HospitalInspections.org

1. Based on document review and interviews the Administrative Staff failed to ensure nursing staff followed patient care plans resulting in 3 of 20 patients falling (Patient's #15, #2 & #16).

A. Review of Patient # 15's Care Plan confirmed hospital staff failed to follow the care plans instructions for alarm usage related to increased fall risk that resulted in Patient #15 falling on the floor. Upon admission, Patient #15 walked with a walker, PT staff documented in the chart Patient #15 was a high fall risk. The patient's bed alarm was off the night of the fall, resulting in Patient #15 laying on the floor naked and in urine for two hours waiting for help to arrive.

B. Interview on 10/25/17 at 7:30 AM with Patient #15 confirmed confusion at night about whereabouts in the hospital. Patient #15 acknowledged belief the staff should have placed alarms on so it would remind him not to get up independently. Patient #15 reported he laid on the floor naked and cold in his own urine for two hours before staff members entered the room and found him. According to Patient #15 the hospital staff could have done more to prevent him from falling on the floor.

C. The interview on 10/30/17 at 3:10 PM with Physical Therapist I confirmed Patient # 15 was a fall risk when admitted to the hospital. Patient #15's safety and judgement was impaired requiring staff assistance with ambulation and alarm usage. Patient #15 remained in need of activities of daily living (ADL) assistance upon discharge to the assisted living.

D. Review of the clinical record revealed Patient #2's care plan identified the patient at high risk for falls and alarms are to be used. The first fall occurred 10/17/17 at 5:45 PM where staff members located Patient #2 on the floor next to the patients bed. No alarm noted on the Inpatient Post Fall Procedure checklist. According to the record review Nurse Manager F documented on a post fall procedure checklist dated 10/19/17 that staff placed Patient # 2 in a wheelchair with no alarm. Patient #2 attempted to stand independently resulting in a fall causing abrasions to both knees.

Interview on 10/26/17 at 7:50 AM Nurse Manager F confirmed the day of Patient #2's second fall 10/19/17 at the staff placed the patient into a wheelchair and failed to attach the personal alarm.

E. Review of the clinical record revealed Patient # 16's care plan included bed alarms that according to documentation failed to be turned on 10/21/17 2:25 AM resulting in Patient #16 getting up alone and falling.

Failure to follow patient care plans resulted in 3 patients falling to the floor, one laid naked in urine for two hours before staff members found the patient and one patient received bilateral abrasions to the knees. The third did not have any noted injuries.

1. Based on interviews and policy review the Hospital failed to have policy and procedure in place to direct staff how to care for feeding tubes placed for liquid nutrition and/or medication administration on 1 of 1 patients reviewed with gastric feeding tubes (Patient #14).

A. According to the clinical record review Patient #14's diagnosis included insertion of a gastro-jejunostomy tube (feeding tube inserted through the stomach into the small intestine) to supply nutrition/medications directly into the small intestine.

B. During an interview on 10/31/17 at 3:50 PM, the Nurse Director A confirmed the hospital failed to have a policy or procedure in place to provide direction for staff members to locate information in reference material Perry and Potter on the care of feeding tubes. According to Nursing Director A the only process in place occurs during staff education upon hire.

C. The interview on 10/31/2017 at 3:00 PM identified Registered Nurse (RN) Z reported during shift change walking rounds with Nurse Educator C that Patient #14's tube feeding pump was beeping. According to Nurse Educator C the feeding pump had been beeping for part of her shift: however she did not have any difficulties with the pump running and delivering Patient #14's tube feeding. RN Z reported she was instructed to change the tubing and it might help the beeping. According to RN Z, she was unfamiliar and lacked knowledge on dealing with occlusions (blockages) in the type of feeding tube Patient #14 had. RN Z confirmed she asked for help from RN D after RN Z changed the tubing twice for Patient #14. RN D gave RN Z direction to contact the physician and inform him RN D ruptured the side of the feeding tube while trying to remove the occlusion.

D. An interview on 10/30/17 at 4:12 PM, confirmed RN D lacked knowledge and familiarity with the type of feeding tube Patient #14 had inserted. RN D identified she proceeded to use techniques to release an occlusion in Patient
#14's feeding tube as she previously used with a different type of feeding tube. RN D replied she did not feel the need to document in Patient #14's chart that she ruptured the side of the feeding tube by the hub where it was inserted into the patient because this was not her patient.

Failure to have a policy related to care of tube feeding devices resulted in RN Z and RN D's lack of knowledge on what to do after Patient #14's feeding tube occluded and RN D's attempts to remove the occlusion caused a rupture in the side of the feeding tube by the hub. Failure to follow proper procedure for different types of feeding tubes could potentially result in unnecessary additional surgeries to repair or replace damaged feeding tubes. Failure to perform proper technique to occluded feeding tubes can cause serious life threatening intestinal injuries and even death.

2. Based on document review and staff interview, the Hospital's administrative staff failed to ensure nursing staff followed the hospital policies referring to hourly rounding for 7 of 20 patients reviewed (Patient's #1, #3, #15, #17,
#18, #19 and #20).

A. Review of Patient #1's locator system report revealed Certified Nursing Assistant (CNA) R exited Patient #1's room on 10/21/17 at 10:58 AM and RN S entered the room at 12:23 PM (time lapse of 1:25hours/minutes) (hrs/min).

