HospitalInspections.org

Based on a review of the Critical Access Hospital (CAH) policy/procedures, medical records and staff and Physician interviews, the CAH failed to ensure the safety of a hospitality patient in the acute care setting.

On January 17, 2010 the discovery of a body near the out building of the CAH, revealed to be an 88 year old hospitality care male patient who had left the CAH unobserved and unattended. The patient's body was discovered in 23 degree weather on the CAH property following a search by police and staff.
The unresponsive patient found outside cold and no vital signs. The body was brought into ER per stretcher. The patients temperature measured 23.6 Centigrade (74.48 degree Fahrenheit) (Normal body temperature 98.6 F) and warm blankets had been applied. A Physical exam noted a lack of respirations, heart rate, the -heart monitor shows asystole, the skin cold-cyanotic and rectal bleeding. Physician pronounced the patient dead at 4:35 AM on 1/17/10.
The patient resided in the hospital's acute care area while the family discussed an admission to the long-term care unit.

This determination based on:

1. Failure to have policies and procedures for alarms (door, bed and chair) used in the CAH for patient safety, refer to C-271.

2. Failure to have a system in place for routinely checking bed and chair alarms functionality prior to patient use and during patient use, refer to C-271, C-294.

3. Failure to have a system in place for routine maintenance of alarms, refer to C-271, C-294.

4. Failure to have a system in place for shift to shift reporting of pertinent information on patients' care, refer to C-294.

5. Failure to have a system in place for orientation of Agency Staff on CAH's routines and policies and procedures, refer to C-271, C-294.

6. Failure to have a system in place to provide documentation of Agency Staff and CAH's Staff's understanding of the alarms systems used for patient's safety, refer to C-271, C-294.

7. Failure to have all doors secured to prevent an acute care patient from wandering out of the hospital unattended.

8. Failure to develop and/or keep current the safety nursing care plan for patients at risk, refer to C-298.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure a patients safety from falls, injuries and elopement.

Based on a review of the Critical Access Hospital's (CAH) policy/procedures and staff interviews, the CAH failed to ensure appropriate written Policies and Procedures were in place to guide staff in providing for patient's safety.

The CAH identified a census of 9 acute care patients. (1 patient moderate fall risk and 5 patients on high fall risk)

Failure to provide Policies and Procedures ensuring the testing, maintenance and staff's understanding of all patient safety devices could and did result in an acute care patient leaving the CAH unattended into 23 degree winter weather and died.

Findings included:

1. Review of the CAH's Nursing Policy and Procedure Manual lacked policies and procedures for the following:
a. Patient Safety alarms (door, bed and chair) used in the CAH.
b. System in place for routine checking patient safety alarms functionality prior to and during patient use.
c. System in place for routine maintenance of patient safety alarms.
d. System in place for shift to shift reporting of pertinent information on patient's care.
e. System in place for orientation of Agency Staff on CAH's routines, policies and procedures.
f. System in place to provide documentation of Agency Staff and CAH's Staff understands the patient safety alarms systems used.

2. a. During an interview on 1/20/10 at 4:30 PM the Director of Nursing stated the Bio Med checks done routinely to the patient beds do not include checking the patient safety alarms. The DON provided the electrical safety inspection form for the electric bed from room 275 identified with the number 4879. The inspection form confirmed the lacked of maintenance checks for patient safety alarms attached to the bed by maintenance.

b. During an interview on 1/21/10 at 4:00 PM the Director of Nursing confirmed the lack of policies/procedures and stated, CAH staff are developing policies/procedures for all types of patient safety alarms will include the maintenance and checking the functionality of patient safety alarms, orientation needs for Agency Staff, pertinent information of patient care related during shift to shift report and documentation of demonstration of all patient safety alarms systems used in the hospital are being created at this time.

c. During an interview on 1/19/10 at 4:40 PM, Staff G CNA (certified nursing assistant) stated the hospital did not provide orientation to the policies/ procedures, hospital routines or hospital patient safety alarm systems since employment March or April 2009.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the safety of a patient, who left the CAH unobserved and unattended, into 23 degree winter weather and expired.

