HospitalInspections.org

The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse.

This CONDITION is not met as evidenced by:
Based on policy review, medical record review and interview, nursing services failed to follow each patient's interdisciplinary care plan to prevent pain and falls for 2 of 13 (Patient #4 and #6) sampled patients.

The findings included:

Review of the hospital's "Interdisciplinary Plan of Care Policy," policy dated 11/17/2020, revealed "...PURPOSE: Provide guidelines for the interdisciplinary team in collaborating, documenting, and integrating the patient's Plan-of-Care from admission to discharge. POLICY: Each discipline is responsible for collaborating, documenting, and integrating the plan of care for each patient..."

Review of the hospital's "Pain Management Program Policy," policy dated 10/10/2020, revealed "...POLICY: To control or relieve the physical and psychosocial consequences associated with pain while maintaining the patient's level of function and overall quality of life...Healthcare professionals will...provide pain interventions in a prompt, caring fashion..."

Review of the hospital's "Fall Prevention Policy," policy dated 12/14/2018, revealed "...purpose is to establish a multi-disciplinary approach to fall prevention and implement fall prevention strategies to prevent falls...Patient fall is a sudden, unintentional descent, with or without injury to the patient that results in the patient coming to rest on the floor..."

Medical record review revealed Patient #4 was admitted to the hospital on 8/5/2022 with diagnoses of Cellulitis of Foot, Leukocytosis and Severe Sepsis without Septic Shock.

Review of the Grievance Log revealed on 8/17/2022, revealed Patient #4 placed a call on the Administrator On Call's line that he had not received his pain medication as ordered and also complained about his late discharge.

Review of the hospital's response letter mailed to Patient #4 dated 8/15/2022, revealed "...We also sent your concerns regarding receiving your pain medications timely to the Nursing Director of the 4th floor so that she could address this with her nurses..."

Review of the Physician Order dated 8/5/2022, revealed "...Acetaminophen...650 mg [milligram]...oral...First Dose..."

Review of the Physician Order dated 8/5/2022, revealed "...Acetaminophen...650 mg...oral...mild pain (1-3 on pain scale)..."

Review of the Physician Order dated 8/5/2022, revealed "...Hydrocodone-acetaminophen (Norco 5 mg-325 mg) ...oral, q4H [every 4 hours] prn [as needed] pain moderate 4-6..."

Review of the Medication Administration Record (MAR) dated 8/5/2022 19:20, revealed "...acetaminophen (Tylenol)...acet325 650 mg 2 tab(s)...Oral..."

Review of the MAR dated 8/5/2022 20:20, revealed , "...acetaminophen (Tylenol)...Pain Present: Yes actual or suspected pain; Medication Effective: No..."

Review of the MAR dated 8/7/2022 06:51, revealed "...Ingredients: acet500 500 mg...Pain Rating at Rest: 7...
Pain-mild or Temp > 100.4 F..."

Review of the MAR dated 8/7/2022 07:51, revealed "...acetaminophen (Tylenol)...Pain Present: Yes actual or suspected pain; Medication Effective: No..Rating Score Rest: 7; Numeric Rating at Rest: 7.."

Patient #4 was care planned for abdominal pain.

Review of the Director of Medical Surgical Services review dated 8/10/2022, revealed "...Patient moved to...room on 8/6 [2022] @ 5:10 AM...Tylenol 8/7 [2022] at [6:51 AM]...Pain Rating of 7 that stayed at 7 (inappropriate drug due to scale for Tylenol was 1-3) and patient reported 7..."

During a telephone interview on 9/13/2022 at 2:15 PM, Registered Nurse (RN) #2 was asked if she remembered patient #3. RN #2 stated that she did not. RN #2 was asked if she would have given Tylenol to a patient with a pain scale of 6 or 7 instead of the prescribed narcotic. RN #2 stated,"...I have never withheld pain medication. I always ask the patient if they want Tylenol if it is too soon to administer the narcotic..." RN #2 was asked if the nurse manager had provided an inservice to the staff nurses regarding pain scale and pain medication administration. RN #2 stated, "No."

