HospitalInspections.org

Based on observation, record review, policy review, document review, and interview the hospital failed to ensure nursing supervised and evaluated the nursing care needs for 5 of 6 patients reviewed (Patient 1, 3, 4, 5, and 6) This deficient practice places the patients at risk for development of wounds, deterioration of current illness, infection, and potential for serious harm and impairment.

Findings Include:

Review of the hospital's policy titled "Medication Administration Record and Medication Administration," dated 01/20/23 showed ... Documentation of Scheduled Medications ... Current B/P [Blood Pressure] must be documented in the MAR [Medication Administration Record] along with time administered in assigned time slots when administering cardiovascular drugs ...

Review of the hospital's undated document titled "Fall Prevention Policy and Procedure" under the section "Management of the Post Fall Patient" dated January 2023, showed if a patient strikes head or it is unknown if a patient strikes head during a fall, nursing staff should complete a thorough nursing assessment. In addition, obtain vital signs and neuro checks, which are to occur every 15 minutes times 4, every 30 minutes times 2, every hour times 4, and every 4 hours for the next 24 hours.

Review of the hospital's policy titled "Sitter Policy," dated 01/05/23 showed Purpose To assure the safety and security of patients who are cognitively impaired and unable to consistently provide for their own safety needs ... [hospital] is committed to ensuring that patients who are highly confused or who have been determined to be at risk for injury or falls are in a safe environment where they are closely observed ... The following steps should be taken when a need for an observer/sitter is identified:
The nurse/charge nurse will contact the Nurse Manager/CNO or designee for authorization to initiate sitter care ...

Review of the hospital's policy titled "Guidelines for Nursing Care Policy and Procedure Manual" dated 01/05/23 showed under "Hygiene" "If no contraindications, bath/shower" "minimum frequency" is "three times/week and PRN [as needed]".


Patient 1

Review of Patient 1's closed/discharged inpatient medical record showed that Patient 5, an 83-year-old male, was admitted on 03/21/23 for Hemiplegia (one-sided muscle paralysis or weakness) and Hemiparesis (weakness on one side or inability to move) following Cerebral Infarction (occurs as a result of disrupted blood flow to the brain d/t problems with the blood vessel that supply it) affecting left non-dominant side. Patient 1 has the following diagnosis': Cerebral Infarction, Dysphagia (difficulty swallowing) following cerebral infarction, Dysarthria (difficulty speaking d/t weakening of the muscles used for speech) following cerebral infarction, Facial weakness following cerebral infarction, Aphasia (a disorder that affects how you communicate) following cerebral infarction, Type 2 Diabetes Mellitus (a problem in the way that the body regulates and uses sugar as fuel) with Hyperglycemia (high blood sugar levels), Pressure ulcer (injury that breaks down the skin and underlying tissue) of sacral region, Repeated falls, Atherosclerotic Heart Disease (build-up of fats and cholesterol in and on the artery walls), Hyperlipidemia (high cholesterol levels in the blood), Hypertensive Heart Disease (heart problems from many years of high blood pressure) with Heart Failure (a condition when the heart doesn't pump enough blood for the body's needs), Heart failure, Rheumatoid arthritis (when the immune system attacks the healthy cells of the joints), Pressure ulcer of right buttock, Pressure ulcer of left buttock, Anemia (when the body doesn't have enough health red blood cells), Cervicalgia (neck pain), Insomnia (trouble falling and/or staying asleep), Atrial fibrillation (an irregular and often very rapid heart rhythm), and Osteoarthritis (when the tissues of the joint break down over time), right shoulder, with a history of Acute Kidney Failure (a sudden episode where the kidneys become unable to filter waste products from the blood) and the Presence of left artificial knee joint.


Review of Patient 1's "Interdisciplinary Notes," dated 05/03/23 at 7:20 PM and signed by Staff I, RN at 7:44 PM showed "At approximately 1845 [6:45 PM], patient was found on the floor beside his bed lying on his right side. He was last seen at 1830 [6:30 PM] in high fowler's position, right side rail down, with his meal tray in front of him eating. Patient is alert, responsive and breathing. He stated he rolled out of bed. He stated to hit his head on the floor. Skin tear noted on his right side of his scalp with moderate bleeding. First aid administered by using wound cleanser to skin tear, and pressure applied until bleeding stopped. He complained of a headache and right hip pain. Vital signs within normal limits BP (blood pressure) 134/70 (normal ranges 90/60 through 130/80), HR (heart rate) -80 (normal range 60 to 100 beats per minute), O2 (oxygen saturation) -98% (normal range 90%-100%) , T (temperature)-97.9 (normal range 97.), 8 to 99.1) RR (respiratory rate)-18 (normal range 12 to 18). Dr called and ordered to send patient to the hospital for CT scan and further eval. 911 called and they transported him in a stretcher to [Hospital]. His daughter notified of transfer."

