HospitalInspections.org

Based on document review and interview, it was determined in 1 of 1 (Pt #1) patient clinical record reviewed, the Hospital failed to ensure adequate patient monitoring was provided to deliver safe patient care. This has the potential to affect all patients receiving care from the Hospital.

Findings include:

1. Pt. #1 was admitted to the hospital on 1/13/2016 with the diagnosis of toxic metabolic encephalopathy/hepatic encephalopathy and alcohol withdrawal with delirium tremens. A Morse fall prevention assessment was performed on admission with a score greater than 45, which is considered a high risk for falls. Pt #1 had 3 falls during hospitalization. On 1/13/16 fall reported at 10:30PM. Pt #1 was found on the floor next to bed. Post Fall Huddle Report indicated Pt #1 was on fall precautions and had a bed alarm that was not activated. Revised Fall Plan of Care: "Better communication regarding bed alarms between nursing staff" Posey vest restraint was ordered at 10:45 PM. Posey restraint was also ordered for 1/15-1/20-and 1/21 due to patient's continued attempts to climb out of bed.

2. On 1/17/2016 fall reported at 10:20 AM. Post Fall Huddle indicated Bed alarm going off. Found patient sitting on floor next to bathroom door with fecal matter on floor, bed and gown. Revised Fall Plan of Care: Bedside commode added and make arrangements for 1:1 sitter-requested on form.

3. On 1/20/2016 fall reported at 3 AM. Post fall Huddle indicated sitter left at 3:00 AM. Patient bed alarm went off, staff reported immediately. Patient found standing in doorway, stumbled backward and fell and hit head and right hip. Further documentation indicated CT (Computed Tomography) of head was negative, however patient sustained a right intrachanteric hip fracture which required surgery.
4. An interview was conducted with charge nurse (E #7) assigned to Pt #1 on 1/20/2016 for the 7 PM to & 7 AM shift. E #7 stated at 10:00 PM on 1/19/2015 when giving staffing and census to the night supervisor, a request was made to have a 1:1 sitter from 3 AM to 7 AM 1/20/2016 because the 1:1 sitter was leaving at 3 AM. E #7 was advised by the night supervisor there were none available. E #7 stated the report she received from the off going 3 AM 1:1 sitter indicated Pt #1 had been taken to the bathroom, returned to bed, the bed alarm turned on prior to departure and the patient was calm for most of the shift. E #7 explained approximately 10 to 15 minutes after the sitter left the bed alarm went off. E #7 stated "The patient had fallen before an assessment could be made to determine if an order for a restrain was needed. We were short two registered nurses."

5. On 2/18/2016 at approximately 2:00 PM the policy titles "Nursing Department Staff Policy" (revised November 2015) was reviewed. It indicated under "Policy: 1. A Staffing Plan is developed for each nursing unit and is reviewed on a regular basis...
The Staffing Plan incorporates daily staffing pattern requirements based on projected
nursing care hours per patient day and anticipated patient volume...Daily optimal staffing targets are defined by the unit staffing plan..."

6. On 2/17/2016 at approximately 1:00 PM the staffing for 1/20/2016 was reviewed with the Director of Nursing (E #3).

7. On 1/20/2016, 2 E Medical/Surgical Unit 7 PM-3 AM census was 28 patients required 6 registered nurses, 3 patient care technicians and 1 one unit secretary. Staffing was 4 registered nurses, 3 patient care technicians and 1 unit secretary. As a result the unit was short 2 registered nurses.

8. On 2/17/2016 at approximately 1:30 PM, an interview was conducted with the Director of Nursing (E #3). E # 3 stated there is no guarantee a companion will be available 24/7. If a patient needs direct constant supervision, the charge nurse is to make a request to the house supervisor for another employee to be assigned the role if available. If a staff member is not available in the hospital, then it is up to the charge nurse to determine if a staff member working on the unit can fill this role. The staffing matrix was reviewed with E #3 and confirmed staffing on the unit was below average staffing requirements based on patient census.

Based on document review and interview it was determined that in 1 of 1 (Pt#1) clinical record reviewed for restraints, the Hospital failed to ensure the order for restraints was complete. This has the potential to affects all patients in restraints.

Findings include;

1. The policy titled "Restraint for Non-Violent Behaviors" (revised 12/2015) was reviewed on 2/17/2016 at approximately 10:00 AM. It indicated under "Procedure
2. Restraints should only be used in response to demonstrated patient behaviors that could cause harm... 4. A. The order must include date/time, type of restraint, reason for restraint and duration. F. Such an order is issued no less often than once each calendar day."

2. Pt #1 was admitted to the hospital on 1/13/2016 with the diagnosis of toxic metabolic encephalopathy/hepatic encephalopathy and alcohol withdrawal with delirium tremens. Pt #1 was initially placed in restraints (safety vest/posey) on 1/13/2016 at 10:45 PM with a physician's order for "patient safety". The physician order did not demonstrate the behavior Pt #1 was exhibiting to warrant restraints. The restraint orders for 1/15/2016, 1/20/2016 and 1/21/2016 do not indicate the duration of the restraint per hospital policy.

