HospitalInspections.org

Based on interviews, review of medical record and/or incident documentation for 4 of 6 patients (Patients 2, 3, 4, and 6), and review of CAH P&Ps, it was determined the CAH failed to ensure patient care and services were provided in accordance with fully implemented P&Ps:
* Responses to and investigations of patient incidents were not conducted, and when conducted were not clear, complete and thorough in all cases to ensure similar incidents did not recur.

Findings include:

1.a. The P&P titled "Unusual Occurrence Reports Policy," dated approved 09/26/2019 was reviewed and included:
* "Unusual Occurrences shall be reported to promote a culture of safety and continual improvement, to improve patient safety and to reduce liability to the organization."
* "An unusual occurrence includes, but is not limited to, any of the following ... a near miss event that could have caused actual or potential harm to a patient or visitor ... an unanticipated adverse outcome, including unexpected complications, or harm to a patient or visitor, regardless of whether any error occurred ... any identified event that is inconsistent with the routine care of the patient or routine operation of the facility ..."
* "An Unusual Occurrence Report (UOR) shall be completed on paper or electronically by the member or members of the workforce or medical staff who are most directly involved in the occurrence, who first observed the occurrence, or who first became aware of the occurrence."
* "An Unusual Occurrence that is regarding a Serious Adverse Event or a [sic] sensitive or urgent in nature should be reported immediately. The supervisor will notify Patient Safety and Risk immediately when a Serious Adverse Event has occurred ..."
* "In all cases where an injury is sustained or harm occurs ... An Unusual Occurrence Report (UOR) should be completed as soon as practical after treatment but no later than the end of the shift on which the Unusual Occurrence occurred."
* "The appropriate manager(s), supervisor, or administrator will review and investigate the occurrence and provide appropriate follow-up documentation to the Patient Safety and Risk department. This documentation may include additional information regarding the incident, further interventions required, overall outcome for persons involved in the incident, and actions taken by staff."
* "Reports with documented manager/supervisor follow-up should be forwarded to Patient Safety and Risk within ten (10) working days of the initial report submission."
* "Additional follow-up and/or communication related to the incident may be requested by Patient Safety and Risk. Significant findings, conclusions, actions or recommendations will be communicated to Administration as appropriate."

1.b. The P&P titled "Safety Event Reports Policy ... SLCH ..." dated approved 01/24/2022 was reviewed and included:
* "Safety Event Reports (SERs) shall be completed to promote a culture of safety and continual improvement, to improve patient safety ... reporting of Safety Events is part of the hospital's Patient Safety, Clinical Risk and Quality Assurance Program ..."
* "A Safety Event includes, but is not limited to ... an unintended event that causes actual or potential harm to a patient or visitor ... a near miss event that could have caused actual or potential harm to a patient or visitor ... an unanticipated adverse outcome, including unexpected complication, or harm to a patient or visitor, regardless of whether any error occurred ... any undesirable event that is inconsistent with the routine care of the patient or routine operation of the facility ..."
* "An SER shall be completed by the member or members of the workforce or medical staff who are most directly involved in the event, who first observed the event, or who first became aware of the event."
* "An SER regarding a Suspected Serious Safety Event or a [sic] sensitive or urgent in nature should be reported immediately ..."
* "SERs may be reported directly to PSCR by any physician or staff member at any time. The reporter may still be asked to submit an SER via the reporting software, RLDatix."
* "In all cases where an injury is sustained or harm occurs ... An SER should be completed as soon as practical after treatment but not later than the end of the shift on which the UOR occurred."
* "The appropriate manager(s), supervisor, or administrator will review and investigate the event or Near Miss and provide appropriate follow-up documentation. This documentation may include referrals to other department managers, additional information regarding the incident, further interventions required, overall outcome for persons involved in the incident, and actions taken with staff."
* "Documented manager/supervisor follow-up should be completed in RLDatix within ten (10) working days of the initial report submission."
* "Additional follow-up and/or communication related to the incident may be requested by PSCR. Significant findings, conclusions, actions or recommendations will be communicated to Administration as appropriate."