I. Based on review of the Critical Access Hospital (CAH) policies/procedures, Bed Exit System (alarm on bed) documentation, medical record, observation, staff interviews, the CAH failed to have a system in place to ensure: testing and routine maintenance of patient safety alarms (door, bed and chair) functions prior to and during patient use. The patient safety alarms are used for prevent patient falls, injuries and elopements.

On January 17, 2010 the discovery of a body near the out building of the CAH, revealed to be an 88 year old acute care male patient who left the CAH unobserved and unattended. The patient's body was discovered in 23 degree weather on the CAH property following a search by police and staff.The patient resided in the hospital's acute care area while the family discussed an admission to the long-term care unit.
The hospital failed to ensure the safety devices performed correctly for a patient with family reported confusion, nursing assessed as high fall risk, and Physician admitted with change in mental status related to a subdural hematoma due to a fall.

The CAH identified a census of 9 acute care patients (1-moderate fall risk, 5-high fall risk), concern for Patient #1.

Failure to ensure the patient safety with properly functioning safety devices resulted in a patient ' s ability to leave the CAH unobserved and unattended into 23 degree winter weather and expire.

Findings included:

1. Review of the CAH's Nursing Policy and Procedure Manual lacked policies and procedures for the following:
a. Safety alarms (door, bed and chair) used in the CAH for patient safety.
b. System in place for routine checking alarms functionality prior to and during patient use.
c. System in place for routine maintenance of alarms.
During an interview on 1/21/10 at 4:00 PM the Director of Nursing confirmed the lack of policies/procedures and stated policies/procedures for all types of safety alarms to include the maintenance and checking the functionality of the alarms-prior and during patient usage.

2. Observation of the Bed Exit System (BES) for the bed assigned to Patient #1 in room 275 and review of paper provided of the Bed Exit System (BES) revealed the system is designed to help reduce patient falls and the serious consequences that can result.
a. Two sensor strips alert the staff if the patient exits the bed....
b. The BES is intended to be used with an overall fall prevention program to enhance patient safety and protection.
c. When the Bed Exit System is activated, it sounds a warning signal placed through the nurse call system, if the patient exits the bed...
During an interview on 1/20/10 at 4:30 PM, the Director of Nursing (DON) stated the CAH lacked the manufacture manual for the Bed Exit System (BES) used by Patient #1. The DON provided a copy of page 21 from the manual faxed to the facility by the manufacture.

3. Patient #1's medical Record review:
a. A review of Patient #1's Medical Record revealed an Emergency Room (ER) visit on 1/12/10 at 6:15 PM due to a fall on Thursday and struck back of his head. On Saturday family began to notice some confusion. Today daughter reports patient was unable to collect BS (blood Sugar) because he couldn't remember how. Patient was incontinent of both stool and urine today.
Pain level: patient denies pain, patient alert times 3 (person, place, time)
Behavior: Cooperative, Anxious and Confused
6:38 PM Blood Sugar level: 59 mg/dl - orange juice with extra sugar given
8:10 PM Blood Sugar level: 109 mg/dl
8:55 PM Neurosurgeon consulted
8:58 PM Patient resting quietly in bed, complains of (c/o) pressure 1 (scale of 0-no pain - 10 worse pain ever) in head with any movement. Physician notified
CT scan of head-blood sugars low on arrival. [Patient] says insulin dose was changed recently. [Patient] has no focal signs and no pain. CT [scan] reviewed by neurosurgeon. Patient wants to go home. Daughter can stay with [patient]. Physician will follow patient in office.
Clinical impression/diagnosis: Subdural Hematoma, Hypoglycemia

CT scan exam without contrast report dated 1/12/10 noted:
Indication for Exam: Confusion, fell and hit back of head, Dizzy when getting up, Patient sates it doesn't feel right.
Conclusion:
Acute subdural hematoma overlying the right cerebral hemisphere with small subdural hematoma also seen overlying the right tentorium cerebelli medial left frontal lobe.

