart failure), Depression, Hypertension (high blood pressure), Pulmonary embolism (blood clot to the lung), and Stroke (cerebral vascular accident)..." Review of the Physician Order dated 11/13/2021 at 0133 by MD #1 revealed Patient #2's ordered activity was "OOB (out of bed) with assistance, and fall precautions..." On 11/16/2021 at 1654 MD #2 transferred Patient #2 to the Step-Down Unit "...Her oxygen became worse this morning, and she went from requiring 2 L (liters) of oxygen to 10 L. She was moved to stepdown [sic]...She is currently tolerating 13 L of oxygen sating 94%. She feels much more tired today and was significant cough [sic]..." Review of the Physician Order on 11/16/2021 at 1239 by MD #2 revealed that her orders including activity were "Order is continued upon transfer"..." Review of the Activity Safety Assessment dated 11/19/2021 at 1000 by Registered Nurse (RN) #3 revealed a Morse fall score of "15" with nursing assessment and safety checks remarking Patient #2 was "in bed, bed alarms on and functioning, call bell within reach, bed position: side rails up x 4..." Review of the Physical Therapy Note dated 11/19/2021 at 1138 by Physical Therapist (PT) #4 revealed that Patient #2 transferred with assistance and rolling walker to bedside chair "SOB (shortness of breath noted and was cued on breathing technique to aid in recovery. Left in chair, all needs met..." Review of the Nurse Note dated 11/19/2021 at 1629 by RN #3 revealed "...PT got patient up in recliner and she tolerated well. Patient removes oxygen and forgets to put it back in place, and O2 (oxygen) sats (saturation) drop rapidly [sic]. Around 1600 patient removed oxygen and O2 sats drop to 36. Staff responded and patient was lethargic and placed on BIPAP (Bi-Level Positive Airway Pressure). New orders received. Family arrived and updated, and MD is currently talking with family." Review of the Event Note dated 11/19/2021 at 1757 by MD #5 revealed " Rapid response called overhead. per nursing patient was noted to have desaturated down to 34% and was found to have removed her oxygenation off.[sic] O2 saturations recovered after supplemental oxygen was placed and she was placed on Bipap, pending transfer to ICU (intensive care unit) for closer monitoring..." Review of the Activity Safety Assessment dated 11/19/2021 at 1800 by RN #3 revealed Patient #2 was "in bed, bed alarm was on and functioning, side rails are up x 2." Record review revealed Patient #2's Morse Fall Score was not reassessed after the rapid response event. Review of the Shift Summary Note dated 11/19/2021 at 1800 by RN #3 revealed "...Patient was found face down on floor laying on Bipap tubing off face." Review of the Nursing Note: Code Blue dated 11/19/2021 at 2110 by Licensed Practical Nurse (LPN) #6 revealed "...1922 CODE BLUE CALLED..." Review revealed Patient #2 was transferred to ICU 11/19/2021 at 2013 by MD #7. Review of the Discharge Summary dated 11/25/2021 at 1722 by MD #8 revealed "...On 19 November she fell out from the bed, took off her BIPAP mask..." Record review revealed that Patient #2 remained on the ventilator and was transferred to a tertiary (hospital for specialized care) care hospital on 11/26/2021 at 2300. Record review failed to reveal a reassessment for falls for Patient #2 after a change in condition that occurred on 11/19/2021 at 1600, and Patient #2 fell on 11/19/2021 at 1922.

Review of the Event Report dated 11/19/2021 at 2029 by RN #3 revealed "Event Code: Unwitnessed. Event Date and Time: 11/19/2021 at 1923. Location: Step Down...Patient was observed on monitor with heart rate of 36, staff entered the room and observed patient face down on floor with Bipap tubing under patient, bed was observed with all four rails up. Son had just left bedside previously. Code was called and staff started CPR (cardiopulmonary resuscitation) ...Affected Body Part/Injury: Other blood observed on mouth area. Patient Condition: Confused. Post Event Conditions: Poor. Treatment Type: Medication Given. Treatment Type: Patient Transferred. Impact on Care: Increased length of stay... Event Severity: Temporary Harm; Prolonged LOS (length of stay) ..."

