HospitalInspections.org

delivery of care

Based on record review and interview, the staff failed to follow the providers orders and their policies and procedures for obtaining vital signs and neurologic (neuro) checks after a fall in 2 of 2 patients with falls (Patient # 1 and #3) in a total of 10 medical records reviewed.

Findings include:

Record review of policy titled Patient Falls #301.28, last revised 3/2021 under Documentation revealed "If a fall occurs, the RN will: a. "document appropriate physical assessment, obtain vital signs and initiate neuro checks... notify physician for further instruction/follow-up. Following a fall a patient will be... assessed every shift X 48 hours, documentation should include appropriate physical assessment and vital signs each shift."

Patient #1's medical record revealed Patient #1 was a 22-year-old admitted on 5/02/2022 with suicidal ideations. Nurse note dated 5/02/2022 at 7:23 PM revealed Patient #1 "States at 1700 (5:00 PM) fell out of bed and hit forehead. Neuro check WNL" (within normal limits). There was no further assessments or vital signs documented. On 5/02/2022 at 8:00 PM neuro checks were ordered for every 4 hours while awake, stop date 5/03/2022 at 8:00 AM. Neuro checks were documented once before 5/03/2022 at 8:00 AM, at 9:25 PM (2 hours and 25 minutes after the fall). Order for post fall evaluation every 8 hours for 48 hours, with the stop date of 5/05/2022 at 4:59 AM, was entered on 5/02/2022 at 9:22 PM. Vital signs were documented on 4 shifts (ordered 8 times), and post fall evaluation was not documented 5/03/2022 on the 11:00 PM to 7:00 AM shift (ordered once per shift).

Patient #3's medical record revealed Patient #3 was a 81-year-old inpatient admitted on 6/04/2022 with a diagnosis of Alzheimer's under a chapter 51 (involuntary admission) for behavioral disturbance. Nursing note 6/08/2022 at 6:22 PM revealed "Noted to be lain (sig) on the floor, outside of his bedroom." Order for medical consult for fall was entered 6/08/2022 at 10:20 PM. On 6/09/2022 at 10:45 AM nursing note revealed "initiated fall checks." Order for post fall evaluation every 8 hours for 48 hours was not entered until 6/09/2022 at 10:45 AM. There were no post fall evaluations documented on the 11:00 PM to 7:00 AM shift on 6/09/2022, 6/10/2022 or 6/11/2022.

On 6/14/2022 at 3:20 PM during an interview with Health Information Manager K and Registered Nurse (RN) J, when asked if there were any other vital signs or neurologic assessments documented in Patient #1 or Patient #3's medical records, RN J stated "I don't see any."

Based on record review and interview, the facility failed follow their policies and procedures to ensure the patient's condition was being monitored by failing to document the patient's progress towards their goals and interventions in 1 of 10 patient's medical records (Patient # 4) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Documentation Guidelines" # 10700859, last revised 11/2021, under Nursing Service revealed "The Primary RN (registered nurse) shall document progress... a minimum of weekly for the first 8 weeks of the patient's hospitalization... This note shall include documentation of progress toward goals and nursing interventions."

Review of Patient #4's medical record revealed Patient #4 was an 81-year-old admitted 4/17/2022 under a chapter 51 hold (involuntary admission) for being violent in his/her group home. There were no weekly progress notes with documentation of how Patient #4 was progressing toward their goals.

On 6/15/2022 at 10:45 AM interview with Health Information Management Supervisor K and Health Information Technician (HIT) L during review of Patient #4's medical record, HIT L stated s/he "didn't see any" weekly progress notes documented in Patient #4's medical record.

Based on record review and interview, the facility failed to collect data to ensure medication reconciliation is completed in a timely basis in 2 of 17 medications reconciled during admission (lamotrigine and testosterone) in a total of 1 of 10 patient's whose medical records were reviewed (Patient #1).

Findings include:

Record review of policy "Medication Management" #212.12 last revised 11/2021 under Medication Reconciliation A. revealed "The Provider reviews and approves the Medication Reconciliation and... will then place medication orders electronically." Under C. revealed "Medication reconciliation is completed by the provider whenever a patient is admitted."

Record review of policy "Incident Report" #205.02, last revised 12/2020 revealed "Incidents - are unexpected or unusual events that are harmful or potentially harmful."

Patient #1's medical record revealed Patient #1, a female to male transgender, was admitted 5/02/2022 at 1:25 AM with suicidal ideation's, . Home medication list provided by the Emergency Department on admission listed both lamotrigine 100 mg and 25 mg one tablet twice daily (mood stabilizer). Order for Lamotrigine 100 mg tablet twice daily on 5/02/2022 at 2:49 AM was entered. Nursing note 5/02/2022 at 10:43 PM revealed Patient #1 was upset about his medications "Pt said he takes lamotrigine 125 mg BID" (twice a day). Lamotrigine 25 mg twice daily was ordered 5/03/2022 at 12:05 PM by Psychiatric Mental Health (PMH) Nurse Practitioner G and given for the first time 5/03/2022 at 7:23 PM. Patient #1 received an incorrect medication dose of lamotrigine for 1-1/2 days.

The home medication list also included testosterone cypionate 200 mg intramuscularly (IM) (male hormone). Order for Internal Medicine to Consult to "confirm and order testosterone IM" was entered 5/02/2022 at 3:16 AM. Nursing notes 5/03/2022 (Tuesday) at 1:56 PM, 9:54 PM and 10:51 PM revealed patient "needs order for weekly Testosterone." He stated it was "due weekly on Tuesdays ...upset he didn't get his testosterone injection. Order for Testosterone cypionate 60 mg subcutaneous injection every 7 days to be given tomorrow with comment "VERIFY DATE OF PREVIOUS DOSE BEFORE ADMINISTERING" was entered on 5/04/2022 at 6:32 PM. Testosterone cypionate 60 mg was administered on 5/05/2022 at 9:47 AM, 3 days and 18 hours after the first request for confirmation of testosterone was entered.

On 6/14/2022 at 3:20 PM during interview with Health Information (HIM) Manager K and Health Information Technician L during medical record review, HIM Manager K confirmed the lamotrigine and testosterone were not reconciled at the time of Patient #1's admission.

On 6/14/2022 at 3:37 PM during interview with Electronic Health Record Registered Nurse (RN) J, when RN J was asked if an incident report was completed when there was a delay in medication reconciliation, RN J stated "no."