2.a. The medical record of Patient 3 was reviewed and included:
* The patient was admitted on 06/14/2020 with diagnoses including pneumonia of both lungs and possible partial small bowel obstruction.
* The patient had quadriplegia and needed assistance with mobility and repositioning. For example:
- CNA notes dated 06/14/2020 at 2059 reflected "Activity: Bedrest; Turn Level of Assist: Dependent, patient does less than 25% Distance Ambulated (ft): 0 ft Ambulation Response: Tolerated well Repositioned: Lying left side; Pillow support Positioning Frequency: Every 2 hours."
- RN notes dated 06/14/2020 at 2199 reflected "Pt repositioned. Multiple pillows used for comfort."
- Flowsheet documentation dated 06/15/2020 at 0435, 0855, 1105, 1257 and 1539 reflected the patient was "Dependent, patient does less than 25%" when turned.
- Flowsheet documentation dated 06/16/2020 at 0608 reflected "Musculoskeletal ...Generalized ... Paralysis ... RUE ... Paralysis ... LUE ... Paralysis ... RLE ... Paralysis ... LLE ... Paralysis."
- Braden scale documentation dated 06/16/2020 at 1506 reflected "Mobility ... Completely immobile."

* Flowsheet documentation dated 06/16/2020 at 2127 reflected "Skin Condition/Temp ...Bruised; Warm; Dry ... Skin Integrity ... Bruising; Redness ... Skin Location ... scattered." This was the first documentation related to these skin alterations (bruising and redness). There was no further nurse assessment that described the skin alterations. For example, there was no description of location, size, pain, possible cause or other information.
* Flowsheet documentation dated 06/17/2020 at 0203 reflected "Skin Condition/Temp ...Bruised; Warm; Dry ... Skin Integrity ... Bruising; Redness ... Skin Location ... scattered." There was no further nurse assessment that described the skin alterations.

* RN notes dated 06/17/2020 at 0730 reflected "... During morning assessment noted increased pain to L hip. Pt reported that while having [their] leg repositioned last night, [they] heard a loud pop, and [they] had been feeling more painful since that time. [Physician] notified. X-ray of L hip ordered."

* Flowsheet documentation dated 06/17/2020 at 1127 reflected "Skin Condition/Temp ...Bruised; Warm; Dry ... Skin Integrity ... Bruising; Redness." There was no further nurse assessment that described the skin alterations.

* Physician orders dated 06/17/2020 at 1259 reflected "Bed rest, up in WC as tolerated; range of motion in left hip as tolerated by pain, avoid traction or pressure on left hip joint."

* Physician discharge summary dated 06/17/2020 at 1300 reflected "On the night prior to discharge, while being repositioned [patient] felt a "pop" in [their] left hip with pain. On exam, [they] did have pain with passive flexion of the hip ... CT of the left hip however did reveal slight buckling of the cortex of the femoral neck suggesting a slightly impacted femoral neck fracture without displacement. The case was discussed with orthopedics, given the patient's overall clinical state, being mostly bedbound, and [the patient's] desire to avoid surgical intervention, patient will be treated with bed rest, range of motion as tolerated and pain control. Care should be given to avoid torsion or traction on that hip to prevent further fracture." The physician discharge diagnoses list included "Nondisplaced fracture of neck of left femur."

* The nursing care plan dated "Start: 06/15/2020" and "Resolved: 06/17/2020" was reviewed and included:
"Problem: Activity Intolerance/Impaired Mobility ..."
Interventions for this problem reflected:
- "Maintain proper body alignment ... PRN"
- "Assess need for assistive/adaptive devices ... PRN"
- "Active/passive ROM as tolerated/ordered ... PRN"
- "Plan activities to conserve energy ... PRN"
- "Collaborate with PT/OT as appropriate ... PRN"
- "Turn patient ... PRN"
"Goal: Mobility/Activity is Maintained at Optimum Level for Patient ..."
"Description: Assess and monitor patient barriers to mobility and need for assistive/adaptive devices. Assess patient's emotional response to limitations. Collaborate with interdisciplinary team and initiate plans and interventions as ordered ... Interdisciplinary."

The care plan was incomplete and not patient specific. Examples included:
* The care plan did not include the patient's skin alterations (bruising and redness).
* The care plan did not include the patient's quadriplegia and extent of mobility assistance needs.
* The care plan did not include the patient's new left hip fracture, including patient specific interventions.
* The care plan was not updated with regard to the physician orders dated 06/17/2020 that reflected "Bed rest, up in WC as tolerated; range of motion in left hip as tolerated by pain, avoid traction or pressure on left hip joint."

* RN notes dated 06/17/2020 at 1545 reflected the patient was discharged.

2.b. Review of incident and investigation documentation for Patient 3 reflected:
Regarding skin alterations (bruising and redness) identified in the medical record, there was no documentation that reflected an investigation had been conducted of those.

