HospitalInspections.org

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Based on Medical Record (MR) review, document review and interview, in one (1) of five (5) medical records reviewed, the facility in its review of a fall incident with severe injury failed to identify problems that would lead to quality improvement for patients at risk for falls (Patient #1).

Findings include:

Review of the medical record of Patient # 1 revealed a 90-year-old who was taken by the Emergency Medical Services (EMS) to the facility's Emergency Department (ED) on 3/16/2023 at 12:07 PM after falling at home two (2) days prior. A CT scan in the ED revealed right tentorial subdural hematoma (SDH-blood leaks out of a blood vessel between the brain and the skull and forms a clot that causes pressure and damage on the brain) and subarachnoid bleed (bleeding in the space between the brain and the skull). On 3/16/2023 at 4:38 PM, the patient was admitted to the Surgical Intensive Care Unit (SICU) with a diagnosis of subarachnoid bleed. On 3/25/23 she was downgraded and transferred to the Telemetry Neurology Unit.

On 4/11/23 at approximately 5:00 PM, the patient was found on the floor sitting on her buttocks beside her bed. Provider examination found the patient was alert and responsive. The patient experienced a rapid neurological decline and was intubated to protect her airway.

At 8:42 PM, the provider noted the patient had a CT scan which revealed a new right sided hematoma and cerebral herniation. She was transferred to the Intensive Care Unit for supportive care.

On 4/12/23 at 9:50 AM, Neuro exam revealed the patient lacked clinical brain stem reflexes. The family was updated with recommendation for palliative care. The family decided to make the patient DNR/DNI (Do Not Resuscitate/Do Not Intubate and to proceed with palliative DNI.

On 4/13/23 AM, two days later, at 9:50 AM, the patient was extubated and died at 10:00 AM.

At interview on 6/9/23 at 11:18 AM, Staff M, RN stated: "In the morning when I came in and report was given to me by the night shift nurse, the patient was sitting on the edge of her bed. We put the patient back and explained to her not to come out ... The patient was in room 11, bed 4 in the B section. The patient's room was not visible from the Nurses Station" Staff M also stated that the patient was able to follow commands, she could stand up but could not walk and it was the first time the patient was seen sitting on the edge of the bed. Staff M stated that a family member was always there by the patient's bedside, but no family member was present during the fall.

The facility conducted a Root Cause Analysis (RCA) on 5/11/23 which concluded the standard of care was met. The facility's fall prevention policy was implemented, and the patient never tried to get out of bed before the fall incident.

The RCA failed to identify problems with the care of the patient who had altered mental status change, was non ambulatory and was observed at the edge of her bed. Corrective actions were not implemented.

Review of the Quality Assurance Performance Improvement Minutes for Nursing Services for the last four (4) quarters March 2022 to March 2023, and Neurosurgery Performance Improvement minutes dated May 22, 2023, did not identify any corrective actions.

The facility failed to identify that when Staff M found the bedfast patient sitting on the side of the bed, Staff M failed to place the patient on close observation, update the care plan, and communicate the change in the patient's status to the interdisciplinary team.

During interview on 6/9/23 at 3:01 PM, Staff D, Chief Medical Officer stated: "The patient was conscious when she tried to get out of bed. The only way to prevent the fall was if someone was in the room, but she was not on one to one (1:1)."
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Based on observation, document review, medical record review and interview, in one (1) of five (5) medical records reviewed, the facility failed to:

a) Protect a patient at risk for falls by implementing appropriate measures to ensure the patient's safety.

b) Ensure that a nursing care plan was updated for a patient at high risk for fall based on changes in the patient's mobility status.

This failure may have contributed to a patient's fall and may have further complicated the patient's brain bleed.

Findings include:

See tags A-0395 and A-0396.
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Based on medical record review, document review and interview, in one (1) of five (5) medical records (MR) reviewed, the facility failed to
implement appropriate measures to maintain the safety of a patient at risk for falls.

This failure may have resulted in serious injury to Patient #1 and may place other patients at risk for adverse outcome.

Findings include:

Review of the medical record of Patient # 1 revealed a 90-year-old female with past medical history of hypertension, diabetes mellitus, chronic kidney disease and high blood cholesterol, who was brought by ambulance to the Emergency Department (ED) on 3/16/2023 at 12:07 PM. The patient was two (2) days status post fall with progressive altered mental status (AMS). The patient had a CT scan which revealed Traumatic Brain Injury (TBI is a brain dysfunction caused by a violent blow to the head) with right tentorial subdural hematoma (SDH is a serious condition where blood collects between the skull and the surface of the brain) and trace subarachnoid hemorrhage (SAH, bleeding in the area between the brain and the brain tissues that cover the brain).
On 4/11/2023 at 8:00 AM, staff documented patient's morse fall risk at 85, (The Morse tool assesses a patient likelihood for falls). The fall assessment included history of falls, age greater than 70, impaired mobility, history of altered mental status, impaired cognition, and altered elimination. A score of 45 and above is considered high risk for falls. On 4/11/2023 at approximately 5:00 PM, the patient had an unwitnessed fall, which resulted in neurological decline. The patient was transferred to Surgical Intensive Care Unit (SICU) for supportive care. The CT scan result showed new hemorrhage with almost 4 cm thick density and over 3 cm of midline shift, severe cerebral compression, and cerebral herniation. On 4/13/2023 the patient expired at 10:00 AM.