Discharged Home with written and verbal instructions given to daughter, verbalized understanding. Patient's daughter given discharge instructions and prescription for Dilantin 100 mg sent home with patient. 100 mg Dilantin tab sent home with patient for initial dose at home in AM.

b. A review of Patient #1's Medical Record revealed a second Emergency Room (ER) visit on 1/14/10 at 1:10 PM due to unresponsive episode, mental status changes.
Grandson reports patient was sitting on edge of bed and would not respond to him. Patient had just gotten out of bed. Family report this is very abnormal for patient. Diagnosed with subdural hematoma 2 days ago, Patient to see neurosurgeon tomorrow at 11:30AM. Patient complains of right sided headache if moving head-no pain when resting.
1:51 PM CT scan ordered - results of head CT-no changes - CVA 1 week old
2:50 PM Physician talking with daughter discussing plan of care
ED (Emergency Department) Timing, reason, intervention and results: Patient continues to have significant head pain with movement. Spoke with neurology who agreed with observation and admission.
Clinical Impression Diagnosis: Altered Mental Status, S/P (Status Post) CVA and Headache
Physician orders on 1/14/10 at 3:30: Admit to Acute Care with admitting diagnosis: Altered Mental Status S/P subdural Hematoma.

c. A review of Patient #1's Medical Record revealed admitted into acute care on 1/14/10 at 3:55 PM from the ER due to unresponsive episode, mental status changes.
Resuscitation Orders: Will not attempt signed by daughter 1/14/10 at 4:16 PM
Initial interview on 1/14/10 at 3:44 PM
Chief Complaint:
Patient presented to emergency dept following an episode of unresponsiveness at home. Patient was seen in ED on 1/12/10 and diagnosed with a subdural subarachnoid bleed. Per neurosurgeon, patient sent home and to follow up with them on Friday. Patient was found unresponsive by grandson today. Patient continues to complain of pressure like pain in head with movement and sharp pains periodically
Home medications included: ASA 81 mg daily and Plavix 75 mg daily
Sleep/Rest Pattern: ...At this time Patient feels sleepy with recent diagnosis. This is a change from before.

Fall risk- History of falling
Fallen in last 3 months - more then one diagnosis - Has IV or other equipment
Weak gait, stooped, steps short - forget limits, overestimates ability
Score 45
High fall risk level 45-60, Implement high risk fall precautions, Inform therapy of high fall risk level
Injury risk: Patient over age 85, Patient on blood thinner {Patient on Plavix and ASA}. Evaluated need for high fall risk

Care Plan dated 1/14/10
Cognitive loss/Alternations in thought process related to a Bleed in the Brain
CAT scan, family reports confused at times
Interventions: use safety equipment as needed ie bed alarm, personal alarm
High Risk for Injury/Falls related to age, unsteady
Interventions: Use gait belt for ambulation

Patient Progress noted:
Blood glucose dated 1/15/10
6:19 AM 66 mg/dl orange juice provided
6:34 AM 70 mg/dl orange juice provided
6:49 AM 89 mg/dl no intervention provided
1/15/10
12:07 AM Patient c/o large sharp rolling pain to right side of head that started at 11:00 PM and ended at 11:45 PM. Patient stated pain started again
1:30 AM Patient states pain is better than it was but is now a pulsing med size ache to the right side of his head
2:30 AM Physician notified of Patient's c/o sudden onset severe right sided sharp pain in head. Neuro intact, ordered APAP (acetaminophen-Tylenol) and to call physician back if no relief with APAP
9:04 AM ASA and Plavix given as ordered
9:20 AM Discharged per wheel chair with grandson, plans at this time to return to Hospitality Care for a couple of days, assist to car.

Patient Progress Notes for this acute hospital stay lacked implementation of the care plan intervention for safety equipment ie patient safety alarms as per CAH policy.