Review of Patient Incident Report dated 05/03/23 showed Patient 1 had a fall at 6:45 PM, his attending Physician was contacted at 6:50 PM and his daughter was contacted at 7:00 PM.

Review of Patient 1's "Interdisciplinary Notes," dated 05/04/23 at 7:59 AM and signed by Staff I, RN at 8:01 AM showed "Patient back from hospital at 0730. Arrived in a wheel chair. He is stable. Alert & oriented x 3. Steri strips noted on his scalp. No complaints of pain/ discomfort. Hoyer (a lift to pick up patients) to bed. he is resting with eyes closed. will continue to monitor"

Review of Post Fall Huddle completed 05/03/23 and signed by Staff I, RN showed "patient stated he rolled to his right".

Review of Patient Incident Report dated 05/03/23 showed that Patient 1 returned and had a negative CT scan.


During an interview on 08/17/23, at 3:04 PM, Staff S, Director of Nutritional Services, Dietician she stated "after I was informed, I did an education with everyone to tell them what we need to do. Then after the investigation, I did the formal education. I'm sure it would be shortly after, but I don't have the dates. Education was completed verbally, and I should have documented it. Educated them on if they are going to be dropping a tray. Any patient that needs assistance (1:1), we won't take the tray in the room. If that is the case, then we have nursing verify the tray and then have them pass the tray."

During an interview on 08/17/23 at 3:45 PM, Staff B, Director of Quality Management (DQM), stated that her investigation after Patient 1's fall on 05/03/23 determined that dietary was responsible for leaving the bed rail down on Patient 1, so she reached out to the director of dietary for re-education, which she was supposed to convey the education to her team. Staff B, DQM stated that after the fall the clinical leaders of the involved departments do a huddle on the unit to see what contributed to the fall and what can be done different.

On 08/18/23, Staff B, Director of Quality Management (DQM) stated that there was no post fall neuro check available for Patient 1's 05/03/23 fall.

Review of Patient 1's record failed to show documented evidence of a 'thorough nursing assessment" and a neuro check as scheduled per hospital policy titled "Fall Prevention Policy and Procedure" under the section "Management of the Post Fall Patient" dated January 2023.


Review of Patient 1's bath/shower record for the duration stay of 03/21/23 through 05/06/23, showed nursing staff completed a bed bath on 04/24/23, 4/29/23, and 5/2/23. The record failed to show nursing staff provided bathing for Patient 1 on any other day during his hospital stay.

Review of Patient 1's Occupation Therapy notes showed the Patient 1 received a sponge bath of only his upper extremities on 03/28/23, a sponge bath on 04/03/23, a bed bath on 04/10/23, a sponge bath on 04/17/23 and 4/20/23: a "sponge bath bed level" on 04/21/23, and a "Sponge bath with cleansing wipes on 04/22/23. On 04/24/22 there is a notation "CNA gave Bed bath", a decline for 04/26/23, a notation of "Bed level with wipes" for 04/27/23, and a sponge bath was completed on 05/04/23.

Review of Patient 1's record showed the hospital failed to give a bath/shower at a "minimum frequency" of "three times/week and PRN" as stated per hospital policy titled "Guidelines for Nursing Care Policy and Procedure Manual" dated 01/05/23 under the section "Hygiene.


Patient 3

Review of Patient 3's inpatient medical record showed that Patient 3, a 49-year-old male (DOB: 08/17/73), was admitted on 07/17/23 for hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Patient 3 has the following diagnosis: hypertension (high blood pressure), hyperlipidemia (high levels of lipids like cholesterol and triglycerides in the blood), peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in a blood vessel), Buerger's disease (blood vessels swell), multiple toe amputations, alcohol dependence, nicotine dependence, and depression.

Review of Patient 3's record showed the hospital failed to complete "24 Hour Chart Checks" on 6 occasions (07/26/23, 07/28/23, 07/30/23, 07/31/23, 08/09/23, and 08/12/23) as ordered.

