HospitalInspections.org

A. Based on interview, record review, and policy review, the provider failed to:
*Ensure a proper nursing assessment was completed, reported, and documented after a potential significant change in condition was noted prior to transfer for one of three sampled patients (4) who had transferred to a long term care facility.
*Document the transfer/hand-off of two of three sampled patients (4 and 6) who had transferred to a long term care facility.
Findings include:

1. Review of the 11/8/13 mandatory report regarding patient 4 received from the receiving long term care facility revealed he had been:
*Transported per stretcher in a for hire wheelchair van from the provider's hospital to the receiving long term care facility fifty to sixty miles away.
*Found without a pulse or respirations by the long term care facility staff and van driver at the time of arrival.
*Pronounced dead at the scene by the coroner.

Review of patient 4's physician discharge summary revealed he had been:
*Admitted on 10/14/13 and discharged on 11/8/2013.
*Admitted for injuries sustained in a motor vehicle accident.
*Diagnosed with several conditions that included diabetes, coronary artery disease, congestive heart failure, aortic stenosis, and respiratory insufficiency.

Review of patient 4's medical record documentation from 10/14/13 to 11/8/13 revealed:
*A telephone order was received at noon by nursing to discharge him.
*The nurse caring for the patient wrote at 1:55 p.m. "Pt. [patient] disch [discharge] - very diaphoretic [sweaty] at this time - will report this to ___ [long term care provider] staff. "No subsequent nursing assessment or vitals were documented to ensure his stability prior to transfer.
*No documentation of charge nurse or physician notification by the staff nurse of the above potential significant change in condition was present.
*No documentation was present related to the transfer/hand-off of the patient to the wheelchair van driver other than noted above.
*He was on two liters of oxygen continuously prior to transfer. No documentation his oxygen was continued during transfer was present.
*No documentation was present that indicated his level of stability at the time of transfer other than what was noted above.

Interview and medical record review on 12/17/13 at 2:00 p.m. with the chief nursing officer (CNO) regarding patient 4's transfer revealed:
*The nurse who was in charge of the patient at the time of his transfer was no longer employed by the provider and would not be available for interview.
*She agreed a nursing assessment and vital signs should had been completed and documented based on the fact the patient was very diaphoretic just prior to the transfer.
*She agreed no nursing documentation of the transfer/hand-off (i.e. patient stability, oxygen level, who received the patient, and so on) was present in the medical record.
*No charge nurse or physician notification had occurred prior to the patient's transfer.

Interview and policy review on 12/17/13 at 2:25 p.m. with the director of quality regarding patient 4's transfer revealed:
*She agreed with the CNO's statements above.
*The provider had no specific policy related to patient transfer documentation requirements.
*No forms or specific documents were used for the nursing documentation of patient transfers. The provider relied on the nurses narrative documentation to record the transfer.
*The only thing documented for sure in the medical record related to transfer was the time of transfer. That information was given to the unit secretary by the nurse and documented on the patient's data sheet.
*The provider's policies for documentation, change in patient condition, and discharge planning noted below had not been followed for the transfer of the patient.

2. Review of patient 6's medical record documentation from 11/6/13 revealed:
*She had an order to transfer that day.
*She was to have been transferred per ambulance on 11/6/13.
*No nursing documentation of the transfer/hand-off (i.e. patient stability, oxygen level, who received the patient, and so on) was present in the medical record.

Interview on 12/18/13 at 10:15 a.m. with the CNO, director of quality, and the lead case manager regarding patient 6's transfer revealed:
*They were unable to inform this surveyor of the status of the patient at the time of transfer.
*The nursing documentation related to the transfer of the patient was incomplete.

3. Review of the provider's 4/1/11 Documentation Standards policy revealed:
*Documentation was to provide a "Complete and concise record of the patients status."
*"Documentation must reflect that the patient has been assessed by a RN every 12 hours and every time there is a significant change in condition."

Review of the provider's 10/1/13 Change in Patient Condition policy revealed:
*A head to toe nursing assessment should be completed at the time of noting a potential significant change in the patient condition.
*The charge nurse should be notified.
*Data collected should include vital signs, rhythm strip, oxygen saturation, and blood glucose level.
*If significant change was confirmed appropriate physician notification and nursing documentation should occur.

Review of the provider's 11/12/11 Discharge, Discharge Planning and Instruction Form revealed "the nurse or designee will ensure proper disposition of patient to the transporting area or team."



