HospitalInspections.org

Based on record review and interview, nursing staff failed to develop, and keep current, a nursing care plan and a fall risk care plan that reflected the patient's goals and needs, and failed to obtain and document telemetry strip monitoring for 1 (Patient #1) of 10 patient records reviewed.

Findings Include:

Pt. #1 was admitted to the facility on 06/03/2024 with seizures. Pt. #1 had a history of hypertension, previous stroke with residual right sided sensory deficit and seizure disorder. Pt. #1 suffered from confusion and agitation during their hospitalization and left against medical advice (AMA) on 06/05/2024 at 10:00 PM.

Development of nursing care plan

Review of the facility's policy ID 14776656, "Interdisciplinary Patient Assessment & Documentation," dated 11/27/2023 revealed: "The admission navigator history and initial plan of care should be completed within 24 hours. Initial interdisciplinary referrals are generated, based on assessment data/risk screens. ...The plan of care should be developed, when possible, in conjunction with the patient/family. A care plan has individualized patient priorities, expected outcomes with target dates, and appropriate interventions. B. When the plan of care has been developed, the healthcare team implements it. Each discipline documents their interventions and the patient's response to these interventions in the patient's health care record."

Review of Pt.#1 medical record revealed no evidence of a nursing care plan throughout Pt.# 1's hospitalization (greater than 24 hours).

Development of fall prevention interventions:

Review of the facility's policy ID 16439940, "Fall Prevention," dated 08/01/2024 revealed: "Patients who score 45 or higher on the Morse Fall Scale (scoring for patients at risk for falls) are considered "high-risk" for falls ...Using a bed or chair alarm for patients who are unable to, choose not to, or may forget to follow safety directions."

Review of the facility's policy ID 16517032, "Safety Management of Clinical Alarms," dated 03/01/2024 revealed: "Clinical associates must assure that all alarms are set to activate at appropriate settings for each patient and are sufficiently audible with respect to distances and competing noise within the unit."

Review of Pt. #1's Adult Patient Care Summary admission sheet completed by RN O on 06/04/2024 at 11:30 AM revealed a Morse Fall Risk Score of 45 (high risk) on admission and 60 at 4:00 PM. Ongoing review of Pt. #1's medical record revealed a bed alarm was initiated and fall risks were reviewed with the patient on 06/04/2024 at 11:30 AM. There was no documentation evident on 06/05/2024 of Morse Fall Risk, fall prevention or any documentation around whether bed alarm was on or off and what the fall risk care plan interventions were for Pt. #1.

Review of Physical Therapy Evaluation 06/04/2024 1:30 PM revealed, "Patient safety/Precautions: Bed and Chair Alarm. Assessment: Cooperative and pleasant, cognition, mobility, and speech appear at baseline ... Pt was left in the room with a chair alarm on and a call button within reach ...Discontinue acute care PT due to baseline mobility/ambulation level."

Review of Occupation Therapy Evaluation 06/04/2024 1:46 PM revealed that Pt. #1 needed help with set up for feeding, bathing and dressing. "Pt was left in the room with a bed alarm on and a call button within reach." Evaluation 06/05/2024 2:02 PM revealed, "Pt with significant improvements this date. Goals met. No further skilled OT intervention is recommended at this time. Subjective: More Alert; Self Care: Showered prior to meeting. Pt was left in the room with a bed alarm off and a call button within reach."

During an interview on 09/03/2024 at 1:47 PM with Patient Care Tech D when asked how a patient is identified as a fall risk Patient Care Tech D stated they look at the fall score in the computer, get it in report, see it on the tips board and see that the patient is in a yellow grown which indicates they are a fall risk. When asked how often patients are rounded on Patient Care Tech D stated, "I round every 2 hours at a minimum but I try and round more frequently if I am able. The RN rounds on the odd hours and I round on the even hours." When asked about the expectation around call light and alarm response times s/he stated that they try and respond immediately. If they are unavailable because they are assisting someone else they request that the RN working with the patient be notified to assist.

During Interview on 09/04/2024 at 8:30 AM with Quality Coordinator M when asked if the care plan was found in the medical record s/he stated, "No we could not find any." When asked if it should be in the record Quality Coordinator M stated, "Yes it should be in the chart."

During an interview on 09/04/2024 at 08:52 AM, Medical Manager RN I stated, "Expectations around charting did not change during down time (a period during which computers were not available and charting was done manually)." S/he stated it was a challenge during down time for all staff to know exactly where to chart as the organization tried to improve forms. They had utilized their twice daily huddles with staff to inform them about downtime documentation forms to utilize for charting. Medical Manager RN I stated, "Charting definitely improved by the end of downtime but it still could have been better."

Lack of Telemetry Documentation:

Review of facility's policy ID 13282525, "Care of the Patient Requiring Telemetry Care" dated 06/06/2023 revealed, "A rhythm strip will be obtained, interpreted..., and documented on admission, transfer with a change in level of care, every shift, and with a change in baseline rhythm...Assessment of rhythm and any necessary interventions are documented."

Review of Pt. #1's medical record revealed on 06/04/2024 07:00 AM that telemetry monitoring was ordered.

Ongoing review of Pt. #1's medical record revealed no telemetry strip documentation was completed on 06/05/2024.

An interview was conducted with Telemetry Tech G 09/03/2024 at 1:40 PM. When asked what the process is around telemetry S/he stated that the order comes in and they admit the person on the monitor. The RN or PCT places the box and electrodes on the patient. The telemetry tech runs the first strip on the patient. They also run strips if there are any irregular rhythms. The nurse caring for the patient runs a strip every shift and does the interpretation of the strip. The nurse also does an interpretation of irregular rhythm strips that the tech places in a basket for them. Those strips are all scanned into the patient's medical record.

During an interview with Nurse Manager RN I and Patient Care Supervisor C on 09/04/2024 at 08:52 AM, both stated telemetry should be documented once a shift by the RN with interpretation of the strip documented in the chart.

During an interview on 09/04/2024 at 10:00 AM with RN P when asked how often telemetry strips needed to be documented RN P said once a shift they need to run strips and document on the rhythm.