3. An interview was conducted with the Director of Nursing (E #3) on 2/17/2016 at 3:30 PM. E #3 stated the reason for the restraint was for patient safety and a restraint order is issued once a calendar day.

Based on document review and interview it was determined in 1 of 1 patient (Pt#1) clinical record reviewed for restraints, the Hospital failed to ensure patient was monitored in accordance with policy. This has the potential to affect all patients in restraints.

Findings include:

1. The policy titled "Fall Prevention and Management:Reducing Harm was reviewed on 2/17/2016 at approximately 3:00 PM. It indicated under "5. Safe use of restraints will be achieved by: D. Patients are assessed and needs attended to minimally upon restraint initiation and every two hours. The following interventions/care are to be provided every 2 hours or more often based upon the individual needs of the patient:
i. restraint intact, ii Need continues, iii. Restraint removed & reapplied, iv. Circulation, sensation, motion check, v. Skin integrity intact, vi. food/fluid, vii Toileted, viii. Range of motion, ix. Turned/repositioned, x. Comfort & privacy measures.

2. Pt #1 was admitted to the hospital on 1/13/2016 with the diagnosis of toxic metobolic encephalopathy/hepatic encephalopathy and alcohol withdrawal with delirium tremens. Pt #1 had vest restraint ordered for 1/15/2016 and 1/21/2016. The nursing documentation lacked two (2) hour assessment on:

- 1/15/2016 at 12:00 PM and 2:00 PM.

- 1/21/2016 at 6:00 AM.

3. An interview was conducted with the Director of Nursing (E #3) on 2/18/2016 at approximately 2:00 PM. E #3 confirmed the two hour safety checks were not done on 1/15/2016 and 1/21/2016.

Based on document review and interview, it was determined in 1 of 1 (Pt #1) patient clinical record reviewed, the Hospital failed to ensure adequate personnel was provided to deliver safe patient care in the prevention of a patient fall. This has the potential to affect all patients receiving care from the Hospital.

Findings include:

1. On 2/18/2016 at approximately 2:00 PM the policy titles "Nursing Department Staff Policy" (revised November 2015) was reviewed. It indicated under "Policy: 1. A Staffing Plan is developed for each nursing unit and is reviewed on a regular basis...
The Staffing Plan incorporates daily staffing pattern requirements based on projected
nursing care hours per patient day and anticipated patient volume...Daily optimal staffing targets are defined by the unit staffing plan..."

2. On 2/17/2016 at approximately 1:00 PM the staffing for the 2 E Medical/Surgical unit for 1/17/2016 and 1/20/2016 was reviewed with the Director of Nursing (E #3). Staffing for the Unit was as follows:

-On 1/17/2016, the 7 AM-3 PM census was 23 patients which required 6 registered nurses, 3 patent care technicians and 1 unit secretary. Staffing was 4 registered nurses and 3 patient care technicians and 1 unit secretary. As a result the unit was short 2 registered nurses.

- On 1/20/2016, the 7 PM-3 AM census was 28 patients which required 6 registered nurses, 3 patient care technicians and 1 one unit secretary. Staffing was 4 registered nurses, 3 patient care technicians and 1 unit secretary. As a result the unit was short 2 registered nurses.

3. Pt. #1 was admitted to the hospital on 1/13/2016 with the diagnosis of toxic metabolic encephalopathy/hepatic encephalopathy and alcohol withdrawal with delirium tremens. A Morse fall prevention assessment was performed on admission with a score greater than 45, which is considered a high risk for falls.

4. On 1/17/2016 Pt #1 was on the 2 E Medical/Surgical Unit. A fall was reported at 10:20 AM. Post Fall Huddle indicated Bed alarm going off. Found patient sitting on floor next to bathroom door with fecal matter on floor, bed and gown. Revised Fall Plan of Care: Bedside commode added and make arrangements for 1:1sitter-requested on form.

5. On 1/20/2016 Pt #1 was on the 2 E Medical/Surgical Unit. A fall was reported at 3 AM. Post fall Huddle indicated sitter left at 3:00 AM. Patient bed alarm went off, staff reported immediately. Patient found standing in doorway, stumbled backward and fell and hit head and right hip. Further documentation indicated CT of head was negative, however Pt #1 sustained a right intrachanteric hip fracture which required surgery.

6. An interview was conducted with charge nurse (E #7) assigned to Pt #1 on 1/20/2016 for the 7 PM to & 7 AM shift. E #7 stated at 10:00 PM on 1/19/2015 when giving staffing and census to the night supervisor, a request was made to have a 1:1 sitter from 3 AM to 7 AM 1/20/2016 because the 1:1 sitter was leaving at 3 AM. E #7 was advised by the night supervisor there were none available. E #7 stated the report she received from the off going 3 AM 1:1 sitter indicated Pt #1 had been taken to the bathroom, returned to bed, the bed alarm turned on prior to departure and the patient was calm for most of the shift. E #7 explained approximately 10 to 15 minutes after the sitter left the bed alarm went off. E #7 stated "The patent had fallen before an assessment could be made to determine if an order for a restrain was needed. We were short two registered nurses."

