HospitalInspections.org

Based on findings from document review, medical record (MR) review, interview, and observation, in 1 of 14 MRs (Patient A) nursing staff did not complete a fall risk assessment. In 2 of 14 MRs (Patient's B and C) documented fall prevention interventions were not implemented. Also, the hospital's policy and procedure (P&P) regarding patient fall assessments did not reflect current practice as observed. These lapses may have placed patients at an increased risk to fall.

Findings include:

-- The hospital P&P titled "Risk/Fall Program" last revised 10/2012, indicated that a fall risk assessment is completed on all patients upon admission, every shift, upon transfer or change in condition.

-- However, per MR review, Patient A's MR did not contain documentation of a fall risk assessment being performed on admission or during hospital stay.

-- During interview on 9/22/15 at 11:30 am with Staff #1, he/she indicated fall risk assessments are not done on obstetrical patients.

-- The hospital P&P titled "Risk/Fall Program" last revised 10/2012, indicated the patients identified as a high risk to fall will have a yellow identification bracelet, be provided slip resistant yellow socks, a yellow star will be placed on the patient assignment board at the nurses station and on the board outside the patient's room.

-- Per MR review, Patient B was identified as a high risk to fall. The MR identified the following fall prevention interventions: a call bell within reach, slip resistant yellow socks and a yellow fall bracelet. However, during observation on 9/22/15 at 2:15 pm, Patient B did not have his call bell within reach, a yellow identification bracelet, and was not wearing yellow slip resistant socks. Additionally, a yellow star was not on the assignment board outside his room.

-- During interview with Staff #2 on 9/22/15 at 2:15 pm, he/she indicated that when a patient is a high fall risk, in addition to interventions listed in the above P&P, a pull tab on the board outside of the patient's rooms is pulled out revealing a symbol (i.e., a patient falling) identifying the patient as a high risk to fall. Staff #2 acknowledged that Patient B did not have all fall interventions in place including pull tab symbol for risk to fall pulled over.

-- Also, per MR review Patient C, was identified as a high risk to fall. The MR identified the following fall prevention interventions: slip resistant yellow socks and a yellow fall bracelet. However, per observation on 9/23/15 at 3:00 pm with Staff #3, Patient C did not have a yellow identification bracelet and was not wearing yellow slip resistant socks. Additionally, there was no yellow star outside his room, and the pull tab symbol to identify Patient C as a high risk to fall had not been pulled. Staff #3 acknowledged these findings.

-- During interview with Staff #4 on 9/22/15 at 3:00 pm, he/she confirmed the use of the boards outside the patient rooms that contains a pull tab revealing a symbol (i.e., a patient falling) identifying the patient as a high risk to fall and acknowledged the Fall P&P did not reflect current practice.

Based on findings from medical record (MR) review, document review and interview, staff did not adequately perform and document pain assessment or reassessment in 1 of 5 MR. Additionally, the hospital pain management P&P was not consistent with generally accepted standards of nursing care.

Findings include:

-- Per review of Patient D's MR, nursing administered oral opioid pain medication on 9/21/15 at 8:03 pm due to a pain level of 7/10 (0-10 scale, 10 worst pain) for lower left quadrant abdominal pain. No re-assessment of Patient D's pain level was documented. Patient D was next medicated for pain on 9/22/15 at 6:37 am, over 10 hours later. There is no documentation that his pain level was assessed at that time and no reassessment of his pain after medication administration.

-- Per review of hospital's P&P titled "Pain Management," last revised 2/2011, healthcare providers choose the pain scale that adapts best to their patients. All scales are based on 0-10. Patient self report using 0-10 scale will be documented. Re-assessment of pain must be done after each pharmacological or non-pharmacological intervention recommended within one hour.

The P&P lacked instruction to staff to document re-assessment of pain after pharmacological or non-pharmacological intervention.

-- During interview with Staff #5 on 9/22/15 at 11:50 am, the above findings were acknowledged.

Based on findings from medical record (MR) review, facility document review and interview, in 6 of 8 MRs reviewed (Patients E, F, G, H, I, and J) verbal/telephone orders were not cosigned by the provider within 48 hours as required by the facility's policy and procedure (P&P).

Findings include:

-- Per MR review, Patient E's MR contained a physician telephone order dated 9/18/15 at 5:35 pm to discontinue Dilaudid, Benadryl 50 mg intravenous every 6 hours as needed, and 1:1 supervision. This order remained unsigned 5 days later on 9/23/15.

Patient F's MR contained a physician telephone order dated 9/20/15 at 4:20 pm for Tylenol 650 mg every 6 hours and Topamax 100 mg. This order remained unsigned 3 days later on 9/23/15.

The same lack of authentication of verbal/telephone orders within 48 hours was found in the MRs of Patients G, H, I, and J.

-- The facility's P&P titled "Physicians Orders," last revised 1/2012, stated "Verbal orders must be authenticated by the ordering physician within 48 hours."

-- During interview on 9/22/15 with Staff #6 at 11:35 am, the above findings were acknowledged.