HospitalInspections.org

Based on document review and interview, the facility failed to ensure a patient's family member/designated decision-maker was informed of treatment/progress in 1 (patient 1) of 10 medical records (MR) reviewed.

Findings include:

1. Review of patient 1's MR indicated: Review of Authorization to Disclose Healthcare Information indicated patient 1 authorized release/exchange of information to R1 as acknowledged per patient 1's signature dated 10/24/20. Review of patient 1's MR lacked documentation of communication between facility staff members and R1.

2. Policy/procedure, Patient Rights, Policy: RR 14.01, revised/reviewed 1/31/19, indicated on page 2: "6. Patients, managing conservator or legal guardians have the right to participate fully in treatment, care and service planning...11. Patients, their conservator, or legal guardian shall be fully informed of the various steps and activities involved in receiving service".

3. Review of patient 1's MR indicated patient 1 experienced a fall on 10/25/20 while in the dayroom of unit 6. The MR lacked documentation the family was notified of the fall.

4. On 1/4/21 at approximately 1300 hours, staff N6 (Director of Nursing) was interviewed and confirmed patient 1's MR lacked documentation related to communication between therapists and R1 during the patient's admission from 10/24/20 to 11/2/20. Staff N6 confirmed patient 1's MR lacked documentation the fall patient 1 experienced on 10/25/20 was communicated to R1.

Based on document review and interview, the facility failed to ensure the safety related to patient falls in 1 (patient 1) of 10 medical records (MR) reviewed.

Findings include:

1. Policy/procedure, Patient Rights, Policy: RR 14.01, revised/reviewed 1/31/19, indicated on page 2: "Patients have the right to be served in a clean, safe and secure environment.

2. Policy/procedure, Fall Precaution, Policy: NR 7.05, revised/reviewed 1/31/19, indicated: "All patiients will be assessed and identified for the potential of being at risk for falls, upon admission. The Falling Stars Program will be initiated if the patient is identified as a "moderate" or "high" fall risk. In the event of a fall occurrence, the patient will be placed on the list to see the medical doctor; the patient will be re-assessed every day until the patient scores 'low' on the Morse Fall Scale Risk assessment".

3. Review of patient 1's MR indicated the patient fell on 10/25/20 and lacked documentation fall precautions were initiated on 10/24/20 (admission) and lacked documenation of a fall risk assessment/score. Review of patient 1's MR indicated the patient was admitted to the facility on 10/24/20 for major depressive disorder, alcohol abuse/detox and history of seizures.

4. On 1/4/21 at approximately 1300 hours, staff N6 (Director of Nursing) was interviewed and confirmed patient 1's MR indicated the patient fell on 10/25/20 while in the dayroom. Staff N6 confirmed fall precautions were not initiated on 10/24/20 upon admission. Staff N6 confirmed fall precautions were initiated on 10/25/20 after the patient fell.

Based on document review and interview, the facility failed to ensure staff document a patient's post-fall assessments in 1 (patients 1) of 10 medical records (MR) reviewed:

Findings include:

1. Review of patient #1 medical record indicated the patient had a fall on 10/25/20. The physician orders dated 10/25/20 at 2200 hours per medical staff D1 (Nurse Practitioner [NP] indicated: Vital Signs every 2 hours x 24 hours, then every 4 hours if stable and every 4 hours between the hours of 2200-0800.

2. The medical record lacked documentation that vitals were taken per order. Review of Nursing Assessment Notes indicated the patient's vital signs were taken on 10/25/20 after the patient's fall at 2200 hours; 10/26/20 at 0200, 0600, 0800 and 2000 hours; 10/27/20 at 0854 and 2000 hours; 10/28/20 at 0800 and 2000 hours; 10/29/20 at 0800 hours; 10/30/20 at 0800 and 2100 hours; 10/31/20 at 0800, 0845 and 2000 hours; 11/1/20 at 0800 and 2000 hours.

2. On 1/4/21 at approximately 1300 hours, staff N6 (Director of Nursing) was interviewed and confirmed patient 1's MR lacked documentation vital signs were taken per order.