HospitalInspections.org

Based on record review and interviews, the facility failed to ensure the rights to a safe environment for two of two patients (Patients #7, #8).

1) Ninety-year old Patient #7 had a history of falling prior to his admission to the hospital. His admission diagnoses included Mood Disorder, Dementia, and Unspecified Psychosis. Approximately 32 hours into his hospital stay, the patient fell and required emergency medical care for his bleeding head wound, fractured neck bone, and broken nose. The patient was in a medical hospital intensive care unit at the time of survey.

2) Patient #8 was hearing impaired and noted with disorganized thoughts and limited insight and judgment. During the early morning hours on the day of survey, staff failed to use more than a verbal name verification to identify Patient #8 who subsequently received medication ordered for another patient.


Findings included:

1) Record Review of Patient #7's Hospital Physician Preadmission Examination Orders dated 05/17/19 at 1052 reflected Patient #7's admission diagnoses that included Mood Disorder Due to General Medical Condition. Medical Diagnoses included Coronary Artery Disease, Hypertension (high blood pressure), and Dementia. The patient's home medication did not include Ativan.


Patient #7's Psychiatric Evaluation dated 05/18/19 at 1323 noted the patient suffered from disorganized, incoherent thought process, impaired memory, and had poor judgement and insight.

Patient #7's Integrated Nursing Fall Risk Assessment dated 05/17/19 reflected the patient had fallen prior to his admission and was assessed to be of high risk to fall again.


Interdisciplinary Treatment Master Plan's dated 05/18/19 noted as fall prevention interventions that Patient #7 "will be monitored 1:1 while in bed or HS [at bedtime] ...every 10 minutes while awake or in day room ..." and staff to "monitor ...[Patient #7's] response to medication administration."


Nursing Progress Notes dated 05/18/19 at 2035 reflected Patient #7 received Ativan "for agitation." Notes dated 05/18/19 at 2135 reflected nursing escorted the patient to his room, instructed him "to get rest and call for assistance." There was no evidence of vital signs taken at that time. On 05/18/19 at 2220, Patient #7 "had an unwitnessed fall ...head laceration ...large cut to his mid/top skull ...EMS activated ..."


Patient #7's Acute Medical Hospital Admission Information reflected Patient #7's emergency admission on 05/18/19 at 2311. The patient had a head wound, broken nasal bone, and a fractured bone in the neck spinal column. A scalp laceration was emergently repaired with three staples on 05/19/19 at 0112. Final diagnoses included Fall, Profound Bradycardia (low heart rate), Fracture of Seventh Cervical Vertebra.


Patient #7's Acute Medical Hospital Operative Note dated 05/21/19 reflected Patient #7 underwent Spinal Fusion and Treatment of Cervical Fracture surgery. He returned to the intensive care unit.


Personnel #3 was telephone interviewed on 05/23/19 at 1304 and stated that Patient #7 had received Ativan for agitation on 05/18/19 at about 2030 and fell in his room two hours later. He had a bleeding wound on his head. Emergency Medical Services were notified. The patient was on fall precautions "because he used a walker." Personnel #3 denied knowledge of the patient's previous falls.


Personnel #6 was interviewed on 05/23/19 at 1550 and acknowledged that the incidence of witnessed falls had almost tripled between 03/2019 and 04/2019. The incidence of unwitnessed falls had increased from 13 to 21 percent of all incidents between 03/2019 and 04/2019.


Record Review of Hospital Policy titled Assessing and Preventing Falls dated 02/01/17 reflected the procedure for nurses to "consider increased observation such as 1:1" for patients on fall precautions.


Mayo Clinic guidelines regarding Ativan dated 05/01/19 reflected " ...elderly patients are more likely to have unwanted effects (e.g. severe drowsiness or unsteadiness) ..." (https://www.mayoclinic.org/drugs-supplements/lorazepam-oral-route/before-using/drg-20072296)


2) Patient #8's Admission Nursing Assessment dated 0512/19 at 2215 reflected the patient was hearing impaired and did not have hearing aids.


Patient #8's Psychiatric Evaluation dated 05/13/19 reflected the patient's diagnoses that included Major Depressive Disorder with Psychotic Features.


Patient #8's Psychiatric Exam Progress Note dated 05/22/19 at 1337 reflected the patient's thought process was "disorganized" with "limited insight and judgement."


Nursing Progress Note dated 05/23/19 at 0550 reflected nursing staff entered Patient #8's room and asked the patient whether she was ...[Patient #16]. Patient #8 said yes. The nurse administered Protonix 20 mg (milligram) to Patient #8.


Personnel #5 acknowledged the above findings during an interview on 05/23/19 and stated the nurse failed to use two patient identifiers to ensure that the nurse provided the right medication to the right patient.