HospitalInspections.org

Based on interviews and documentation review the Hospital failed to conduct a thorough investigation and identify all opportunities for improvement for one of one patients (Patient #1).

Findings included:

The Complainant was interviewed on 8/19/10 at 9:00 A.M. and said the family member reported the following: Patient #1, who resided at home, fell while working in the yard, and sustained a left hip fracture. Surgery was performed and Patient #1 was then transferred to a skilled nursing facility (SNF) for rehabilitation therapy. Patient #1 was just days away from returning home, was walking independently with a walker, and was alert and oriented. Patient #1 became confused, developed an increased temperature and there was question of a urinary tract infection because the Foley catheter had been recently removed. On 7/12/10 Patient #1 was sent to the Hospital's ED for an evaluation.

Review of the medical record indicated that a copy of physician orders, containing medications, diagnoses, and mobility orders, was forwarded from the SNF to the Hospital with Patient #1. Although the orders did not identify Patient #1's fall history they included: an order to use an assistive device as indicated (walker/cane/crutches) but did not specify which device was being used, and diagnoses of a pathological fractured hip (fracture that occurs in a weakened bone as a result of a disease state; documentation, dated 7/15/10, indicated that pathology from Patient #1's previous surgery was suggestive of left hip involvement of low grade lymphoma); hip replacement surgery; muscle weakness; difficulty in walking, and depressive/mood disorder.

The ED Triage Assessment/Record, dated 7/12/10, indicated that Patient #1 arrived via ambulance stretcher. Patient #1 was confused and obedient. Patient #1's ability to ambulate was not witnessed. Patient #1 denied using an assistive device. The safety assessment included check-off boxes for recent falls, sensory/motor deficits, unable/unwilling to follow commands, and no risk. Patient #1 was not considered a safety risk.

The Triage Nurse who assessed Patient #1 was interviewed on 8/20/10 at 8:20 A.M. The Triage Nurse reported not remembering Patient #1 and not remembering who supplied Patient #1's information. The Triage Nurse reported the usual practice was to obtain fall history from the patient/family member. The Triage Nurse reported he/she would ask the patient about the fall history even if the patient was confused.

The medical record documentation, dated 7/12/10, indicated that Patient #1 was examined by the ED Physician. ED physician documentation consisted of a hand written evaluation and a dictated report. The hand written report did not address Patient #1's mental status other than to say Patient #1 had been lethargic. The dictated report indicated that Patient #1 was considered to be slightly confused, oriented to person and place but not to date/time, and the gait was not tested because Patient #1 reported feeling too weak to walk. The report dictated was on 7/12/10 at approximately 11:50 P.M. and was not transcribed until 7/13/10 at approximately 6:00 A.M.

The ED Physician who cared for Patient #1 was interviewed on 8/19/10 at 11:55 A.M. The ED Physician reviewed the medical record documentation and stated Patient #1 was confused and a poor historian. The ED Physician said the family member was there and would have been the main source of information.

The Complainant said the family member reported that while Patient #1 was in the ED, Patient #1 remained confused and attempted to get off the stretcher unassisted by climbing out the bottom and pulling out the intravenous line which had to be reinserted.

Review of the ED documentation, dated 7/12/10, indicated that there was no documentation regarding Patient #1's alleged behavior.

The nurses assigned to Patient #1 in the ED were interviewed as follows: the first ED nurse to care for the Patient (ED Nurse #1) was unavailable for an interview at the time of the survey. ED Nurse #2 was interviewed on 8/20/10 at 10:25 A.M. ED Nurse #2 reported not remembering Patient #1.

The medical record documentation, dated 7/12/10, indicated that diagnostic testing was ordered and performed, an intravenous line was inserted, and fluids/antibiotics were administered. Patient #1 was admitted to the Medical/Surgical (Med/Surg) Unit for further monitoring.

The Hospital's Policy/Procedure titled Hand Off Communication indicated that the exchange of information should include up-to-date data and facts regarding the patient's care, treatment and services, condition and any recent or anticipated changes.

