HospitalInspections.org

Based on record review and staff interview, the Condition of Participation for Services is not met relating to facility failed practices including delivery of safe care, training of Nursing staff and policy development including:

Facility failed to provide a safe environment for patients at High Fall Risk, resulting in a life ending head injury for Patient 2. C - 1048 Facility failed to properly train staff for post fall care for 3 of 3 Agency Contract Registered Nurses. C-1046
Facility failed to provide updated fall management for needs of patients with head injuries with last review/revision in 2014. C - 1008

Facility census at time of Patient 2 life ending head injury was 9, with an average daily census of 4.5 - 6. This failed practice has the potential to affect all patients of the CAH (Critical Access Hospital). The CAH had 182 acute inpatients for fiscal year dates 5/1/20-4/30/21.


Cross Reference citations at:
C- 1048 - Provision of Care
C- 1046 - Staff Training
C- 1008 - Policy Development


C- 1048 - Provision of Care
Based on staff interview, record review, policy review, observations and review of patient falls, the facility failed to maintain a safe environment by ensuring nursing staff were educated on performing post fall assessments and necessary care interventions for 1 of 10 sampled patients identified at High Fall Risk. 4 of those 10 patients had falls with 2 patients sustaining serious injury. Patient 2 had a second fall while on anti-coagulant (blood thinning) medication therapy and sustained a life ending subdural hematoma (brain bleed) head injury.

C - 1046 Staff Training
Based on personnel file review and staff interview the CAH (Critical Access Hospital) failed to ensure the temporary outside agency nurses (Travel Nurses) are oriented to facility job specific duties with validation of completed facility competencies for 3 of 3 agency RN's (Registered Nurses) reviewed.


C - 1008 Policy Development
Based on policy and procedure review and staff interview the CAH (Critical Access Hospital) failed to ensure the Fall Management policy and procedure was reviewed at least biennially with Last review/revision in 2014.

Monitoring Policies


Based on policy and procedure review and staff interview the CAH (Critical Access Hospital) failed to ensure the Fall Management policy and procedure was reveiwed at least biennially. This failed practice has the potential to affect all patients of the CAH. The CAH had 182 acute inpatients for fiscal year dates 5/1/20-4/30/21.

Findings are:

A. Review of the policy and procedure titled "Fall Management" revealed the policy approval date as 11/2014 and the policy revised date as 11/2014 revealing a lack of evidence of at least biennial reviews.

B. Interview with the Chief Nursing Officer (12/8/21 at 8:28 AM) confirmed the last time the governing board had reviewed the policy was in 2014.

Training of Staff


Based on personnel file review and staff interview the CAH (Critical Access Hospital) failed to ensure the temporary outside agency nurses (Travel Nurses) are oriented to facility job specific duties with validation of completed facility competencies for 3 of 3 agency RN's (Registered Nurses) reviewed. This failed practice has the potential to affect all patients of the CAH. The CAH had 182 acute inpatients for fiscal year dates 5/1/20-4/30/21.

Findings are:

A. Review of the entire personnel file for Agency RN A (hire date 11/1/21) revealed a lack of documentation to facility job specific duties with validation of completed "Tri Valley Health System - Travel Nurse Competency Assessment" form.

- Review of the entire personnel file for Agency RN B (hire date 8/30/21) revealed a lack of documentation to facility job specific duties with validation of completed "Tri Valley Health System - Travel Nurse Competency Assessment" form.

-Review of the entire personnel file for Agency RN C (hire date 9/30/21) revealed a lack of documentation to facility job specific duties with validation of completed "Tri Valley Health System - Travel Nurse Competency Assessment" form.

B. Interview with the Chief Nursing Officer (12/8/21 at 10:46 AM) confirmed the above temporary outside agency RN files lacked a completed facility specific Travel Nurse Competency Assessment form. The Chief Nursing Officer stated "It was missed just being honest with you" and confirmed there is not a policy and procedure in place to address travel nurse's orientation to the facility.