Discharge Summary:
88 year old diabetic patient experienced a fall on 1/7/10 and presented at ER on 1/14/10 after grandson stating that he was unable to arouse him for 5 minutes from sleep. CT on 1/12/10 demonstrated evidence of an acute subdural hematoma in the right side and subarachnoid hemorrhage overlying the left temporal lobe.
A full neuro and physical exam found no neurological deficits at this time. Discussed concern for patient to be home alone unsupervised over the weekend. Spoke with daughter and patient agreed to admit to hospitality auspice (support). Patient in agreement with this and wanted to ensure that we kept a good eye on the sequela from his falls recently. Patient will discharge into hospitality on 1/15/10 which is Friday...
Will keep an eye on patient and will see him on Monday

d. A review of Patient #1's Medical Record revealed an admission into hospitality care on 1/15/10 at 1:11 PM from the acute care for respite, physician order to continue home medications.
Initial Interview 1/15/10 at 3:15 PM
Chief complaint:
Patient presented to emergency dept following a episode of unresponsiveness at home. Patient was seen in ED on 1/12/10 and was diagnosed with a subdural subarachnoid bleed. Per neurosurgeon patient sent home and to follow up with them on Friday. Patient found unresponsive by grandson today. Patient continues to complain of pressure like pain in head with movement and sharp pains periodically.
[Patient] returns from appointment with neurologist.
Home medications included: ASA 81 mg daily and Plavix 75 mg daily
Sleep/Rest Pattern: ...At this time Patient feels sleepy with recent diagnosis. This is a change from before.

Fall risk assessment on 1/15/10 at 3:25 PM, Patient #1 assessed as a high fall risk due to prior fall at home, has IV, weak gait, stooped, steps short, forgets limits, and overestimates ability. Patient #1's injury risk noted, "Patient over age 85, Patient on blood thinner (Plavix and ASA). Evaluated need for high fall risk..."

Care Plan dated 1/15/10
Cognitive loss/Alternations in thought process related to a Bleed in the Brain
CAT scan, family reports confused at times
Interventions: use safety equipment as needed ie bed alarm, personal alarm
High Risk for Injury/Falls related to age, unsteady
Interventions: Use gait belt for ambulation

Patient Progress notes
1/15/10 from Physician admit order at 8:10 AM to 4:50 PM Patient #1 ' s medical record lacked documented evidence for the implementation of the safety devices high fall risk patients as per CAH policy.

4:50 PM noted, "...when entered room patient states "I feel [fell] on the floor and got up myself." Patient was sitting in chair. State he was trying to get up and I did not wish to bother the nurses. [I] explained that he should put his call light on and always ask for help. Small quarter size scrap noted on right knee. Right knee cleaned and band-aide applied. Chair alarm placed under patient and patient states he will ask for assistance when getting up."

Nursing documented chair alarm and bed alarm during routine checks for 1/15/10 after the Patient ' s fall at 4:50 PM.

1/16/10
12:30 PM Pain assessment noted an acute large generalized head pain as ache, intermittent: Patient states "it comes and goes depending on how I am sitting or moving", sharp. Intervention: PRN med given, assist to position to comfort emotional support provided.

6:24 PM Pain assessment noted an acute med generalized head, right sided jaw/facial pain from head as ache, intermittent, radiating. Intervention: Emotional support provided
6:26 PM Fall risk assessment: remained on high fall risk

Nursing notes document chair alarm and bed alarm during routine checks for 1/16/10.

1/17/10
2:30 AM Bed alarm on

3:40 AM
Went into patient ' s room to do vitals and assessment, Patient #1 was not in the room. This nurse searched solarium and nearby patients rooms. When unable to find [Patient #1], went to nurses ' station and notified Registered Nurse (RN) and Agency Certified Nurse Aide (CNA). We started looking in all the rooms and bathrooms, utility rooms, closets in acute care. We went down the stairs and the elevator and looked in the lobby and all the open doors on first floor. I called the RN in the Long Term Care (LTC) to see if the patient had gone down there. She said they hadn't seen him and her and the LTC CNA started helping look for him. The Agency CNA drove her car around the block to see if the patient was outside. At 4:05 AM the sheriff ' s office was notified.

7:18 AM
Iowa Donor Network referral made. Not a candidate per representative

11:20 AM
Mortician here to collect body, body sealed in body bag and zipper sealed with tag by mortician with this nurse as witness, family leaving.

