HospitalInspections.org

Based on medical record review and staff interviews, the facility failed to provide a sitter as ordered for 1 of 3 sampled patients with sitter orders (Patient #6).

The findings include:

Closed medical record review on 09/03/2013 of Patient # 6 revealed a History and Physical dictated by the attending Physician (Physician #1) on 02/23/2013. Review revealed an 80-year-old female was admitted to the named facility on 02/22/2013 for abdominal distention and nausea and vomiting. Continued review revealed "HISTORY OF PRESENT ILLNESS...evaluation in the emergency department with CT (computed tomography) scan shows findings suggestive of a small bowel obstruction most likely in the distal small bowel ...PAST MEDICAL HISTORY...severe coronary artery disease ...dementia ..."

Review of the attending Physician's (#1) Discharge Summary dictated 03/04//2013 revealed the patient was discharged to home on 03/02/2013. Continued review revealed "...HOSPITAL COURSE: Following initial admission and initation of conservative management, the patient failed this and her obstruction progressed at which point she was taken to the operating room. Medical Service was consulted for her medical management. The patient had a laparotomy with extensive lysis of adhesions and reversal of her colostomy. Postoperatively, the patient had episodes of confusion requiring removal and replacement of her feeding tube on two occasions ..."

Review of the Physician Orders dated 02/22/2013 at 1700 revealed "please provide sitter 7pm - 7am pt (patient) (with) dementia and fall risk" Continued review of the Physician Orders dated 02/25/2013 at 1040 revealed "D/C (discontinue) 1:1 sitter (sitter at bedside). If patient remains agitated after administration of PRN (as needed) meds (medications) place patient in ... soft wrist restraints." Continued review of the Physician Orders on 02/26/2013 at 1000 revealed "1:1 sitter for 24 hrs (hours)..."

Further review of the record revealed Nurses Notes dated 02/24/2013 at 2041 revealed "...pt arousable, not aware of who she is or where she is and not oriented to time ...increased risk for falls..." Review of the Nurses Notes on 02/25/2013 at 0305 revealed "pt pulled out NG (nasogastric) tube, called (name of physician) said to put NG tube back in ...RN (registered nurse)...put in NG tube." Continued review of the Nurses Notes revealed on 02/25/2013 at 0400 "patient pulled out NG tube once, RN put it in again and pt pulled it out. Sitter is ordered for patient. Will put NG tube in again when sitter is available to monitor patient. Son is at bedside but apparently unable to prevent patient from pulling at wires. When inserting the second NG tube, pt fought and there was a large skin tear to the left hand." Continued review of the Nurses Notes revealed on 02/25/2013 at 0818 revealed "pt very confused, not oriented at all..." Continued review revealed on 02/25/2013 at 1105 "...pt has history of dementia ...pt calm at this time, medication to be administered as needed for pain and agitation, 1:1 sitter discontinued per MD (medical doctor) order. Fall precautions in place." Continued review of Nurses Notes on 02/25/2013 at 1435 revealed "patient pulled NG tube after repeatedly being told to leave NG tube alone...patient continue to be very confused..." Continued review revealed on 02/25/2013 at 1842 "patient awake, confused, and attempting to get out bed and pull out IV..." Continued review revealed on 02/25/2013 at 2130 "daughter at bedside. Daughter upset because doctor stopped the sitter order and the family can not stay at hospital all the time. They do not want the patient to fall or keep pulling tubes out. No prn meds ordered but for pain and daughter stated that will not help with the confusion ..." Continued review of Nurse Notes n 02/26/2013 at 0814 revealed "pt confused and at times anxious/agitated. Unsuccessful with reorientation. Pt attempting to climb out of bed. Daughter came around 2100 and spent the night."