The Chief Quality Officer was emailed on 9/14/2022 and questioned if the Nursing Director of the 4th floor had addressed the issue of her nurses administering the correct pain medication per pain scale and physician orders with her nurses. The Chief Quality Officer's response via email dated 9/13/2022 at 4:03 PM, "...Per the CNO [Chief Nursing Officer]: We have had ongoing education each quarter of this year regarding pain and have now added additional training in the upcoming staff meeting since we had already had the meeting in August prior to the incident..." On 9/13/2022 at 5:08 PM, the Chief Quality Officer emailed "...In reading the letter again, it did not state a timeframe in which the director would address the staff , therefore, the leader felt it was best to address at the next staff meeting where she had good attendance..."

Review of the medical record revealed Patient #6 was admitted to the facility on 8/2/2022 with diagnoses of Acute Kidney Injury (AKI), Chronic Stage III, General Weakness, Hyponatremia, and Urinary Tract Infection (UTI).

Review of the Falls Information dated 8/2/2022, revealed "...(High Fall Risk (5+ pts) Bed Pressure Alarm, Fall Risk Arm Band on Patient, Fall Risk Sign on Door, Fall Risk Sign in Room, Placed in Fall Risk Gown, Fall Risk Slippers, "Preventing Falls" Info Given, 30 Minute Rounding, Room Close to Nurse's Station ..."

Review of the History and Physical dated 8/4/2022, revealed "...Patient admitted for medical reasons mechanical fall this morning, left hip pain, CT taken due to inability to walk and pain throbbing severe, shows nondisplaced minimally displaced subcapital fracture bedrest, NPO [nothing by mouth] today..."

Review of Care/Order Sets (care plan) dated 8/3/2022 at 6:01 AM, Patient #6 had a Morse Fall Code of 45 indicating she was a high risk for falls.

Review of the Nursing Note dated 8/3/2022, revealed "...Patient fell in room, unwitnessed, tech on other side of curtain and heard pt [patient] fall. Stated, "I had to go to the bathroom" and "I tripped on something and fell." Pain in left hip and painless hematoma on left side of forehead. Vitals WNL [within normal limits] and PERRLA [pupils equal, round, reactive, light, and accommodation]. Provider notified and added orders for x-ray of hip and CT of head..."

Review of the Computerized Tomography (CT) Left Lower Extremity Without Contrast, Hip dated 8/3/2022 1:42 PM, revealed "...Acute subcapital fracture proximal left femur with mild impaction. Moderate osteoarthritis. Osteopenia..."

Review of the Discharge Summary dated 8/5/2022, revealed "...patient tried to get up to the restroom on the first hospital day of her hospital stay and fell CT showed a fracture of her left hip so [Named Physician #5] was consulted she underwent repair on 8/4 in the meantime, she continued PT [Physical Therapy] and treatment for UTI [Urinary Tract Infection] will dc [discharge] with cefdinir [Antibiotic] as well and her long term care facility will assess her PT [Physical Therapy] needs electrolytes corrected..."

Review of the Root Cause Analysis Worksheet undated, revealed "...Date of Event...8/3/2022...On 8/3 [2022] at 0830 patient fell trying to get out of bed. Patient sustained a hematoma on her forehead and had complaints of left hip pain. Initial x-ray done at 0919 was negative for a fx [fracture] but a CT done at 1339 [2:39 PM] showed an acute subcapital fracture of the proximal left femur...The bed alarm was not engaged and there was no fall mat placed beside the bed...No fall mat on floor...because nurse stated she did not remember to do so...Bed alarm not engaged...because...just not set..."

Review of the facility's "Fall Prevention Policy," revealed "...REQUIRED ACTION...Implement "Protective" and "Preventative" interventions for Morse fall score of [greater than or equal to 45] for all High risk to fall patients...Include (but not limited to)...Apply High Risk to Fall armband ...Apply High Risk to Fall magnet on door rim...Activate Bed alarm...put bed in lowest position...Bedside floor mats for patients at increased risk of injury from a fall by using the mnemonic ("ABCS"): age over 85...bone disorders...coagulation disorders...surgery..."

During a telephone Interview with RN #3 on 9/14/2022 at 12:21 PM, RN #3 was asked why there were no falls mats or bed alarm activated when Patient #6 fell. RN #3 stated, "...It was just, um, in report, I thought she was going to the bedside commode by herself..." RN #3 was asked if she knew what fall interventions were on Patient #6's care plan. RN #3 stated,"...The patient fell within 30 minutes beginning of the shift...After I had time to look at the chart I did..."

During an interview with the Risk Manager Director/Patient Safety Officer on 9/14/2022 at 2:25 PM, she stated, "...a Morse score of 45 or higher is considered at High Risk...The patient should have had fall mats according to the ABCS because she was on heparin..."