The nurse assigned to Patient #1 at the time of transfer from the ED (ED Nurse #3) was interviewed on 8/20/10 at 12:55 P.M. Nurse #3 said, when giving a report, mental status was addressed only if it played a a role in what was going on with the patient. Nurse #3 said confusion would have been reported however; Nurse #3 had no recollection of Patient #1 or the hand off communication.

The nurse who admitted Patient #1 to the Med/Surg Unit (Med/Surg Nurse #1) was interviewed on 8/20/10 at 7:00 A.M. Nurse #1 reported receiving a verbal report from the ED regarding Patient #1 and reported there was no mention of Patient #1's behaviors or mental status.

The admission assessment, dated 7/12/10, 11:08 P.M., indicated that a fall risk assessment was performed. The assessment indicated that Patient #1 had no history of falls, was alert and oriented to person, place, date/time, and walked steady. Patient #1 was assessed as being at low risk for falls. Documentation indicated the call bell was placed within reach, the bed was in the low position and there were 2 siderails in the up position. Documentation indicated Patient #1's skin was intact.

Med/Surg Nurse #1 said Patient #1 arrived to the Unit on a stretcher and was not accompanied by a family member. Nurse #1 said the fall risk assessment results were based on observations and patient interview. Nurse #1 reported observing Patient #1 get off the stretcher, walk from the bottom of the bed to the top, and climb into the bed without assistance or complaints of pain. Nurse #1 said Patient #1 was able to correctly identify person, place, and date/time. Nurse #1 said Patient #1 was still in street clothing, therefore only the skin that was visible was assessed. Nurse #1 reported not being aware of the scar from recent hip surgery. Nurse #1 reported it was the end of the shift and handed Patient #1 off to Med/Surg Nurse #2. Nurse #1 said when Patient #1 was last seen, Patient #1 was in bed with the call bell and and a urinal within reach.

Review of the medical record documentation, dated 7/13/10, indicated that Patient #1's vital signs were taken at approximately 12:23 A.M. by the certified nurse aide assigned to the Unit (CNA #1). The admission assessment was completed by Med/Surg Nurse #2 at approximately 1:00 A.M. Review of the assessment indicated that Patient #1 was asked about the musculoskeletal history which included a history of fractures, and surgeries. Patient #1 reported having a total knee replacement. There was no mention of the recent hip surgery. Patient #1 denied having pain. At approximately 2:30 A.M. a fall risk assessment was completed and was unchanged from the previous assessment. Documentation indicated the call bell was placed within reach, the bed was in the low position and there were 2 siderails in the up position. Documentation indicated that fall prevention interventions were implemented and included: toileting every 2-3 hours; ambulation aides provided, and nonskid slippers. Documentation indicated Patient #1 was a 1 person assist, had poor safety awareness, was continent, and used a urinal independently. Documentation indicated that a skin assessment was performed and Patient #1's skin was intact.

CNA #1 was interviewed on 8/20/10 at 7:10 A.M. CNA #1 reported being on duty for the night shift (11:00 P.M. to 7:00 A.M.). CNA #1 said at the beginning of the shift Patient #1 rang the call bell and reported needing to void. CNA #1 said Patient #1 reported having a fractured hip. CNA #1 reported giving Patient #1 a urinal and instructing Patient #1 to call for assist. CNA #1 said Patient #1 did ring the call light when finished voiding and the urinal was emptied. CNA #1 reported telling Med/Surg Nurse #2 about Patient #1's fractured hip. CNA #1 said Patient #1 rang several more times throughout the shift to use the urinal and request a drink. CNA #1 said hourly rounding was done and each time Patient #1 was in bed (feet were visible from the doorway).

Med/Surg Nurse #2 was interviewed on 8/20/10 at 12:45 P.M. Nurse #2 said that at the beginning of the shift Patient #1 was given medications and the admission assessment was completed. Nurse #2 said Patient #1 was quiet, able to converse, and was sitting in bed fully clothed. Nurse #2 said Patient #1 was able to correctly communicate person, place and date/time. Nurse #2 said Patient #1 spoke about having knee surgery and did not mention hip surgery however; Nurse #2 saw in the electronic medical record Patient #1 had hip surgery. Nurse #2 reported assessing the skin that was visible and not undressing Patient #1. Nurse #2 said while performing the fall assessment Patient #1 reported there was no history of falls and reported he/she was unable to ambulate. Nurse #2 said Patient #1 was reminded to use the urinal. Nurse #2 said hourly rounding was performed and each time Patient #1 was sleeping with the call bell in reach.

