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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Nursing staff failed to ensure equipment used for fall precautions, specifically bed alarms, were functioning in 1 of 3 observations conducted (Patient #7). The facility failed to ensure nursing staff implemented fall precautions according to the patients needs and who were considered at risk for falls (Patients #7).

A-0396 The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. The nursing care plan may be part of an interdisciplinary care plan. The facility failed to ensure nursing staff re-evaluated patients' care needs, as well as the effectiveness of the care plan to maintain the patient's health and safety for patients in 1 of 10 medical records reviewed for patients with falls (Patients #5). This failure resulted in continued patient falls.

A-0405 Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient ' s care as specified under §482.12(c), and accepted standards of practice. The facility failed to administer time sensitive medications within the specified time frame. This failure was identified in 4 of 4 patients who had time sensitive medications ordered (Patients #2, #3, #5 and #10).

Based on observations, interviews and document reviews, nursing staff failed to ensure equipment used for fall precautions, specifically bed alarms, were functioning in 1 of 3 observations conducted (Patient #7).

Findings include:

Facility policy:

The Falls Prevention policy read, a score greater than 10 indicated the patient would be at risk. Those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls. The at risk interventions may include, but were not limited to, use of bed alarms/chair alarms.

References:

The Posey KeepSafe Deluxe manufacturer's instructions read, to reduce the risk of serious injury or death, ALWAYS follow these steps after putting the sensor in place and before leaving patients unattended. DO NOT use any alarm or sensor that does not alarm each time it was tested. Make sure alarm was ON and in monitoring mode (monitoring indicator LED was flashing green). Check that the RJ11 plug on the sensor cable is not damaged (plug broken, or wires disconnected) and was securely connected to the alarm. Disconnecting the sensor from the alarm will cause the alarm to activate. This was called a "failsafe" mode. Disconnect the sensor to make sure the failsafe mode works. DO NOT use the alarm if the alarm does not sound when the sensor was disconnected.

Audible low battery warning. Alarm "chirps" about every 15 seconds when batteries need changing. This sound was different than any of the alarm tones and easily alerts caregivers of the need to change batteries. Change batteries at once.

DO NOT allow batteries to deplete while in the alarm. Change batteries immediately when hearing the low battery "chirp." If the alarm low battery alert was chirping or the alarm does not power up, the batteries were depleted and must be removed.

After changing batteries, test the alarm and sensor for proper operation prior to putting in service with a patient, and each time before leaving the patient unattended. If the alarm and/or sensor did function properly, remove the alarm and sensor from service and replace them with a properly functioning alarm and or sensor.

1. Nursing staff failed to ensure bed alarms used for patients, who were at risk for falls, were functional.

a. On 5/22/19 at 9:05 a.m. an observation was conducted on the 4th floor with Nurse Manager #4 (Manager #4) to ensure fall precautions were in place and functional. During the observation, it was noted the LED indicator light, on the Posey KeepSafe Deluxe, was not flashing for Patient #7.

Patient #7's nurse was at the bedside and stated the alarm was working fine 1.5 hours ago. Registered Nurse (RN) #12 stated the patient moved earlier in the morning and the alarm went off; however, she was unsure if the alarm was from Patient #7 or from one of the patients in a nearby room. RN #7 proceeded to change the batteries on the alarm, but it still would not turn on. She stated the patient was about to get a bed bath and then get out of bed, at which time she would replace the alarm with a functional one.

Manager #4 stated the alarms were checked each shift upon initial patient assessment, with repositioning and when the patient was transferred out of the bed.

A follow up observation was conducted on 5/22/19 at 5:00 p.m., the same day. Patient #7 was noted to have a bed alarm in place in which the LED light was flashing indicating the alarm was working.

b. On 5/23/19 at 5:43 p.m. an interview was conducted with Manager #4. He stated, the reason the bed alarm for Patient #7 was not functioning was due to the batteries. Manager #4 stated there was no way to know how long the alarm had not been functioning, but he felt confident it was not a long period. Manager #4 stated staff were frequently in the patient's room in order to reposition, check vital signs, answer call lights and/or administer medications.

c. An interview was conducted with Certified Nursing Assistant (CNA) #8 on 5/23/19 at 2:20 p.m. She explained the bed alarms were used to alert staff if a patient was trying to get up. She stated she verified the function of the alarms by applying pressure on the pad then releasing it. Additionally, CNA #8 stated if there was a red light flashing then the batteries needed changing, although she was unsure of the time frame which the batteries had to be changed.

CNA #8 stated every time she would check vital signs or blood glucose levels, she would verify the bed alarm was functional by checking for the flashing LED light.

d. An interview was conducted with RN #10 on 5/23/19 at 4:18 p.m. RN #10 stated the bed alarms were checked every time a patient was repositioned by looking at the flashing LED light. She stated the bed alarm was an important intervention to help patients not fall out of the bed.

