HospitalInspections.org

Based on interview and record review, the facility failed to ensure a Registered Nurse evaluated the nursing care for each patient as evidenced by:
1) failing to document an assessment in a patient's medical record until 8 hours and 20 minutes after a fall and failing to ensure a STAT x-ray was taken before 9 hours and 11 minutes for 1 (#2) of 10 (#1- #10) patients sampled;
2) failing to ensure a patient's medical record contained accurate documentation of the patient's power of attorney's request to not release medical information to any person other than herself for 1 (#2) of 10 (#1-#10) patients sampled.
Findings:
1) Failing to document an assessment in a patient's medical record until 8 hours and 20 minutes after a fall and failing to ensure a STAT x-ray was taken before 9 hours and 11 minutes.
Review of the medical record for Patient #2 revealed he was a 91 year old male admitted to the hospital on 8/1/14 with the admitting diagnosis of Depressive Disorder. His other diagnosis included Anemia, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Chronic Pain and Dementia.
Review of the hospital Incident Report Log for August 2014 revealed an Incident/ Accident Report for Patient #2 dated 8/3/14 at 12:40 a.m. The report listed the incident as, "Per pt. (patient) he was walking to the bathroom and fell. States he did not hit his head. C/O (complains of) R (right) hip pain. X-ray ordered."

Review of the medical record for Patient #2 revealed he had a physician's order dated 8/3/14 at 12:45 a.m. for a Hip x-ray right hip STAT (immediately).

Review of an x-ray report for Patient #2 from Company "A" revealed he had not received an x-ray of his right hip until 9:56 a.m. on 8/3/14.

A review was made of the medical record for Patient #2 with S3DirInternalAuditing and S4Administrator. After the review, they confirmed there was no documentation in the medical record of an assessment of Patient #2 after his fall on 8/3/14 at 12:40 a.m. or a description of the incident by any staff member until 8/3/14 at 9:00 a.m. by S6NP (eight hours and 20 minutes after the fall occurred). Further review revealed no documentation in Patient #2's medical record of the fall on the Close Observation Sheet where 15 minute visual assessments had been documented by a mental health technician. Additional review also revealed no documentation for the delay in Patient #2 receiving the x-ray of his hip (9 hours and 11 minutes after the STAT x-ray order had been written).

In an interview on 9/2/14 at 2:40 p.m. with S3DirInternalAuditing, she verified there should have been an assessment by the nurse in the medical record immediately after Patient #2's fall on 8/3/14 and a note about the fall itself. She said S7PA was actually at the hospital when the fall occurred and wrote the order for the x-ray to be taken. S3DirInternalAuditing said S7PA should have also written a note and an assessment of Patient #2 after his fall. S3DirInternalAuditing also confirmed the STAT x-ray should have been done within 2 hours and she did not have an explanation as to why it took over 9 hours. S3DirInternalAuditing said there was no policy for timeliness of an x-ray and the contract with the x-ray company did not specify how quickly they would respond to a STAT order. S3DirInternalAuditing said Company "A" did not want to commit to a time frame for response time.

In an interview on 9/2/14 at 2:45 p.m. with S4Administrator, she said there was a lack of assessment and documentation about Patient #2's fall on 8/3/14 by the mental health technician performing 15 minute visual assessments, the nursing staff and S7PA who was on the unit.

2) Failing to ensure a patient's medical record contained accurate documentation of the patient ' s power of attorney's request to not release information to any person other than herself.
Review of a court document for Patient #2 dated 11/25/09 revealed one of his daughters (Daughter #1) had been appointed his power of attorney (POA) to make decisions for him on various affairs including the following in part:
17. Medical Decisions: To make any and all medical decisions related to treatment of the physical and/or mental health of the Principal, including but not limited to consultation with and granting authorization to hospitals, doctors, nurses and other medical personnel to take appropriate action regarding the physical and/or mental health of the Principal. Said agent is authorized to make all decisions concerning Principal's medical care and treatment, including the right to decline same, and make any decisions required concerning any nursing home care. Agent is further authorized to see that the terms of any living will executed by the Principle are implemented.

