HospitalInspections.org

Based on medical record review, hospital policy and procedure review, supporting documentation and staff interviews, nursing staff failed to promote and protect patient's rights, as evidenced by failure to implement fall prevention interventions for a high fall-risk patient who subsequently sustained an injury post fall and was transferred to a higher level of care for surgical interventions (A-0144) in 1 (one) of 5 (five) patients (Patient #10).

The effect of this practice resulted in the hospital failure to comply with conditions of participation for Patient Rights.

Based on medical record review, hospital policy review, and staff interviews, nursing staff failed to provide a safe environment and implement fall prevention interventions for a high fall-risk patient who subsequently sustained an injury post fall and was transferred to a higher level of care for surgical interventions in 1 (one) of 5 (five) patients (Patient #10).

Findings included ...

Review of the hospital policy titled, "Fall Assessment, Prevention, and Management Policy" dated 04/20/2022 showed, The Nurse performs the initial patient assessment of Fall Risk Factors and Fall Injury Risk Factors upon admission ...Fall Risk Assessment Tool: High Fall Risk- History of more than one fall within 6 months before admission, Patient has experienced a fall during this hospitalization, Patient is deemed high fall-risk per protocol (seizure precautions)...Fall Prevention Strategies- All Healthcare workers shall: Implement universal fall prevention strategies and maintain fall precaution interventions as appropriate... The following UNIVERSAL fall prevention safety interventions are recommended for ALL patients: Orient to surroundings ...Educate patient/family ...Answer call lights promptly ...Maintain safe unit/room environment ...At risk patients scoring Moderate or High fall risk- The following are ADDITIONAL fall prevention safety interventions ... Activate bed/chair exit alarms, where available ..."

Review of the medical record on 03/22/2023 at approximately 4:30 PM with Employee #17, Nurse Manager- 5A, showed Patient #10 is a 73-year-old man who was admitted to the facility on 02/21/2023 with a neutropenic fever of 102 degrees Fahrenheit. Patient has a history of lymphoma (cancer), anemia (low blood cells) and thrombocytopenia (low platelet count that can cause bruising and bleeding). Additional medical record review showed Patient #10 was assessed as a "High Fall Risk - More Than 1 Fall Within 6 Months Before Admission. Fall Injury Assessment: Age > (greater than) 65; Bleeding Risk; Fracture Risk".

Further medical record review of the Nursing Assessment, dated 02/23/2023 at 2100 (9:00 PM) showed universal fall precautions but lacked documentation of additional fall prevention safety interventions for high fall risk patients i.e., Activate bed/chair exit alarm.

Review of the Post Fall Assessment dated 02/24/2023 showed, "0020 (12:20 AM), Patient found on the floor on his back. Pt (Patient) stated he was trying to go to the BR (Bathroom) but fell right shoulder first. Bump found on the right side of his head. Provider notified at 0030 (12:30 AM)."

Review of the medical record showed a STAT (emergent- without delay; immediately) Head CT (Computed Tomography) scan was ordered on 02/24/2023 at 0045 (12:45 AM) status post fall and performed on 02/24/2023 at 6:29 AM. Findings from the CT of the brain showed "a new subdural hematoma. An X-ray of the right hip was performed on 02/24/2023 at 9:31 AM for complaints of Right hip pain and revealed an acute fracture of the right superior pubic ramus with no significant displacement."

Review of the Provider's Progress Note dated 02/24/2023 showed "Urgent transfer to another medical facility for possible craniotomy and clot evacuation as we do not offer intracranial surgery."

Review of the Discharge Summery dated 02/24/2023 showed, " Disposition: Pt transferred to [facility] via ambulance for emergent neurosurgical intervention for epidural hemmorrhage."

The surveyor conducted a telephone interview on 03/27/2023 at approximately 12:33 PM with Employee # 32, Night Shift Charge Nurse- 5A regarding Fall Risk Precautions and Interventions. Employee # 32 stated, "We [nurses] implement fall precautions even when family is present at the bedside. We assist patients to the bathroom and activate bed and chair alarms. The bed alarm was not activated when Patient #10 fell around midnight."

Employee # 32 acknowledged the findings at the time of the interview.

Based on medical record review, policy and procedure review, supporting documentation and staff interviews, the hospital staff failed to (1) activate a rapid response according to hospital policy in (1) one of (4) four patients (Patient #10) and (2) communicate a discrepancy with a transfer request in accordance with hospital policy resulting in a delay of care for a patient who sustained injuries post fall and was transferred to a higher level of care for surgical interventions in (1) of one (4) patients (Patient #10).

Findings included ...