Regarding the left hip fracture, incident documentation reflected:
* The incident "Event" date/time was 06/17/2020 at 0730.
* "Comments:" documented by "Risk" dated 06/18/2020 at 1252, the day after the patient reported the incident, reflected "Patient reported that sometime during the previous night [they] heard a loud pop from [their] left hip while having [their] left leg repositioned. This was reported to the physician ... who ordered the required imaging. A small fracture was noted to the left femoral neck."
The documentation further reflected:
* The "Date Received" was 06/18/2020.
* The "Date of Initial Follow up:" dated 06/23/2020 reflected "[Physician] discussed with me and stated [they] discussed with [physician] from GSRMC. There was no surgical recommendation and [they] explained to the patient. Patient was discharged; asked if [they] wanted to have [their family members] called and [they] stated [they] would call them once [they were] settled after discharge ..."
* A note dated 07/22/2020," 35 days after the patient reported the incident, reflected "... In w/c d/t GBS (last 11 years) lives in AFH ... radiograph showed osteopenia without obvious fracture. CT of the left hip however did reveal slight buckling of the cortex of the femoral neck suggesting a slightly impacted femoral neck fracture without displacement ... The case was discussed with orthopedics ... patient will be treated with bed rest, range of motion as tolerated and pain control."
* "Comments" dated 02/11/2021 reflected "... no further issue r/t original event noted in chart, will close."
* "Immediate impact on patient" was blank.
* "Underlying Causes" was blank.
* "Medication Type" was blank.
* "Additional Action Taken:" was blank.
* "Date of Additional Follow Up:" was blank.
* "Level of Harm:" was blank.
* "Was there a deviation from GAPS (Generally Accepted Perf:)" was blank.
* "Did the deviation reach the patient?:" was blank.
* "Did the deviation cause moderate to severe harm or death:" was blank.
* "General Follow up Group:" was blank.

There was no documentation that reflected an investigation of the left hip fracture incident had been conducted. For example,
* No documentation of interviews with staff who participated in repositioning the patient "during the previous night" or other staff who may have information.
* No documentation of interviews with the patient to gather additional information.
* No investigation sought to narrow down the time the patient "heard a loud pop" from their hip.
* No further documentation of follow up actions, significant findings, conclusions, actions or recommendations as appropriate in accordance with the CAH's P&P.
* The RN notes in the medical record reflected on 06/17/2020 at 0730, the patient reported hearing a pop. There was no documentation the RN or other staff who first became aware of the incident or were most directly involved completed a UOR; and no documentation a UOR was completed no later than the end of the shift on which the incident occurred in accordance with the CAH's P&P.

2.c. During an interview with the QD on 03/15/2023 at 1405 regarding the left hip fracture incident the QD stated "When something like that happens it should be reported and an investigation conducted."

2.d. During an interview with the VPPCS on 03/15/2023 at 1450 regarding the left hip fracture incident the VPPCS stated "There's not an investigation."

2.e. During an interview with the QD on 03/15/2023 at 1500, they confirmed the lack of nurse assessment of skin alterations (bruising and redness) identified in the medical record.

2.f. During an interview with the MSNM on 03/15/2023 at 1540, they stated they had no documentation of interviews conducted with staff about the left hip fracture incident.

2.g. During an interview with the MSNM on 03/15/2023 at 1555, they confirmed the nursing care plan was not updated after the patient reported hearing a pop or after the left hip fracture was identified.

2.h. During the exit conference on 04/13/2023 at 0830, the findings related to skin alterations (bruising and redness) in the medical record were discussed and the hospital was given the opportunity to provide an investigation of those. No documentation that reflected an investigation had been conducted was received.

3.a. Review of incident and investigation documentation regarding Patient 2 reflected that on 06/25/2020 at 2100 "... bed alarm went off. CNA, responded ... Pt was found kneeling next to the side of the bed ... [patient] said [they] wanted to get up and check for something in the cupboard ... assessed for injuries and none were found. Pt was too weak to get up with 2-person assist, so [Charge RN] came in to assist ... used the lift to get [patient] safely back in bed. Incontinence brief changed ... Fall Huddle completed ..."
* "Immediate impact on patient:" was blank.
* "Underlying Causes:" was blank.
* "Medication Type:" was blank.
* "Initial Follow Up:" was blank.
* "Action Taken:" was blank.
* "Initial Follow Up Completed by:" was blank.
* "Date of Initial Follow Up:" was blank.
* "Additional Action Taken:" was blank.
* "Levels of Harm:" was blank.
* "Was there a deviation from GAPS (Generally Accepted Perf:)" was blank.
* "Did the deviation reach the patient:" was blank.
The documentation lacked a clear, complete, and thorough investigation. Examples included:
* There was no investigation that reflected how long the bed alarm sounded before staff responded.
* There was no investigation that reflected when the patient was last checked for incontinence, and whether incontinence was a contributing factor to the incident.
* The documentation reflected a fall huddle was completed. There was no further fall huddle information.