Continued review of the medical record revealed a Special Observation Record (sitter flow sheet) which allowed for documentation every 15 minutes. Continued review of the record revealed codes 1-5 to describe the patient's care and observation; codes 6-17 described the patient's behavior. Continued review of the Special Observation Record on 02/23/2013 at 2115, 2130, 2145, 2200, 2215, 2230, 2315, 2330, and 2345 revealed "2 (direct observation)/16 (restless)". Continued review revealed the next documented observation was on 02/25/2013 at 0700 (30 hrs and 45 minutes since the last observation and 3 hours and 55 minutes after pt #6 pulled out her NG tube). Continued review of the observation record revealed no sitter documentation from 02/24/2013 at 0000 through 02/25/2013 at 0645.

Interview on 09/04/2013 at 1035 with RN Patient Care Manager #1 revealed "We try to get sitters for patients who are trying to pull out tubes. We do encourage families to stay. Restraints are the last resort. If we see the patient is pulling at their tubes we will call the doctor for a sitter order and place a sitter with them ...No sitter is documented on the 24th or 25th..." Interview confirmed no sitter was provided as ordered.

Interview on 09/04/2013 at 1120 with Patient Care Manager #2 revealed "We provide a sitter based upon the patient's needs...if they are confused and restless or pulling at their tubes, if they are a fall risk...when a sitter is ordered we provide someone to sit with the patient at all times and they document on the flow sheet every 15 minutes the patient care, observation, and behavior. The patient (#6) initially had a sitter ordered because of her dementia and fall risk from 02/22/2013 until 02/25/2012 at which time the sitter was removed because she was calm and no longer pulling at her tubes. The family was upset over this because they have two small children at home and couldn't stay at the hospital all the time...but we felt the patient was calm enough to remove the sitter. Yes, she (Patient #6) did end up pulling out her NG (Nasogastric) tube and her IV (intravenous) when no sitter was present ...there is no documentation by a sitter on 02/25/2013 at midnight through 0645...there should have been a sitter at the bedside on this night ...but lack of documentation indicates there was no sitter present." Interview confirmed the facility failed to provide a sitter as needed and ordered.

Interview on 09/04/2013 at 1335 with Administrative Staff revealed "...we are evaluating the need for a sitter versus the convenience of utilizing sitters. We have asked the nursing staff to look at the appropriateness of the sitter versus just putting a sitter with the patient because the family requests one...we evaluate on a daily basis the patient care requirements for continued sitter needs...the items that we consider when ordering a sitter are the patient's fall risk assessment, if they are high risk for falls; their mental status, are they confused; are they pulling at tubes and wires...this patient was high risk for fall and did have dementia...this patient could have been a candidate for a sitter based upon their assessment..." Interview confirmed the facility failed to provide a sitter as ordered by the physician.

Based on review of the hospital's policies & procedures, staff interview and review of medical records, the facility failed to ensure a patient's post discharge needs were met for 1 of 6 sampled patients with discharge planning (#6).

The findings include:

Review of the hospital's policy and procedure/guideline "Discharge Planning" dated April 2000, revealed "...assessment for appropriate discharge is coordinated by the Coordination of Care Department. Each patient is screened for discharge planning needs on admission, and referrals are made to the Coordination of Care department as appropriate. Discharge planning is performed in collaboration with the patient, family, case management staff, and other involved services ....The Coordination of Care Department is responsible for facilitating the continuum of care. Acute Care Nurse Navigators, Medical Social Workers along with the other care providers identify those patients who may require services after discharge. The Acute Care Nurse Navigator and/or Medical Social Worker initiate contact with external organizations and agencies to facilitate a smooth and timely transition from hospitalization to the home or institutional environment by efficiently coordinating interdisciplinary planning efforts."

Closed medical record review on 09/03/2013 of Patient #6 revealed a History and Physical dictated by the attending Physician (Physician #1) on 02/23/2013. Review revealed an 80-year-old female admitted to the named facility on 02/22/2013 for abdominal distention and nausea and vomiting. Continued review revealed "HISTORY OF PRESENT ILLNESS...evaluation in the emergency department with CT (computed tomography) scan shows findings suggestive of a small bowel obstruction most likely in the distal small bowel ...PAST MEDICAL HISTORY: Past medical history is significant for severe coronary artery disease, atrial fibrillation, hypertension, abdominal aortic aneurysm, dementia, chronic kidney disease, sever chronic obstructive pulmonary disease (COPD), chronic anemia. PAST SURGICAL HISTORY: Past surgical history includes cholecystectomy, laparotomy and Hartmann procedure (Colostomy) ....SOCIAL HISTORY: she lives with family."