The hospital failed to implement fall interventions for Patient #6 resulting with Patient #6 falling and breaking her hip.

Refer to A0396.

A registered nurse must supervise and evaluate the nursing care for each patient.

This standard is not met as evidenced by:
Based on policy review, medical record review and interview, nursing services failed to ensure a patient who was assessed as high risk for falls had interventions in place for 1 of 13 (Patient #6) sampled patients.

The findings included:

Review of the hospital's "Fall Prevention Policy," policy dated 12/14/2018, revealed "...purpose is to establish a multi-disciplinary approach to fall prevention and implement fall prevention strategies to prevent falls...Patient fall is a sudden, unintentional descent, with or without injury to the patient that results in the patient coming to rest on the floor..."

Review of the facility's "Fall Prevention Policy," revealed "...REQUIRED ACTION...Implement "Protective" and "Preventative" interventions for Morse fall score of [greater than or equal to 45] for all High risk to fall patients...Include (but not limited to)...Apply High Risk to Fall armband ...Apply High Risk to Fall magnet on door rim...Activate Bed alarm...put bed in lowest position...Bedside floor mats for patients at increased risk of injury from a fall by using the mnemonic ("ABCS"): age over 85...bone disorders...coagulation disorders...surgery..."

Review of the medical record revealed Patient #6 was admitted to the facility on 8/2/2022 with diagnoses of Acute Kidney Injury (AKI), Chronic Stage III, General Weakness, Hyponatremia, and Urinary Tract Infection (UTI).

Review of the Falls Information dated 8/2/2022, revealed "...(High Fall Risk (5+ pts) Bed Pressure Alarm, Fall Risk Arm Band on Patient, Fall Risk Sign on Door, Fall Risk Sign in Room, Placed in Fall Risk Gown, Fall Risk Slippers, "Preventing Falls" Info Given, 30 Minute Rounding, Room Close to Nurse's Station ..."

Review of the History and Physical dated 8/4/2022, revealed "...Patient admitted for medical reasons mechanical fall this morning, left hip pain, CT[Computerized Tomography] taken due to inability to walk and pain throbbing severe, shows nondisplaced minimally displaced subcapital fracture bedrest, NPO [nothing by mouth] today..."

Review of Care/Order Sets (care plan) dated 8/3/2022 at 6:01 AM, Patient #6 had a Morse Fall Code of 45 indicating she was a high risk for falls.

Review of the Nursing Note dated 8/3/2022, revealed "...Patient fell in room, unwitnessed, tech on other side of curtain and heard pt [patient] fall. Stated, "I had to go to the bathroom" and "I tripped on something and fell." Pain in left hip and painless hematoma on left side of forehead. Vitals WNL [within normal limits] and PERRLA [pupils equal, round, reactive, light, and accommodation]. Provider notified and added orders for x-ray of hip and CT of head..."

Review of the CT Left Lower Extremity Without Contrast, Hip dated 8/3/2022 1:42 PM, revealed "...Acute subcapital fracture proximal left femur with mild impaction. Moderate osteoarthritis. Osteopenia..."

Review of the Discharge Summary dated 8/5/2022, revealed "...patient tried to get up to the restroom on the first hospital day of her hospital stay and fell CT [Computerized Tomography] showed a fracture of her left hip so [Named Physician #5] was consulted she underwent repair on 8/4 in the meantime, she continued PT [Physical Therapy] and treatment for UTI [Urinary Tract Infection] will dc [discharge] with cefdinir [Antibiotic] as well and her long term care facility will assess her PT [Physical Therapy] needs electrolytes corrected..."

Review of the Root Cause Analysis Worksheet undated, revealed "...Date of Event...8/3/2022...On 8/3 [2022] at 0830 patient fell trying to get out of bed. Patient sustained a hematoma on her forehead and had complaints of left hip pain. Initial x-ray done at 0919 was negative for a fx [fracture] but a CT done at 1339 [2:39 PM] showed an acute subcapital fracture of the proximal left femur...The bed alarm was not engaged and there was no fall mat placed beside the bed...No fall mat on floor...because nurse stated she did not remember to do so...Bed alarm not engaged...because...just not set..."

During a telephone Interview with RN #3 on 9/14/2022 at 12:21 PM, RN #3 confirmed Patient #6 should have had her bed alarm engaged and falls mats per her care plan.

