HospitalInspections.org

Based on observations, interviews, and record reviews, it was determined that the Hospital failed to follow and implement its own Plan of Care for 3 (Patient Samples #3, #4 and #5) out of 10 sampled patients. The facility also failed to assure appropriate care plans were developed (Patient Sample #9). The failed practice did not assure goals were established for patients according to individual needs, nor that the goals were evaluated, addressed, revised and/or updated.


The findings include:


First observation made on 6/22/16 at 11:00 AM:

Surveyor observed a patient (Patient #3) in Room 37-2. Patient had a yellow fall risk sign by the door. No bed alarm was observed. The Chief Nursing Clinical Officer (CNO), who accompanied the surveyor stated, "I'll find out what happened to his bed alarm. He should have one, and we will get one right away. He is a fall risk."

Record review of nursing progress notes revealed he had a history of falls and his current fall score at the time of survey was a 17 (10 and above = High Risk for Fall) on 6/23/16. Care Plan review revealed "At risk for falls," was identified with a goal to be free of falls. Intervention included: "Implement safety measures."

The hospital failed to ensure adequate fall prevention measures were in place for Patient #3.


2. Second observation made on 6/22/16 at 11:15 AM:

Surveyor observed a patient (Patient #5) in Room 39-2, who also had a yellow fall risk sign by the door.

Upon observation, the bed alarm was not attached to patient.

The CNO who accompanied the surveyor, stated, "I'll find out what happened. She should have her bed alarm attached. She is a fall risk."

Record review of nursing progress notes revealed her current fall score was a 10 (10 and above = High Risk for Fall) as of 6/23/16.

Care plan review revealed, "At risk for falls," was identified with a goal to be free of falls. Intervention included: "Implement safety measures."


3. Third observation made on 6/22/16 at 11:35 AM:

Surveyor observed a patient (Patient #7) in Room 41 who also had a yellow fall risk sign by the door.

Upon observation, the patient did not have any fall safety measures actively in place, such as fall mats or bed alarm.
In an interview with Employee A (Nurse) on 6/22/16 at 12:50 PM, it was stated to surveyor, "The sign was from the previous patient. It's a mistake. The current patient in there is not a fall risk. That sign is being removed." Upon record review, it was revealed that patient is indeed not a fall risk. His fall score was an 8 and he had no history of falls.



4. Fourth observation made on 6/22/16 at 11:55 AM:

Surveyor observed a patient (Patient #4) in Room 31-1 lying perpendicular on the bed by himself in the room. His door was open. The two signs on the door revealed the yellow fall risk sign and blue eye balls sign. Upon observation of the patient, his foot was almost touching the floor mat and he was perpendicular on the bed; there was no alarm ringing since it was not connected. Nobody was aware. No staff members were nearby for immediate assistance. Additionally, patient was non-verbal. The bed was not in the lowest position. Surveyor needed to ask the CNO who accompanied the surveyor, to locate his bed alarm and it was found not connected.

Surveyor also could not locate his nurse in the area during this observation.
Strong odor of feces was noted by both CNO and Surveyor. The patient was in need of hygiene measures, since he had a large bowel movement. The CNO then called for assistance from two CNAs.


The CNO stated, "I'll find out what happened. He should have his bed alarm attached. He is at high risk for falls. The blue eyeball signs mean all eyes on deck. All patients at high risk for falls should have their bed alarm connected and fall mats automatically placed. Nursing is responsible to ensure that fall prevention measures are in place."


Record review of Nursing Progress Notes revealed his current fall score was a 23 (10 and above = High Risk for Fall, with 23 being a notably high score) as of 6/23/16.

Care Plan review revealed, "At risk for falls," was identified with a goal to be free of falls." Intervention included: "Implement safety measures."

The hospital failed to ensure adequate fall prevention measures were in place for Patient #4.



5. Record review of Patient #9, with a primary diagnosis of respiratory failure, revealed a Care Plan for falls. Patient was observed during Medication Administration on 6/22/16 at 12:35pm. Surveyor noted patient vented lying in bed obtunded (low functioning).

There were no fall risk signs by the entrance in her room. Her current fall score was a 1, which is not a fall risk.


During interview with CNO on 6/23/16 at 11am, she stated that she did not understand why the nurse care planned Patient #9 for falls. She stated, "That is not appropriate. That should not be in her Plan of Care. I need to in-service Nursing."