HospitalInspections.org

31048

Based on record reviews and interviews, the hospital: 1) failed to ensure the RN supervised and evaluated the nursing care for each patient for 2 (#1, #2) of 5 patients reviewed for nursing supervision; 2) failed to ensure the ED nurse followed hospital policy and protocol on fall risk assessment for 2 (#3, #4) of 5 patients reviewed for fall risk assessments; and 3) failed to ensure the nursing staff followed hospital policies and procedures for documenting verbal orders for restraints for 1 (#1) of 2 (#1, #5) patients reviewed for restraints in a total sample of 5.

Findings:

1) failed to ensure the RN supervised and evaluated the nursing care for each patient for 2 (#1, #2) of 5 patients reviewed for nursing supervision

Patient #1
Review of Patient #1's ED record revealed he was a 67 year-old male who was brought to the ED from a nursing home for complaints of nausea, vomiting and dehydration. Patient #1 had a history of Liver Cirrhosis, COPD, Hypertension, Hypothyroidism, Venous Stasis, Gallbladder Disease, and Depression, and a history of smoking. It was documented Patient #1 was not ambulatory due to his health status and weak condition, and utilized a wheelchair for mobility. Patient #1 was assessed as a fall risk with the following documented: "Fall risk assessment completed per protocol. Risk factors identified include patient age greater than 65 years. Fall interventions initiated. Patient placed on stretcher. Side rails up x's 2. Brakes on; Bed in low position. Patient visible from nurses' station and identified as a fall risk by chart flagged. Call light in reach of patient. Instructed not to get up without assistance." The triage RN documented the patient's status as "alert." Documentation of the ED physician's examination revealed the patient was alert and oriented times three.

Review of the policy "Vital Signs on Emergency Center Patients" presented by S4ED as current, revealed in part: Procedure: 2. Vital signs are to be taken before discharge as follows: ESI level 1 or 2, every 30 minutes prior to ED exit; ESI level 3, every 1 hour prior to ED exit; and ESI level 4 or 5, Triage vital signs may be used if total ED visit is less than 4 hours and are normal. Ongoing Vital Signs: 3. ESI level 3, every 1-2 hours or as indicated, but not longer than every 4 hours."

Review of the patient's medical record revealed the patient's vital signs were assessed on 05/04/16 at 10:58 p.m., and were within normal limits. The patient had been evaluated and treated by the ED physician, and there was an entry documented by the RN on 05/05/16 at 2:30 a.m. the physician had written discharge orders, but there was no documented evidence the RN had an actual encounter with the patient at that time, and the vital signs and assessment data areas did not contain any assessment documentation. Patient #1 was awaiting transportation back to his nursing home. An entry dated 05/05/16 at 3:50 a.m. revealed, in part, "heard noise from patient's room. Patient found on floor. Lacerated noted to right temporal area."

Review of Patient #1's ED record revealed vital signs were assessed on 05/04/16 at 10:58 p.m., and there was no documented evidence in the ED medical record that the patient or the patient's vital signs had been assessed on 05/05/16 at 3:00 a.m. as per policy and procedure.

Review of a document containing the incident investigation and summary revealed, in part, Patient #1's ED room was in front of the nurses' station, and the patient had the side rails up; however, there was not a full view of Patient #1's ED room because the curtain surrounding the ED bed was not completely drawn back. (Name of the ED RN) said it appeared that the patient had scooted down to the end of the stretcher and attempted to get off of the stretcher.

In an interview on 07/12/16 at 3:35 p.m., S4ED reviewed the ED medical record, and confirmed there was no further documentation that the side rails were up after the documentation on 05/04/16 at 10:45 a.m.

In an interview on 07/13/16 at 10:40 a.m., S4ED confirmed there was no policy and procedure for how often patients are to be reassessed when they are discharged and awaiting transportation out of the ED, but S4ED presented and reviewed the policy and procedures for vital signs assessment in the ED and the patient's medical record with surveyor, and she verified 4 hours of time had lapsed since the patient had a vital signs assessment, and she confirmed there was no documented evidence in the ED medical record the RN had assessed, evaluated, or checked on Patient #1 between the hours of 1:35 a.m. and the time Patient #1 fell off of the stretcher. S4ED confirmed this was not in compliance with the policy and procedure for vital signs assessment in the ED, and Patient #1 should have been assessed and evaluated by the RN prior to the time of the incident on 05/05/16.

