HospitalInspections.org

Based on document review, observation and interview, the facility failed to ensure that nursing staff accurately completed fall assessments for 4 of 4 patients (#12, #17, #18, #19), failed to ensure that nursing staff implemented fall interventions for 5 of 8 ( #5, #7, #11, #15, #16) patients once they were identified as a fall risk and failed to ensure that nursing staff follow policy and procedure for dating Intravenous (IV) tubing lines for 5 of 6 patients (#4, #5, #6,# 8, #12), resulting in the potential for patient injury and poor patient outcomes for all patients treated at the facility. A total universe of 19 patients' medical records were reviewed. Findings include:

On 03/02/2015 at 1100 review of the medical record for patient #12 and on 03/03/2015 between 0900 and 1145 review of medical records for patient's #17-19 revealed the following:

Patient #12 was admitted on 02/28/2015 and was placed into the Intensive Care Unit. The patient had a history of Multiple Sclerosis (MS). On 03/01/2015 at 2247 the patient's fall risk score was documented as 5 (3 point for poly pharmacy and 2 points for mobility deficit/weakness.) A score greater than 4 identified the patient as at risk for falls. Then on 03/01/2015 at 2300 after the patient sustained a fall, the fall risk score was documented as a 7. The patient was given 4 points for a fall and 3 points for poly pharmacy.

In an interview on 03/02/2015 at 1110 with staff M, when queried as to why the 2 points for the mobility deficit/weakness was no longer identified on the fall assessment, staff M stated, "It should be." When queried if he would still identify the patient as having mobility deficit/weakness, he stated, "Yes, because of her MS."

On 03/03/2015 at 0900 during review of a medical record for patient #17 revealed that the patient had been admitted on 11/09/2014 from a nursing home. The nursing assessment completed on the patient on 11/09/2014 identified as "needing assistance" for ambulation, transferring, eating, bathing, grooming, and elimination. The patient was identified as a high risk for fall and was given a total score of 13. The score was based on-3 point for receiving a central nervous system (CNS) medication, 2 points for being over the age of 65, 2 point for altered elimination, 2 point for cognitive deficit, 2 points for sensory deficit and 2 point for mobility deficit. Then on 11/10/2014 at 2300 the next fall assessment score was 9. The patient was given a score of 2 points for greater than 65 years of age, 3 points for the CNS medication, 2 points for sensory deficit and 3 points were added for poly pharmacy. The nurse completing the assessment had dropped off the 2 points for mobility deficit, 2 points for altered elimination, 2 points for cognitive deficit and 2 points for mobility deficit.

In an interview with staff D on 03/03/2015 at 0925, when queried as to why these would no longer be on the fall assessment, he stated, "I am not sure why they didn't count them since the patient was identified on the nursing assessment as needing assistance."

On 03/03/2015 at 0930, review of a second medical record for patient #17 from 11/20/2014 revealed a fall assessment completed 11/21/2014 at 0200 and the patient was scored an 8. The patient was given 2 points for cognitive deficit, 2 points for depression, 2 points for age greater than 65 and 2 points for altered elimination. The patient sustained a fall on 11/21/2014 at approximately 0227 (un-witnessed fall). On 11/23/2014 at 2030 the patient's fall risk score went from an 8 to an 11. The fall risk were then identified the the same 4 risk plus 3 points for poly pharmacy. The nursing staff never included any points on the fall risk score for the fall that had occurred on 11/21/2014.

In an interview with staff D on 03/03/2015 at 1040, he confirmed the findings and stated, "I don't know why she was not given 4 points after the fall."

In another interview with staff A (Director of Quality) on 03/03/2015 at 1045, when queried about the inconsistencies in the fall assessments, she stated, "They should be documenting every risk that the patient has on the assessment. I can see where we have an area for improvement here."

