HospitalInspections.org

Based on interviews and record reviews, the hospital failed to develop nursing care plan interventions in response to ongoing assessments of the patient's needs in 1 of 3 patients reviewed (Patient #1).

The findings included:

On 06/16/19 at 2:44 AM, Patient #1 arrived at the Emergency Department (ED), via Emergency Medical Services (EMS). The patient presented with altered mental status and generalized weakness. His wife accompanied him, stating that he woke at 2:00 AM to go to the bathroom and slid off the bed. She could not get him back to bed and called 911. The patient's history included a cerebrovascular accident (CVA) 15 years ago with mild residual right hemiparesis and expressive aphasia.

At 2:49 AM, a stroke alert was called. The ED physician report revealed no new motor deficit, but the patient was uncooperative on examination, needing sedation, Ativan 2 milligrams IV (intravenous), for CT (computerized tomography) scan of brain, and angiograms of the head and neck. Neurology was called and found the patient was not a candidate for a Tissue plasminogen activator (TPA) as the patient was on coumadin and his international normalized ratio (INR) >1.7 (greater than 1.7).

The impression of the CT Scan of the brain revealed 'a large chronic left middle cerebral artery territory left temporal parietal infarct with encephalomalacia. No acute intracranial hemorrhage. The angiograms of the head and neck revealed no large vessel occlusion and the physicians ruled out a stroke.'

On 06/16/19 at 3:16 AM, the patient's toxicology test revealed Alcohol, Quantitative (0-10mg/dl) was 15 high.

On 06/16/19 at 8:41 AM, the patient was admitted to the telemetry floor.

On 06/16/19 at 4:09 PM, the Nursing Plan of Care revealed document neurovascular checks; 4:53 PM, create fall precautions; and 7:43 PM, create Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA).

On 06/16/19 at 8:00 PM, the clinical / nursing documentation revealed a fall intervention in use: bed exit alarm, family presence, patient at high risk for falls.

On 06/16/19 at 8:22 PM, review of RN-A's (Regisitered Nurse-A) nursing note revealed 'report given to RN-E; RN-B (night charge nurse) present and aware of patient status. Patient is combative and at risk for fall. Fall precautions in place. Patient would benefit from a sitter, in addition to family presence, due to confusion and combativeness. Concerns verbalized to the night charge nurse (RN-B), and the covering nurse (RN-E).'

On 06/16/19 at 8:30 PM, review of charge nurse RN-B's nursing note revealed report received from RN-A. The report included: 'Patient very combative. Jumping out of bed, not following instructions and very high risk for falls, due to noted unsteadiness. Unable to leave bedside to complete shift change reports at this time due to patient's impulsiveness and my concern for his safety. Charge RN-B aware and reaching out to MD's A & B (Medical Doctor) for orders. Patient's spouse at bedside for most of the day. Also, having a difficult time trying to control patient. Patient pulling on IV and monitor leads constantly. Safety protocol in place.'

On 06/16/19 at 8:54 PM, review of charge nurse RN-B's nursing note revealed 'spouse at bedside. Patient at times is combative. Patient is non-verbal, non-compliant with safety precautions. Patient is extremely agitated. Does not follow instructions. Patient is very high risk to fall. MD-B notified by phone call. Order received for Ativan IV one dose. Second call placed to MD-A via service. Bedside RN advised.'

On 06/16/19 at 9:53 PM, review of charge nurse RN-B's nursing note revealed 'MD-A notified by phone of patient's condition and aware patient received Ativan IV per MD-B. MD-A suggests CIWA Protocol. MD-B notified no new orders received from MD-A. CIWA ordered by MD-B. Bedside RN advised.'

On 06/17/19 at 3:18 AM, review of charge nurse RN-B's nursing note revealed at approximately 3:00 AM, 'staff heard loud noise from patient's room. Upon entering the room, patient and his daughter found on floor. Patient has bump over his left eye and laceration on left eyebrow. Patient assisted back to bed with the assistance of 4 staff. MD-B notified immediately of fall. Stat CT Brain ordered.'