Review of Patient 3's "Medication Administration Record," dated 07/21/23 at 10:05 PM failed to show a blood pressure documented when administering the cardiovascular medication carvedilol (Coreg).


Patient 4

Review of Patient 4's closed/discharged inpatient medical record showed that Patient 4, a 73-year-old female was admitted on 04/13/23 for orthopedic aftercare following a C3 [Cervical vertebrae 3] through T1 [Thoracic vertebrae 1] anterior cervical discectomy and fusion with a C6 [cervical vertebrae 6] wedge osteotomy, and a subsequent C2 [cervical vertebrae 2] through T4 thoracic vertebrae 4] posterior cervical instrumented fusion. Patient 4 has the following diagnosis: cervical stenosis (narrowing of the spinal canal), hypertension (high blood pressure), type 1 diabetes (condition in which the pancreas does not make enough insulin), Graves' disease (autoimmune disorder that can cause overactive thyroid), hypothyroidism (thyroid doesn't create and release enough thyroid hormone), and atrial fibrillation (abnormal heartbeat). Patient 4 does have an insulin pump.

Review of Patient 4's "Interdisciplinary Notes," dated 04/14/23 at 8:40 PM showed Pt arrived back to facility from hospital ...Insulin administration today was based of accuchecks completed by the Rahab[sic], and not off the patient's glucometer as it was found to not [be] as accurate.

Review of Patient 4's "Interdisciplinary Notes," dated 04/14/23 at 8:40 PM failed to show physician notification of patient's return.


Review of Patient 4's "Physician's Orders," dated 04/14/23 at 14:00 [2:00 PM] showed Insulin Lispro (HumaLOG) 100/ML. Inject subcutaneously Every Four Hours- SEE SLIDING SCALE Glucose Reference Range: 70-105 mg/dL High Alert Med! [From 151 to 200 = 2 units] [From 201 to 250 = 3 units] [From 251 to 300 = 4 units][From 301 to 350 = 5 units][From 351 to 400 = 8 units][>400 CALL MD].

Review of Patient 4's "Physician's Orders," dated 04/14/23 at 14:00 [2:00 PM] failed to show insulin units for blood glucose levels between 105 and 150.

Review of Patient 4's "Medication Administration Record," dated 04/15/23 at 6:22 AM showed a blood glucose level of 129.

Review of Patient 4's "Medication Administration Record," dated 04/16/23 at 5:40 AM showed a blood glucose level of 147.

Review of Patient 4's "Medication Administration Record," dated 04/17/23 at 6:16 AM showed a blood glucose level of 140.

Review of Patient 4's "Medication Administration Record," dated 04/18/23 at 1:29 AM showed a blood glucose level of 63.

Review of Patient 4's "Medication Administration Record," dated 04/18/23 at 6:32 AM showed Insulin Lispro (HumaLOG) 100/ML not given, no blood glucose levels documented, and "parameter not met."

Review of Patient 4's "Physician Order's," dated 04/14/23 at 1400 [2:00 PM] showed Accuchecks Every Four Hours, Request Type: Routine,

Comments: call MD for blood sugar >400 and anytime patient is symptomatic.

Review of Patient 4's "Treatment Administration Record," dated 04/14/23 at 7:30 AM showed the accucheck was completed but failed to show the blood glucose level.

Review of Patient 4's "Treatment Administration Record," dated 04/14/23 at 3:40 PM showed the accucheck was completed but failed to show the blood glucose level.

04/18/23 Miscellaneous Order: Before Meals and at Bedtime, Request Type: Routine, Comments: patient may have own insulin pump and administer own insulin per patient and family request.

Review of Patient 4's "Treatment Administration Record," dated 04/20/23 at 2:11 PM showed accucheck as not completed and the reason as [patient] showed that her dexcom (an implanted continuous glucose monitor) was just replaced and needs 2 hours before it can work.

Review of Patient 4's "Treatment Administration Record," dated 04/22/23 at 10:44 PM showed accuchecks were not completed and the reason as patient checks her own blood sugar.

Review of Patient 4's "Treatment Administration Record," dated 04/23/23 at 1:36 AM showed accuchecks were not completed and the reason as patient has an insulin pump.