Review of patient #18's record reviewed on 03/03/2014 at 1050 revealed that the patient was admitted on 01/26/2015. The fall assessment was completed on 01/26/2015 at 0641 with a fall risk score of 10. The patient was given 4 points for a history of fall, 3 points for poly pharmacy, 2 points for mobility and 1 point for being male. The score did not contain points for the patient being over 65 years of age. When the re-assessment was completed at 1057 score was then changed to 12 when staff added 2 points for the patient being over 65. Then at 1530 the patient was scored 18 points for fall risk when the staff added 3 points for cardiac medication and 3 point for central nervous system (CNS) medication. Review of the patient's medication record at the time of admission identified both the CNS and cardiac medications.

In an interview with staff D on 03/03/2015 at 1110, staff D confirmed the findings and stated, "It looks like they all do this (mis-score)."

On 03/03/2015 at 1115, during review of the medical record for patient #19 revealed that a fall assessment was completed on 02/10/2015 at 2330 and the patient was scored a 15 for fall risk. The patient was given 4 points for a history of fall, 3 points for poly pharmacy, 2 points for age over 65, 2 points for altered elimination, 2 points for cognitive deficit and 2 points for mobility deficit. Then on 02/12/2015 at 1406 the fall risk score was decreased to an 11 when staff dropped off the altered elimination and cognitive deficit. Then on 02/14/2015 at 0747 the score was increased to 13 when staff re-added the altered elimination. Then on 02/14/2015 at 2142 the score was back up to 15 when the staff re-added the cognitive deficit.

In an interview with staff D on 03/03/2015 at 1130, staff D again confirmed the findings.

On 03/02/2015 between 1130 and 1300 during tour of the intensive care unit, the 4th floor and the 2nd floor, patients were reviewed for implementation of fall precautions/interventions for patients identified as being at risk for falls.

On 03/02/2015 at 1135 review of the 2nd and 4th floors revealed that outside of some of the patient rooms was a picture of a big yellow spot. When staff F was queried as to what the yellow spot represented, she stated, "It is a sun. It identifies that the patient is a fall risk." When queried as to what else is done, staff F replied, "We put on the yellow gripper socks and the yellow arm band." When staff was again queried as to if the sun was for bed one or two, staff F stated, "That is a good question."

On 03/02/2015 at 1145 in an interview with patient #5, who was identified as at risk for fall, when queried if he had on a pair of yellow socks and a yellow arm band, he stated, "No." Observation of the patient's arms and feet confirmed that no yellow socks or arm band were present.

Observation and interview of patient #7 on 03/02/2015 at 1150 also revealed the yellow sun outside of the patient's door but no yellow socks or arm band on the patient.

On 03/02/2015 at 1200, revealed the yellow sun outside of the private room for patient #11, however the patient did not have a yellow arm band or yellow socks.

On 03/02/2015 at 1210 during an observation of patient #15, the patient's wife queried why I was looking at her husband. Explained that patients were being looked at who were at increased risk for fall and to see if staff had initiated interventions. It was explained that the patient was being reviewed for yellow sun outside the door, yellow socks and a yellow arm band. The patient's wife stated, "Oh, they just came in and put them on him a few minutes ago. He has been here since the 24 th." The patient's wife was referring to the 24 th of February.

On 03/02/2015 at 1230, a yellow sun was noted to be on the door for patient #16 was observed sitting in a chair in the hall way. The patient did not have on the yellow gripper socks that identified her as a fall risk. The patient's yellow arm band was not visible since the patient had a long sleeve sweater on.

In an interview with staff N, she confirmed the findings for all the patients. When queried how often staff get education regarding fall assessments and interventions, she stated, "At least annually and in this case more often."

