HospitalInspections.org

Based on medical record reviews, staff interview, policy and procedure review, review of incident reports, and other facility's document review. It was determined that the facility failed to ensure that 4 of 8 sampled patients (#2,#3,#4,#5) received care in a safe environment.

A review of the facility's document titled "MICU Events" from 1/6/21 to 6/7/21 revealed that there were four incidences of falls at the medical intensive care unit. Further review of the log revealed that P#1 fell from the toilet on 3/22/21, P#2 fell from the bed on 3/18/21, P#3 fell from the bed on 3/23/21, P#4 fell from the chair on 5/20/21.

A review of Patient (P) #2 medical record revealed that P#2 was admitted to the facility on 2/24/21 at 11:30 p.m. for respiratory distress. Further review of the facility's record revealed that P#2 fell from the bed on 3/18/21 at 10:00 p.m. A review of the facility's incident report revealed that P#2 fell from the bed shortly after hourly rounding. P#2's fall was unobserved by the hospital staff. A review of P#2 medical record failed to reveal a documented post-fall patient assessment. A detailed review of P#2 medical record failed to reveal an hourly neurological check after the fall. There was no documented physician or nursing progress note about the fall. Further review of P#2 medical record failed to reveal that the physician and P#2's family were notified about the fall. A review of P#2 medical record revealed that P#2 fall risk score was 50 (High risk is 45 - higher) on 3/18/21 at 8:00 p.m. Further review of P#2 medical record failed to reveal a fall care plan at the time of the incident. P#2 fall prevention and management plan were initiated on 4/14/21 several days after the fall incident.

A review of Patient (P) #3 medical record revealed that P#3 was admitted to the facility on 3/22/21 at 11:53 p.m. for pneumonia. Further review of the facility's record revealed that P#3 fell from the bed at the facility on 3/23/21 at 5:30 p.m. A review of the facility's incident report revealed that P#3 was resting after chest tube placement and thereafter observed sitting on the floor next to the bed. Further review of P#3 medical record failed to reveal a documented post-fall patient assessment. There was no documented hourly neurological check after the fall. There were no documented nursing or physician progress notes about the fall. Further review of P#3 medical record failed to reveal that the physician and P #3's family were notified about the fall.

A review of Patient (P) #4 medical record revealed that P#4 was admitted to the facility on 5/15/21 for cardiac arrest. Further review revealed that P#4 fell at the facility on 5/20/21 from the chair, P#4 reported feeling lightheaded and fell forward out of the chair at around 1:50 p.m. P#4 was faced down on the floor in a small pool of blood coming from his head. P#4 was assessed by a physician and a CT head and C-spine were ordered on 5/20/21 at 2:39 p.m. A review of P#4 CT head report revealed a left frontal scalp laceration above the eyebrow there was no evidence of intracranial hemorrhage (blood in his brain). A detailed review of P#4 medical record failed to reveal that an hourly neurological assessment was done and documented for P#4 after the fall. No neurological checks were documented post-fall until 8:00 p.m. on 5/20/21.

A review of P#4 medical record revealed that P#4 fall risk score on admission was 50 (High risk:45 - higher). Further review of P#4 medical record failed to reveal a fall care plan at the time of his admission. P#4's fall prevention and management plan were initiated on 5/21/21 at 3:50 a.m. several hours after P#4 fall incident.

A review of P#5 medical record revealed that P#5 was admitted to the hospital on 1/17/21 at 5:33 p.m. P#5 initial fall assessment was completed on 1/17/21 at 8:00 p.m. P#5 fall risk score was 35 (Medium risk 25-44) on admission. Further review of P#5 medical record failed to reveal a fall care plan at the time of his admission. P#5's fall prevention and management plan were initiated on 1/19/21 at 3:25 p.m.


During an interview with Nurse Manager (NM) BB on 06/08/2021 at 10:26 a.m. in Conference Room 2543, she revealed that patients are assessed for falls on admission and continually during their admission stay. In addition, NM BB stated that all patients admitted to the Medical Intensive Care Unit (MICU) are considered at risk for falls. NM BB acknowledged that P#1 and P#2 did not have a Fall Care Plan initiated until two days following their admission. She confirmed there was no documented assessment for P#3 after a sustained fall on 03/18/21. There were no nursing or MD progress notes related to P#3's fall. NM BB acknowledged there were no documented neurological checks after P#4 fell on 05/12/21. She confirmed that P#5 did not have a care plan for Falls despite being assessed as a moderate fall risk on admission to the facility. NM BB stated that it was her expectation for the nursing staff to initiate a Fall Care Plan for each patient. She stated that it was also her expectation for the nursing staff to document a patient's post-fall status, MD and family notification post-fall, and a detailed description of the fall in the medical record.


