HospitalInspections.org

1. Based on reviews of an incident report, policies and procedures, and staff interviews Baptist Medical Center failed to follow its established policies and procedures to conduct complaint investigations and notify the complainant in writing of the results of the investigation.
The findings included:
a. A review of the complaint conducted on 5/23/12 at 9:30 a.m. in the conference room with the director of risk management of Baptist Health System revealed the administrative director spoke to the complainant via telephone and he complained his wife had fallen and the nursing staff was unaware of the incident until he returned and found her on the floor. He also informed her, he had already complained to the nurses about the interruption in her tube feeding, the lack of response to the call bell, and the lack of hourly rounding by the nursing staff. Based on her verbal apology on the day of the incident she assumed the issue was resolved. No evidence was provided the complainant was contacted on the results of an investigation.
b. A review of grievance/complaint policy and procedures and an interview with the administrator on 5/24/12 at 11:30 a.m. in the conference revealed she could not provide evidence of compliance with hospital procedures to inform the complainant in writing of the results, how the investigation was conducted or when it was completed.

1. Based on reviews of medical records, policies and procedures, and staff interviews Baptist Medical Center nursing staff failed to update nursing care plans relative to current nursing assessments and medical plans.
The findings included:
a. A review of the medical record conducted on 5/24/12 at 10:30 a.m.in the hospital's conference room revealed the patient was classified as a high risk for falls based on an assessment conducted in the Emergency Department on 3/4/12/ at 6: 26 p.m. The patient scored a 21 on an assessment in which a score of greater than 10 is considered a high risk. According to the emergency department record the risk factors the patient had included: (i) unsteady, (ii) on pain medication, (iii) had a recent fall, (iv) weakness, and (v) assistive device.
b. Upon admission and transfer to unit 3W the patient was essentially downgraded and placed on basic fall prevention based on an initial assessment conducted on 3/5/12 at 09:15 a.m. using the Baptist Health System approved "Hendrich II Fall Risk Assessment Tool". Between 3/5/12 and until the patient was injured due to a fall on 3/8/12 her risk assessments fluctuated between high risk and risk - specific without any escalating intervention plans by the nursing staff or in the nursing plan of care contrary to the established policies and procedures. At the time of the fall the patient did not have a bed alarm on and had not been visited by the nursing staff for at least an hour.
c. Interviews conducted on 5/24/12 at 11:00 a.m. with the nursing staff involved in the patient's care revealed the day of the incident 3/8/12 the patient used the call bell three times and no one responded to answer to the bell verbally or responded to her room. The patient's husband and son had left her to get lunch and they were the first to find her on the floor with an injury to her arm. No evidence was provided to support the basic fall prevention plan that included hourly rounding was performed. No evidence the high risk fall plan for patients scoring a 5 or greater is flagged as "priority " for call light response at the nurses ' station had been enacted. No evidence of risk specific intervention plan for addition of a bed alarm to indicate when the patient was out of bed until after the fall.