Interview on 03/09/2022 at 1000 with RN #3, who had Patient #2 on 11/19/2021 revealed "...after the 1st safety event, all 4 bedrails were up...All lights were on, her son was present, and she was asleep...I thought she was safe, the son was at bedside..." Interview revealed that RN #3 did not recall completing a fall reassessment after the rapid response event occurred. Interview revealed that the hospital policy was not followed.

Interview on 03/10/2022 at 1055 with Step Down Unit Manager, RN #9 revealed that "...the expectation for fall reassessments for patients with a change in condition was to follow hospital policy..." Interview revealed that hospital policy was not followed for Patient #2 after her rapid response event on 11/19/2021 at 1600.

Interview on 03/10/2022 at 1115 with Chief Nursing Officer, revealed "...we want our patients to be safe...Yes, a fall reassessment should be completed per hospital policy..." Interview revealed that hospital policy was not followed for Patient #2. Interview revealed that the Fall Prevention Adult policy was in place with new Nursing Documentation Software that began for nursing documentation using the MFS on 10/01/2021. Interview Chief Nursing Officer revealed "...The policy was awaiting... review in the PPM (policy procedure manual) system and got hung up in PPM. (This has been an issue of late with PPM and random users) When I realized it was still out there, I moved it to draft... set it to approved..." Interview revealed the above policy was in use for fall prevention on 10/01/2021.



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2. Closed medical record review on 3/10/2022 revealed Patient #8 was a 93-year-old patient admitted on 01/28/2022 with Acute Respiratory Failure with hypoxia secondary to COVID-19. Review of Fall Risk Assessments revealed Patient #8 was a moderate fall risk. Review of Moderate Fall Risk Precautions dated 02/01/2022 at 0728 revealed, "...Provide call light within reach and ask patient to demo use... Make sure patient's belongings are within reach... Response to teaching-fall risk: demonstrates knowledge..." Review of Safety Checks revealed an hourly round was preformed on 02/01/2022 at 1530 and the subsequent round performed at 02/01/2022 at 1700. Review of Nurses Notes dated 02/01/2022 at 1848 revealed, "CNA (certified nursing assistant) called out to nurse and stated that patient was in the floor next to her bed. Patient had an incontinent bowel movement during fall. Patient's only complain was back pain, which she had complained about previously to fall. Patient has an abrasion on her back which is unrelated to the fall. No visible injuries noted. She did have a small bruise on her left hip, however it is undetermined if bruise was caused by the fall. Patient stated she was trying to answer the phone when she fell out of the bed. She was assisted back in the bed by two nurses and two CNAs. Her Foley remains intact and draining, IV became dislodged. Patient is A&O (alert and oriented) x3. Her response to time was delayed but correct. MD, (named) was notified. Pelvic X-ray CT of head." Review of Discharge Summary dated 02/06/2022 at 1319 revealed, "...Patient's hospital course was complicated by development of GI bleed felt to be likely sequelae of steroid use prompting discontinuation. Otherwise patient had worsening renal indices, and respiratory status. Ultimately candid goals of care discussion yielded transition to DNR (do not resuscitate) status, and addition of palliative measures... Patient continued to worsen, with respect to respiratory status mentation etc., and ultimately passed peacefully on 2/6 with nursing staff..." Medical record review revealed Patient #8 expired on 02/06/2022 at 1256 at the facility. Record review revealed 1 hour and 30-minute window preceding Patient #8 fall where no hourly rounding was documented as performed.

Review of incident report dated 02/01/2022 at 1725 for Patient #8 revealed, "Status: In Progress... Incident Type: Fall... Unwitnessed... Event Date: 02/01/2022 Event Time 17:00... Pre-Event Conditions: Alert. Patient has episodes of confusion... Treatment Type... Comment: Imaging ordered... "

Interview on 03/09/2022 at 1505 with Risk & Compliance revealed falls data was aggregated for review. Interview revealed none of the falls had been investigated with a Root Cause Analysis (RCA) for potential trends. Interview revealed no further analysis was performed because the patient falls did not result in a major injury to the patient.

Interview on 03/10/2022 at 1455 with LPN #7 revealed she cared for Patient #8 on 02/01/2022. Interview revealed LPN #7 recalled Patient #8's fall. Interview revealed LPN #7 recalled rounding at approximately 1600 to administer medications. Interview revealed the CNA was expected to perform the 1700 hourly rounds and drop off meal trays. Interview revealed the CNA found Patient #8 on the floor. Interview revealed, "the unit has been very busy this year" and staff "try to document at the time done."