A review of the facility's policy number 170 titled "Falls Prevention and Management Policy" last reviewed on 1/19/2021 revealed that the purpose of the policy is to establish a multidisciplinary approach to prevent falls and reduce the risk of injury from falls. This policy will outline the hospital falls prevention and management program to include the establishment of procedures to assess fall risk, implementation of fall reduction strategies, and description of documentation procedures and post-fall management.
Process & Procedures:
A. Response to fall Occurrence
1. Patient Falls
A. Assess patient for signs/symptoms of injury and immediate needs and stabilize as necessary.
B. Obtain vital signs, assess mental status/level of consciousness, level of pain, range of motion, and weight-bearing (if appropriate).
C. Notify the Adult Rapid Response Team or Pediatric Evaluation Team (PET) if the fall has been preceded by an acute change in mental or physical status.
D. Notify the physician assigned to the patient's care.
E. Reorient the patient to call the bell and re-educate the fall prevention plan.
F. Complete an incident report using the electronic reporting system.
G. During periods of downtime, a paper reporting form may be used.
H. Notify the Nurse Manager or Nursing Supervisor and Risk Management when a fall results
in a significant major injury.
I. Communicate to the oncoming nurse assigned to the patient's care and the charge nurse a fall has occurred.
J. Consider the need for additional interventions such as a safety attendant
K. Event Documentation and reporting within patient's medical record:
I. For inpatient units initiate the post-fall power plan.
ii. Document the fall, circumstances, description of any injury, fall-related interventions, and outcomes in the patient's chart.
iii. During periods of downtime, follow downtime procedures.

A review of the facility's policy number 384 titled "Patient Rights and Responsibilities Policy" last reviewed on 8/2/2018 revealed that the hospital is committed to providing safe, quality medical care to every patient. It is our policy to respect the individuality and dignity of every patient. The hospital supports the patient's right to know about their medical condition and the right to participate in the decisions that affect their well-being.
As a patient, or when appropriate, the patient's representative as allowed by law, you have the following rights:
1. Safe Care
a. To expect reasonable continuity of care when appropriate and to be informed of available and realistic patient care options when care at our facility is no longer appropriate.

b. To impartial medical care without regard to race, color, sex, national origin, disability, age, religion, marital status, citizenship, gender identity, gender expression, sexual orientation, and/or other legally protected classification.


c. To receive care in a safe environment while maintaining your privacy.

d. To be free from all forms of abuse or harassment.


e. To be free from any form of restraint or seclusion as a means of coercion, discipline, convenience, or retaliation by staff.

f. To access state and community protective services.


g. To appropriate assessment and management of your symptoms, including pain.

h. To express any concerns or grievances orally or in writing without fear of reprisal.

2. Information
a. To be informed of the nature of your illness and treatment options, including potential risks, benefits, alternatives, and outcomes in terms you can understand.
b. To know the names of your primary physician and other practitioners providing your care.
c. To have any restrictions on communications discussed with you.
d. To access your medical records within a reasonable time frame and have them
explained unless restricted by law.
e. To be informed and to give or withhold consent if our facility proposes to engage in or perform research associated with your care or treatment.
A review of the facility's policy number 379 titled "Patient Safety Event Reporting Policy" last reviewed 5/14/2019 revealed that the hospital is committed to improving the quality and safety of patient care through the following:
1. Identification and evaluation of errors, near misses, or hazardous/unsafe conditions that are a threat to patient safety or have the potential to result in patient harm.
2. To improve systems and processes
3. To foster a culture of safety and learning across the organization by openly discussing patient safety at all levels.
Patient Safety Event - An event, incident, or condition that could have resulted or done result in harm to the patient and can be but is not necessarily the result of a defective system or process design, a system breakdown, equipment failure, or human error.

Communication with Patients and Families
1. Commence communication immediately, as soon as possible, and within 24 hours of discovery.
a. The attending physician should be informed and included in all decisions/communications.
b. Risk Management should be informed and included in all decisions/communications.
2. Assessment and Preparation
a. Determine primary communicator and support team within the organization.
b. Determine the facts that will be communicated based upon information available at the time of communication
c. Determine the logistics (location, audience)
3. Communication
a. Disclosure- tell the patient/family what happened.
b. We will apologize to the patient/family affected by the event.
c. Assure ongoing care
d. Commit to continued communication and support, identifying a contact person for the patient/family, and establish a communication timeline as needed.