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B. Based on interview, record review, and policy review, the provider failed to ensure the nursing staff:
*Implemented appropriate fall strategies in accordance with the nursing assessment for three of three sampled patients (1, 2, and 3) identified as high fall risk.
*Completed care plan revisions for one of three sampled patients (1) after sustaining a fall.
*Completed neurological checks and vital sign monitoring in accordance with facility policy for three of three sampled patients (1, 2, and 3) that sustained a fall.
*Accurately documented an injury for one of three sampled patients (3) that sustained a fall.
*Documented all falls for one of three sampled patients (2) during his hospital stay.
*Documented physician notification for one of three sampled patients (2) that sustained falls.
Findings include:

1. Review of patient 1's medical record revealed he had been admitted on 10/11/13 with diagnoses of status post coronary artery bypass, fluid overload, renal failure, and respiratory failure.

Review of patient 1's nurses progress notes revealed:
*On 10/15/13 at 12:15 p.m. he had been found on his knees at the bedside and had sustained a small abrasion on his knee. His bed alarm was reset to a higher sensitivity.
*On 10/16/13 at 3:35 a.m. he had been found on his knees at the bedside. There was no documentation his plan of care had been reviewed or revised.
*There was no documentation of a third fall by the patient on 10/18/13 at 9:00 a.m. as had been reported on the provider's quality management fall report. The quality management fall report had indicated the patient had slipped from the chair onto the floor.

Interview and review of patient 1's medical record on 12/18/13 at 10:45 p.m. with the CNO and director of quality revealed:
*The nursing staff had not contacted the patient's physician as required per hospital protocol after the patient's falls on 10/15/13 and 10/18/13.
*There was no documented neurological checks and vitals documented by the nursing staff after each of the patient's falls.
*Neurological checks and vital signs should have been taken and documented every hour X (times) 4, then every 2 hours X 4, and then every 4 hours X 3 as required by the provider's July 2013 Fall Reduction Program policy.
*The patient was on an anticoagulant (blood thinner) and the neurological checks and vital signs should have been continued for an additional 48 hours.
*There were no indications on the patient's 24 Hour Patient Record & Plan of Care that it had been reviewed and updated.

2. Review of patient 3's medical record revealed she had been admitted on 10/26/13 and was discharged on 11/27/13. Diagnoses documented for the patient included cadaveric kidney transplant, cardiac arrest, blood transfusion reaction, transfusion related lung injury. She had been admitted to the hospital for reconditioning, kidney function monitoring, and respiratory weaning.

Review of patient 3's nurses progress/narrative notes dated 10/26/13 at 6:30 p.m. revealed the patient had a tracheostomy, was legally blind, and alert and "Oriented X 3" (to person, place, and time).

Review of patient 3's 24 Hour Patient Record & Plan of Care documentation on 10/26/13 at 6:30 p.m. revealed the patient had altered mental/cognitive status, no history of falls, was not receiving persistent sedation, and had conditions affecting her gait. The patient had been placed on standard fall reduction strategies.

Review of the instructions on the 24 Hour Patient Record & Plan of Care for completing the fall risk assessment revealed "If any of the following is "Yes", Enhanced Fall Reduction Strategies must be implemented":
*Altered mental/cognitive status.
*A history of falls.
*Received medications with intent of persistent sedation.
*Had conditions effecting gait (walking).

Enhanced Fall Reduction Strategies included low bed and the use of a bed alarm in addition to standard fall reduction strategies.

Review of patient 3's 24 Hour Patient Record & Plan of Care documentation revealed:
*On 11/24/13 at 7:05 p.m.:
-The nurse had been called to the patient's room because the patient was on the floor.
-Vital signs documented at that time revealed her blood pressure was 146/80, heart rate 77 beats per minute, and her oxygen saturation was 96 percent (%).
-The patient had been Hoyer lifted back to bed and her vital signs were retaken (blood pressure 142/68, heart rate 78, and her oxygen saturation was 100%).
-The patient had not complained of pain and had a small abrasion (skin scrape) to the bridge of her nose.
-The staff had implemented enhanced fall reduction strategies that included: moving the patient closer to the nurse's station, lowering the patient's bed to the floor, and applying a bed alarm.
*On 11/24/13 at 8:15 p.m. a hematoma (a mass of clotted blood under the skin tissue that resulted from broken blood vessels) was noted to the patient's left forehead and the patient's vital signs were stable. There was no further description of the hematoma size or hematoma measurements noted for comparison with subsequent assessments.