Review of the document for Patient #2 titled Consent for Involvement in Treatment dated 8/1/14 at 5:15 p.m. revealed in part:
Family/Significant Other Consent and Authorization of Disclosure of Treatment- I authorize the organization to acknowledge my presence and to discuss my treatment with the individual(s) listed below. Further review revealed Daughter #1 was added to the list on 8/1/14 and designated as the POA. The other names on the list included Patient #2's son, Daughter #2, and a grandson which were all added on 8/13/14.
Review of the medical record for Patient #2 revealed no documentation of the Consent for Disclosure of treatment to be amended or rescinded. Further review revealed no documentation to withhold medical information from other family members by Daughter #1 who had the POA.
In an interview on 8/29/14 at 2:38 p.m. with S2RNCharge, she said Daughter #1 was the POA for Patient #2. S2RNCharge said Daughter #1 told her not to give any medical information to anyone else because of Patient #2's interdiction process (the legal process by which persons who are unable to make their own decisions receive a curator to make these decisions for them). S2RNCharge verified this request not to share information about Patient #2 had not been documented in his medical record.

In an interview on 8/29/14 at 3:15 p.m. with S1DON, she said the hospital policy for releasing information on patients was that the family member or friend of the patient had to have a secret code given out by the patient or power of attorney to access information. S1DON said on admission, the people listed on the Consent for Involvement and Treatment sheet could also receive information. S1DON said Daughter #1 was the power of attorney for Patient #2 and gave her siblings permission for visitation with Patient #2 and permission to receive general information only. S1DON said the request by Daughter #1 to not share information was not documented in the medical record and it was just communicated to staff by word of mouth.

In an interview on 9/2/14 at 9:10 a.m. with S4Administrator, she said she spent a lot of time with Daughter #1 who was power of attorney for Patient #2. S4Administrator said on 8/13/14, Patient #2's son tried to visit but was not listed as a visitor by the POA. S4Administrator said the staff called and asked Daughter #1 if Patient #2's son could visit. S4Administrator said Daughter #1 said yes, but only wanted the family members to visit and did not want them to receive information. S4Administrator said Daughter #1 allowed Daughter #2, Patient #2's son and Patient #2's grandson's names to be added to the Consent for Involvement in Treatment sheet on 8/13/14. S4Administrator verified the document contained a statement that authorized the hospital to discuss Patient #2's treatment with the persons listed on the document. S4Administrator also verified there was no written documentation in Patient #2's medical record to rescind this document or not to give information to family members. S4Administrator said the document listed that the family could receive information, but it was really being improperly used as a visitation sheet by the staff. S4Administrator verified all of the information about not disclosing information to family members had been verbal between staff and Daughter #1 and should have been documented in the medical record. S4Administrator said she agreed that there was a lack of documentation and review of the medical record alone made it appear the family listed on the Consent for Involvement in Treatment had permission to receive information about Patient #2.

Based on interview and record review, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by not including interventions for an identified problem of being a fall risk for 1 (#2) of 10 (#1-#10) patients sampled.
Findings:
Review of the hospital Policy titled Fall Assessments/Re-Assessment and Precautions revealed in part:
Policy: All patients will be assessed and identified for the potential of being at risk for falls upon admission and every 7 days and /or immediately after a fall if identified as moderate or high risk.
-If fall precautions are identified, High Risk for Falls Treatment Plan is initiated by RN.
-Fall Precautions-Interventions for Moderate Risk: Place yellow fall risk arm band on patient; Place fall precautions sign on patient chart; Fall precaution identified on observation form; Educate on fall prevention/precaution to patient; Patient placed on "Falling Star" program.
-Fall precautions-Interventions for High risk: All of moderate risk interventions; Bed alarm highly recommended for night time use (nursing decision is based on patient variables); Non-skid footwear

Review of the medical record for Patient #2 revealed he was a 91 year old male admitted to the hospital on 8/1/14 with the admitting diagnosis of Depressive Disorder. His other diagnosis included Anemia, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Chronic Pain and Dementia.
Review of the hospital document for Patient #2 titled Nursing Assessment revealed it had been completed on 8/1/14 at 1:45 p.m. Further review revealed Patient #2 had obtained a fall risk score of 16 which placed him at moderate risk (a score of 7-17 indicated a moderate risk for falls and a score above 17 was indicative of being high risk for falls).

Review of the document titled Multidisciplinary Integrated treatment Plan Problem List for Patient #2 revealed he had the following problems identified on 8/1/14:
1. Altered Mood r/t Depression and Anxiety;
2. Altered health maintenance r/t (related to) HTN (Hypertension), GERD (Gastroesophageal Reflux Disease), Aspiration, Dizziness, Chronic Pain;
3. Risk for falls. No interventions had been selected for the problem of being a fall risk.

In an interview on 9/2/14 at 2:40 p.m. with S3DirInternalAuditing, she verified Patient #2 ' s care plan for the problem identified as being a fall risk was incomplete because no interventions had been selected for the problem.

In an interview on 9/2/14 at 2:45 p.m. with S4Administrator, she verified Patient #2 ' s care plan for being a fall risk was incomplete because it lacked nursing interventions.