Based on interviews and document reviews, the facility failed to ensure nursing staff re-evaluated patients' care needs, as well as the effectiveness of the care plan, to maintain the patient's safety in 1 of 4 medical records reviewed for patients which sustained falls (Patient #5).

Findings Include:

Facility policies:

The policy, Assessment/Re-Assessment Interdisciplinary Patient, read the goal of assessments and reassessments was to provide an interdisciplinary approach of individual patient care needs and to plan and implement patient specific care. Patients were re-evaluated by a licensed nurse at a minimum of every 12 hour shift, based on level of care and patient needs. Patient reassessment was based on evaluation of a patient's response to care or treatment and/or to respond to a significant change in status, diagnosis or condition.

According to the policy, Falls Prevention, a Score of > 10 = At Risk. Those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls. The At Risk interventions may include, but were not limited to: use of "risk for falls" sign/device to communicate risk to all caregivers (Falling Leaves, Falling Stars, bracelets, etc); use of a "remember to call for help" sign posted in patient's room to remind patient to call for assistance before getting out of bed; use of Bed Alarms/Chair alarms; turn (or position) bed with one side to the wall and place floor mat along entry/exit side of bed; avoid use of full-length side rails; move patient closer to the Nurse's Station; rehab evaluation and treatment as appropriate for conditioning/strengthening options/use of assistive devices; pharmacy review of medications for fall risk potential; use of low bed; select suitable chairs that have armrests or another appropriate geriatric chair; and consider family staying, or changes needed in staffing.

In the event that a patient fall occurs, regardless of the score of the Initial Fall Risk screen, he/she will be automatically considered at risk for falls, additional interventions will be considered, and the Care Plan revised to reflect increased risk.

1. Nursing staff failed to re-evaluate and adjust the care plan after Patient #5 fell.

a. Review of Patient #5's medical record revealed the patient was admitted on 4/12/19 at 10:45 a.m. He was admitted for rehabilitation following a brain bleed and for weaning of his tracheostomy (a tube inserted for assistance with breathing). On 4/27/19 at 7:29 a.m., the change of condition section of the record revealed the patient sustained a fall. The patient subsequently sustained two additional falls, on 4/27/19 at 3:30 p.m. and again on 4/28/19 at 3:37 p.m.

Further record review revealed the patient had a fall risk screen completed on 4/24/19 at 7:07 a.m. with a score of 9; then again on 4/30/19 at 1:18 p.m. with a score of 23. This was in contrast to the policy, Fall Prevention, which stated patients were rescreened for fall risk with a change in condition.

Record review for Patient #5 revealed on 4/26/19 at 10:02 p.m., the fall risk interventions in place were to maintain the bed in low position, perform fall risk assessment, place padded floor mats at each side of bed, obtain restraint order if necessary, provide adequate light, and reinforce calling for assistance before attempting activities. Continued review of the medical record showed the same interventions in place on 4/27/19 at 10:00 a.m., which was after the patient sustained the first fall. Furthermore, there was no change to the fall risk interventions or plan of care on 4/27/19 at 10:30 p.m. or 4/28/19 at 8:55 p.m., after the patient sustained the second and third falls. This was in contrast to the policy which stated in the event of a patient fall, there would be consideration of additional interventions and revision to the Care Plan.

b. On 5/23/19 at 12:12 p.m., an interview was completed with Director of Quality #3 (DOQ #3). DOQ #3 confirmed there was no additional updated plan of care or fall risk interventions documented after each of the patient's three falls. DOQ #3 was able to identify administration of Seroquel (a medication used to treat mental or mood conditions), per the physician's orders on 4/27/19 at 7:35 a.m. DOQ #3 stated there was no update to the patient's plan of care until 4/30/19 at 2:36 p.m., in which an order was identified to monitor fall risk medications.

DOQ#3 stated the purpose of care plans was to communicate what was being done with the patient and to document the information for additional communication means.

Based on document review and interviews, the facility failed to administer time sensitive medications within the specified time frame. This failure was identified in 4 of 4 patients who had time sensitive medications ordered (Patients #2, #3, #5 and #10).

Findings include:

Facility policy:

The Timely Administration of Scheduled Medications policy, read the policy established a guideline for the timely administration of scheduled medications while maintaining patient safety and the required therapeutic effect of administered medications. Time-critical, scheduled medications should be administered within 30 minutes before or after the scheduled dose time. Time critical medications lists would include a limited number of drugs where delayed or early administration of more than 30 minutes could cause harm or sub-therapeutic effect. The pharmacy may note on the medication administration record entry that a medication was designated as a "time critical medication."

1. The facility failed to ensure time sensitive medications, identified by the pharmacy, were administered within the specified time frame.

a. Review of Patient #2's medication administration record (MAR) showed the patient was ordered to receive six different medications which were identified as time sensitive and must have been administered 30 minutes before or after the scheduled time.