Patient #2
The patient arrived to the ED (Emergency Department) on 03/26/16 at 5:32 a.m. by EMT (Emergency Medical Transport) from a NH (Nursing Home). The patient's date of birth was 03/07/24, and he was 92 years old. The patient reportedly fell out of bed at the NH. The patient was triaged at 5:32 a.m. by S10RN in the ED. The patient's chief complaint was "a fall out of bed." The patient's medical history included, in part: a history of falls, Chronic Obstructive Pulmonary Disease, a prior left Total Hip Arthroplasty from a prior hip fracture, Emphysema, and a restricted right extremity. A Fall Risk Assessment was initiated and completed by S10RN with identifying factors to include: medications, age greater than 65 years, history of falls, and impaired mobility and cognition. S10RN initiated fall interventions to include in part: side rails up x's 2, brakes on bed, bed in lowest position, and patient placed on stretcher and visible from nursing station. The patient had an x-ray and a CT scan and later had been determined by the ED physician at 7:40 a.m. that the patient could return to the NH. The patient was awaiting transport back to the NH as documented by S11RN. S11RN further documented that the call light was within reach of the patient, the side rails were up x's 2, the bed was in the lowest position, and the patient was told not to get out of bed without assistance. At 8:05 a.m. S11RN's documentation revealed that the patient was found on the floor at the bedside, the patient was examined by the ED physician and placed back on the stretcher. The patient had a skin tear to the left arm and the patient reported pain to the left hip. The patient was admitted to the hospital for further treatment/evaluation of a left hip dislocation/fracture and an Incident Report was completed. A review of the Incident Report revealed the patient was in a sitting position on the edge of bed (at patient request) to use a urinal. S11RN went behind the curtain while the patient used the urinal, and she heard the patient slip to the floor. S11RN pulled the curtain back and the patient was on the floor. The patient was examined by the ED physician and was returned to the stretcher and new orders were written for the patient to be admitted for further treatment/evaluation.

In an interview on 07/13/16 at 8:40 a.m. with S13RN, she indicated that S11RN was in orientation at the time of the incident and that she (S13RN) was her preceptor. S13RN indicated that S11RN was presently out of town and unavailable for interview. S13RN indicated that she (S13RN) was right outside of the patient's room at the time of the incident. S13RN indicated that since the patient was assessed as a fall risk and fall interventions had been initiated, the patient probably should not have been allowed to sit on the side of the bed unassisted to use the urinal and other options should have been explored by the nurses. She indicated that S11RN probably felt the patient would be able to sit on the edge of bed to urinate with the nurse right behind the curtain.

2) failed to ensure that the ED nurse followed hospital policy and protocol on fall risk assessments for 2 (#3, #4) of 5 patients reviewed for fall risk assessments

A review of the Fall Risk Assessment Protocol for the ED revealed, in part: Risk Factors Identified: severe pain; postural hypotension; nausea; dizziness; vertigo; patient medications; over age 65; history of falling; fainting; impairment in mobility, sensation, sight, hearing, cognition. Interventions Needed: stretcher; wheelchair; side rails up times 1 or 2; bed low position; brakes on; visible from the nurses' station; Identified patient as a "fall risk" on band, chart, room. At Bedside: family; companion; sitter; staff; child held by parent. Call Light in Reach of: patient; parent; family; companion. Patient Instructed: Don't get up without assistance.
Patient #3
The patient arrived to the ED on 03/07/16 at 10:21 p.m. by private vehicle with family. The patient's date of birth was 06/16/62 and she was 53 years old. The patient was triaged at 10:51 p.m. by S14RN in the ED. The patient's chief complaint was "abdominal pain, nausea and vomiting, diarrhea and dizziness, and the patient was pale and shaking." The patient's medical history included in part: anxiety, sinus problems, chronic headaches, lupus, and depression. A Fall Risk Assessment was initiated by S14RN at 11:09 p.m. with no risks noted and no identifying factors noted, and therefore, no fall interventions were initiated. The patient was seen by the ED physician and medications were ordered and given for the admitting symptoms, and the patient was discharged home on 03/08/16 at 1:27 a.m. in stable condition. A further review of the nurse's notes revealed documentation by S14RN that the patient had a fall while in the ED, during triage with S14RN. The nurse's notes revealed the patient was found on the floor by the triage RN, S14RN, after she returned to the triage area with a manual blood pressure cuff. The documentation revealed the patient was assessed and brought to a treatment room on a stretcher.
In an interview on 07/12/16 at 4:10 p.m. with S14RN, she indicated that she was having difficulty getting the automatic blood pressure cuff to capture the patient's blood pressure. She indicated that the patient was anxious and not able to keep from shaking, and she (S14RN) felt that was why the automatic blood pressure machine was having problems capturing the blood pressure. She further indicated that the patient's blood pressure may also have been too low to capture on the machine. S14RN indicated that the patient's husband was in the triage room with the patient, and the patient was sitting in a wheelchair when she left to retrieve the manual blood pressure cuff. S14RN indicated that when she returned to the triage room, the patient was lying on the floor, and the husband said the patient just fell out of the chair. S14RN indicated that she reported the incident to the ED charge nurse and the ED Director, and she was told to complete an Incident Report. S14RN indicated that the patient probably should have been identified as a Fall Risk with Fall Risk interventions in place due to her complaint of nausea and dizziness. The Incident Report revealed that the patient was not identified as a Fall Risk.