7. On 2/17/2016 at approximately 1:30 PM, an interview was conducted with the Director of Nursing (E #3). E # 3 stated there is no guarantee a companion will be available 24/7. If a patient needs direct constant supervision, the charge nurse is to make a request to the house supervisor for another employee to be assigned the role if available. If a staff member is not available in the hospital, then it is up to the charge nurse to determine if a staff member working on the unit can fill this role. The staffing matrix was reviewed with E #3 and confirmed staffing on the unit was below average staffing requirements based on patient census.

Based on document review and interview, it was determined in 1 of 1 patient (Pt#1) clinical record reviewed, the Facility failed to ensure the nursing plan of care was revised and current with required intervientions to ensure a safe patient environment. This has the potential to affect all patients receiving care from the Hospital.

Findings include:

1. The policy titled "Fall Prevention and Management:Reducing Harm was reviewed on 2/17/2016 at approximately 3:00 PM. It indicated under "2. A. The Fall Prevention Plan of Care (POC) (Appendix A) is activated for patients at high risk for falls/injury. This is reviewed each shift and revised based on the patient's condition".

2. Pt #1 was admitted to the hospital on 1/13/2016 with the diagnosis of toxic metabolic encephalopathy/hepatic encephalopathy and alcohol withdrawal with delirium tremens. Pt #1 fell on 1/17/2016 and 1/20/2016. The "Post Fall Huddle" for 1/17/2016 and 1/20/2016 were reviewed on 2/16/2016 at approximately 11:00 AM. The 1/17/2016 "Post Fall Huddle" indicated the plan of care was to be revised adding a fall intervention of 1:1 supervision for Pt #1. The revision of 1:1 supervision was not documented as added to the plan of care.

3. A chart review and interview was conducted with the Director of Nursing (E #3) on 2/16/2016 at approximately 1:30 PM. E #3 stated and verified there was no documentation indicating the plan of care was revised to include 1:1 supervision of the patient.

Based on document review and staff interview, it was determined in 1 of 1 (Pt #1) patient chart reviewed with a consent for surgery, the Hospital failed to ensure the consent for a surgical procedure was accurate. This has the potential to affect all patients requiring a surgical consent.

Findings include:

1 On 2/16/2016 at approximately 1:00 PM Pt #1's medical record was reviewed. Pt #1 was admitted to the hospital on 1/13/2016 with a diagnosis of toxic metabolic encephalopathy/hepatic encephalopathy and alcohol withdrawal with delirium tremens. Pt #1 was scheduled to have the surgical procedure right hip closed reduction and cephalomedullary nailing with possible open reduction and internal fixation. A telephone consent was obtained from Pt #1's health care surrogate and verified by two (2) registered nurses. The first name on the consent was incorrect.

2. An interview was conducted with Director of Nursing (E #3) on 2/17/2016 at approximately 2:30 PM. E #3 reviewed the consent and confirmed the consent had the wrong first name. E #3 provided documentation a pre-induction safety check and time out protocol was followed to identify the correct patient.

Based on document review and staff interview, it was determined for 1 of 10 (Pt #2) patient, the Hospital failed to provide patient education on Clostridium difficile (C diff) in a timely manner which has the potential to negatively affect all patients and staff in the 2C- Surgical Intensive Care Unit.

Findings include:

1. On 2/17/16 at 10:00 AM, the Hospital policy "C. Diff" (revised 1/15) was reviewed. "II. Risk factors and clinical symptoms. Category B, # 4 stated "Pt and visitors are instructed about the isolation and use of gown and gloves...".

2. On 2/17/16 at 10:30 AM, a review of Pt #2's medical record was conducted. Pt #2 was readmitted to the Hospital on 1/13/16 from a extended care facility with questionable Sepsis, Urinary Tract Infection symptoms and Clostridium difficile. A positive C. Diff result was called to 2C ICU (Intensive Care Unit) Registered Nurse (RN) on 1/14/16 at 8:45 AM. An order for patient isolation was entered on 1/14/16 at 11:16 AM. The first documentation of infection control education on C. Diff given to Pt #2 was on 1/15/16 at approximately 1:00 AM- over 12 hours after the order for patient isolation was received.

3. On 2/17/16 at approximately 9:30 AM an interview with 2C ICU nurse manager (E #6) was conducted. E #6 verbalized that Pt #2 was placed into contact isolation on admission as a precaution before the lab results were completed. No documentation of this isolation precaution was found. E #6 verbalized that C. Diff education was not given and documented until 1/15/16.