A review of the facility's policy number 3299 titled "Nursing Documentation Policy" last reviewed 11/14/2019 revealed that the nursing care documentation guidelines will be adhered to assure care is provided to and documented for each patient based on a nursing assessment. The documentation of assessment, plan, intervention and patient response shall occur as close to the real-time of occurrence as possible. The goal of the assessment is to determine the care, treatment, and services that will meet the patient's initial and continuing needs.
Reassessment
a. Each patient is reassessed as necessary based on the plan of care or changes in condition.
b. Reassessment may also be based on the patient's diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; discharge planning needs; and/or setting requirements.
c. Pain is reassessed, and interventions implemented based on the patient's pain score, acceptable pain goal, and perception of pain relief.
d. Reassessment of the patient shall be performed at regular intervals in the course of care
by nursing staff.
e. Reassessments are performed to determine a patient's response to care/treatment.
f. Reassessment shall take place when there is a significant change in a patient's condition
or a change in diagnosis.

Based on medical record reviews, staff interview, policy and procedure review, review of incident reports, and other facility's document review. It was determined that the facility failed to initiate a fall care plan upon admission for 4 of 8 sampled patients (#1,#2,#4,#5).


A review of the facility's document titled "Power Plan" revealed that the P #1 plan of care included fall prevention and management plan. P#1 fall care plan was ordered on 3/19/21 however the plan was not initiated until three days later. P#1 fall care plan was initiated on 3/22/21 at 2:58 p.m. through 3/26/21 at 2:07 p.m. A review of P#1 medical record failed to reveal a fall care plan at the time of his admission.

A review of Patient (P) #2 medical record revealed that P#2 was admitted to the facility on 2/24/21 at 11:30 p.m. for respiratory distress. Further review of the facility's record, revealed that P#2 fell from the bed on 3/18/21 at 10:00 p.m. A review of the facility's incident report revealed that P#2 fell from the bed shortly after hourly rounding. P#2's fall was unobserved by the hospital staff. A review of P#2 medical record failed to reveal a documented post-fall patient assessment. A detailed review of P#2 medical record failed to reveal an hourly neurological check after the fall. There was no documented physician or nursing progress note about the fall. Further review of P#2 medical record failed to reveal that the physician and P#2's family were notified about the fall. A review of P#2 medical record revealed that P#2 fall risk score was 50 (High risk is 45 - higher) on 3/18/21 at 8:00 p.m. Further review of P#2 medical record failed to reveal a fall care plan at the time of the incident. P#2 fall prevention and management plan were initiated on 4/14/21 several days after the fall incident.

A review of Patient (P) #4 medical record revealed that P#4 was admitted to the facility on 5/15/21 for cardiac arrest. Further review revealed that P#4 fell at the facility on 5/20/21 from the chair, P#4 reported feeling lightheaded and fell forward out of the chair at around 1:50 p.m. P#4 was faced down on the floor in a small pool of blood coming from his head. P#4 was assessed by a physician and a CT head and C-spine were ordered on 5/20/21 at 2:39 p.m. A review of P#4 CT head report revealed a left frontal scalp laceration above the eyebrow there was no evidence of intracranial hemorrhage (blood in his brain). A detailed review of P#4 medical record failed to reveal that an hourly neurological assessment was done and documented for P#4 after the fall. No neurological checks were documented post-fall until 8:00 p.m. on 5/20/21.
A review of P#4 medical record revealed that P#4 fall risk score on admission was 50 (High risk:45 - higher). Further review of P#4 medical record failed to reveal a fall care plan at the time of his admission. P#4's fall prevention and management plan were initiated on 5/21/21 at 3:50 a.m. several hours after P#4 fall incident.

A review of P#5 medical record revealed that P#5 was admitted to the hospital on 1/17/21 at 5:33 p.m. P#5 initial fall assessment was completed on 1/7/21 at 8:00 p.m. P#5 fall risk score was 35 (Medium risk 25-44) on admission. Further review of P#5 medical record failed to reveal a fall care plan at the time of his admission. P#5's fall prevention and management plan were initiated on 1/19/21 at 3:25 p.m.


An interview was conducted with the Chief Nursing Officer CNO AA and the Nurse Manager NM BB on 6/7/21 at 2:40 a.m.in the conference room. NM BB explained that an admission assessment is performed once a patient arrived on the floor. NM BB further explained that the admission assessment included a fall risk assessment, she said that all the patients at the Medical Intensive Care Unit (MICU) are considered at risk for falls. NM BB explained that a fall risk plan is initiated for everyone on the unit and P#1 fall risk score when he arrived on the unit was 35 (facility's range Low risk: 0 -24, Medium risk: 25 - 44, High risk: 45 - higher). NM BB explained that on 3/19/21 at 6:56 p.m. P#1 had a weak gait and fall risk score increased to 45, she further explained that this prompted a fall prevention and management program to be ordered for the patient. NM BB explained that the program included supervision with toileting. NM BB said that patient is typically encouraged to use a bedpan when they had a bowel movement but if they insist on using the toilet, they will assist the patient to get on the toilet and pull the curtain for patient privacy. NM BB explained that the staff would stay in the room at the backside of the curtain to assist the patient get off the toilet once they are done. NM BB explained that the nurse remained in P#1's room after assisting him to get on the toilet and stood behind the curtain waiting on the patient. NM BB explained that a post-fall plan was initiated for P#1 after the incident. She further explained that a physician, nursing, and an hourly neurological assessment were performed for P#1 after the incident. NM BB explained that the CT scan and follow-up X-ray for the patient were normal findings.