On 03/02/2015 at 1600, review of the facility's policy titled, "Inpatient Fall Assessment and Prevention, #EHR044, Last Revision Date & Key Change(s): "21 JUN 13", stated, "Policy: To provide a process to identify, plan, implement and evaluate the care for adult patients who are at risk for falling. Inpatient High Fall Risk Interventions, Applies to all inpatients identified as high fall risk (CPM {company that offers facilities evidenced based care programs} Fall Risk Assessment Score greater than or equal to 4) and is the responsibility of the RN (Registered Nurse). Place Fall Risk signage within the patient's care area clearly visible to all Health care Team members. Apply a Yellow ArmBand to the patient's arm and yellow socks to the patient's feet."

On 03/02/2015 between 1100 and 1200 during tour and observations on the ICU unit, 2nd and 4th floors the following observations were made:

At 1100, patient #12 was noted to have 3 intravenous (IV) tubing lines. The IV tubings did not contain dates as to when they were hung. When staff N was queried as to what is the facility's policy for labeling tubing, she stated, "It is supposed to be labeled with a orange sticker that we have when it is put up." She confirmed at this time that the tubing was not dated.

At 1140, patient #4 was observed with a bottle of "Nitro" (heart medicine) hanging and no date on the tubing.

At 1145, patient #5 had both a primary IV and an IV piggyback ( an additional bag of IV fluid that is lined in with the primary bag) neither of the IV were observed with dated stickers.

At 1147, patient #6 was observed with two undated IV lines.
When the nurse (staff O) was queried as to why the IV lines were not dated, she stated, "Were supposed to have these orange stickers but I couldn't find any this morning."

At 1155, patient #8 was observed with two undated IV lines.

In an interview with the Chief Nursing Officer on 03/03/2015 at 1200, when queried if she was aware of the above issues with fall assessments not being accurate, fall interventions/precautions not being implemented after patient's are being identified as a fall risk and the IV tubings not being dated, she stated, "I am very aware of them now. We will take what ever steps we need to to correct these issues."

On 03/02/2015 at 1700, during review of the facility's policy titled, "IV Therapy: Peripheral Sites, #510.00", Current Approval Date: "July 2013", stated "D. Tubing, 7. All tubing shall be labeled with the date and time it was hung."

Based on document review, observation and interview, the facility failed to ensure that nursing staff accurately completed fall assessments for 4 of 4 patients (#12, #17, #18, #19), failed to ensure that nursing staff implemented fall interventions for 5 of 8 ( #5, #7, #11, #15, #16) patients once they were identified as a fall risk and failed to ensure that nursing staff follow policy and procedure for dating Intravenous (IV) tubing lines for 5 of 6 patients (#4, #5, #6,# 8, #12), resulting in the potential for patient injury and poor patient outcomes for all patients treated at the facility. A total universe of 19 patients' medical records were reviewed. Findings include:

On 03/02/2015 at 1100 review of the medical record for patient #12 and on 03/03/2015 between 0900 and 1145 review of medical records for patient's #17-19 revealed the following:

Patient #12 was admitted on 02/28/2015 and was placed into the Intensive Care Unit. The patient had a history of Multiple Sclerosis (MS). On 03/01/2015 at 2247 the patient's fall risk score was documented as 5 (3 point for poly pharmacy and 2 points for mobility deficit/weakness.) A score greater than 4 identified the patient as at risk for falls. Then on 03/01/2015 at 2300 after the patient sustained a fall, the fall risk score was documented as a 7. The patient was given 4 points for a fall and 3 points for poly pharmacy.

In an interview on 03/02/2015 at 1110 with staff M, when queried as to why the 2 points for the mobility deficit/weakness was no longer identified on the fall assessment, staff M stated, "It should be." When queried if he would still identify the patient as having mobility deficit/weakness, he stated, "Yes, because of her MS."