Review of the attending Physician's (#1) Discharge Summary dictated 03/04//2013 revealed the patient was discharged to home on Saturday 03/02/2013. Continued review revealed "...HOSPITAL COURSE: Following initial admission and initiation of conservative management, the patient failed this and her obstruction progressed at which point she was taken to the operating room. Medical Service was consulted for her medical management. The patient had a laparotomy with extensive lysis of adhesions and reversal of her colostomy. Postoperatively, the patient had episodes of confusion requiring removal and replacement of her feeding tube on two occasions ...The patient was doing well with no fever. There were some electrolyte abnormalities that were corrected ...FOLLOW UP: The patient will follow up with me in the office in nine days for staple removal. The patient's Jackson-Pratt drain was removed. There was no evidence of a wound infection at the point of discharge..."

Review of the Discharge Planning Assessment completed by Case Management/Discharge Planner dated 02/25/2013 revealed "Living situation: lives with family; Cognition: disorientated to all spheres all of the time; Functional status: dependent in meal preparation; dependent in grocery shopping, ambulatory with mechanical assistance; Behavioral pattern: Confused; Comments: ...she lives at home with her son and daughter in law and they are her caretakers. Patient has dementia. Son states she will return home with them at discharge."

Review of the Case Management (Discharge Planner) discharge note dated 03/02/2013 (Saturday) at 1003 revealed "client has d/c (discharge) orders to go home family has all the DME (durable medical equipment) they need. Per (name of Physician #1) no home health; family cares for patient. Daughter will f/u (follow up) with Dr's (doctors)".

Continued review of the medical record revealed the patient (#6) was readmitted to the hospital via the Emergency Department on 03/06/2013 with chief complaint of "Diarrhea, pain when urinating, wheezing, desaturation, on 2 liters of oxygen at home at 74% (normal 95-100%)."

Review of the Physician's (Physician #2) Discharge Summary dictated 03/12/2013 revealed a discharge date of 03/14/2013 to a Skilled Nursing Facility (SNF) for rehabilitation (rehab). Continued review revealed "Final Discharge Diagnoses: 1. diarrhea, most likely from short colon syndrome ...2. The patient had a urinary tract infection with Vancomycin Resistant Enteroccoccus (VRE infection) being treated. 3. She also had funguria with Candida Albicans being treated. 4. She has debility. She is being transferred to subacute rehab for gait mobility ..."

Telephone interview on 09/04/2013 at 1515 with Patient #6's Discharge Planner/Case Manager revealed "I felt like this patient needed home health and called (name of physician [Physician #1]) for home health orders and he stated 'no get her out, discharge her'. There was no discussion of allowing the patient to stay through the weekend so home health and home PT (physical therapy) could be arranged. He (Physician #1) did not give me the option of letting the patient stay until Monday. I think we tried to go up the chain of command because I really felt home health and PT was needed for this patient. I spoke with the Charge Nurse and she called the house supervisor. The patient was sent home without the benefit of home health which I felt she really needed." Interview confirmed the patient's post discharge needs were not met.

Interview on 09/05/2013 at 1540 with the Director of Discharge Planning revealed "yes, this patient needed home health and we made the patient aware she could get her PCP (primary care provider) to order the things she need; if she needed home health she could call and get her PCP to give her an order. I know this was a Saturday and the PCP office is closed but they would have someone on call ...the discharge planner/case manager coordinates the discharge needs for the patient ...No, we did not arrange Home Health post discharge for this patient ..." Interview confirmed the patient's post discharge needs were not met.

NC00087592, NC00087073, NC00090702, NC00086935