On 06/17/19 at 4:00 AM, review of nursing note revealed 'heard loud noise behind patient's bedroom door while speaking to patient care technician (PCT) nearby in the hallway side regarding his care. Daughter heard screaming and quickly entered room followed by other staff. Daughter noted on floor with her left leg supporting father's head, and bleeding noted on his forehead. Assisted by other staff, patient picked up and eased onto bed. Patient taken to CT Stat as ordered. CT completed and patient back to floor. Patient still somewhat agitated but being monitored by PCT sitting in room now along with daughter.'

On 06/17/19 at 5:24 AM, review of the nursing note revealed the radiologist reported the results of the CT Scan of Brain shows acute right hemorrhagic infarct. MD-A and MD-B notified.

On 06/17/19 at 3:49 AM, the findings of the CT Brain Scan revealed acute right posterior division middle cerebrovascular accident infarct with small degree of hemorrhagic conversion measuring 11 x 8 millimeters.

On 06/17/19 at 7:36 AM, the patient was transferred to the Intensive Care Unit (ICU) accompanied by his daughter. Patient does not respond. Bruising noted to left eye with gauze dressing in place.

On 06/18/19 at 12:50 PM, review of MD-C's Progress Note revealed the patient required transfer to the ICU after he fell with a CT Brain showing Intracranial Hemorrhage (ICH). Impression: 1. Traumatic ICH status/post fall; 2. Agitated Delirium/ETOH Withdrawal; 3. Diabetes Mellitus.

06/19/19 at 11:24 AM, review of MD-C's Progress Note revealed initially thought Traumatic ICH status post fall, later assessed as Acute Right-CVA with hemorrhagic conversion.

On 06/25/19, the patient was discharged to hospice.

Reviewed the facility report for Patient #1, with the Patient Safety Director, on 09/25/19 at 12:11 PM, revealed she stated she was the Director of the Telemetry Unit when the patient fell. A facility report was generated, and she conducted the investigation. She stated that when the patient was found on the floor, after a thud was heard, no bed alarm was heard. The CT scan was ordered, and the patient was transferred to ICU.

Review of the facility Corrective Action revealed: The Director of Telemetry implemented the Patient Safety Performance Improvement Team. Their purpose is to coach and teach staff purposeful hourly rounding, the Go Green Initiative (checking each of the fall precautions when doing your rounds such as, bed in low position, bed exit alarm on, bedside table & personal affects in reach, call bell near patient, urinals are empty). She stated that there was no investigation as to why the Sitter Justification Policy & Procedure was not followed and a sitter assigned to Patient #1.

Review of the Sitter Justification Policy & Procedure revealed the following procedure:
1. The nurse will identify patients at risk for harm or in need of additional attention.
2. The nurse will document the risk factors in the medical record.
3. The nurse will assess and document at least every shift.
4. The nurse will request a sitter by completing the "Sitter Justification Record" and requesting the Department Director's approval or the Nursing Supervisor's approval in the absence of the Director.
5. The Department Director/Nursing Supervisor will review the medical record to determine whether all appropriate interventions have been implemented. The Director/Supervisor will approve of deny sitter request after consultation with the Chief Nursing officer or Administrator On-Call.
6. Upon Departmental approval of the sitter, the Director/Supervisor will sign the "Sitter Justification Record" and place the form in the Sitter Justification notebook.

On 09/24/19 at 1:15 PM, the Patient Safety Director stated that the staff were treating the patient with medication sedation per the CIWA Protocol, for alcohol withdrawals and were not focusing on the fall risks. Although they did have the patient on fall precautions, including the bed exit alarm, she stated the decision regarding fall risk precautions and/or sitters being assigned is the responsibility of nursing.

On 09/25/19 at 4:45 PM, the Patient Safety Director stated that after RN-A reported to RN-B & RN-E, the patient's condition and that he would benefit from a sitter, they should have contacted the physicians for an order for a sitter. She stated they contacted the physicians, but the order given was for the CIWA protocol and Ativan medication for alcohol withdrawals. She stated that RN-A was following the Sitter Justification Policy & Procedure by notifying RN-B & E. She stated RN-B & E should have ordered the sitter themselves, per the Sitter Justification Policy & Procedure, as there were 8 sitters available in the hospital.