Patient #2 was ordered to receive cholestyramine (a medication which could be used to treat diarrhea) every 12 hours, specifically at 7:00 a.m. and 7:00 p.m. On 5/15/19, the medication was scheduled for administration at 7:00 a.m.; however, it was not administered until 2:00 p.m., which was 7 hours after the scheduled time. Similarly, on 5/15/19, the medication was scheduled for administration at 7:00 p.m., but was not administered until 9:06 p.m., which was more than two hours after the scheduled time. The MAR showed the patient received 12 total doses of this medication, four of which were outside the 30 minute timeframe as specified by the policy.

Further review of Patient #2's MAR revealed a second separate order for cholestyramine, scheduled at 9:00 a.m. and 9:00 p.m. On 5/10/19, the 9:00 p.m. scheduled medication was not administered until 1:40 a.m., 4 hours and 40 minutes after the scheduled time. Similarly, on 5/12/19, the 9:00 a.m. dose of cholestyramine was not administered until 1:24 p.m., 4 hours and 24 minutes after the scheduled time. The MAR showed the patient received 12 total doses of this medication, 11 of which were outside the 30 minute timeframe.

Record review of Patient #2 revealed an order for valproic acid, a medication used to treat seizures, due at 9:00 a.m. and 9:00 p.m. starting on 4/15/19. There were four total doses documented as administered and all four doses were outside the 30 minute timeframe specified by policy. Additionally, there was a separate order for an increased dose of valproic acid which started on 4/18/19. There were 11 total doses documented as administered, four of which were given outside the 30 minute timeframe.

b. Review of Patient #5's MAR showed the patient was ordered to receive three different medications which were identified as time sensitive and must be administered 30 minutes before or after the scheduled time.

Patient #5 was ordered to receive levetiracetam (a medication used to prevent seizures) at 9:00 am and 9:00 p.m. daily. The medication was identified on the MAR as a time sensitive medication to be administered within 30 minutes before or after the scheduled time. On 4/21/19 the medication was scheduled for administration at 9:00 p.m.; however, it was not administered until 11:47 p.m., which was 2 hours and 47 minutes after the scheduled time.

Similarly on 4/16/19, the medication was scheduled for 9:00 a.m. but was administered until 11:06 a.m., more than 2 hours after the scheduled time. The MAR showed the patient received 34 total doses of this medication, 19 of which were outside the 30 minute timeframe as specified by policy.

Further review of Patient #5's MAR revealed an order for lacosamide, a medication used to treat seizures, which was scheduled for administration at 9:00 a.m. and 9:00 p.m. On 5/1/19, the medication was due for administration at 9:00 p.m.;, however, the medication was not administered until 12:22 a.m., which was 3 hours and 22 minutes after the scheduled time. An additional 12 administrations of lacosamide were identified, 8 of which were outside 30 minutes of the scheduled time.

c. Record review of Patient #10's MAR revealed two different medications which were identified as time sensitive and to be administered within 30 minutes of the scheduled time. The first medication was oxycodone sustained release (a medication given for pain which lasts for an extended time frame) scheduled for administration at 9:00 a.m. and 9:00 p.m. There were five documented administrations of this medication, three of which were administered outside the 30 minute window.

Further review of Patient #10's MAR identified orders for the medication levetiracetam. This medication was ordered for administration at 9:00 a.m. and 9:00 p.m. and was identified as time sensitive to be administered within 30 minutes of the scheduled time. There were seven total doses identified as administered, three of which were outside the 30 minute timeframe.

d. Similar findings were revealed in Patient #3's medical record in which time sensitive medications were administered outside of the 30 minute time window.

e. On 5/23/19 at 4:05 p.m. an interview was conducted with Registered Nurse (RN) #10. RN #10 stated most medications were to be administered within one hour before or one hour after the scheduled time, with the exception of time sensitive medications. She explained medications identified as time sensitive on the MAR were to be given within 30 minutes before or after the scheduled time. RN #10 stated the reason the timeframe was different for time sensitive medications was because the time for the medication to reach peak effect was more critical.

f. On 5/23/19 at 4:31 p.m. an interview was conducted with Pharmacist #11. Pharmacist #11 verified time sensitive medications were expected to be administered within 30 minutes of the scheduled time. She stated types of medications which were time sensitive may include anti-seizure, anti-rejection, antibiotics and schedule opioid medications. Pharmacist #11 stated the importance of the administration time frame was to keep the medication levels within a patient's blood consistent. She stated for example anti-seizure medications needed a consistent level within the bloodstream to prevent the patient from having seizures.

Pharmacist #11 stated the timeliness of time sensitive medication administration was not currently being monitored by leadership due to the lack of improvement when it was previously monitored. Pharmacist #11 stated the medication dispensing machine did not specifically identify time sensitive medications, but stated medications were identified as time sensitive in the MAR.