Documentation indicated that at approximately 6:20 A.M. Patient #1 was found on the buttocks on the floor in front of the bed. Patient #1 reported returning from the bathroom and fell.

CNA #1 said that at approximately 6:00 A.M. Patient #1 rang for the urinal which was provided. CNA #1 reported leaving the room to perform blood sugars on other patients. CNA #1 reported passing by Patient #1's room and noting Patient #1's feet were not visible. CNA #1 said Med/Surg Nurse #2 was in the corridor preforming a task. CNA #1 reported asking Med/Surg Nurse #1 if he/she had seen Patient #1 and Med/Surg Nurse #2 reported he/she was going into see Patient #1.

Nurse #2 said at approximately 6:20 A.M. he/she was in the corridor passing medications and was diagonal to Patient #1's room. Nurse #2 said CNA #1 passed by Patient #1's room and told Nurse #2 Patient #1 was up and was in the bathroom. Nurse #2 said CNA #1 did not enter Patient #1's room. Nurse #2 said right after a thud was heard and Patient #1 was found seated on the floor. Med/Surg Nurse #2 said this was the first time a patient on his/her assignment had fallen. Nurse #2 said after an assessment was completed Patient #1 was lifted back to bed by several staff members and the physician was notified. Nurse #2 said it was the physician's responsibility to contact the family however; before the physician could examine Patient #1, Patient #1 had called and notified the family of the fall. Med/Surg Nurse #2 said at that point the shift had ended and report was given to Med/Surg Nurse #3.

The Complainant said that the family reported after receiving Patient #1's telephone call, the family member called the nursing station to confirm the call, then came to the Hospital only to find Patient #1 was still in street clothing.

Med/Surg Nurse #3 was interviewed on 8/19/10 at 11:35 A.M. Nurse #3 reported after receiving report assessing Patient #1 and noting Patient #1 was still in street clothing and was confused. Nurse #3 said Patient #1 was undressed, the physician and nursing supervisor were notified, a hip x-ray was ordered, and Patient #1 was undressed.

The medical record documentation, dated 7/13/10, indicated that a hip x-ray was performed which revealed a left hip fracture. An orthopedic consult was obtained. Due to Patient #1's other medical issues (severe neutropenia) surgery was delayed until 7/20/10.

Review of documentation from the Hospital indicated that the family spoke with the Patient Advocate and a complaint was filed. Review of the complaint indicated that the family member reported to the Advocate that Patient #1 pulled out the intravenous line and kept trying to get off the stretcher while in the ED. The family member felt Patient #1 should have been placed on safety precautions due to behaviors in the ED. The complaint did not include the fact that Patient #1 was still in street clothing since admission to the Hospital. The Hospital initiated an investigation.

The Director of Quality and Patient Safety and the Risk Manager were interviewed together on 8/19/10 and throughout the survey. They said interviews were conducted with Med/Surg Nurse #1 and #2, and with CNA #1 and a medical record review was performed and an interdisciplinary review was performed. They said the investigation determined the fall was not preventable and that everything was done appropriately. The Director said they were not made aware of the issue with street clothing.

The investigation did not address the complaint alleging Patient #1 displayed unsafe behaviors in the ED.

The investigation did not identify that: full skin assessments were not performed; the musculoskeletal assessment was inaccurate because Med/Surg Nurse #2 was aware of recent hip surgery but did not document; the fall risk assessment completed by Med/Surg Nurse #2 was inaccurate because Nurse #2 said Patient #1 reported being unable to ambulate however; the mobility section of the fall risk assessment was coded as ambulates steady/device.

Based on interviews and documentation review the Hospital failed to act upon deficient practice identified during the course of an investigation of a fall with injury for one of one patients (Patient #1).