Patient Care and Treatment


Based on staff interview, record review, policy review and review of patient falls, the facility failed to maintain a safe environment by ensuring nursing staff were educated on performing post fall assessments and necessary care interventions for 1 of 10 sampled patients identified at High Fall Risk. 4 of those 10 patients had falls with 2 patients sustaining serious injury. Patient 2 had a second fall while on anti-coagulant (blood thinning) medication therapy and sustained a life ending subdural hematoma (brain bleed) head injury.
Facility census at time of this injury was 9, with an average daily census of 4.5 - 6. This failed practice has the potential to affect all patients of the CAH. The CAH had 182 acute inpatients for fiscal year dates 5/1/20-4/30/21.


Findings are:

A. Review of Patient 2 medical record revealed admission to Emergency Department for chest pain on 11/6/21. Patient was admitted to Acute care for Exacerbation of Congestive Heart Failure (CHF) on 11/7/21 until transferred to Swing bed (rehabilitative care program) on 11/10/21. Patient was identified as a High Fall risk with "forgets limitations" A MORSE tool (scoring system for fall risk to initiate fall prevention measures) fall score was completed on 11/7/21 with a score of 100 "high" and was redone on 11/10/21 with a score of 110 still in HIGH risk category. Patient 2 was to have interventions including room alarm light alert on red, call light in reach, bed and chair alarms, yellow gripper socks.

Facility Incident Report (QDC) from 11/16/21 at 1720 (5:20pm) revealed Patient 2 was crawling out of recliner with the feet elevated and fell off the end of the recliner foot rest landing on right side. Chair alarm was going off and patient yelling (sisters first name). This was was witnessed at the last minute by two Registered Nurses. Patient was assisted getting up and back to bed a 1.5 X 1.5 cm (centimeter) approximate 1/2 inch skin tear noted to right elbow and is cleaned and dressing applied. Abrasion to bridge of nose cleaned and left open to air. Sister (First name) notified of this fall. Patient is resting in bed with bed alarm and chair alarm on. Call light in lap. NO Post Fall Assessment was completed after this fall on 11/16/21.

Facility Incident Report from 11/24/21 at 2030 (8:30pm) revealed Patient 2 sustained an unwitnessed unalarmed fall. Incident Report notes "at 2030 loud noise from patients room heard at nurses station. Sound was immediately followed by patient calling out "help me". Patient lying on his back in bathroom hold back of head. Edema (swelling) noted to back of head. Patient states he feels able to stand. Nurse assists patient to standing. Patient assessment WNL (within normal limits - usual for patient) except for edema ("goose egg") to back of head. Vital signs obtained et (and) WNL. Chair alarm was not in chair at time of fall. Nurse puts chair alarm under patient. Patients sister (first name) notified of fall at 2040 (8:40pm). (Medical provider on call name ) APRN (Advanced Practice Registered Nurse) notified of fall at 2100 (9:00pm).

No other documentation of nursing assessment or post fall care was documented on that shift for Patient 2.
The next Nursing note entry from 11/25/21 at 0830 (8:30pm) was from LPN (LIcensed Practical Nurse) E noting "Patient 2 unresponsive at this time, pupils fixed and dilated. Charge nurse notified and Dr. (doctor) (NAME) notified of patient condition."

RN - F at 0835 (8:35am) charted "this nurse was notified by LPN E that patient was more lethargic and not wanting to awaken for breakfast. THis nurse had LPN - E (NAME) check pupils and they are 2.5 mm (millimeter) pinpoint size and very sluggish (not reacting to light). Dr (name) was notified of these findings and that this patient is on Plavix (blood thinning medication) and orders for a HEAD CT (computed tomography) series of x-ray images without contrast and STAT (immediate) read (by Radiologist). Radiology is notified at 0843 (8:43am) of these orders.

CT orders recorded from 11/25/21 for Patient 2 the Radiology read of HEAD films noting "Less than 5 mm in thickness acute (new) right lateral convexity hyperdense subdural hematoma" (a pool of blood between the brain and it's outermost covering). Subdural hematomas can be a medical emergency - usually caused by head injury strong enough to burst blood vessels. Age, and blood thining drugs create increase risk.

Clinical note entry at 1338 (1:38pm) on 11/25/21 by RN - F recorded "at 1110 (11:10am) orders received from DR (primary care) that patient will be transferred to Good Samaritan Hospital via AIR CARE (helicopter service). Orders for IV Mannitol (medication to reduce brain swelling) 300mL (milliliters) to be given and a Foley (catheter) to be inserted (into bladder ) to keep accurate I&O (intake and output of urine)..... Dr (primary care) is working on a hospital with neurology to accept this patient. 1150 (11:50am) order received to hold Mannitol and transfer at this time as Neurology states this patient is not a surgical candidate. Dr (primary care) notified family that surgical intervention would not benefit recovery. Family's wish for comfort care noted to Dr (primary care). Air CARE canceled.