During an interview with Nurse Manager (NM) BB on 06/08/2021 at 10:26 a.m. in Conference Room 2543, she revealed that patients are assessed for falls on admission and continually during their admission stay. In addition, NM BB stated that all patients admitted to the Medical Intensive Care Unit (MICU) are considered at risk for falls. NM BB acknowledged that P#1 and P#2 did not have a Fall Care Plan initiated until two days following their admission. She confirmed there was no documented assessment for P#3 after a sustained fall on 03/18/21. There were no nursing or MD progress notes related to P#3's fall. NM BB acknowledged there were no documented neurological checks after P#4 fell on 05/12/21. She confirmed that P#5 did not have a care plan for Falls despite being assessed as a moderate fall risk on admission to the facility. NM BB stated that it was her expectation for the nursing staff to initiate a Fall Care Plan for each patient. She stated that it was also her expectation for the nursing staff to document a patient's post-fall status, MD and family notification post-fall, and a detailed description of the fall in the medical record.

A review of the facility's policy number 170 titled "Falls Prevention and Management Policy" last reviewed on 1/19/2021 revealed that the purpose of the policy is to establish a multidisciplinary approach to prevent falls and reduce the risk of injury from falls. This policy will outline the hospital falls prevention and management program to include the establishment of procedures to assess fall risk, implementation of fall reduction strategies, and description of documentation procedures and post-fall management.
Process & Procedures:
A. Response to fall Occurrence
1. Patient Falls
A. Assess patient for signs/symptoms of injury and immediate needs and stabilize as necessary.
B. Obtain vital signs, assess mental status/level of consciousness, level of pain, range of motion, and weight-bearing (if appropriate).
C. Notify the Adult Rapid Response Team or Pediatric Evaluation Team (PET) if the fall has been preceded by an acute change in mental or physical status.
D. Notify the physician assigned to the patient's care.
E. Reorient the patient to call the bell and re-educate the fall prevention plan.
F. Complete an incident report using the electronic reporting system.
G. During periods of downtime, a paper reporting form may be used.
H. Notify the Nurse Manager or Nursing Supervisor and Risk Management when a fall results
in a significant major injury.
I. Communicate to the oncoming nurse assigned to the patient's care and the charge nurse a fall has occurred.
J. Consider the need for additional interventions such as a safety attendant
K. Event Documentation and reporting within patient's medical record:
I. For inpatient units initiate the post-fall power plan.
ii. Document the fall, circumstances, description of any injury, fall-related interventions, and outcomes in the patient's chart.
iii. During periods of downtime, follow downtime procedures


A review of the facility's policy number 3299 titled "Nursing Documentation Policy" last reviewed 11/14/2019 revealed that the nursing care documentation guidelines will be adhered to assure care is provided to and documented for each patient based on a nursing assessment. The documentation of assessment, plan, intervention and patient response shall occur as close to the real-time of occurrence as possible. The goal of the assessment is to determine the care, treatment, and services that will meet the patient's initial and continuing needs.
Reassessment
a. Each patient is reassessed as necessary based on the plan of care or changes in condition.
b. Reassessment may also be based on the patient's diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; discharge planning needs; and/or setting requirements.
c. Pain is reassessed, and interventions implemented based on the patient's pain score, acceptable pain goal, and perception of pain relief.
d. Reassessment of the patient shall be performed at regular intervals in the course of care
by nursing staff.
e. Reassessments are performed to determine a patient's response to care/treatment.
f. Reassessment shall take place when there is a significant change in a patient's condition
or a change in diagnosis.
g. Patients will be reassessed by a registered nurse at least every shift to document changes in the patient's condition, and/or diagnosis, and to determine the patient's response to intervention.
h. For any patient returned to the unit after an elopement, the charge nurse will be notified, and the patient will be reassessed.
i. Nursing reassessment of a patient will reflect at a minimum:
I. A review of the patient's specific data
ii. Pertinent changes
iii. Responses to intervention
iv. Appropriate frequency for the patient population and/or individual patient need
v. Assessments and reassessments are documented in the electronic health record and appropriate paper records are utilized for documentation during downtime.