On 03/03/2015 at 0900 during review of a medical record for patient #17 revealed that the patient had been admitted on 11/09/2014 from a nursing home. The nursing assessment completed on the patient on 11/09/2014 identified as "needing assistance" for ambulation, transferring, eating, bathing, grooming, and elimination. The patient was identified as a high risk for fall and was given a total score of 13. The score was based on-3 point for receiving a central nervous system (CNS) medication, 2 points for being over the age of 65, 2 point for altered elimination, 2 point for cognitive deficit, 2 points for sensory deficit and 2 point for mobility deficit. Then on 11/10/2014 at 2300 the next fall assessment score was 9. The patient was given a score of 2 points for greater than 65 years of age, 3 points for the CNS medication, 2 points for sensory deficit and 3 points were added for poly pharmacy. The nurse completing the assessment had dropped off the 2 points for mobility deficit, 2 points for altered elimination, 2 points for cognitive deficit and 2 points for mobility deficit.

In an interview with staff D on 03/03/2015 at 0925, when queried as to why these would no longer be on the fall assessment, he stated, "I am not sure why they didn't count them since the patient was identified on the nursing assessment as needing assistance."

On 03/03/2015 at 0930, review of a second medical record for patient #17 from 11/20/2014 revealed a fall assessment completed 11/21/2014 at 0200 and the patient was scored an 8. The patient was given 2 points for cognitive deficit, 2 points for depression, 2 points for age greater than 65 and 2 points for altered elimination. The patient sustained a fall on 11/21/2014 at approximately 0227 (un-witnessed fall). On 11/23/2014 at 2030 the patient's fall risk score went from an 8 to an 11. The fall risk were then identified the the same 4 risk plus 3 points for poly pharmacy. The nursing staff never included any points on the fall risk score for the fall that had occurred on 11/21/2014.

In an interview with staff D on 03/03/2015 at 1040, he confirmed the findings and stated, "I don't know why she was not given 4 points after the fall."

In another interview with staff A (Director of Quality) on 03/03/2015 at 1045, when queried about the inconsistencies in the fall assessments, she stated, "They should be documenting every risk that the patient has on the assessment. I can see where we have an area for improvement here."

Review of patient #18's record reviewed on 03/03/2014 at 1050 revealed that the patient was admitted on 01/26/2015. The fall assessment was completed on 01/26/2015 at 0641 with a fall risk score of 10. The patient was given 4 points for a history of fall, 3 points for poly pharmacy, 2 points for mobility and 1 point for being male. The score did not contain points for the patient being over 65 years of age. When the re-assessment was completed at 1057 score was then changed to 12 when staff added 2 points for the patient being over 65. Then at 1530 the patient was scored 18 points for fall risk when the staff added 3 points for cardiac medication and 3 point for central nervous system (CNS) medication. Review of the patient's medication record at the time of admission identified both the CNS and cardiac medications.

In an interview with staff D on 03/03/2015 at 1110, staff D confirmed the findings and stated, "It looks like they all do this (mis-score)."

On 03/03/2015 at 1115, during review of the medical record for patient #19 revealed that a fall assessment was completed on 02/10/2015 at 2330 and the patient was scored a 15 for fall risk. The patient was given 4 points for a history of fall, 3 points for poly pharmacy, 2 points for age over 65, 2 points for altered elimination, 2 points for cognitive deficit and 2 points for mobility deficit. Then on 02/12/2015 at 1406 the fall risk score was decreased to an 11 when staff dropped off the altered elimination and cognitive deficit. Then on 02/14/2015 at 0747 the score was increased to 13 when staff re-added the altered elimination. Then on 02/14/2015 at 2142 the score was back up to 15 when the staff re-added the cognitive deficit.

In an interview with staff D on 03/03/2015 at 1130, staff D again confirmed the findings.

On 03/02/2015 between 1130 and 1300 during tour of the intensive care unit, the 4th floor and the 2nd floor, patients were reviewed for implementation of fall precautions/interventions for patients identified as being at risk for falls.

On 03/02/2015 at 1135 review of the 2nd and 4th floors revealed that outside of some of the patient rooms was a picture of a big yellow spot. When staff F was queried as to what the yellow spot represented, she stated, "It is a sun. It identifies that the patient is a fall risk." When queried as to what else is done, staff F replied, "We put on the yellow gripper socks and the yellow arm band." When staff was again queried as to if the sun was for bed one or two, staff F stated, "That is a good question."