3.b. During an interview with QD on 03/16/2023 at 1030 they reviewed the incident and investigation documentation and confirmed the investigation was not thorough and complete. The QD stated they were not able to find a fall huddle and "We missed some of these things."

4.a. Review of incident and investigation documentation regarding Patient 4 reflected "Telemetry monitor ordered for specific patient, tele was placed on this patient, however monitor was still entered for another patient. Therefore, data was being entered into the wrong patient's chart and had an emergency occurred with the patient who was being monitored staff would not have known which room to respond to as information was entered incorrectly."
* "Event Date" reflected 12/18/2022. There was no documentation of the time of the incident.
* "Injury Incurred?" reflected "No."
* "Follow-Up Actions" dated 12/20/2022 at 1052 reflected "CCU staff didn't discharge the previous patient out of the tele system. Nurse manager educated with all staff to discharge a patient's information once [they] no longer [need] tele monitor."
* "Outcome Actions Taken" included "Discussed Event with Staff Involved" and "Policy/Procedure: Modified, Created, Reviewed."
The documentation lacked a clear and thorough investigation. For example,
* There was no investigation that reflected how long tele monitoring data was "entered into the wrong patient's chart."
* There was no investigation that reflected who identified the incident or how it was identified.
* There was no investigation that reflected potential or actual contributing factors about how or why "staff didn't discharge the previous patient out of the tele system."
* There was no documentation of the outcome of the discussion with the staff involved.
* There was no further information about the P&P that was modified, created and reviewed as a result of the incident.

4.b. During interview with the QD, MSNM and CCU NM on 03/16/2023 at 1305, they confirmed the investigation was not clear. QD, MSNM and CCU NM reviewed the medical record for 20 minutes and were not able to determine with certainty how long tele monitoring information was entered in the wrong patient's chart.

5.a. Review of incident and investigation documentation regarding Patient 6 reflected that on 02/14/2023 at 1324 "Heard patient coughing in [their] room ... heard a loud crash. Went to [their] room and found [them] on the floor ... reports coughing and blacking out and hitting the floor. [Patient] was sitting on the edge of the bed eating when the event occurred. No obvious injuries observed."
* "Specific Event Type" reflected "Fall Reported, Not Observed."
* "Injury Incurred?" reflected "Unknown."
* "Other attempted action prior to fall" reflected "Eating."
* "Do you know the last rounding date and time?" reflected "No."
* "Were there fall safety precautions in place at time of fall?" reflected "Yes."
* "Type of fall safety precautions in place at time of fall" was blank.
* "Was the nurse call used?" reflected "No."
* "Why do you think the patient fell?" reflected "Coughing episode with low O2 saturation, patient reports blacking out for a minute."
* "How could the fall have been prevented?" reflected "No."
* "What specifically can you change to prevent the patient from falling again?" reflected "Fall Precautions Put Into Place Bed Alarm On."
* "Follow-Up Actions" dated 02/16/2023 at 1557 reflected "Noting could have prevented this fall. We want patients sitting up and functioning at their highest level of mobility. If [patient] had a bed alarm on it would have just alerted us that [they] fell. Patient with no injury."
The documentation lacked a clear and thorough investigation and follow up actions. Examples included:
* There was no further investigation related to the patient's report of "coughing" and "blacking out," including potential contributing factors.
* The documentation reflected the patient was eating prior to the fall. There was no investigation related to whether this contributed to the patient's coughing and reported blacking out.
* There was no investigation that reflected the patient's oxygen saturation level before or after the fall incident.
* The documentation unclearly reflected "attempted action" prior to the fall was "Eating."
* The documentation reflected the patient did not use the nurse call. The investigation was not clear if the nurse call was or was not in reach of the patient at the time of the fall.
* The documentation reflected the last rounding date and time was not known. There was no investigation related to when the patient was last checked by staff before the fall incident.
* The time of the incident was not clear. The incident investigation documentation reflected the event time was 1324. However, review of the medical record in finding 5.b. included documentation related to the fall "occurrence" at 1300 and 1357, and not 1324 as described in the investigation documentation.
* The documentation reflected inconsistent information regarding whether the patient experienced an injury. For example, documentation unclearly reflected no injury, no obvious injuries, and unknown injury. However review of the medical record in finding 5.b. reflected the patient experienced "apparent injury or complains of injury," right shoulder soreness, and minor injury.
* The follow-up actions reflected "Nothing could have prevented this fall" and a bed alarm "would have just alerted us that [the patient] fell." The investigation was not thorough or complete. Therefore, it was not clear how it was determined nothing could have prevented the fall.