During an interview with the Risk Manager Director/Patient Safety Officer on 9/14/2022 at 2:25 PM, she confirmed a patient with a Morse score of 45 or higher is considered at High Risk and should have had fall mats according to the ABCS because she was on heparin..."

Based on policy review, medical record review and interview, nursing services failed to follow each patient's interdisciplinary care plan to prevent pain and falls for 2 of 13 (Patient #4 and #6) sampled patients.


The findings include:


1. Review of the hospital's "Interdisciplinary Plan of Care Policy," policy dated 11/17/2020, revealed "...PURPOSE: Provide guidelines for the interdisciplinary team in collaborating, documenting, and integrating the patient's Plan-of-Care from admission to discharge. POLICY: Each discipline is responsible for collaborating, documenting, and integrating the plan of care for each patient..."


Review of the hospital's "Pain Management Program Policy," policy dated 10/10/2020, revealed "...POLICY: To control or relieve the physical and psychosocial consequences associated with pain while maintaining the patient's level of function and overall quality of life...Healthcare professionals will...provide pain interventions in a prompt, caring fashion..."


Review of the hospital's "Fall Prevention Policy," policy dated 12/14/2018, revealed "...purpose is to establish a multi-disciplinary approach to fall prevention and implement fall prevention strategies to prevent falls...Patient fall is a sudden, unintentional descent, with or without injury to the patient that results in the patient coming to rest on the floor..."


2. Medical record review revealed Patient #4 was admitted to the hospital on 8/5/2022 with diagnoses of Cellulitis of Foot, Leukocytosis and Severe Sepsis without Septic Shock.


Review of the Grievance Log revealed on 8/17/2022, revealed Patient #4 placed a call on the Administrator On Call's line that he had not received his pain medication as ordered and also complained about his late discharge.


Review of the hospital's response letter mailed to Patient #4 dated 8/15/2022, revealed "...We also sent your concerns regarding receiving your pain medications timely to the Nursing Director of the 4th floor so that she could address this with her nurses..."


Review of the Physician Order dated 8/5/2022, revealed " ...Acetaminophen ...650 mg [milligram] ...oral ...First Dose ..."


Review of the Physician Order dated 8/5/2022, revealed " ...Acetaminophen ...650 mg ...oral ...mild pain (1-3 on pain scale) ..."


Review of the Physician Order dated 8/5/2022, revealed " ...Hydrocodone-acetaminophen (Norco 5 mg-325 mg) ...oral, q4H prn pain moderate 4-6 ..."


Review of the Medication Administration Record (MAR) dated 8/5/2022 19:20, revealed "...acetaminophen (Tylenol)...acet325 650 mg 2 tab(s)...Oral..."

Review of the MAR dated 8/5/2022 20:20, revealed , "...acetaminophen (Tylenol)...Pain Present: Yes actual or suspected pain; Medication Effective: No..."


Review of the MAR dated 8/7/2022 06:51, revealed "...Ingredients: acet500 500 mg...Pain Rating at Rest: 7...
Pain-mild or Temp > 100.4 F..."


Review of the MAR dated 8/7/2022 07:51, revealed "...acetaminophen (Tylenol)...Pain Present: Yes actual or suspected pain; Medication Effective: No..Rating Score Rest: 7; Numeric Rating at Rest: 7.."


Patient #4 was care planned for abdominal pain.


Review of the Director of Medical Surgical Services review dated 8/10/2022, revealed " ...Patient moved to ...room on 8/6 [2022] @ [at] 5:10 AM ...Tylenol 8/7 [2022] at [6:51 AM] ...Pain Rating of 7 that stayed at 7 (inappropriate drug due to scale for Tylenol was 1-3) and patient reported 7 ..."


During a telephone interview on 9/13/2022 at 2:15 PM, Registered Nurse (RN) #2 was asked if she remembered patient #3. RN #2 stated that she did not. RN #2 was asked if she would have given Tylenol to a patient with a pain scale of 6 or 7 instead of the prescribed narcotic. RN #2 stated, " ...I have never withheld pain medication. I always ask the patient if they want Tylenol if it is too soon to administer the narcotic ..." RN #2 was asked if the nurse manager had provided an inservice to the staff nurses regarding pain scale and pain medication administration. RN #2 stated, "No."


