HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the patient representative's right to participate in the development and implementation of the plan of care was met. This deficient practice was evidenced by failure to ensure the patient's representative was notified of a change in condition resulting in a revision of the plan of care for 1 ( Pt. #4) of 5 (Pt. #1 - Pt. #5) sampled patient records reviewed.
Findings:

Review of the incident report log revealed on 11/15/2022 Patient #4 sustained an unwitnessed fall.

Review of the policy and procedure titled, "Witnessed and Unwitnessed Fall Algorithm" revealed, in part, for an unwitnessed fall, "notify patient/s family/significant other".

Review of the medical record revealed no documentation of the family being notified as per the hospital's policy/procedure and algorithm.

In interview on 1/10/23 at 10:20 a.m., S9RN, while navigating the electroni medical record, indicated there was no documentation of the family or representative notified of the fall as per the policy/procedure and algorithm.

Review of the form titled, "Patient Post Fall Huddle Follow-Up" revealed a line indicating "Supervisor, family, MD notified and whom" with a response that the supervisor, primary MD were notified.. There was no documentation on the form of notification to the family regarding Patient #4s fall.

In interview on 01/10/2023 at 1:05 p.m. S4RN and S5RN verified there was no documentation in the medical record or on the form that the family had been notified.

Based on record review and interview, the hospital failed to provide the adequate number of personnel to provide nursing care to all patients as needed. This deficient practice is evidenced by the hospital not meeting the staffing ratio for Certified Nursing Assistants (CNA) on the night shift requiring 2 CNA's for a patient census of 26.
Findings:

Review of the incident report log revealed on 11/15/2022, Patient #4 sustained an unwitnessed fall.

Review of the form titled, "Patient Post Fall Huddle Follow-Up" revealed Patient #4 sustained an unwitnessed fall on 11/15/2022 at 2:45 a.m.

Review of the daily staffing guidelines for Unit 'a' revealed with a census of 26 patients, there should be 2 C.N.A.s on the 7:00 p.m. - 7:00 a.m. night shift.

Review of the form titled, "Patient Post Fall Huddle Follow-Up" revealed on 11/15/2022 there was 1 CNA assigned to the shift when Patient #4 fell. Further review revealed a question on the form which read, in part, "What could have been done to prevent this fall?" with a response of "Better staffing ratio".

In interview on 01/10/2023 at 8:50 a.m. S11PS indicated staffing grid on unit 'a' on the night shift, there should be 2 CNAs with a census of 26 patients. S11PS further indicated on 11/15/2022 there was only 1 CNA on the night shift and verified that there was a shortage of staff.