5.b. The medical record of Patient 6 was reviewed and included:
* The patient was admitted on 02/13/2023 with diagnoses including bronchospasm and acute respiratory failure with hypoxia.
* Flowsheet notes dated 02/14/2023 at "Row Name" time 1300 recorded by the RN at 1357 reflected "Fall Occurrence ... Unassisted ... Unobserved - reported ... Patient room ... Patient fainted ... Fall with apparent injury or complains of injury ..."
* DO notes dated 02/14/2023 at 1501 reflected "Received call from RN stating patient had fallen and hit [their] head ... later stated [they] 'blacked out' and hurt [their] shoulder. Per patient, [they] had a coughing spell while eating lunch. [Patient] was trying to catch [their] breath but became so short of breath [they] fell forward hitting head on [their] side table and then falling to the ground on [their] right shoulder ... states [their] right shoulder is now sore."
* Flowsheet notes dated 02/14/2023 at 1540 reflected "Pain Score ... 8 ... Pain Location ... Shoulder."
* PT notes dated 02/20/2023 at 1330, six days after the incident, reflected the patient reported falling during their hospital stay, landing on their "R side (shoulder, trunk, hip, and knee)," and continued soreness.
* Flowsheet notes dated 03/21/2023 at 1027, more than a month after the incident, reflected "Falls ... Level of Injury Minor."

* The nursing care plan was reviewed and lacked documentation that reflected a nursing care plan was kept current based on an assessment of the patient's individualized needs. For example, the care plan was not modified, including addition of individualized interventions, after the patient reported fainting, falling, and hitting their head on a table.

5.c. During an interview with QD on 03/16/2023 at 1545 they reviewed the medical record and confirmed there was no documentation that reflected the care plan had been modified or evaluated to determine if it needed modification based on an assessment of the patient after the incident.

Based on interviews, review of medical record documentation for nursing services and incident documentation for 2 of 2 patients (Patients 3 and 6), and review of CAH P&Ps, it was determined the CAH failed to ensure a nursing care plan was developed, implemented and kept current for each patient based on assessment of the patient's individualized needs in accordance with CAH P&Ps related to:
* Fracture care and mobility, including in accordance with physician orders;
* Falls; and
* Skin alterations.

Findings include:

1. Refer to the findings at Tag C1006, CFR 485.635(a)(1) regarding Patients 3 and 6. The findings reflect the CAH's failure to ensure nursing care plans were developed and implemented based on an assessment of each patient's individualized needs including patient specific fracture care and mobility, falls, and skin alterations.

2.a. The P&P titled "Standard of Care for Inpatients, Nursing Policy - SLCH," dated approved 08/07/2020 was reviewed and included:
* "The Standards of Care are fundamental activities to providing quality age-considerate patient care."
* "Assessment ... Reassess the patient to determine response to treatment ... when a significant change occurs in the patient's condition/diagnosis ..."
* "Care and Treatment ... Based on the assessment process, care is planned, delivered, monitored, and modified to meet the patient need or acuity plan ... Advance the patient's level of activity as ordered ..."
* "Continuum of Care ... Interdisciplinary care planning will be coordinated and updated as the patient's condition warrants. This planning will continue from admission through discharge, including any follow-up care ... Foster good communication with Hand-offs between providers and staff as needed."

2.b. The P&P titled "Care plan preparation - Procedure ... SLCH ..." dated 07/10/2017 reflected:
* "A care plan directs a patient's nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings, and it embodies the components of the nursing process, assessments, diagnoses, planning, implementation, and evaluation."
* "You must update and revise the plan throughout the patient's stay based on the patient's response."
* "Select interventions that will help the patient achieve the stated outcome for each nursing diagnosis. Include specific information, such as the frequency or particular intervention technique ... Evaluate the patient's progress and revise the care plan as appropriate."