HospitalInspections.org

Based on interview, the Critical Access Hospital (CAH) failed to develop a policy which included a set of specific criteria for observation bed utilization. This had the potential to affect all patients in the CAH.

Findings include:

A policy related to criteria for utilization of an observation bed was requested for review. The director of nursing (DON) confirmed on 2/13/18, at 3:45 p.m. that no observation criteria policy had been developed and/or approved by the medical staff and that providers often question when observation status was appropriate. It was confirmed the utilization of observation bed data had been reviewed by staff. However, it was verified that specific criteria had not been developed for placement in and/or discharge from observation status, and that a well-defined set of specific, clinically appropriate services which are clearly distinguishable from those used for inpatient admission and discharge was lacking.

No policy was provided but only a diagnoses list used for review by providers.

Based on observation, interview, and record review, the Critical Access Hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: : K291, K372, K711, K914, K926

Based on interview and record review, the Critical Access Hospital (CAH) failed to ensure nursing staff provided ongoing assessment and evaluation for 1 of 1 patient (P14) reviewed who was admitted post-fall with a head injury.

Findings include:

Document review indicated P14 arrived by ambulance on 10/18/17, at 3:40 p.m. to the emergency room (ER) post fall at home while using a lift chair. When questioned by staff of the events surrounding her fall, P14 was noted to be unable to complete her thoughts. P14 reported pain in the left side of her neck, head and right ribs, felt dizzy and complained of a headache. P14 complained of weakness on the left side and abnormal sensation. P14's pupil response was initially documented as delayed and sluggish. P14's computerized tomography (CT) scan dated 10/18/17, indicated no intra-cranial bleeding but a new focal scalp hematoma (blood clot) was evident and swelling to the right posterior (back of head) region. P14's Glasgow coma scale at the time of the noted assessment dated 10/18/17, was 13 (indicating mild brain injury). Documentation indicated that P14 had fallen one week prior and had been previously examined (4 days prior). At that time, the CT scan of her head identified that P14 had a hematoma (a solid swelling of clotted blood within the tissues) swelling to her right upper head. P14 also had bruises on the right outer lower leg from the previous fall. Documentation also indicated that P14 would sleep unless being spoken to. P14's medication included Coumadin (blood thinner). Coumadin lab values were high (prothrombin/international normalized ratio [PT/INR] was 40.4/3.8), indicating at high risk for bleeding. P14 was admitted to acute care with orders for IV fluids, electrolyte monitoring, and to re-evaluate her mental status during the course of her treatment for recovery.

Review of the P14's 10/18/17, nursing orders were as follows:
(1) Primary diagnosis: Delirium
(2) Secondary diagnoses: low sodium, low potassium, weakness and deconditioning; (no mention of the fall or head injury sustained by P14 earlier prior to admission).
(3) Vital signs every 4 hours; (no mention of any neurological assessment post head injury).

P14's plan of care entered by nursing staff included: offer fluid intake encouragement; (no mention of any other interventions for staff to perform as part of their nursing assessment).

Review of P14's nursing progress notes during the hospitalization from 10/18/17, beginning at 3:40 p.m. through her discharge on 10/19/17, at 11:23 a.m. identified that nursing staff assessed P14's neurological status only twice. After the initial assessment , five (5) hours later at 8:07 p.m., when the second assessment was conducted it was noted P14 was "seeing things". Her neurological status was not evaluated again until almost 9 hours later, at 4:45 a.m. At 9:54 a.m. nursing staff noted that P14 commented, "There he is, it is my son. I was told he was dead and we had a funeral, but he is standing here. He is not talking to me, but he is here." P14 asked the nurse whether her son was talking to her and further stated "I wonder who we buried." No further assessment was performed related to neurological status nor was it noted the physician was informed of these findings. Nursing progress notes and monitoring of P14 were documented only every 1 to 3 hrs during P14's stay. P14 was determined to be a fall risk.

Review of the physician progress note dated 10/19/17, indicated P14 was admitted to acute care status post-fall dated 10/18/17, and was reported by nursing staff to be very confused. Interview with P14 at that time by the admitting physician (MD-A) indicated P14 was talking about someone having taken her slippers that morning and she found them hanging on the wall above the clock. MD-A was concerned P14 had shingles with encephalopathy (swelling of the brain) and after consultation with a physician located at the transferring hospital, the decision was made to transfer P14 out to the larger facility for continued medical care.

When interviewed on 2/13/18, at 3:30 p.m. with the chief nursing officer (CNO) related to P14's neurological, head injury, and fall risk status, she concurred P14 had no ongoing evaluations related to post-fall status and high risk neurological issues . The CNO's expectations included that nursing staff evaluate all patients with head injury for neurological status.

Review of the facility's 5/30/17, Registered Nurse Position Description policy revealed nursing staff were to obtain a comprehensive nursing history and assessment specific to hospital and standards of nursing care. They were to formulate individual written plans of care and communicate care with providers and notify the chief nursing officer of acute changes in a patient's condition and carry out appropriate nursing interventions.

Review of the facility's 9/2017 Fall Prevention Program policy indicated nursing staff were to assess all patients upon admission. Some factors included history of falls, cognition, mobility, and age. Nursing interventions will include initiation of appropriate care plan and hourly rounding during the day and every half hour from 9:00 p.m. to 7:00 a.m.

The facility had no policy for neurological assessment on patients with head.