On 03/02/2015 at 1145 in an interview with patient #5, who was identified as at risk for fall, when queried if he had on a pair of yellow socks and a yellow arm band, he stated, "No." Observation of the patient's arms and feet confirmed that no yellow socks or arm band were present.

Observation and interview of patient #7 on 03/02/2015 at 1150 also revealed the yellow sun outside of the patient's door but no yellow socks or arm band on the patient.

On 03/02/2015 at 1200, revealed the yellow sun outside of the private room for patient #11, however the patient did not have a yellow arm band or yellow socks.

On 03/02/2015 at 1210 during an observation of patient #15, the patient's wife queried why I was looking at her husband. Explained that patients were being looked at who were at increased risk for fall and to see if staff had initiated interventions. It was explained that the patient was being reviewed for yellow sun outside the door, yellow socks and a yellow arm band. The patient's wife stated, "Oh, they just came in and put them on him a few minutes ago. He has been here since the 24 th." The patient's wife was referring to the 24 th of February.

On 03/02/2015 at 1230, a yellow sun was noted to be on the door for patient #16 was observed sitting in a chair in the hall way. The patient did not have on the yellow gripper socks that identified her as a fall risk. The patient's yellow arm band was not visible since the patient had a long sleeve sweater on.

In an interview with staff N, she confirmed the findings for all the patients. When queried how often staff get education regarding fall assessments and interventions, she stated, "At least annually and in this case more often."

On 03/02/2015 at 1600, review of the facility's policy titled, "Inpatient Fall Assessment and Prevention, #EHR044, Last Revision Date & Key Change(s): "21 JUN 13", stated, "Policy: To provide a process to identify, plan, implement and evaluate the care for adult patients who are at risk for falling. Inpatient High Fall Risk Interventions, Applies to all inpatients identified as high fall risk (CPM {company that offers facilities evidenced based care programs} Fall Risk Assessment Score greater than or equal to 4) and is the responsibility of the RN (Registered Nurse). Place Fall Risk signage within the patient's care area clearly visible to all Health care Team members. Apply a Yellow ArmBand to the patient's arm and yellow socks to the patient's feet."

On 03/02/2015 between 1100 and 1200 during tour and observations on the ICU unit, 2nd and 4th floors the following observations were made:

At 1100, patient #12 was noted to have 3 intravenous (IV) tubing lines. The IV tubings did not contain dates as to when they were hung. When staff N was queried as to what is the facility's policy for labeling tubing, she stated, "It is supposed to be labeled with a orange sticker that we have when it is put up." She confirmed at this time that the tubing was not dated.

At 1140, patient #4 was observed with a bottle of "Nitro" (heart medicine) hanging and no date on the tubing.

At 1145, patient #5 had both a primary IV and an IV piggyback ( an additional bag of IV fluid that is lined in with the primary bag) neither of the IV were observed with dated stickers.

At 1147, patient #6 was observed with two undated IV lines.
When the nurse (staff O) was queried as to why the IV lines were not dated, she stated, "Were supposed to have these orange stickers but I couldn't find any this morning."

At 1155, patient #8 was observed with two undated IV lines.

In an interview with the Chief Nursing Officer on 03/03/2015 at 1200, when queried if she was aware of the above issues with fall assessments not being accurate, fall interventions/precautions not being implemented after patient's are being identified as a fall risk and the IV tubings not being dated, she stated, "I am very aware of them now. We will take what ever steps we need to to correct these issues."

On 03/02/2015 at 1700, during review of the facility's policy titled, "IV Therapy: Peripheral Sites, #510.00", Current Approval Date: "July 2013", stated "D. Tubing, 7. All tubing shall be labeled with the date and time it was hung."