The Chief Quality Officer was emailed on 9/14/2022 and questioned if the Nursing Director of the 4th floor had addressed the issue of her nurses administering the correct pain medication per pain scale and physician orders with her nurses. The Chief Quality Officer's response via email dated 9/13/2022 at 4:03 PM, "...Per the CNO [Chief Nursing Officer]: We have had ongoing education each quarter of this year regarding pain and have now added additional training in the upcoming staff meeting since we had already had the meeting in August prior to the incident..." On 9/13/2022 at 5:08 PM, the Chief Quality Officer emailed "...In reading the letter again, it did not state a timeframe in which the director would address the staff , therefore, the leader felt it was best to address at the next staff meeting where she had good attendance..."


3. Review of the medical record revealed Patient #6 was admitted to the facility on 8/2/2022 with diagnoses of Acute Kidney Injury (AKI), Chronic Stage III, General Weakness, Hyponatremia, and Urinary Tract Infection (UTI).


Review of the Falls Information dated 8/2/2022, revealed " ...(High Fall Risk (5+ pts) Bed Pressure Alarm, Fall Risk Arm Band on Patient, Fall Risk Sign on Door, Fall Risk Sign in Room, Placed in Fall Risk Gown, Fall Risk Slippers, "Preventing Falls" Info Given, 30 Minute Rounding, Room Close to Nurse's Station ..."


Review of the History and Physical dated 8/4/2022, revealed " ...Patient admitted for medical reasons mechanical fall this morning, left hip pain, CT taken due to inability to walk and pain throbbing severe, shows nondisplaced minimally displaced subcapital fracture bedrest, NPO [nothing by mouth] today ..."

Review of Care/Order Sets (care plan) dated 8/3/2022 at 6:01 AM, Patient #6 had a Morse Fall Code of 45 indicating she was a high risk for falls.


Review of the Nursing Note dated 8/3/2022, revealed " ...Patient fell in room, unwitnessed, tech on other side of curtain and heard pt [patient] fall. Stated, "I had to go to the bathroom" and "I tripped on something and fell." Pain in left hip and painless hematoma on left side of forehead. Vitals WNL [within normal limits] and PERRLA [pupils equal, round, reactive, light, and accommodation]. Provider notified and added orders for x-ray of hip and CT of head ..."


Review of the Discharge Summary dated 8/5/2022, revealed " ...patient tried to get up to the restroom on the first hospital day of her hospital stay and fell CT showed a fracture of her left hip so [Named Physician #5] was consulted she underwent repair on 8/4 in the meantime, she continued PT [Physical Therapy] and treatment for UTI [Urinary Tract Infection] will dc with cefdinir [Antibiotic] as well and her long term care facility will assess her PT [Physical Therapy] needs electrolytes corrected ..."


Review of the Root Cause Analysis Worksheet undated, revealed " ...Date of Event ...8/3/2022 ...On 8/3 [2022] at 0830 patient fell trying to get out of bed. Patient sustained a hematoma on her forehead and had complaints of left hip pain. Initial x-ray done at 0919 was negative for a fx [fracture] but a CT done at 1339 [2:39 PM] showed an acute subcapital fracture of the proximal left femur ...The bed alarm was not engaged and there was no fall mat placed beside the bed ...No fall mat on floor ...because nurse stated she did not remember to do so ...Bed alarm not engaged ...because ...just not set ..."


Review of the facility's "Fall Prevention Policy," revealed " ...REQUIRED ACTION ...Implement "Protective" and "Preventative" interventions for Morse fall score of [greater than or equal to 45] for all High risk to fall patients ...Include (but not limited to) ...Apply High Risk to Fall armband ...Apply High Risk to Fall magnet on door rim ...Activate Bed alarm ...put bed in lowest position ...Bedside floor mats for patients at increased risk of injury from a fall by using the mnemonic ("ABCS"): age over 85 ...bone disorders ...coagulation disorders ...surgery ..."


During a telephone Interview with RN #3 on 9/14/2022 at 12:21 PM, RN #3 was asked why there were no falls mats or bed alarm activated when Patient #6 fell. RN #3 stated, " ...It was just, um, in report, I thought she was going to the bedside commode by herself ..." RN #3 was asked if she knew what fall interventions were on Patient #6's care plan. RN #3 stated, " ...The patient fell within 30 minutes beginning of the shift ...After I had time to look at the chart I did ..."


During an interview with the Risk Manager Director/Patient Safety Officer on 9/14/2022 at 2:25 PM, she stated, " ...a Morse score of 45 or higher is considered at High Risk ...The patient should have had fall mats according to the ABCS because she was on heparin ..."