HospitalInspections.org

Based on record review and interview the hospital failed to thoroughly investigate an anomalously reported incident involving patient safety. This deficiency is evidenced by the failure of the hospital to thoroughly investigate 1( #2) of 9(#1, #2, #R1, #R2, #R3, #R4, #R5, #R6 and #R7) reported incidents reviewed for possible delay in care.
Findings:

Review of incident reports to the hospital internal reporting SOS system listed as possible delay in care revealed on 10/13/2022 an anonymous staff member expressed concerns about the care provided to Patient #2. The staff member reported, "Overnight on Tuesday 10/11 into the early morning of 10/12 patient's spouse reports that she noted multiple times to nightshift staff that the patient was acting differently. His speech was off. She thought maybe he had a concussion. Reports that the staff did not call the provider to assess the patient, just checked vitals and said that his symptoms were expected after surgery. Upon assessment by the day shift the morning of 10/12, patient had left sided weakness and facial droop. A stroke code was called and stroke confirmed on MRI."

In interview on 11/30/2022 10:06 a.m., S4UM verified she had reviewed the nursing care provided for the night of 10/11/2022. She spoke with the nurse providing care that night, but she was not aware the family had voiced concerns of an unwitnessed fall with possible concussion. S4UM verified she did not ask the nurse providing care on the evening of 10/11/2022 if the family had voiced concerns about changes in mental status and the possibility of a fall with resulting concussion.

Review of the focused review initiated by the SOS report was performed by the surveyor. The report failed to investigate why the family felt the patient had a concussion, if the patient had suffered a fall, and if the nurse providing care on the evening of 10/11/2022 neglected the family's concerns of possible head trauma with concussion.

In interview on 11/30/2022 at 9:39 a.m., S3RiskMgr. verified the report did not include an investigation into why the family felt the patient had a concussion and if the nurse had ignored the family's concerns.

Based on record review and interview the hospital failed to ensure nursing staff adhered to the policies and procedures of the hospital. This deficiency is evidenced by failure of the nursing staff to evaluate the patient and notify the licensed practitioner in 1(#2) of 1 reviewed records involving mental status changes after concerns of an unwitnessed fall were presented by the patient's family.

Findings:

Review of the document titled "Fall Prevention Bundle" provided as in service training to the facility's nursing staff, "If the patient falls, notify the practitioner and enter the appropriate documentation per the organization's practice."

Review of incident reports to the hospital internal reporting SOS system listed as "Possible Delay in Care" revealed on 10/13/2022 an anonymous staff member expressed concerns about the care provided to Patient #2. The staff member reported, "Overnight on Tuesday 10/11 into the early morning of 10/12 patient's spouse reports that she noted multiple times to nightshift staff that the patient was acting differently. His speech was off. She thought maybe he had a concussion. Reports that the staff did not call the provider to assess the patient, just checked vitals and said that his symptoms were expected after surgery. Upon assessment by the day shift the morning of 10/12, patient had left sided weakness and facial droop. A stroke code was called and stroke confirmed on MRI." A focused review of the patient's care was performed in response to the report but failed to investigate if the family's concern of a possible fall with resulting concussion was addressed by the nursing staff.

A focused review of the patient's care performed in response to the incident report was reviewed by the surveyor. The report failed to investigate if the family's concern of a possible fall with resulting concussion was addresses by the nursing staff.

In interview on 11/30/2022 at 10:15 a.m., S4UM verified if a patient falls or there is question of an unwitnessed fall, the patient should be assessed, vital signs taken and the physician should be notified.

Review of Patient #2's medical record was performed during the interview on 11/30/2022 at 10:15 a.m. Review of the records for the evening of 10/11/2022 failed to reveal documentation by the nurse of the family's concerns that the patient was acting differently and concerns of a concussion. S4UM also verified there was also no documentation the licensed practitioner was contacted.

In interview on 11/30/2022 at 10:18 a.m., S4UM verified the nurse should have documented the family's concerns and the licensed practitioner should have been notified if there were concerns of a fall with head injury.