Interview on 03/10/2022 at 1055 with the Nurse Manager revealed that staff were expected to document care provided to patients. Interview revealed that staff were expected to follow the facility policy regarding rounding.

Interview on 03/10/2022 at 1220 with the CNO revealed staff were expected to keep patients safe and follow facility policy. Interview revealed if additional resources were needed for patient safety, leadership would have made resources available.

3. Open medical record review on 3/10/2022 revealed Patient #9 was a 60-year-old male admitted on 01/24/2022 with Right Cerebrovascular accident (CVA) and COVID-19. Review of Fall Risk Assessments revealed Patient #8 was a high fall risk. Review of Nurses Notes dated 02/16/2022 at 1513 revealed, "Fall Note; Patient was sitting in chair. The patient said he slid out of the chair and did not hit his head. He said he was trying to get up to go to the bathroom. Upon assessment no abrasions or signs of injury appeared on the patient. MD notified. The patient was aided back to the bed with bed alarm on." Review of patient one hour rounding documentation revealed between 02/15/2022 at 1500 and 02/18/2022 at 2300 (80 hours) documentation of one hour observations exceeded one hour (60 minutes) on fifteen occasions (range 71 to 125 minutes) and exceeded two hours (120 minutes) on twelve occasions. Medical record review failed to reveal post fall assessment related to a subsequent fall.

Review of incident report dated 02/16/2022 at 1515 for Patient #9 revealed, "Status: In Progress... Incident Type: Fall... Unwitnessed... Event Date: 02/16/2022 Event Time: 15:15... Description of Event: Prior to the patient's fall, the patient was sat into the chair from the bed earlier in the shift. My CNA and I had neither place the patient in the chair and are not certain who sat the patient in the chair but the chair alarm was not set on the patient. I received a call from the CNA that the patient was just discovered on the floor. I went to check on the patient and the patient was being pulled up by 4 staff members and put back into the chair. The CNA and I placed clean sheets on the bed and then the two of us transferred the patient in the bed from the chair and set the bed alarm on and all 4 side rail up... After assessment I did not see any physical signs of injury and the patient appeared to at (sic) baseline. MD (named physician) was notified..."

Review of incident report dated 02/17/2022 at 1315 for Patient #9 revealed, "Status: In Progress... Incident Type: Fall... Witnessed Assisted... Event Date: 02/17/2022 Event Time: 13:15... Description of Event: Patient was sitting in the chair and yelling out that he was "going home". CNA went into the room because the chair alarm was going off. Patient stood up despite being asked by CNA to sit down. HE then shoved CNA and he himself landed in the floor. Patient did not hit his head and denied all injury or pain. Dr (named physician) was notified."

Interview on 03/10/2022 at 1505 with RN #8 revealed she cared for Patient #9 on 02/16/2022. Interview revealed RN #8 recalled Patient #9 and his fall. Interview revealed RN #8 was at the nurses' station charting when she was notified that Patient #9 had fallen. Interview revealed Patient #9 had been placed up in a chair without the chair alarm being activated. Interview revealed hourly rounds were expected to be performed hourly. Interview revealed it was hard to document hourly rounds and sometimes the reminder to do rounding would fall off her to do list in the electronic charting system. Interview revealed staff did their best with hourly rounding.

Interview on 03/10/2022 at 1055 with the Nurse Manager revealed that staff were expected to document care provided to patients. Interview revealed that staff were expected to follow the facility policy regarding rounding.

Interview on 03/10/2022 at 1220 with the CNO revealed staff were expected to keep patients safe and follow facility policy. Interview revealed if additional resources were needed for patient safety, leadership would have made resources available.

4. Review of a facility medical record on 03/10/2022 revealed Patient #11 was a forty-six-year-old female admitted from the emergency department on 03/07/2022 for a cough, chest pain and lower extremity swelling. Review of the Hospitalist ' s HPI (history of present illness) dated 03/07/2022 at 1504 revealed Patient #11's medical history included diabetes, HFrEF (heart failure with reduced ejection fraction), PAF (paroxysmal atrial fibrillation) and dextrocardia (heart pointed opposite normal orientation). Review of patient one hour rounding documentation revealed between 03/07/2022 at 1700 and 03/09/2022 at 0235 (31 hours and 35 minutes) documentation of one hour observations exceeded one hour (60 minutes) on twelve occasions (range 67 to 152 minutes) and exceeded two hours (120 minutes) on four occasions (range 120 to 152 minutes).

