HospitalInspections.org

Based upon interviews and record reviews, the facility failed to ensure nursing staff are available to provide bedside care for 2 (two) out of 10 sampled patients (SP) #1, and 2.

The findings include:

1.On 07/03/14, Sampled Patient #1 medical record showed the patient had surgical procedure, and was transferred to the Intensive Care Unit (ICU) in stable condition. The nursing note documented on 07/06/14 at 03:10 am, the pt (patient) was found on floor. The patient stated she was on her way to bathroom when she lost her balance. The patient was asked why she did not use the call bell. The Pt stated that she thought she could make it. The patient was found to have a hematoma on the back of her head.

In an interview with the Risk Manager on 08/04/14 at 12:45 pm, she stated that the patient fell and had a subdural hematoma. At 1:15 pm on 08/04/14, the Risk Manager stated that there was only one CNA (Certified Nursing Assistant) on the floor that night. The Risk Manager further stated that later on, SP#1 stated that she called and no one answered the call light.
On 08/04/14 at 5:27 pm, in a telephone interview the Director of 8th Floor Unit stated that after the incident (SP#1 fall), I had a fall huddle with the staff. We reviewed the specifics and discussed the fact that even though the patient was alert and oriented and the nurse instructed the patient to use the call light, the bed alarm was not on because the patient was not identified as a fall risk.

On 08/04/14 at 6:10 pm, the Chief Nursing Officer stated that the Fall Prevention policy has not been revised because the policy is a system policy and is not specific only to this facility.

2.In an interview with SP#2 on 08/04/14 at 11:00 am, the patient ' s family member, stated that they have had some issues since they've been on this floor, getting help (from the staff) to get out of bed. The family member stated that she called three times and one hour later the CNA (Certified Nurse Assistant) came. She was told that the CNA was with someone else. The family member also stated, "They told me to call the number, and when I push the button to the Nurse's Station, it takes forever for them to attend to our needs. I went out in the hallway 6 (six) times and asked for help. I called and told them I needed help. The Charge Nurse came after all those calls."
3. Review of the staffing assignments on 8 south showed only one CNA on the night shift (7pm to 7am) on 07/30/14 with a census of 25 patients.