Review of Patient 4's "Treatment Administration Record," dated 04/11/23 to 08/15/23 showed nursing staff failed to take blood sugars using the hospital's equipment 3 of 67 opportunities.

During an interview on 08/17/23 at 1:32 PM, Staff C, Chief Nursing Officer (CNO) stated patients in this setting direct their own pumps. Staff C, CNO stated nursing staff don't load, monitor, or manage in any capacity. Staff C, CNO stated the nursing staff is still required to check patient blood sugar levels with the hospital's machines. Staff C, CNO stated that the minimum frequency would be before meals and at bedtime. Staff C, CNO stated that it is not acceptable for staff to not complete accuchecks because a patient monitors own machine.


Patient 5

Review of Patient 5's closed/discharged inpatient medical record showed that Patient 5, an 83-year-old male (DOB 03/27/40), was admitted on 04/10/23 for: Other malaise - syncope due to uncontrolled hypertension (high blood pressure). Patient 5 has the following diagnosis: acute syncope (fainting or passing out) falls, weakness, diabetes mellitus type 2 (condition that happens because of a problem in the way the body regulates and uses sugar as fuel), hypotension (low blood pressure), hypokalemia (low potassium levels), chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should), history of COVID-19, coronary artery disease (condition caused by plaque buildup in the wall of the arteries that supply blood to the heart), hypothyroid (condition in which the body doesn't create and release enough thyroid hormone into the body), history of prostate cancer.

Review of the hospital's undated document titled "Post Fall Huddle" failed to show "Sitter" as a "Recommendation" option.

Review of Patient 5's "Nursing Shift Assessment," dated 04/12/23 at 9:30 PM showed the Morse Fall Screening total score of 65 with greater than 45 placing Patient 5 in the high fall risk category.

Review of Patient 5's "ADL Flowsheet," dated 04/13/23 at 2:00 AM showed safety alarms used.

Review of Patient 5's "Interdisciplinary Notes," dated 04/13/23 at 2:40 AM showed the nurse heard the patient calling for help. Upon entering the room, found the patient seated on the floor near the bathroom door entrance leaning on the bathroom door. The bathroom door was closed. Called for help to assist the patient. Assessment done. Patient stated he tried to standup and fell hitting the back of head. At the time of assessment, he stated his head is not hurting but sore to touch. Patient denied the need to use the bathroom.

Review of Patient 5's "Neurological Assessment," dated 04/13/23 at 02:40 AM showed vital signs and neuro checks completed.

Review of Patient 5's record showed the hospital failed to document vital signs and neuro checks as scheduled per hospital policy titled "Fall Prevention Policy and Procedure" under the section "Management of the Post Fall Patient" dated January 2023.

Review of Patient 5's "Interdisciplinary Notes," dated 04/13/23 at 3:14 AM showed the patient complained of headache 5/10 (0 being no pain, 10 being the worst pain) Tylenol administered.

Review of Patient 5's "Interdisciplinary Notes," dated 04/13/23 at 03:21 AM showed "The attending physician notified. Order received to send the patient to acute care for CT scan of the head without contrast with non-emergent transportation."

Review of Patient 5's "Interdisciplinary Notes," dated 04/13/23 at 3:30 AM showed "Contact on file Daughter notified. Daughter stated any ER accepting the patient's insurance is ok."

Review of Patient 5's "Interdisciplinary Notes," dated 04/13/23 at 04:23 AM showed AMR [American Medical Response] transferred the patient to [acute care hospital] for CT [computerized tomography] scan of the head without contrast. Patient took his cell phone with him.

Review of Patient 5's "Provider Progress Note," dated 04/13/23 at 9:31 AM showed "Patient had a fall early this morning attempting to stand. He endorses hitting his head and was sent out to acute care for a head CT".

Review of Patient 5's "Nursing Shift Assessment," dated 04/13/23 at 11:00 AM failed to show bed/chair alarms checked, set and audible. Further, Patient 5's "Nursing Shift Assessment," dated 04/13/23 at 11:00 AM showed a Morse Fall Risk Assessment Total Score: 80, Greater than 45 indicates a High Fall Risk.

Review of Patient 5's "Interdisciplinary Notes," dated 04/13/23 at 11:05 AM showed Patient is back from the ER [Emergency Room] with his daughter.

Review of Patient 5's "Post Fall Huddle," dated 04/13/23 at 07:22 AM showed the bed/chair alarms were not on and did not sound.

