HospitalInspections.org

Based on interview and record review, the facility failed to ensure the Plan of care was updated, kept current, and the response to interventions were documented, for 1 (#4) of 10 patients reviewed, resulting in the potential for unmet needs and less than optimal outcomes. Findings include:

On 11/20/2019 at approximately 0900, medical record review revealed the patient of concern was a 64 year old female who was admitted for observation through the Emergency Department on 03/01/2019, patient reported having diarrhea for 4 months. She was admitted as an inpatient on 03/02/2019 to room 2216, (across from the Nursing station on Atrium East.)
Admitting Diagnosis: History of Alcohol Abuse, Anemia, Fall risk, Skin integrity risk, Chronic Obstructive Pulmonary Disease (COPD), Diverticula/Bowel resection, Pulmonary Emboli, Hypertension, Irregular heart rate, Lupus, Menopause, Osteoporosis, History of Panic attacks, Smoker since age 20, stomach ulcer, Degenerative spinal Arthritis, Spinal Stenosis.
The RN admission assessment included results of the Morse Fall scale:
On 03/01 Patient documented Morse Fall Scale: 85= (High risk 51 or above)
History of falling within 3 months: 25
Secondary Diagnosis: 15
Ambulatory aid, walker/crutches/cane: 15
Intravenous/Heparin lock: 20
Gait/Transferring, weak: 10
Mental status, oriented to own ability: 0
Action: Implement High Risk Fall Prevention Interventions including"Environmental safety Measures"

On 03/02, 03/03, and 03/04 Nurse Assistants documented in the flow chart the interventions related to the environmental safety measures but not in the care plan documentation. The Patient continued to be documented as Morse fall scale: 85. Documentation of Non-skid slippers, wheeled walker, ambulation to the bathroom with stand by assist and uses call light appropriately.

Day of incident (patient fall) 03/05/2019 0724
Patient documented Morse fall scale:85. Documentation non-skid slippers, wheeled walker and
independent to the bathroom, independent in room, independent transfer/oral care/peri care, and appropriate call light use. Care Plan did not reflect change in care to independence.

The Individualized Plan of care documentation related to "Environmental Safety Measures" expectations included: Adequate room lighting, or bed alarm, or bed locked/low position, or call light within reach, or non-skid footwear use, or side rails up 1 of 4 or 2 of 4.
The Care Plan was only documented on by an RN at admission 03/01/2019 and 3 additional times on 03/04-at 1800, 2005, and 2330
Response to documented interventions provided by nurse assistants 03/05/2019 at 0000 and 0724 could not be located.

On 11/20/2019 at 1100 staff H was interviewed while providing electronic Medical Record Review. Staff H was asked if there was any further documentation that could be located? Staff H stated "I have looked and can not find any further documentation."

On 11/20/2019 at 1000 the policy titled "Assessment of Patients: Medical-Surgical Documentation Guidelines" dated revised 7/2019 was reviewed. On page 1 of 4 under iii. Procedure: it states, 6. Falls Activity Interventions- if Morse Scale greater than 45, RN will receive a Discern Notification to initiate Falls Risk Specific Individualized Plan of Care (IPOC) and a task to complete the falls Interventions Activity to document Fall Interventions...on page 3 of 4 under C. IPOCs it states, "Chart on IPOCs every 8 hours..."