1/17/10 at 4:20 AM ER admit:
Unresponsive, Patient found outside unresponsive, cold, no vital signs. [Patient #1 ' s body was] brought into ER per stretcher. Temp 23.6 Centigrade (74.48 degree Fahrenheit) (Normal body temperature 98.6 F) Warm blankets applied. no respirations, no heart rate-heart monitor shows asystole. temp 23.6 C. Rectal bleeding noted, skin cold, cyanotic, Physician pronounced at 4:35 AM.
Temp was taken by temporal scanner, unable to obtain rectal temp.
4:50 AM Physician notified
4:50 AM Physician progress note: Called to pronounce patient dead. Was found outside hospital, RN reports last seen about 2:30 AM, patient was asleep
PEAN (physical exam) Pulseless, apneic, pronounced at 4:35 AM
4:55 AM Daughter was notified
5:37 AM Physician notified
7:50 AM Funeral home contacted per Physician
EXPIRED: Time of death 4:35 AM

Addendum to ER record
1/18/10 at 10:20 AM
Supplement to my previous progress note:
This patient appeared to be dead when I arrived in the ED about 4:30 AM on 1/17/10. I was advised when notified by phone that patient was a "DNR" and I in fact already knew that because I recognized him from his recent ED visit, at which time we had discussed his wishes briefly.
No resuscitation efforts were underway when I arrived or should they have been given the patients wishes.
That would include attempts to warm the patient.

Preliminary Report of investigation by Medical Examiner:
1/17/10
3:25 AM last seen alive
4:35 AM Death pronounced
4:10 AM found
4:05 AM Police notified
5:37 AM M.E. (Medical Examiner) notified
Probable cause of death:
1. Hypothermia
2. Due to Exposure
Contributing factor: Brain Bleed
Narrative summary of circumstances surrounding Death:
Decedent was a self-pay hospitality patient at GCMH and was last seen by nurse's aide approximate 3:25 AM. He was found to be MIA (Missing in Action) at 3:45 AM. A search was mounted and he was found by a nurse outside lying in a face down in a fetal kneeling position along side some equipment next to the boiler room building. He was brought into the ER where he was examined by the ER doc who found him to be pulseless and apneic. The Physician ascertained the patient was a DNR and chose to attempt no formal resuscitation.
4. During an interview on 1/19/10 at 2:40 PM, Staff C, Registered Nurse (RN) Manager of acute care in-patients, stated Sunday AM (1/17/10) she received a phone call informing a patient had wandered out of the acute care setting to the outside and had died. Staff C stated on arrival to the CAH on Monday, she checked the bed in room 275 and found the alarms non-functioning. Staff C confirmed Patient #1's room #275 during his stay in acute care.
Staff C stated when she checked the bed alarm on 275, the side rail lacked the red light indicating the activation of the alarm, although the call light on the wall in the patient ' s room lighted up-the call light above room 275's door in the hall did not light up and the alarm did not sound.
Staff C lacked knowledge of any policies/procedures for testing patient safety devices prior to or during patient usage.
Staff C lacked knowledge of when/if the alarm had ever been check for functioning or any maintenance schedules for patient safety alarms.
Staff C acknowledged the door leading down 21 steps to the main floor lacked a door alarm.
Staff C acknowledged the elevator leading to the main floor lacked an alarm or any device to let staff know of the elevator usage.
Staff C stated the call light must be turned off manually in the patient's room. When the patient safety alarm work properly, if the Patient gets up from the bed, the alarm sounds/call light lights up in hall above door and at the nursing station; the staff must enter the Patient's room to manually turn off the call light and alarm.

5. During an interview on 1/19/10 at 4:40 PM Staff G Agency CNA stated at 12:30 AM Patient #1 observed in the doorway to room 275. Patient ambulated from the bed to the doorway. Staff G said the patient ' s call light was not on at that time and Staff G did not hear any alarms sounding at this time. Staff G cared for the patient and Patient #1 returned to bed. Staff G notified the nurse Patient #1 had gotten up at 12:30 AM.