Interview on 03/10/2022 at 1055 with the Nurse Manager revealed that staff were expected to document care provided to patients. Interview revealed that staff were expected to follow the facility policy regarding rounding.

Interview on 03/10/2022 at 1220 with the CNO revealed staff were expected to keep patients safe and follow facility policy. Interview revealed if additional resources were needed for patient safety, leadership would have made resources available.

5. Review of a facility medical record on 03/10/2022 revealed Patient #12 was a sixty-eight-year-old female admitted from the emergency department on 03/09/2022 for shortness of breath and bilateral lower extremity swelling. Review of the Hospitalist's HPI (history of present illness) dated 03/09/2022 at 2133 revealed Patient #12's medical history included diabetes, chronic respiratory failure, COPD (chronic obstructive pulmonary disease) and she was dependent on supplemental nasal cannula oxygen at 3 liters/minute. Review of activity orders revealed Patient #12 remained on bed rest and was at high risk for falling: Morse fall risk score was 95 at admission. Review of patient one hour rounding documentation revealed between 03/10/2022 at 0000 and 03/10/2022 at 1334 (13 hours and 34 minutes) documentation of one-hour observations exceeded one hour (60 minutes) on four occasions (range 65 to 113 minutes).

Interview on 03/10/2022 at 1055 with the Nurse Manager revealed that staff were expected to document care provided to patients. Interview revealed that staff were expected to follow the facility policy regarding rounding.

Interview on 03/10/2022 at 1220 with the CNO revealed staff were expected to keep patients safe and follow facility policy. Interview revealed if additional resources were needed for patient safety, leadership would have made resources available.

6. Review of a facility medical record on 03/10/2022 revealed Patient #13 was an eighty-six-year-old male admitted from the emergency department on 03/06/2022 for a five-day history of exertional chest pain. Review of the Hospitalist's HPI (history of present illness) dated 03/06/2022 at 1634 revealed Patient #13's medical history included diabetes, CAD (coronary artery disease), CABG (coronary artery bypass graft surgery) in 1984, and chronic anemia (low red blood cell count). Review of activity orders revealed Patient #13 was at moderate risk for falling: Morse fall risk score was 45 at admission. Review of patient one hour rounding documentation revealed between 03/09/2022 at 0707 and 03/10/2022 at 1536 (32 hours and 29 minutes) documentation of one-hour observations exceeded one hour (60 minutes) on eight occasions (range 68 to 109 minutes).

Interview on 03/10/2022 at 1055 with the Nurse Manager revealed that staff were expected to document care provided to patients. Interview revealed that staff were expected to follow the facility policy regarding rounding.

Interview on 03/10/2022 at 1220 with the CNO revealed staff were expected to keep patients safe and follow facility policy. Interview revealed if additional resources were needed for patient safety, leadership would have made resources available.

Based on policy review, medical record review, and staff interview, the facility staff failed to maintain a complete and accurate medical record by failing to retain telemetry recordings for 2 of 2 patients with telemetry orders and with change in patient condition (Code Blue) reviewed. (Patient #2, Patient #3).

Findings included:

Review of the hospital policy titled "Nursing Care Standards-Stepdown Unit" date approved 11/01/2019 revealed "...1. Policy: D. Data collection will be ongoing throughout hospitalization...J. ECG (electrocardiogram) Monitoring: 1. All patients admitted to Stepdown Unit (SDU) will have their ECG monitored continuously with assessment and documentation with shift assessments and every 4 hours or more often if indicated/changes,...ECG monitoring is accomplished using bedside cardiac monitors..."