Patient 2 remained unresponsive at facility on Comfort Cares until time of death pronounced at 12:25pm on 11/27/21.
Death Discharge Summary listed Cause of Death: Subdural Hematoma.

B. Personnel File review on 12/8/21 for RN- A (traveler status) revealed a "competency evaluation/verification tool of safe patient care delivery" at the hospital was not completed early November 2021 when RN started working night shifts at the hospital.

Phone Interview with RN - A on 12/7/21 at 9:30am regarding patient 2's fall on 11/24/21, revealed " Patient 2 was awake for approximately one hour after fall. patient requested to go to bed at approximately 9:30pm. " RN- A related "felt terrible - I know I should of done neuro checks"( Neurological checks are completed after a fall/head injury to assess mental status, motor function, reflexes, sensory function.) RN - A reported told the on-call medical provider ( who was at facility for a patient in the Emergency Room) that patient 2 had fallen and hit head with a goose egg, the provider looked up patient medication list on computer portal and verfied was on Plavix. RN A does not recall any verbal order given by the provider that evening and nothing was recorded in the medical record by the provider at that time of the fall reporting that night.. RN - A further related " this is where I really made a mistake started to look up policy on falls but did not get the task completed and did know how to look up policy and that Neuro checks are basic nursing, I did not wake patient up like I should of done."
RN- A stated "Patient 2 had nightly rounding completed by RN -A and alternating approximately hourly with Nurse Aide - D on night shift to check for respirations (breathing)". RN - A stated "did not take flashlite in room to check swelling on back of head and did not wake patient the entire shift." RN - A stated she "spoke with the other nurses ( 2 RN's) on night shift, and they gave procedural step reminders to notify provider and family, complete QDC ( incident report)." No formal review/notification with the charge nurse was completed and no further information exchanged with the other 2 RN's on that shift.

Interview on 12/6/21 at 12:57pm with APRN ( Advanced Practice Registered Nurse) medical provider on call on 11/24/21 revealed:
"was in facility for ER (Emergency room patient) and notified of Fall for Patient 2 with a "goose egg to back of head, alert, oriented talking to sister." APRN looked up Patient 2 medication list and noted Plavix and related to RN "monitor fo neuro changes, watch close if any changes and we'll need to get CT (Computed Tomography) multiple x-ray images". APRN stated was inhouse all night as on call so stays in the facility overnight but did not go physically see Patient 2. No orders were entered into Patient 2s record on the night of the fall after conversation with RN-A about the fall and head injury. APRN stated "whether a Doctor order or not, you check pupils, alertness, orientation baseline, extremity function and any changes nofity physician" and
"At a minimum every 4 hours neuro checks should be completed, but can do in 15 minute increments if indicated by patient need."
APRN stated did not receive any further information on that night shift about patient 2 and was notified on 11/26/21 of findings of CT results of subdural hematoma for Patient 2. (11/25/21 was Thanksgiving holiday).

APRN charted & noted as a " late entry" on 11/26/21 at 1000 (10:00am) for 11/24/21 2100 (9:00pm) "notified by nursing staff patient was found on the floor in the bathroom. was told patient was A/O (alert & oriented) X 3 (times three- alert to person, place and time) and essentially his normal. Patient did converse with sister on phone without difficulty. Chart reviewed and noted Plavix as one of medications. Nurse orderd to monitor for neuro status changes and to notify me if changes noted and to plan on a CT scan of the head if changes occur."


C. Review of facility Fall Management policy 1078269 (last revised 11/2014) noted protocol for Fall occurrence:
Interview with Quality/Risk Nurse on 12/6/21 at 11:15 am revealed; The policy was not updated to reflect current facility practice and Electronic Systems being utilized including MediTech and QDC reporting.

The Fall POLICY recorded:
Charge Nurse is responsible to ensure completion of fall report on the SQSS (previous electronic reporting system).
First aide and crani (head) checks will be initiated if indicated.
The Charge Nurse will document the incident in the nursing notes section on HMS (prior Electronic Health Record name).