HospitalInspections.org

Based on review and interview the facility failed to:
1.) have a process in place for physician/practitioner to communicate when going on or off call.

2.) ensure patients with falls were assessed by a Physician or Nurse Practitioner during their medical exams to ensure there was no injuries.

3.) ensure nursing assessed, monitored, reported, and documented, patient falls and injuries, according to facilities policy and procedures in 3(1, 2, and 3) out of 5 (1-5) charts reviewed.


Patient #1
Review of patient #1's chart revealed he was admitted to the facility on 8/7/18 at 1730 (5:30PM) with a diagnosis of schizophrenic bipolar. He also has a diagnosis of hypertension, diabetes, and shortness of breath. Review of the chart revealed Patient #1 had an incident report dated 8/7/18 at 1930 (7:30PM). The report stated, "Pt ambulated to bathroom per staff stated, 'I blacked out' (states he has history of syncopal episodes and reports last one was 2 days ago.) pt hit head. Neuro's begun."

Review of Patient #1's Nursing Multi-Disciplinary Note dated 8/7/18 at 2031 (8:31PM) stated, "At 1930 this nurse was notified of pt on floor of bathroom. Staff Unable to obtain v/s while pt on floor. Staff assisted pt to chair and was able to obtain v/s at this time. Pt stated he went to bathroom and 'blacked out'. Reports hx of syncopal episodes. Dr. ___ (staff #5) notified @ 2026. Pts family was called at 2022 but no answer. left message to call. No apparent injuries noted. Pt hit head. Neuro's begun and continue at this time. Will continue to monitor for delay injury."

Review of Patient #1's physician progress notes and History and Physical was reviewed. The Nurse Practitioner (NP) saw the patient on the following day 8/8/18 and performed a History and Physical exam. There was no mention in the exam concerning the patients fall and head injury on 8/7/18. The psychiatrist also saw Patient #1 on 8/8/18 and there was no documentation that the physician was aware of the fall the day before or documented any findings.

An Interview with staff #1 and #2 was conducted in the morning of 1/8/19. Staff #1 and #2 confirmed there was no documentation by the practitioners of the patient's accident on 8/7/18. Staff #1 stated that she was not aware how the practitioners communicated with one another concerning patient issues. Staff #1 reported that the psychiatrist and the NP talk daily but there was no written communication in how one physician reports off to another one on call or from day to day. Staff #2 reported that the nurse should be reporting to the physician when physician rounds are in progress. Staff #2 confirmed there was no process in place to make sure the physician was updated from the physician on call or if the nurses were communicating to the physicians during patient rounding.


Patient #2
Patient #2 was an 85 y/o male patient that was admitted to the facility on 8/3/18. Patient #2 had a diagnosis of Schizoaffective disorder, Bipolar type. Patient had a diagnosis of diabetes, hypertension, depression, and arrhythmia.
Review of the nurse's notes dated 8/10/18 at 0230 (2:30AM) stated, "Pt was standing in TV room visiting with another resident when he lost balance and fell backwards hitting his head. Pt was assessed from head to toe with small bruise to the back of his head noted. Neuro checks initiated. Dr. ___ (psychiatrist staff #4) notified and pt.'s son ___ (sons name) will continue to monitor 0630 (6:30AM) Call placed to ___ (NP staff # 5). Pt c/o rt shoulder pain with movement. Medicated with Tylenol 325mg 2 tabs po awaiting new orders for poss x-ray series of rt shoulder."

Review of the Daily Nurses Note for 8/10/18 revealed there was no check mark by the "Neuro checks" under nursing interventions. Only one set of vital signs were found on the note with no time. There was no documentation in the chart of any neurological checks.

Review of the policy and procedure Neurological Assessment policy #AS-11 stated the responsible nurse will:

"5. Guidelines for completing Neurological Assessment Checklist: Document the date and time of each assessment o Upon initial finding of potential head injury/neurological trauma, initiate Neurological Assessment Checklist Neurological Assessment Checklist will be completed as follows: Upon initial finding then, Every 15 minutes after initial assessment x4 then, Every 30 minutes x 2 then, Every 60 minutes x 2 then, Once per shift for 3 days unless otherwise ordered by physician/Licensed Independent Practitioner (LIP).

6. All Neurological Assessments should include vital signs which will be documented in conjunction with the medical record.
*Any change in condition and/or abnormal Neurological Assessment findings must be reported to physician/Licensed Independent Practitioner (LIP)."

Review of the physician notes (staff #4) revealed there was a physician note dated 8/10/18 at 1:00PM. There was no documentation of the patients fall earlier that morning. There was no documentation that the NP or nurse on duty had communicated to the physician concerning the patient's shoulder pain. There was no documentation of neurological checks performed.

Review of the Multi-Disciplinary notes dated 8/13/18 at 1505 (3:05PM) revealed the social worker documented, "Pt alert and oriented to person. States he doesn't feel well is breathing gruffly (sic) attempts to motion his head hurts. Met with pt to check pt progress and complete MMSE. Pt unable to complete some of MMSE, is very distracted by not feeling well. Notified nurse LVN of pt current state, continue to monitor."

There was no documentation found of nursing documentation concerning the social worker's assessment and findings. There was no documentation that the physician was notified or concerning the fall on 8/10/18.

Review of Patient #2's Medication Administration Record (MAR) revealed patient #2 was complaining of pain on 8/13/18 at 1930 and was administered Tylenol 650mg. Review of the nurse's notes dated 8/10/18 at 2230 (10:30PM) revealed the patient was having no pain and there was no documentation that he had pain. Review of the MAR revealed the patient was medicated for "pain" with Tylenol 650mg. There was no documentation of what type of pain or where the pain was. There was no documentation of the physician being notified of the continuing pain. Patient #2 was administered Tylenol 650mg by mouth on the following dates and times:
8/13/18 at 1930 (7:30PM)
8/14/18 at 1825 (6:25PM)
8/15/18 at 1800 (6:00PM)
8/16/18 at 1600 (4:00PM)
8/17/18 at 1840 (6:40PM)
8/19/18 at 2200 (10:00PM).


Patient #3
Patient #3 was a 71 y/o male patient that was admitted to the facility on 12/17/18. Patient #3 was admitted with Dementia and Alzheimer's disease.

Review of Patient #3's incident report revealed a fall on 12/18/18 at 1920 (7:20PM). The incident stated the patient was "confused." The report stated, "patient found on floor sitting on bottom stated boots slipped and lost his balance. Scuffed marks on floor near patient. Denies hitting head. denies pain." (sic) The NP was notified of the fall on 12/18/18 at 2030 (8:30PM). There was no documentation that the nurse did a head to toe assessment, reassessment of the "Fall Risk Assessment", or ambulatory safety measures put in affect.

Review of the "Physician Progress Note" dated 12/19/18 at 11:05AM revealed no documentation of Patient #3's fall or outcome. There was no documentation found that the NP "on call" notified the primary physician of the patients fall or if the physician was aware the fall had occurred.