6. During an interview on 1/20/10 at 9:35 AM with Staff H, RN stated Patient #1 under her nursing care on 1/16/10 from 7:00 PM until 7:00 AM. Staff H administered Patient #1 medication at 9:30 PM and assisted putting the patient to bed. Staff H turned on the patient safety alarm prior to putting the patient into bed. The alarm light came on but the alarm did not sound. The sound part of the alarm did not function properly, but the call light part of the alarm still worked. Staff G said at 3:40 AM when going to assess Patient #1, the patient not observed in the bed of room 275 and the call light was not on.

II. Based on review of the Critical Access Hospital (CAH) policies/procedures, Bed Exit System (alarm on bed) documentation, personal files, and staff interviews, the CAH failed to have a system in place to ensure:
a) Shift to shift reporting of pertinent information on acute patient care
b) Orientation of Agency Staff on CAH's routine and policy/procedures prior to working with patients
c) Documentation of CAH staff and Agency staff understand alarm systems used for patient safety
d) Patient Care plans are developed, updated and implemented according to the current patients individualized needs (refer to tag 298)

The CAH failed to ensure the acute care staff reported pertinent patient care information during shift changes.
The hospital failed to orientate Agency Staff, prior to working with acute care patients, on the CAH ' s safety devices of how the devices are turned on/off, what the correct function of the devices and why a patient would have the safety devices in place.
The CAH failed to ensure acute care and agency staff knowledge of all safety devices with demonstration and documentation of safety alarm education.

The cumulative effect of lack of staff orientation and education on safety devices failed to ensure the safety of a hospitality patient (Patient #1) in the acute care setting, from leaving the CAH unobserved and unattended into 23 degree winter weather and expire.

The CAH identified a census of 9 acute care patients (1-moderate fall risk, 5-high fall risk) Concern for Patient #1

Findings included:

1. Review of the CAH's Nursing Policy and Procedure Manual lacked policies and procedures for the following:
a) Shift to shift reporting of pertinent information on patient care
b) Orientation of Agency Staff on CAH's routine and policy/procedures prior to working with patients
c) Documentation of CAH staff and Agency staff understand alarm systems used for patient safety
During an interview on 1/21/10 at 4:00 PM the Director of Nursing stated the CAH lacked policies/procedures for shift to shift report and were creating policy/procedures for shift to shift report to indicated all the pertinent information to be reported.
The DON stated the CAH lacked policies/procedures for orientation for Agency Staff prior to working with acute care patients, the creation of this policy/procedure to be completed today.
The DON stated the CAH lacked policies/procedures for CAH staff and Agency staff orientation and/or education to the CAH's acute care patient safety alarms. The DON stated, the acute care staff and Agency staff, prior to their next shift, are to be educated on the policies/procedures, demonstrate their knowledge of all types of safety alarms (bed/chair/door), and the documented evidence placed in their personal file.

During an interview on 1/19/10 at 4:40 PM Staff G stated a lack of training by the hospital for using patient alarms and received no orientation prior to working at the hospital and since employment with the hospital.

The cumulative effect of the lack of policies and procedure for staff guidance of care, lack of orientation to the patient safety alarms system, lack of orientation for Agency staff to the CAH's routine and polices, lack of a detailed pertinent patient information report and the lack of the replacing a patient safety alarm know to be faulty or report the faulty patient safety alarm resulted in the CAH ' s inability to ensure the safety of a hospitality patient, who left the CAH unobserved and unattended into 23 degree winter weather and expired.

I. Based on review of Critical Access Hospital (CAH) policies/procedures, open and closed medical records, and staff interviews, the CAH failed to develop and keep current the safety care plan for patients at risk in two of eight closed (Patients #2 and #3) patient medical records and 1 of 6 (Patient #4) open medical records reviewed. The CAH identified a census of 9 acute care in-patients (1 identified as moderate fall risk and 5 patients as high fall risk).

Failure to develop and/or maintain a current nursing care plan for each inpatient could prevent the care of patients to meet each of their individual needs.