Review of patient 3's neurological flow sheet for 11/24/13 and 11/25/13 revealed:
*Neurological checks and vital signs had been initiated on 11/24/13 at 7:55 p.m.
*Neurological checks and vital signs had been obtained at 7:55 p.m., 8:15 p.m., 9:30 p.m., 10:30 p.m., 11:30 p.m., 1:30 a.m., 4:30 a.m., 6:30 a.m., and 8:30 a.m.
*The neurological checks and vital signs had not been completed every hour X (times) 4, then every 2 hours X 4, and then every 4 hours X 3 as required by the provider's July 2013 Fall Reduction Program policy.

Interview and review of patient 3's medical record on 12/17/13 at 1:45 p.m. with the CNO and director of quality revealed:
*The patient had been admitted to the hospital with a tracheostomy, was on a ventilator, had been weaned off the ventilator on 10/29/13, and had altered mental/cognitive status during her entire hospital stay.
*Because of the patient's altered mental status and condition affected her gait nursing staff should have implemented enhanced fall risk strategies in addition to the standard fall risk strategies at the time of her admission.
*After the patient's fall on 11/24/13 the staff had not consistently ensured enhanced fall precautions had been implemented.
*The patient had been found on the floor on 11/24/13 and later that day the staff had observed the formation of a hematoma. The nursing staff should have documented a description of the hematoma size. Without that description there was no documentation for nursing staff to compare the hematoma appearance during subsequent assessments.
*The nursing staff had not documented neurology checks and vital signs in accordance with the provider's policy.

Review of patient 3's physician progress note dated 11/25/13 revealed the patient had fallen out of bed, the CT scans were negative, the patient was "Still a little confused", and MRI reports were pending.

3. Review of patient 2's medical record revealed on 12/8/13 at 9:00 p.m. the patient had been found on the floor, her bed alarm was ringing, and she had a laceration on her left eye.

Review of patient 2's 24 Hour Patient Record & Plan of Care dated 12/8/13 revealed:
*The patient had altered mental/cognitive status and had a right leg amputation which would have affected her gait.
*Enhanced fall reduction strategies had not been implemented for the patient prior to the fall.

Review of patient 2's Neurological Flow Sheet from 12/8/13 through 12/9/13 revealed after the patient had been found on the floor, neurological checks and vital signs had been obtained and documented:
*On 12/8/13 at 9:00 p.m., 9:?? (unable to read time), 10:00 p.m., 11:00 p.m., and 12:00 p.m. (midnight).
*On 12/9/13 at 2:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., and 4:00 p.m.
*The neurological checks and vitals signs had not been completed "Every hour X (times) 4, then every 2 hours X 4, and then every 4 hours X 3" as required by the provider's July 2013 Fall Reduction Program policy.

Interview and review of patient 2's medical record on 12/18/13 at 10:45 a.m. with the CNO and director of quality confirmed neurological checks and vital signs had not been completed in accordance with the provider's Fall Reduction Program but should have been.

4. Review of the provider's July 2013 Fall Reduction Program revealed:
*"For those patients deemed at very high fall risk due to persistently alter mental status or a history of fall, additional precautions called 'Enhanced Fall Prevention' will be required."
*Assessment of the patient:
-"Every patient on admission will be categorized as 1) Fall Risk-Normal, or 2) Fall Risk - High. The differentiation will be made based upon two evidence-based factors: history of falls and persistent altered mental or cognitive status."
-"Fall Risk - High is any patient with a history of falls or persistent altered mental or cognitive function, and conditions that effect the patient's gait (new prosthesis, neurological-orthopedic conditions contributing to altered gait). Altered mental or cognitive status can be due to delirium, organic dysfunction (Alzheimer's disease), and traumatic or organic brain injury."
-"All patients have Standard Fall Reduction Strategies."
-"Fall Risk - High will have Enhanced Precautions implemented."
-"Documentation will be on a 24 Hour Nursing Flow Sheet."
-"Post fall assessment must include: 1) Vital signs, 2) (complete) location and quality of any pain, 3) complete neurological and vascular assessment, 4) observation for fractures, especially hip fracture (leg shortening, abduction, external rotation), 5) bruising, 6) lacerations."
-"Patient will be on Neuro-vascular checks with vital signs: every hour x (times) 4, every 2 hours X 4, every 4 hours X 3. If patient is on anticoagulants continue neurovascular checks every 4 hours X 48 hours."
-Physician notification of the patient fall should have occurred in accordance with the provider's SBAR reporting system.

Review of the provider's 4/1/11 Documentation Standards policy revealed the documentation must reflect the patient had been assessed by a registered nurse every 12 hours and every time there was a significant change in the patient's condition.