HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure the registered nurse supervised and evaluated the nursing care for each patient related to fall risk assessment and implementation of fall risk interventions and seizure precautions for 4 of 5 (N1, N3, N4 and N5) closed patient medical records reviewed.

Findings:

1. Policy No.: NSI-SFT_04 titled, "Seizure Precautions" was reviewed on 1/20/11 at 3:00 PM and indicated, on pg. 2, bulleted points under Documentation section, "Chart when seizure precautions implemented and that precautions are maintained every shift..."

2. Policy No.: PC_07 titled, "Risk for Fall and/or Entrapment Guidelines" was reviewed on 1/20/11 at 3:00 PM and indicated on pgs. 2 and 3, bulleted points, "Once the patient is identified as Risk for Fall...Check patient every 2 hours and assess for reorienting needs, toileting needs, food/fluid needs...Reassessment of Risk Factors shall be performed each shift and documented on the nursing documentation record."

3. Review of closed patient medical records on 1/20/11 at 12:00 PM indicated Patient:
A. N1 (client named in complaint) was a 39-year-old admitted through the ED on 11/30/10 at 19:49 PM with a chief complaint of "seizures, GM (grand mal) times two" and was transferred to the Intensive Care Unit (ICU) on 12/1/10 at 01:45 AM for further medical management. Other documentation in the medical record included:
a. per Nurse ED Notes dated 11/30/10 at 20:08 PM, "arrived unconscious, incontinent of bladder. Began seizing again on the cart..."
b. per History & Physical dated 12/1/10 at 14:20 PM, "known history of...seizure disorder..."
c. per Fall Risk Assessment dated 12/1/10 at 03:26 AM and 12/4/10 at 05:55 AM, the patient's Morse Fall Risk was assessed and it was indicated that patient was a fall risk. Morse Fall Risk assessment was lacking for 12/2/10 and 12/3/10.
d. per Daily Care/Safety Flowsheet dated:
i. 12/1/10 at 02:00 AM to 06:00 AM and 20:00 PM to 12/2/10 at 00:00 AM, patient was assessed to be a seizure risk, but lacked documentation of implementation of seizure precautions.
ii. 12/2/10 at 02:00 AM through 12/4/10 at 16:00 PM, lacked documentation of seizure risk and documentation of implementation of seizure precautions. Laked documentation on 12/2/10 and 12/4/10 every two hours of fall risk interventions.

B. N3:
a. per History & Physical dictated 11/30/10 at 4:50 PM, "history of seizure disorder..."
b. per Daily Care/Safety Flowsheet dated 11/30/10 through 12/4/10:
i. patient was assessed to be a seizure risk, but lacked documentation of implementation of seizure precautions.
ii. lacked documentation on 12/3/10 and 12/4/10 every two hours of fall risk interventions.
c. per Fall Risk Assessment dated 11/30/10 through 12/4/10, the patient's Morse Fall Risk was assessed and it was indicated that patient was a fall risk. Morse Fall Risk assessment was lacking for 12/1/10 and 12/2/10.

C. N4:
a. per History & Physical dictated 10/13/10 at 17:14 PM, "seizure activity..."
b. per Daily Care/Safety Flowsheet dated 10/13/10 through 10/25/10:
i. patient was assessed to be a seizure risk, but lacked documentation of implementation of seizure precautions.
ii. lacked documentation on 10/15/10 and 10/16/10 every two hours of fall risk interventions.
c. per Fall Risk Assessment dated 10/13/10 through 10/25/10, the patient's Morse Fall Risk was assessed and it was indicated that patient was a fall risk. Morse Fall Risk assessment was lacking for 10/14/10, 10/15/10, 10/17/10 and 10/22/10.

D. N5:
a. per History & Physical dictated 12/1/10 at 10:32 AM, "New onset seizures..."
b. per Daily Care/Safety Flowsheet dated 12/1/10 through 12/5/10:
i. patient was assessed to be a seizure risk, but lacked documentation of implementation of seizure precautions.
ii. lacked documentation on 12/5/10 every two hours of fall risk interventions.
c. per Fall Risk Assessment dated 12/1/10 through 12/5/10, the patient's Morse Fall Risk was assessed and it was indicated that patient was a fall risk. Morse Fall Risk assessment was lacking for 12/3/10 and 12/4/10.

4. Personnel Personnel P5 was interviewed on 1/20/11 at 12:11 PM and confirmed, Morse Fall Risk assessments are to be done daily, as well as assessments every two hours by the nurse that fall risk interventions are in place for patients determined to be a fall risk. Also, patient's who are at risk for seizures should have documentation that seizure precautions have been implemented as required per facility policy and procedure. This was lacking as described for the above-mentioned patients.