Findings included:

A. A review of the CAH's Comprehensive Care Plans policy dated 3/05 noted the following:
1. A care plan will be initiated within 4 hours of admission by RN and shall be based on needs identified from the initial assessment findings.
2. The comprehensive care plan is designed to:
b. Incorporate risk factors associated with identified problems
3. The care plans shall be reviewed and updated daily and as needed with condition changes.

B. Medical Record review:
1. A review of Patient #2's closed medical record revealed an admit date of 1/1/10.
a. A fall risk assessment dated 1/1/10 noted Patient #2 to be a moderate risk for falls due to weak gait, uses ambulatory aids and has an IV. Injury risk noted patient over age 85, takes an aspirin a day.
b. Updated Fall/Injury Risk Assessments:
1/2/10 "Patient over age 85. If at risk, at least moderate fall risk. Patient moved to high fall risk."
1/3/10 "Patient fell about a month ago..., Patient remains on High Risk for falls".
c. A review of Patient #2's care plan lacked a plan of care for high fall risk.

2. A review of Patient #3's closed medical record revealed an admit date of 1/10/10.
a. A fall risk assessment dated 1/10/10 noted Patient #3 to be a high risk for falls due to impaired gait, poor balance, uses ambulatory aids, has an IV and mental status of overestimates ability.
b. Updated Fall/Injury Risk Assessments:
1/11/10 "Patient over age 85. Evaluate need for high fall risk. Patient moved to high fall risk."
1/12/10 "Patient over age 85. Evaluate need for high fall risk. Patient moved to high fall risk."
c. A review of Patient #3's care plan lacked a plan of care for high fall risk.

3. A review of Patient #4's open medical record revealed an admit date of 1/19/10.
a. A Physician order dated 1/19/10: "Act[activity]: Fall Risk, Bedside Commode, with assist only.
b. A fall risk assessment dated 1/19/10 noted Patient #4 to be a moderate risk for falls due to fallen in last 3 months, weak gait, stooped, steps short, uses ambulatory aids, and has an IV.
b. Updated Fall/Injury Risk Assessments:
1/20/10 "Implement high risk fall precautions."
"Patient over age 85. Evaluate need for high fall risk. Patient moved to high fall risk."
c. A review of Patient #4's care plan lacked a plan of care for the physician ordered interventions of bedside commode and up with assist only and an updated plan of care for high fall risk as per their policy.

C. Interviews:
a. During an interview on 1/21/10 at 2:20 PM, Staff B Registered Nurse (RN) stated care plans are started on admit by admitting nurse. Care plans are reviewed daily and updated with change of conditions.
b. During an interview on 1/21/10 at 2:20 PM, Staff A, RN stated when a patient condition changes from moderate fall risk to high fall risk the care plan is to be updated. The care plan should have reflected the Physician order of the bedside commode and up with assist only.
c. During an interview on 1/19/10 at 4:40 PM, Staff G Agency CNA stated " no access to patient care plans " . Staff G not aware of where the patient care plans are located and does not have access to the nursing progress notes.


II. Based on review of CAH Patient Falls policy, medical record, observation, patient and staff interviews the CAH failed to implement and follow up on the effectiveness of the care plan interventions for patients at high risk in 2 of 6 (Patient #1 and #4).

Failure to implement interventions of the current nursing care plan for patients could result in falls with injuries or possible elopement.

Findings included:

1. A review of the Patient Falls policy dated 10/09 revealed the following:
a. "...The assessment is used to identify a patient's falls risk level and to implement the appropriate interventions to prevent falls."
b. "the nurse completing the initial (admission) fall risk screening is responsible for implementing the required interventions as well as developing an individualized plan of care for the moderate to high risk patient...."
c. High Risk: bed alarm, personal alarm and/or chair alarm

