HospitalInspections.org

Based on medical record review, staff interview and facility document review, the facility staff failed to ensure Patient 1's (Pt1) family was notified of their fall that occurred on 12/14/23 at 1:25 a.m., as per facility policy.

The findings included:

Pt1 was admitted to this facility on 12/6/23 for management and evaluation of fluid overload causing shortness of breath, generalized swelling and substantial weight gain.

The review of Pt1's medical record contained fall documentation by nursing staff.
Staff member #12 (SM12), on 12/14/23 at 1:25 a.m., documented in part, "Notified (doctor) of patient fall. Patient had called using call light, CNA (certified nursing assistant) answered the call light to find patient sitting on the floor. No obvious injury. Patient has been sitting/sleeping in chair per patient preference and stated (they) slipped out of the chair. Patient is alert and oriented without any deficits noted, however, when asked if patient hit head, patient stated head hit floor. Vital signs WNLs (within normal limits). New order for head CT without contrast. Will continue to monitor."
Staff Member #9 (SM9) on 12/14/23 at 6:09 a.m., documented in part, "Patient experienced an unwitnessed fall at 0130. This nurse found the patient sitting on the floor after (they) pressed the call light for help. Patient stated, "I was pulling my blanket up and leaned forward, I just tipped over." Assist x3 to help patient back to bed. VS (vital signs) taken, paged doctor. Patient stated (they) hit their head- STAT Head CT performed. Currently patient is on 4-5 L NC (nasal cannula) while asleep, but baseline is 2LNC. No changes in AO (alert oriented) status, remains A&Ox4. No complaints of pain per patient. Bed alarm on, call light within reach, bed locked and in lowest position. Plan of care ongoing."

In an interview with SM9, the morning of 1/9/24, the surveyor asked about Pt1's fall and actions that were taken. SM9 stated that they found Pt1 on their bottom on the floor. Once it was known that Pt1 hit their head, a CT of the head was ordered, vital signs were taken and Pt1 was alert and oriented to person, place, time and event. With assistance from other staff, Pt1 was placed back into the bed. SM9 confirmed that they didn't notify Pt1's family at the time of the fall and didn't call Pt1's family prior to their shift ending on 12/14/23.

In an interview with SM12, the morning of 1/9/24, the surveyor asked about Pt1's fall and actions that were taken. SM12 recalled that they were notified of the fall around 1:30 a.m. of this unwitnessed fall. They went to Pt1's room and asked for additional assistance with getting Pt1 back in bed. They assessed Pt1 injuries and found none. Pt1 was alert and oriented, and once up off the floor, they walked to the bed with assistance. SM12 requested that SM9 do the event write up and to notify the doctor and Pt1's family. SM12 entered the adverse event in the facility's adverse event system. SM12 told the surveyor that they did not call Pt1's family and did not follow up to see if the family was called prior to their shift ending on 12/14/23.

In an interview with SM10, the morning of 1/9/24, when the surveyor asked about the procedure related to notifying the family of a fall, SM10 stated, "Family would be notified of a fall."

A facility policy, Patient Care Services Falls Risk Assessment/Prevention Measures, last reviewed 06/12/2023, evidenced, in part, " ...G. Post Fall Actions ...4. Notify family."

This identified deficiency was discussed with the leadership team at the exit conference on 1/9/24 at 1:45 p.m.

Based on medical record review, staff interview and facility document review, the facility staff failed to ensure:
A, one (1) of three (3) patients included in the survey sample received an initial skin assessment and ongoing skin assessments every twenty-four (24) hours, as per facility policy. Patient #1 (Pt1)
B, one (1) of three (3) patients received hourly monitoring as per facility policy. Patient #1

Findings included:

A,
Pt1 was admitted to this facility on 12/6/23 for management and evaluation of fluid overload causing shortness of breath, generalized swelling and substantial weight gain.

The review of Pt1's medical record failed to contain evidence clinical staff completed on admission an appropriate initial skin assessment, including presence or absence of pressure injuries.

During this hospital stay Pt1's medical record evidenced two (2) of seven (7) skin/pressure injury assessments were completed. First skin/pressure injury assessment was completed on 12/7/23 at 7:30 p.m. and a sacral (area at lower back/tailbone) wound was noted in the flowsheet. The second skin/pressure injury assessment was completed on 12/9/23 at 9:45 a.m. and a sacral injury was noted in the flowsheet. The medical record failed to contain evidence of interventions taken to treat and/or prevent worsening of the pressure injury.

Documentation in the facility's adverse event log evidenced the following, "12/14/23 Skin/Tissue, Patient found to have a stage II on sacral area."

In an interview with Staff Member #5 (SM5) on 1/8/24 at approximately 2:45 p.m., the surveyor asked SM5 about the timing of skin assessments at this facility. SM5 explained that a skin assessment is conducted on admission and then additional skin assessments should be performed every twenty-four (24) hours.

A facility policy titled "Pressure Injuries, Prevention and Care", last review date 04/28/2021, evidenced, in part, "I. Assessment ...a. An RN (registered nurse) and an RN or LPN (licensed practical nurse) is to perform a skin and/or wound assessment on admission. b. An RN is to perform a skin and/or wound assessment every 24 hours and when there is a change in status."

B,
Pt1's complete medical record was reviewed on 1/8/24 at 2:15 p.m., including Pt1's hourly rounding flowsheets from 12/6/23 through 12/14/23. These flowsheets included rounding on patients for: bathroom, pain, position, personal items, plan, and precautions.
Three (3) of nine (9) daily flowsheets evidenced that Pt1 did not receive appropriate hourly rounding on those days.
12/7/23- between the hours of 12:00 a.m. and 11:40 p.m., nineteen (19) of twenty-four (24) patient checks were completed.
12/8/23- between the hours of 2:08 a.m. and 10:00 p.m., fifteen (15) of twenty-four (24) patient checks were completed.
12/9/23- between the hours of 12:36 a.m. and 11:00 p.m., sixteen (16) of twenty-four (24) patient checks were completed. Pt1 was off the unit for five (5) hours and sixteen (16) minutes.

A facility policy titled "Patient Care Services Falls Risk Assessment/Prevention Measures", last reviewed 06/12/2023, evidenced, in part, " ...C. Interventions 1. All patients are to have intentional rounding addressing the 6 Components defined below: Bathroom ....Pain ...Position ...Personal Items ...Plan ...Precautions ...Hourly visual checks (assessing the six components of rounding)."

These identified deficiencies were discussed with the leadership team at the exit conference on 1/9/24 at 1:45 p.m.