Patient #4
The patient was transferred to the ED on 05/30/16 at 7:38 p.m. by EMT from another hospital for treatment/evaluation of a cervical neck fracture. The patient was in a cervical collar. The patient's date of birth was 10/28/23 and he was 92 years old. The patient had reportedly had a fall while walking and tripped and landed on his head at home. The patient was triaged at 7:29 p.m. by S16RN in the ED. The patient's chief complaint was "a fall while walking." The patient's medical history included in part: Hypertension, Gout, Depression, and Anxiety. A review of the ED record revealed no evidence that a Fall Risk Assessment was initiated or completed by S16RN or any other nurse. A further review of the patient's ED record revealed that the patient was found on the floor by a family member when they returned to the patient's ED room. An Incident Report was completed. A review of the Incident Report revealed the patient was in the bed with the side rails up x's 2, the bed was in the lowest position, and had family at the bedside most of the time. A further review revealed the family had stepped out, and when the family member returned, the patient's door was closed and family said they thought that staff was inside the room so they did not enter the room right away. When they (family) entered the room, they found the patient on the floor. The patient was examined by the ED physician and had a laceration to his left elbow which was repaired by the ED physician, and he had a skin tear which was dressed. The patient was admitted to the hospital for treatment/evaluation of his chief diagnosis upon admit (cervical fracture). The Incident Report further revealed poor communication with family, and the patient should have been in a direct line of sight by staff with the patient's door open.
.
In an interview on 07/13/16 at 9:50 a.m. with S4ED, ED Clinical Manager, she indicated that the Fall Risk Assessment screen shot used in the ED identified risk factors from a list of risk factors, and the interventions were initiated based upon the risk factors. The triage RNs checked the appropriate risk factors and checked the interventions that were appropriate for each individual patient. She indicated that a Fall Risk Assessment was not initiated for Patient #4 by S16RN as per hospital policy and protocol. She indicated that Fall Risk Assessments were usually completed by the triage nurse because the documenting of a Fall Risk Assessment was under the triage portion of the ED record. An interview was unable to be conducted with S16RN. S4ED indicated that S16RN was not presently employed at the hospital, and was working out of town. S4ED indicated that any nurse can initiate a Fall Risk Assessment and interventions. S4ED indicated that the Fall Risk Assessment, staff communication with family, and Incident Report documentation was in-serviced with the ED staff at the June staff meeting.

3) failed to ensure the nursing staff followed hospital policies and procedures for documenting verbal orders for restraints for 1 (#1) of 2 (#1, #5) patients reviewed for restraints

Patient #1
Review of Patient #1's record revealed he was a 67 year-old male who was brought to the ED from a nursing home on 05/04/16 for complaints of nausea, vomiting and dehydration. He had a history of Liver Cirrhosis, COPD, Hypertension, Hypothyroidism, Venous Stasis, Gallbladder Disease, Depression, and a history of smoking. Further review revealed Patient #1 was transferred from the Intensive Care Unit to the 7th floor on 05/06/16. Patient #1 was admitted to the 7th floor unit in soft wrist restraints because he was "Confused or disoriented" and "Attempting to dislodge his medical line/device."

Review of a Policy and procedure entitled "Non-Violent Restraints" presented as current, revealed, in part: "Philosophy: . . . As a part of this commitment, we feel that all patients have the right to appropriate assessment and management of restraint use in the event that restraint use is deemed a medical necessity. C. Orders for restraint must include . . . 4) Reason or clinical justification for restraint."

Review of the "Restraint Order-Medical/Surgical" documented dated 05/08/16 at 9:30 a.m. revealed, in part, under the section "Clinical Reason for Restraint" included "Confused or Disoriented" checked off, but did not include the clinical reason for restraint "Attempting to dislodge medical line/device" checked off. Review of the nurse's notes dated 05/08/16 revealed Patient #1 was oriented to self only, and he had periods of confusion and disorientation. On 05/08/16 at 9:30 a.m., Patient #1 still had an intravenous access in place via a saline lock ordered by the physician, and he had current physician orders for medications to be administered intravenously until he was discharged from the hospital on 05/09/16.

In an interview on 07/12/16 at 2:00 p.m., S8RN indicated the soft-wrist restraints for Patient #1 were utilized because he was confused and disoriented, and he attempted to pick at and potentially pull out his intravenous access. S8RN reviewed the "Restraint Order-Medical/ Surgical" document dated 05/08/16 at 9:30 a.m., and confirmed she neglected to document (by checking off) the clinical reason for the restraints to include "Attempting to dislodge medical line/device," and she should have checked off that clinical justification on the restraint order form because it applied to Patient #1's status.

In an interview on 07/13/16 at 9:15 a.m., S7Director reviewed the physician's order sheet for restraints dated 05/08/16 at 9:30 a.m. and the patient's medical record, and S7Director confirmed the clinical reason for the restraints was identified as "confused or disoriented," and S8RN did not accurately document the clinical reason for restraints by forgetting to check off "Attempting to dislodge medical line/device," and S8RN should have checked off that clinical reason because it was appropriate and applied to Patient #1's status.