2. A review of Patient #4's open medical record revealed an admit date of 1/19/10.
a. A physician history and physical dated 1/19/10 noted, "...presented to the ER [emergency Room] today after having been transported by ambulance...report states she had fallen to the floor and she conveys to me that she in-fact fell twice at her house...Physical Examination: This is an alert and oriented female who was actually standing when I entered the room and headed for the bathroom..."
b. An admission to acute care Physician order dated 1/19/10 at 1:21: "Act[activity]: Fall Risk, Bedside Commode, with assist only.
c. A fall risk assessment dated 1/19/10 noted Patient #4 to be a moderate risk for falls due to fallen in last 3 months, weak gait, stooped, steps short, uses ambulatory aids, and has an IV.
d. An updated fall risk assessment dated 1/20/10 "Patient over age 85. Evaluate need for high fall risk. Patient moved to high fall risk."

e. The surveyor's observation of Patient #4 on 1/21/10 at 3:05 PM revealed a lack of a patient "Fall Risk" wrist band as per the policy for high fall risk patients or a commode next to the bed as per physician order.

f. Interviews:
1) During an interview on 1/21/10 at 2:13 PM, Patient #4 stated the staff assisted to the bathroom since yesterday (1/20/10) and doesn't remember a bedside commode ever being in the room. The Patient stated, "In the beginning I did get up on my own, now I have to have help, this started yesterday".
2) During an interview on 1/21/10 at 2:20 PM, Staff A, RN confirmed she admitted Patient #4 but did not remember the Physician order for the commode and up with assist only. Staff A stated the care plan should have reflected the Physician order of the bedside commode and up with assist only.

3. A review of Patient #1's closed medical record revealed an admit date of 1/14/10 at 3:55 PM. into acute care.
a. Physician orders dated 1/14/10 at 3:30 PM noted admit to acute care, diagnosis as Altered Mental Status, due to subdural Hematoma.
b. Initial interview dated 1/14/10 at 3:44 PM noted a fall risk assessment, Patient #1 assessed as a high fall risk due to prior fall at home, has IV, weak gait, stooped, steps short, forgets limits, and overestimates ability. Patient #1's injury risk noted, "Patient over age 85, Patient on blood thinner (Plavix and ASA). Evaluated need for high fall risk..."
c. Care plan dated 1/14/10 noted
...cognitive loss/alternation in thought process related to bleed in brain...family reports confused at times. Interventions included...use safety equipment as needed i.e. bed alarm, personal alarm.
... High risk for injury/falls related to age, unsteady... Interventions included...use gait belt for ambulation.
d. Patient Progress notes dated 1/14/10 lacked documentation the implementations of safety devices for patients assess at high fall risk as per CAH policy.

Patient #1's Physician orders on 1/15/10 at 8:10 AM noted admit to Hospitality care.
a. Fall risk assessment on 1/15/10 at 3:25 PM, Patient #1 assessed as a high fall risk due to prior fall at home, has IV, weak gait, stooped, steps short, forgets limits, and overestimates ability. Patient #1's injury risk noted, "Patient over age 85, Patient on blood thinner (Plavix and ASA). Evaluated need for high fall risk..."
b. Patient Progress notes on 1/15/10 from Physician admit order at 8:10 AM to 4:50 PM lacked documentation the implementation of safety devices for patients assess at high fall risk as per CAH policy.
c. Patient Progress note on 1/15/10 at 4:50 PM noted, "...when entered room patient states "I feel [fell] on the floor and got up myself." Patient was sitting in chair. State he was trying to get up and I did not wish to bother the nurses. Explained that he should put his call light on and always ask for help. Small quarter size scrape noted on right knee. Right knee cleaned and band-aide applied. Chair alarm placed under patient and patient states he will ask for assistance when getting up."

d. During an interview on 1/21/10 at 2:20 PM, Staff A, Registered Nurse (RN) confirmed she had admitted Patient #1. Staff A remembered asking the nurse coming on to place alarms on the bed and chair for Patient #1. Staff A confirmed the medical record lacked documentation of safety alarms implementation until after Patient #1 stated he fell. Staff A stated it was her responsibility as the admitting nurse to place the alarms. Staff A stated, the alarms should have been placed before he fell due to the high fall risk assessment.

The cumulative effect of these systemic care plan problems resulted in the CAH ' s inability to ensure the safety of the patients in the acute care setting from falls, injuries due to falls and elopement.