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Based on policy review, medical record review, observation during tours and staff interviews; the hospital nursing staff failed to complete a fall risk assessment for 2 of 7 patients (#5 and #6) and failed to place fall risk signage on the doorframe for 2 of 5 patients (#1 and #2) and failed to reassess the patient response to a pain management intervention within the allotted time frame for 1 of 6 patients with pain medication orders (#5) and failed to perform a pain assessment prior to pain medication intervention for 2 of 6 patient that received pain medication (#3 and #6).

The findings included:

Review of hospital policy, "Falls Prevention and Resources" with a revision date of July 2015 revealed the purpose of the policy was to establish guidelines to mitigate the risk of patient falls. Review revealed the nursing staff was to complete a fall risk assessment during each shift. Review revealed a fall risk score of 0-24 was considered as low risk; a score of 25-44 was considered as moderate risk and a score of 45 and higher was considered as high risk. Review revealed patient(s) identified at risk for falls would have signage placed outside on the patient's room doorframe.
Review of the hospital policy, "PAIN MANAGEMENT"with a revision date of May 2011 revealed the pain assessment should be based on the patient report of intensity level of pain. Further review revealed the pain assessment will be assessed and monitored for the presence of pain at stated intervals including with each new report of pain and at regular intervals per the unit standard of care. Further review revealed a comprehensive pain assessment includes but not limited to using a zero (0) to 10 pain scale (0 equals no pain and 10 equals worst possible pain). Review revealed after a pain medication intervention the {electronic documentation system} would generate a task for review of the medication effectiveness.
Review of the hospital policy, "Patient Assessment / Reassessment" with a revision date of November 2013 revealed reassessment was a component of the patient plan of care which would be conducted throughout the continuum of care. Review revealed the reassessment of the patient response to treatment and care was used to determine the "appropriateness and effectiveness" of the care decision. Review revealed reassessment of pain intervention entailed a one (1) reassessment if pain medication administered by mouth and within 15-20 minutes after intravenous (vein).

1. Closed medical record review conducted August 20, 2015 revealed patient #5, a 64 year-old was admitted to the hospital on May 20, 2015 with an admitting diagnosis of Pneumonia (lung infection) and Hyponatremia (low sodium). Review revealed from admission to discharge date of June 3, 2015; the nursing staff failed to complete a fall risk assessment for each shift for 2 of 15 days (May 28, 2015 and June 2, 2015). Review revealed the patient was ordered Morphine-MS Contin (pain med) 15 mg by mouth every six (6) hours as needed for shortness of breath (SOB) and wheezing (lung sounds). Review revealed on May 28, 2015 at 2140; the patient was administered Morphine-MS Contin and at 2340 (2 hours later), the pain score reassessment was performed. Review failed to reveal the nursing staff reassess the pain intervention within 1 hour of a pain medication administration by mouth.
Interview conducted August 20, 0215 at 1500 with Unit Manager #1 revealed a fall risk assessment should be performed for each shift (12 hours). Interview revealed fall risk assessment was not completed for each shift for 2 of 15 days. Interview revealed no additional documentation was available.
Interview conducted August 21, 2015 at 0920 with Unit Manager #1 revealed reassessment for all as needed medication were reassessed within 1 hour. Interview revealed the {electronic documenting system} would provide an indicator for all as needed medication reassessment. Interview revealed the reassessment was not conducted within 1 hour after administration.

2. Closed medical record review conducted August 20, 2015 revealed patient #6, an 87 year-old was admitted to the hospital May 19, 0215 with an admitting diagnosis of Cerebral Vascular Accident (CVA-stroke) and Malignant Hypertension (severe high blood pressure). Review revealed from admission to discharge date of June 4, 2015; the nursing staff failed to complete a fall risk assessment for each shift for 2 of 17 days (May 25, 2015 and May 31, 2015). Review revealed on August 17, 2015; the patient underwent hip surgery. Review reviewed the patient was ordered Morphine (pain medication) one (1) milligram (mg) every three (3) hours intravenous as needed for pain. Further review revealed on August 16, 2015 at 1904, the patient was administered 1 mg of Morphine by intravenous. Further review revealed the patient pain score after pain medication administration was seven (7). Review failed to reveal the nursing completed a pain score assessment prior to the administration of pain medication. Review revealed at 2343, the patient was administered 1 mg of Morphine by intravenous. Further review revealed on August 17, 2015 at 0013; the patient behavior after pain medication administration was documented as sleep. Review failed to reveal the nursing completed a pain score assessment prior to the administration of pain medication. Review revealed on August 18, 2015 at 1053, the patient was administered 1 mg of Morphine by intravenous. Further review revealed at 1200, the patient pain score after pain medication administration was three (3). Review failed to reveal the nursing staff completed a pain score assessment prior to the administration of pain medication.
Interview conducted August 19, 2015 at 1648 with Unit Manager #1 revealed no pain score was documented per policy for pain medication administration and no additional information was available.
Interview conducted August 20, 0215 at 1500 with Unit Manager #1 revealed a fall risk assessment should be performed for each shift (12 hours). Interview revealed fall risk assessment was not completed for each shift for 2 of 15 days. Interview revealed no additional documentation was available.

