HospitalInspections.org

Based on document review, record review and staff interview it was determined the facility failed to provide appropriate safety measures in one (1) of one (1) medical records reviewed in which a patient fell out bed (patient #1). This failure has the potential to cause serious injury to patients receiving care at the facility.

Findings include:

1. A review of the medical record for patient #1 revealed the patient was receiving the services of another agency to provide one (1) to one (1) supervision of the patient. The caregiver was not trained by the facility and left the patient unattended without notification to the nursing staff. On 5/9/18 the patient fell out of bed and obtained a laceration to the head. As a result the patient had to be placed in a cervical collar (c-collar) and taken for a computed tomography (CT) scan of the head and neck. He was provided wound care for the laceration to his head. No serious harm came to the patient.

2. A review of the facility policy entitled "Falls Prevention", last reviewed 9/2717, revealed it states, in part: "> 45 = High risk." The policy further states: "...to recognize specific interventions to prevent patient falls. Examples may include but are not limited to the following; ... application of bed alarms."

3. A review of the medical record for patient #1 revealed he was considered a high fall risk and placed on fall precautions; however, there was no bed alarm in place on the patient's bed prior to him falling out of bed on 5/9/18.

4. An interview with the Licensed Practical Nurse on 5/30/18 at approximately 2:30 p.m. revealed the patient did not have a bed alarm on because one (1) to one (1) care was being provided by the personal caregiver.

5. In an interview with the Nurse Manager on 5/30/18 at approximately 12:40 p.m. she concurred with the above findings.

Based on record review and staff interview it was determined the facility failed to provide an adequately trained individual to provide one (1) to one (1) supervision for a patient who fell out of bed (patient #1). This failure has the potential to cause serious injury to patients receiving care at the facility.

Findings include:

1. A review of the medical record for patient #1 revealed the patient had a personal caregiver providing one (1) to one (1) supervision during his hospital admission from 5/4/18 to 5/15/18. The caregiver was not a trained employee of the facility.

2. An interview with the Chief Nursing Officer on 5/30/18 at approximately 9:00 a.m. revealed the hospital "does not train these individuals to provide one (1) on one (1) care to the patient".

3. An interview with the Chief Community Regulatory Affairs Officer (CCRAO) on 5/30/18 at approximately 8:45 a.m. revealed on 5/9/18 the personal caregiver of patient #1 came to the nurse's desk and informed the nursing assistant sitting at the desk that the patient needed his "diaper changed". The nursing assistant informed the caregiver she needed to find the nurse caring for the patient and she would be there to change him. The nursing assistant found the nurse and was on the way to the patient's room when Registered Nurse #1 informed them she had found the patient laying in the floor. The CCRAO stated the caregiver failed to notify anyone that she was leaving the floor. The patient did not have anyone at bedside at the time of his fall.

4. In an interview with the Nurse Manager on 5/30/18 at approximately 12:45 p.m. she concurred with the above findings.

Based on document review, record review and staff interview it was determined the nursing staff failed to administer scheduled medications in accordance with the physician's orders. This failure has the potential to delay the patient's healing process and lead to poor patient outcomes.

Findings include:

1. A review of the medical record for patient #1 revealed on 5/11/18 Zosyn 3.375 grams Inter Venous Piggyback (IVPB) was scheduled to be given to the patient every six (6) hours. The record indicated the patient received a dose on 5/11/18 at 10:37 p.m. and did not receive another dose of the drug until 5/12/18 at 9:20 a.m. There was no documentation in the record to explain the delay in administering the medication.

2. A review of the medication administration record on 5/14/18 revealed patient #1 was scheduled to receive Zosyn 3.375 grams IVPB at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. The record indicated the patient did not receive the medication doses scheduled for 6:00 a.m. and 12:00 p.m. with no documentation as to why the doses were missed.

3. An interview with the Director of Pharmacy on 5/31/18 at approximately 10:10 a.m. revealed all antibiotics are considered "time critical drugs". She stated they are supposed to be given within one (1) hour of the scheduled time. When questioned about the delayed and missed doses of Zosyn for patient #1, she stated, "I have no idea why the medicine wasn't administered." She stated the pharmacy is open twenty-four (24) hours a day. If the unit was out of stock they only had to call the pharmacy to have the medication refilled.

4. A review of the facility policy entitled "Medication Administration", approved 7/29/15, revealed it states, in part: "Time-critical scheduled medications are those for which an early or late administration of greater than thirty (30) minutes might cause harm or have significant negative impact on the intended therapeutic or pharmacological effect." The policy further states: "Time-critical medications/medication types may include, but not limited to scheduled doses of injectable antibiotics..."

5. In an interview with the Nurse Manager of the Medical-Surgical floor on 5/30/18 at approximately 12:45 p.m. she stated she was unable to find out why the nurse had missed the doses of Zosyn and concurred with the above findings.