On 6/9/2023 at 11:14 AM, a telephone interview was conducted with staff M, RN patient's assigned nurse. Staff M reported the following: during hand off report with the night nurse on 4/11/2023 at approximately 7:00 AM, the patient was observed sitting at the edge of the bed. Patient was assisted back to bed and was educated on safety measures. Patient could follow commands; she was able to stand up but could not walk. The patient was in a room not visible to the nursing station because there was no bed available near the nursing station at that time. The patient's family was always with the patient, and she had never attempted to get out of bed on her own prior to this time. Staff M also stated that she conducted hourly rounds by herself, and she changed the patient's bed alarm setting to sensitive at the time of observation. Staff M was unable to recall when last she conducted hourly rounds prior to the patient fall at 5:00 PM.

Review of the facility policy and procedure, (P&P) titled: "Purposeful Rounding", last reviewed 3/16/2023, states "purposeful and timely rounding is an evidence-based practice strategy to routinely meet patient care needs, promote patient safety, decrease the occurrence of preventable patient events, and proactively address problems before they occur".

The facility policy and procedure, (P&P) titled: "Delegation, Assignment and Supervision", last reviewed on 1/20/2022, states" The RN is legally responsible for assessing, analyzing, synthesizing, and evaluating data collected on patients, and determining whether additional assessment or intervention is warranted.

There was no evidence that observation of significance made by staff M regarding changes in the patient's bed mobility status was used to address the patient's care needs and promote patient safety. The patient was cognitively impaired, alert, oriented x 1, and had been diagnosed with TBI. There was no documented evidence that hourly rounds were conducted on 4/11/2023 between 7 AM to 5 PM when the patient was found on the floor. Staff M did not consider the need for close observation of the patient.

These findings were shared with facility Staff D (Chief Medical Officer), Staff E (Chief Nursing Officer), and Staff P (Director Quality Assurance) during the survey exit meeting on 6/9/2023 at 3:00 PM.
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Based on medical review, document review and interview, in one (1) of five (5) medical records (MR) reviewed, it was determined, the nursing staff failed to revise a patient's nursing care plan and communicate changes to the interdisciplinary team to ensure the patient's safety.

This failure may have contributed to an adverse outcome for Patient # 1 and may place other patients at risk for harm.

Finding include:

Review of the medical record of Patient # 1 revealed a 90-year-old female with past medical history of hypertension, diabetes mellitus, chronic kidney disease and high blood cholesterol, who was brought by ambulance to the Emergency Department (ED) on 3/16/2023 at 12:07 PM. The patient was two (2) days status post fall with progressive altered mental status (AMS). The patient had a CT scan which revealed Traumatic Brain Injury (TBI is a brain dysfunction caused by a violent blow to the head) with right tentorial subdural hematoma (SDH is a serious condition where blood collects between the skull and the surface of the brain) and trace subarachnoid hemorrhage (SAH, bleeding in the area between the brain and the brain tissues that cover the brain).

On 4/11/2023 at 8:00 AM, staff documented patient's morse fall risk at 85, (The Morse tool assesses a patient likelihood for falls). The fall assessment included history of falls, age greater than 70, impaired mobility, history of altered mental status, impaired cognition, and altered elimination. A score of 45 and above is considered high risk for falls. On 4/11/2023 at approximately 5:00 PM, the patient had an unwitnessed fall, which resulted in neurological decline. The patient was transferred to Surgical Intensive Care Unit (SICU) for supportive care. The CT scan result showed new hemorrhage with almost 4 cm thick density and over 3 cm of midline shift, severe cerebral compression, and cerebral herniation. On 4/13/2023 the patient expired at 10:00 AM.

On 6/9/2023 at 11:14 AM, a telephone interview was conducted with Staff M, RN patient's assigned nurse. Staff M reported the following: during hand off report with the night nurse on 4/11/2023 at approximately 7:00 AM, the patient was observed sitting at the edge of the bed. Patient was assisted back to bed and was educated on safety measures. Patient could follow commands; she was able to stand up but could not walk. The patient was in a room not visible to the nursing station because there was no bed available near the nursing station at that time. The patient's family was always with the patient, and she had never attempted to get out of bed on her own prior to this time. Staff M also stated that she conducted hourly rounds by herself, and she changed the patient's bed alarm setting to sensitive at the time of observation. Staff M was unable to recall when last she conducted hourly rounds prior to the patient fall at 5:00 PM.

Review of the facility policy and procedure, (P&P) titled: "Falls/Falls Injury Prevention Program", last reviewed on 9/21/2022, states: " ...The plan of care should include care practices specific to the risk factors identified from the population-specific assessment tool(s) used, as well as from identified needs that may not have been captured by the assessment tool ... The patient's risk factor for falls, fall-related injuries and presence of special condition/needs are communicated during shift hand-off. The shift hand off will also include any change in fall risk factors during the shift ... and findings from hourly rounding".

There was no documented evidence that the patient's plan of care was revised to include care practices specific to the risk factors identified by Staff M. In addition, there was no documented evidence of hourly rounding and close monitoring of the patient.

These findings were shared with facility Staff D (Chief Medical Officer), Staff E (Chief Nursing Officer), and Staff P (Director Quality Assurance) during the survey exit meeting on 6/9/2023 at 3:00 PM.