Review of Patient 5's "OT [Occupational Therapy] Discharge Summary," dated 04/19/23 at 1:30 PM showed Patient 5 asleep on his back in bed upon arrival. The bed alarm was not turned on upon arrival.

Review of Patient 5's record showed the hospital failed to document vital signs and neuro checks post fall.

Review of Patient 5's record showed the hospital failed to notify the physician upon Patient 5's return to the hospital after receiving a CT post fall at acute hospital.


During an interview on 08/16/23 at 1:30 PM, Staff Q, Registered Nurse (RN) stated we didn't do additional neuro checks that morning [04/13/23]. Staff Q, RN stated when a patient returns from a hospital, we do vitals and write a note and write what we get from the paperwork and what was done and if they changed the orders. We also call the doctor and let them know that the patient has returned. Document that as well. Staff Q, RN stated there are occasions in which the hospital uses sitters.

During an interview on 08/16/23 at 2:50 PM, Staff N, Registered Nurse (RN) stated "When someone falls, we do a repeat Morse fall score and update the score. Do their vitals, call the doctor. If they hit head, we follow the procedure and do neuro checks. We have sheets that are at the nurse's station that we do neuro checks and fill out and give to unit secretary to scan to the chart."

During an interview on 08/17/23 at 09:06 AM, Staff T, Registered Nurse (RN) stated that after a fall, the neuro check is found on the assessment tab in the electronic medical record. Staff T stated that first check how the patient is doing, vitals, and pupils. You check them every 15 minutes for one hour, then every 30 for one hour, then every hour for four hours, then every shift after that.

During an interview on 08/17/23 at 1:32 PM, Staff C, Chief Nursing Officer (CNO) stated that the nurse should complete a full assessment when a patient returns from receiving a procedure at an outside facility. Staff C, CNO stated the expectation is that nurses conduct and document communication to physicians regarding the results of tests, if known, outside facility recommendations, and order changes, if any. Staff C, Chief Nursing Officer (CNO) stated physician orders are required to not do neuro checks post fall. In a subsequent interview on 08/18/23 at 10:29 AM, Staff C, CNO stated I have put staff members with a patient who we felt needed a sitter. Staff C, CNO stated there is a form to fill out to get permission to allow the sitter. When I have attempted to initiate that, I have been told not to by Staff A, Chief Executive Officer (CEO). Staff C, CNO stated Staff C does not generally fill out the post fall analysis. In a subsequent interview on 08/18/23 at 12:24 PM, Staff C, CNO stated that nursing documentation of Patient 5's return to the hospital on 04/13/23 is not present. Staff C, CNO stated there is not a policy for when a patient has a change of condition or physician notifications.


Patient 6

Review of Patient 6's closed/discharged inpatient medical record showed that Patient 6, an 28-year-old male, was admitted on 05/05/23 for "Critical Illness Myopathy (any disease that affects the muscles that control voluntary movement in the body)" with "Surgical wound to abdomen/chest" and the diagnosis' of Dysphagia (difficulty swallowing), Dysarthria (difficulty speaking d/t weakening of the muscles used for speech) and Anarthria (loss of articulate speech), Schizoaffective Disorder (a mental health problem with psychosis as well as mood symptoms), Thrombocytosis (when the body produces too many platelets), Abnormal weight loss, Adult Failure to Thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity), and a history Developmental Delay(deficits in certain skills; fine, motor, social, cognitive, or language skills), Gastrostomy (surgical opening through the skin of the abdomen to the stomach), and Oral cancer. Patient 6 had a PICC line placement on 05/09/23 for IV antibiotic therapy for a developed a fever and "WBC's trending up". Patient 6 was discharged 05/17/23 to a Skilled Nursing facility.

Review of Patient 6's record showed that for the duration of stay from 05/05/23 through 05/17/23, nursing staff completed bed baths on 05/07/23, 05/08/23, and 05/14/23. There was a refusal documented on 5/06/23.

Review of Occupation Therapy records showed Patient 6 performed "OT Self-Care" that was "Dependent" under the section titled "Shower/Bathe .." on 05/15/23.

Review of Patient 6's record showed the hospital failed to give a bath/shower at a "minimum frequency" of "three times/week and PRN" as stated per hospital policy titled "Guidelines for Nursing Care Policy and Procedure Manual" dated 01/05/23 under the section "Hygiene".