3. Open medical record review conducted August 19, 2015 revealed patient #1, an 81 year-old was admitted to the hospital on August 16, 2015 with an admitting diagnosis of Falls Injury and Severe Sepsis (infection). Review revealed from August 16, 2015 to August 19, 2015; the patient fall risk score ranged from 60 to 100 (high risk).
Observation during tour of Unit A conducted August 20, 2015 at 1335 revealed patient #1 was located in room {123}. Observation revealed no signage on the doorframe indicating patient #1 was at risk for falls.
Interview with Unit Manager #2 during unit tour revealed patient #1 was at risk for falls and no signage was located on the doorframe.

4. Open medical record review conducted August 20, 2015 revealed patient #2, an 87 year-old was admitted to the hospital on August 17, 2015 for a hip fracture due to a fall at residence. Review revealed from August 17, 2015 to August 19, 2015; the patient fall risk score ranged from 60 to 95 (high risk).
Observation during tour of Unit A conducted August 20, 2015 at 1335 revealed patient #2 was located in room {321}. Observation revealed no signage on the doorframe indicating patient #2 was at risk for falls.
Interview with Unit Manage #2 during unit tour revealed patient #2 was at risk for falls and no signage was located on the doorframe.

5. Closed medical record review revealed patient #3, a 68 year-old that was admitted to the hospital on August 16, 2015 with an admitting diagnosis of fall and syncope (fainting). Review revealed on August 17, 2015; the patient underwent hip surgery. Review reviewed the patient was ordered Morphine (pain medication) one (1) milligram (mg) every three (3) hours intravenous as needed for pain. Further review revealed on August 16, 2015 at 1904, the patient was administered 1 mg of Morphine by intravenous. Further review revealed the patient pain score after pain medication administration was seven (7). Review failed to reveal the nursing completed a pain score assessment prior to the administration of pain medication. Review revealed at 2343, the patient was administered 1 mg of Morphine by intravenous. Further review revealed on August 17, 2015 at 0013; the patient behavior after pain medication administration was documented as sleep. Review failed to reveal the nursing completed a pain score assessment prior to the administration of pain medication. Review revealed on August 18, 2015 at 1053, the patient was administered 1 mg of Morphine by intravenous. Further review revealed at 1200, the patient pain score after pain medication administration was three (3). Review failed to reveal the nursing staff completed a pain score assessment prior to the administration of pain medication.
Interview conducted August 19, 2015 at 1648 with Unit Manager #1 revealed no pain score was documented per policy for pain medication administration and no additional information was available.

Based on policy review, medical record reviews, and staff interviews; the hospital nursing staff failed to obtain and document post transfusion vital signs for 1 of 3 patients (#2) that were administered blood products.
The findings include:
Review of the hospital policy, "Blood Administration" with a revision date of December 2013 revealed the administration of blood products procedure included 2 nurses' signatures and post transfusion vital signs should be documented on the transfusion record.
1. Open medical record review conducted August 20, 2015 revealed patient #2, an 87 year-old that was admitted to the hospital on August 17, 2015 with an admitting diagnosis of closed hip fracture related to fall at residence. Review of the August 19, 2015 laboratory results revealed at 0405, the patient had a hemoglobin (red blood count) level was 7.0 (low). Review revealed at 0734, the physician ordered for transfusion of red blood cell product. Review revealed at 0955, the patient consented to the administration of blood products. Review revealed two (2) nurses signatures as a verification of the patient information with the blood product information. Review of the transfusion record revealed vital sign documentation occurring at the minute and hourly intervals during the transfusion. Review revealed the blood transufsion was complete within (4) hours. Review failed to reveal the time the transfusion completed and failed to reveal documentation of post transfusion vital signs.
Interview conducted on August 20, 2015 at 1320 with Medical Laboratory Technologist (MLT) #1 revealed the transfusion was incomplete due to the lack of the post transfusion vital signs documentation.


NC00108947