1. Closed medical record review on 03/08/2022 revealed Patient #2, a 59-year-old female patient admitted on 11/13/2021 with Covid pneumonia and a urinary tract infection. History and Physical dated 11/13/2021 at 0157 by Medical Doctor (MD) #1 revealed "...Plan: The patient was admitted to telemetry unit with bilateral infiltrates consistent with coronavirus pneumonia...Past History: Acute arthritis (sudden onset of joint inflammation and pain), Acute respiratory failure with hypoxia (inability of the respiratory system to meet the body's oxygenation, and ventilation requirement), Anxiety, Breast Ca (cancer), CAD (coronary artery disease), CHF (congestive heart failure), Depression, Hypertension (high blood pressure), Pulmonary embolism (blood clot to the lung), and Stroke (cerebral vascular accident)..." On 11/16/2021 at 1654 MD #2 transferred Patient #2 to the Step-Down Unit"...Her oxygen became worse this morning, and she went from requiring 2 L (liters) of oxygen to 10 L. She was moved to stepdown [sic]..." Review of the Shift Summary Note dated 11/19/2021 at 1800 by RN #3 revealed "...Patient was found face down on floor laying on Bipap (bi-level positive airway pressure) tubing off face." Review of the ED (emergency department) Inpatient Procedure note dated 11/19/2021 at 1959 by Doctorate of Nurse Practice (DNP) #10 revealed "...A CODE BLUE was called. Arrived to room 425 to find the hospitalist and nursing staff along with respiratory attending to an unresponsive patient lying in the floor...She had a bradycardic rhythm in the 50s..." Medical record review failed to reveal documentation of telemetry recordings on 11/19/2022 for Patient #2 at 0800, 1200, 1600, or during Code Blue at 1922. Record review revealed that Patient #2 was transferred to intensive care unit and remained on the ventilator until she was transferred to a tertiary (specialty) care hospital on 11/26/2021 at 2300.

Interview on 03/09/2022 at 1100 with SDU Nursing Manager revealed the patients in the SDU have cardiac monitoring strips assessed by the nurse every 4 hours, and in any rapid response or code blue event, and are retained in the permanent medical record. Interview revealed "...I looked at those strips in my chart review, they were labeled 'fall event'..." Interview revealed the Code Blue strips dated 11/19/2021 for Patient #2 were reviewed by the Nurse Manager, but were not available in the medical record review for surveyor review. Interview revealed the facilities expectation for retaining a complete and accurate record were not met.

Interview on 03/10/2022 at 1516 with the CNO revealed the facility staff were unable to locate the telemetry recordings for Patient #2 and that the telemetry strips were to be scanned into the medical record.

Interview on 03/10/2022 at 0912 with the HIM Director revealed the facility's expectation to maintain a complete and accurate medical record. Interview revealed the telemetry recordings should have been in the patient medical record. Interview revealed the medical records staff scan all documents received from the physical medical record from the unit. Interview revealed the staff manually reviewed all the scanned documents for completeness and accuracy. Interview revealed if the document was not in the scanned medical record, then medical record staff did not receive it. Interview revealed physical copies of the medical record are destroyed after confirmation of scanning.



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2. Closed medical record review of Patient #3 revealed a 72-year-old male admitted to the medical-surgical unit of the facility on 01/26/2022 at 1235. Review of the Hospitalist History and Physical dated 01/26/2022 at 1238 revealed admitting diagnoses of Acute respiratory failure with hypoxia, Pneumonia due to 2019-nCOV (COVID-19, Coronavirus), Elevated troponin, Acute encephalopathy, Hypertension, Acute Kidney Injury, and COPD (Chronic Obstructive Pulmonary Disease). Review of Physician Orders revealed telemetry was ordered on 01/26/2022 at 1230 and discontinued on 02/07/2022 at 1807. Review of telemetry strips revealed telemetry strips were available for 01/27/2022 through 02/03/2022 and 02/05/2022 through 02/07/2022. Record review revealed Patient #3 was discharged 02/09/2022 at 1215 to a Rehabilitation Facility. Medical record review failed to reveal documentation of telemetry recordings on 02/04/2022 for Patient #3.

Interview on 03/10/2022 at 1516 with the CNO revealed the facility staff were unable to locate the telemetry recordings for Patient #3 and that the telemetry strips were to be scanned into the medical record.

Interview on 03/10/2022 at 0912 with the HIM Director revealed the facility's expectation to maintain a complete and accurate medical record. Interview revealed the telemetry recordings should have been in the patient medical record. Interview revealed the medical records staff scan all documents received from the physical medical record from the unit. Interview revealed the staff manually reviewed all of the scanned documents for completeness and accuracy. Interview revealed if the document was not in the scanned medical record, then medical record staff did not receive it. Interview revealed physical copies of the medical record are destroyed after confirmation of scanning.


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