Findings included:

Please refer to Standard A-0287 for medical record information.

The investigation identified through interviews with Medical/Surgical Nurses #1 and #2 that they did not review the information forwarded from the skilled nursing facility regarding Patient #1 however; the Hospital did not act upon that information and implement a corrective action plan to ensure that patient information provided from other facilities or other departments within the Hospital (such as the ED) are reviewed by the receiving nursing staff.

Based on interviews and documentation review the Hospital failed to ensure that: 1) patient information from the transferring facility was reviewed by nursing staff admitting one of one patients (Patient #1); 2) skin assessments were properly performed by the nursing staff; 3) the musculoskeletal assessment portion of the admission assessment was accurately completed for one of one patients (Patient #1); 4) the fall risk assessment was accurately completed for one of one patients (Patient #1), and 5) fall risk interventions were appropriately implemented for two of four patients (Patient #2 and Patient #3).

Findings included:

Please refer to Standard A-0287 for medical record information and interviews with staff regarding Patient #1.

1) The investigation identified through interviews with Medical/Surgical Nurses #1 and #2 that they did not review the information forwarded from the skilled nursing facility regarding Patient #1 that identified diagnoses of a pathological fractured hip (fracture that occurs in a weakened bone as a result of a disease state); hip replacement surgery; muscle weakness; difficulty in walking, and depressive/mood disorder.

2) Review of the medical record documentation, dated 7/12/10 and 7/13/10, indicated that several skin assessments were performed that indicated Patient #1's skin was intact.

Interviews with Med/Surg Nurse #1, #2, and #3 and with CNA #1 determined that Patient #1 remained in street clothing from admission to the Medical/Surgical Unit on 7/12/10 until after the fall on 7/13/10. Interviews with Med/Surg Nurses #1 and #2 indicated that only the skin visible outside the clothing was assessed.

3) Review of the medical record documentation, dated 7/13/10, indicated that the admission assessment was completed by Med/Surg Nurse #2. Review of the assessment indicated that Patient #1 was asked about the musculoskeletal history which included a history of fractures, and surgeries. Patient #1 reported having a total knee replacement. There was no mention of the recent hip surgery.

Med/Surg Nurse #2 was interviewed on 8/20/10 at 12:45 P.M. Nurse #2 said the admission assessment was completed. Nurse #2 said Patient #1 spoke about having knee surgery and did not mention hip surgery however; Nurse #2 saw in the electronic medical record Patient #1 had hip surgery.

4) Med/Surg Nurse #2 said while performing the fall risk assessment Patient #1 reported there was no history of falls and reported he/she was unable to ambulate.

Review of the medical record documentation, dated 7/13/10, indicated that the fall risk assessment was completed. The assessment indicated that Patient #1 had no history of falls, was alert and oriented to person, place, date/time, and walked steady/device.

5) A tour of the Med/Surg Unit was conducted on 8/19/10 with the Director of Quality and Patient Safety, the Risk Manager, and the Patient Care Director present. The Patient Care Director said patients identified as at risk for falls had the following in place: a green dot next to their name on the patient board at the nursing station; a green identification bracelet or green dot on the bracelet, and green nonskid slipper socks. Observation determined that fall risk was also addressed in the patient Kardex and plan of care. During the tour 4 patients were randomly chosen for a review (Patient #2, Patient #3, Patient #4, and Patient #5). Observation and review determined the following:

Review of medical record documentation for Patient #2 indicated that Patient #2 was assessed as at risk for falls. Documentation indicated that interventions included: the fall sticker, fall bracelet, nonskid socks, and a bed alarm.

Observation during the tour of the patient board and Patient #2 indicated that none of the interventions were in place.

Review of the medical record documentation for Patient #3 indicated that Patient #3 was assessed as at risk for falls. Documentation indicated that interventions included the fall sticker; fall bracelet, and nonskid socks. A bed alarm was not implemented as Patient #3 was alert and oriented.

Observation during the tour of the patient board and Patient #3 indicated that the bracelet and socks had not been implemented.

Fall prevention for Patients # 4 and #5 was in compliance.