B. Review of Patient# 3's clinical record revealed a fall earlier in the day. The locator system report identified RN V left the patient room on 10/11/2017 at 4:33 PM and CNA W entered the room at 5:56 PM (time lapse of 2:23hrs/min). On 10/11/17 at 10:55 PM Licensed Practical Nurse (LPN) X exited the patient room and RN Y entered the room on 10/12/17 at 1:40 AM (time lapse of 2:45hrs/min ) .

C. Review of Patient #17's locator system report revealed CNA T exited the patient room on 10/10/17 at 3:19 AM the next identified person to enter the room was RN U at 5:23 AM (time lapse of 2:04hrs/min) .

D. Review of Patient #18's locator system report revealed CNA O left the patient room on 10/4/17 at 6:56 PM returning at 8:56 PM (time lapse of 2:00hrs/min). On 10/4/17 RN P exited Patient #18's room at 9:46 PM and CNA Q entered the patient room 10/5/17 at 6:57AM (time lapse of 9:21hrs/min)

E. Review of Patient #19's locator system report revealed RN AA exited Patient#19's room on 10/21/17 at 1:24 PM and RN Z entered the room at 4:07 PM (time lapse of 3:43hrs/min).

F. Review of Patient #20's locator system report revealed RN AA left the patient room on 9/13/17 at 12:47 AM and RN AA entered the patient room again at 3:47 AM (time lapse of 3:00hrs/min).

G. Interview with Nurse Director A confirmed staff members failed to follow the rounding policy as the practice had changed and the policy was not updated accordingly.

H. Review of the Hourly Rounding Guideline Policy # NL 256, last updated 2/2016 revealed, in part: Purpose: The purpose of performing hourly rounding is to enhance patient satisfaction, reduce patient falls, reduce patient call light use and promote effective pain management. This guideline defines the procedure for performing hourly rounding ...1) Inpatient: a) Hourly from 0600- 2200.... OPERATIONAL DEFINITTIONS: Hourly Rounds are rounds made by the unit based clinical staff (RN, LPN, CNA or PSA(Patient Service Assistant) to proactively address patient needs related to pain, positioning, toileting and the proximity of items such as call light, telephone and over-bed tray ...b) Every two hours between 2200 and 0600 ...7) In the event the patient is asleep or off of the unit, leave a "visitor card" on the patients' bedside table. a) Visitor cards will be kept in the patient's drawer outside of the patient's room. b) Please use a small dry erase marker on the cards. c) The cards should be left on the bedside table ... 8) Staff will document rounds using the workflow terminal buttons.

I. RN B's interview on 10/31/2017 at 12:30 PM RN B revealed she never heard of "visitor cards" until she was looking at the rounding policy earlier that day.

J. During tour on 10/23/2017 at 10:30 AM observation of patient rooms revealed no visitor cards in patient rooms or outside of patient rooms as identified in policy.

K. During observations on 10/24/2017 at 5:45 AM House Supervisor E stated all nurses and nurse aides get a locator and a phone each shift, the main unit supervisors can run a locator system to show how often rounds are done and who was in the room of each patient and for how long.

Failure to follow the Hospital's policies related to Hourly Rounds potentially placed patients that are at high risk of falls at greater risk due to a lack of regular supervision.

3. Based on document review and interview the Administrative Staff failed to ensure nursing staff members followed Physician orders to provide appropriate care and treatment for 1 of 10 patients at high risk of falls (Patient #4).

A. Review of Patient #4's medical record revealed the attending physician charted Patient #4 as impulsive and continued to get up out of bed without assistance. Patient #4 was a post craniotomy (brain surgery) patient with dementia, cognitive impairment, altered elimination and impulsiveness. Patient #4's Physician orders directed staff to have the patient wear a helmet when out of bed and required a 1:1 sitter.

B. During an interview on 10/26/17 at 10:30 AM RN Manager F reported 1:1 interventions are in place for this patient between 9/20/17 to 9/24/17. RN Manager F identified a lack of documentation for 1:1 sitters if CNA's performed the activity.

C. During interview on 10/31/17 at 7:50 AM, CNA CC confirmed charting is always done on sitter sheets when CNA's are responsible for 1:1 with a patient.

D. Review of clinical documentation revealed the 1:1 sitter was discontinued on 9/20/17 at 2:57 PM and not resumed until 9/24/17 at 7:00 AM, two days after Patient #4's first fall.

Failure to follow physician orders resulted in Patient #4 falling to the floor. Failure to follow physician orders could potentially result in physical harm or even death.

4. Based on review of documents Administrative Staff failed to ensure nursing staff followed the Adult Patient Fall Reduction Plan Policy.

A. Review of Patient #3's clinical documents for Inpatient Post Fall Procedure Checklist revealed the patient returned from surgery without fall risk measures in place.

B. Review of Patient # 4's clinical documents for Inpatient Post Fall Procedure Checklist revealed staff failed to place the patient on fall precautions according to policy even after the criteria was met.

C. Review of the policy labeled Adult Patient Fall Reduction Plan Policy # 2025, revised July 2017 revealed, in part: Purpose: In order to promote a culture of safety, due to the risk of serious physiological and psychological injuries related to falls, a fall reduction plan is used ...Adult patients are at high risk when they are confused, disoriented, or impulsive, have symptomatic depression, altered elimination, have dizziness or vertigo, are male, received antiepileptic's or benzodiazepines, or are unable to rise independently from a chair.

Failure to follow this policy resulted in 1 of 10 patients falling to the floor.