Review of the hospital policy titled, "Rapid Response Team (RRT)/ Cardiopulmonary Resuscitation (Arrest/Code) Policy dated 01/09/2023 showed, " Guideline for activation of an Adult RRT: Post fall in the following situations: Patient is 65 or older and is on anticoagulant therapy, fall is associated with head trauma, pain or confusion ... Appendix G: RRT Members and Responsibilities- Team of health care providers that respond urgently to all adult medical emergencies and all inpatient medical urgencies when requested to intervene in the sudden or unexpected deterioration in a patient's condition. The RRT members will be able to offer clinical expertise and manpower in emergent, non- code situations."

Review of the hospital policy titled, "Imaging Policies and Protocols Administrative" dated 12/21/2018 showed, STAT exams are to be performed within one hour of their ordering unless patient condition or other extenuating circumstances exist."

Review of the Procedures and Job expectations for the Patient Transport Department dated, 01/01/2023 showed, "Patient transport are required to track any delays through the EPIC system (always adding a reason for the delay). If a request is cancelled, call requesting department and notify reason for cancelling."

1. Review of the medical record on 03/22/2023 at approximately 4:30 PM with Employee #17, Nurse Manager- 5A, showed Patient #10 is a 73-year-old man who was admitted to the facility on 02/21/2023 with a neutropenic fever of 102 degrees Fahrenheit. Patient has a history of lymphoma (cancer), anemia (low blood cells) and thrombocytopenia (low platelet count that can cause bruising and bleeding). Additional medical record review showed Patient #10 was assessed as a "High Fall Risk - More Than 1 Fall Within 6 Months Before Admission. Fall Injury Assessment: Age > (greater than) 65; Bleeding Risk; Fracture Risk".

Review of the Post Fall Assessment dated 02/24/2023 showed, "0020 (12:20 AM), Patient found on the floor on his back. Pt (Patient) stated he was trying to go to the BR (Bathroom) but fell right shoulder first. Bump found on the right side of his head. Provider notified at 0030 (12:30 AM)."

Further review of the medical record showed a STAT (emergent- without delay; immediately) Head CT (Computed Tomography) scan and Spinal X-rays were ordered on 02/24/2023 at 0045 (12:45 AM) status post fall and performed on 02/24/2023 at 6:29 AM, six (6) hours after the fall.

The surveyor conducted a telephone interview on 03/27/2023 at approximately 12:33 PM with Employee # 32, Night Shift Charge Nurse- 5A regarding the process for activating a rapid response after a fall. Employee #32 stated, "After a fall, a Rapid Response should be called if a patient is 65 and older and on a blood thinner, if a patient hits his head, and/or if there is an injury. After the fall, the patient was alert and oriented and we notified the doctor, but we should have called a Rapid Response because he was over 65 and had a low platelet count and he had a bump on his head. The CT technician said ED (Emergency Department) patients had STAT CT scans ordered as well, but the Rapid Response would have triggered the emergency for a CT scan and expedited the scan."

The medical record lacked documentation of a Rapid Response activation which delayed care and treatment. Employee # 32 acknowledged the findings at the time of the interview.

2. Review of the medical record on 03/22/2023 at approximately 4:30 PM with Employee #17, Nurse Manager- 5A, showed Patient #10 is a 73-year-old man who was admitted to the facility on 02/21/2023 with a neutropenic fever of 102 degrees Fahrenheit. Patient has a history of lymphoma (cancer), anemia (low blood cells) and thrombocytopenia (low platelet count that can cause bruising and bleeding). Additional medical record review showed Patient #10 was assessed as a "High Fall Risk - More Than 1 Fall Within 6 Months Before Admission. Fall Injury Assessment: Age > (greater than) 65; Bleeding Risk; Fracture Risk".

Review of the Post Fall Assessment dated 02/24/2023 showed, "0020 (12:20 AM), Patient found on the floor on his back. Pt (Patient) stated he was trying to go to the BR (Bathroom) but fell right shoulder first. Bump found on the right side of his head. Provider notified at 0030 (12:30 AM)."

Review of the medical record showed a STAT (emergent- without delay; immediately) Head CT (Computed Tomography) scan and Spinal X-rays were ordered on 02/24/2023 at 0045 (12:45 AM) status post fall and performed on 02/24/2023 at 6:29 AM, six hours after the fall.

Review of a provider's note dated 02/24/2023 showed "Nursing staff has been calling CT and transport throughout the evening trying to get the CT scan done. At this time the nursing supervisor was notified of the CT issue, and she will attempt to have it expedited ..."

Review of the facility's Root Cause Analysis Report dated 02/24/2023 showed the transport request was entered incorrectly and the transporter was unable to reach the CT tech to state that the transport request was cancelled. The transporter called the ED CT tech on 02/24/223 at 0400, one hour after the transfer request.

The surveyor conducted a telephone interview on 03/23/2023 at approximately 3:55 PM with Employee # 33, CT Technician- ED regarding the transfer request process. Employee # 33 stated, "After I speak to the nurse to determine if the patient is ready for CT, I will put the transfer request in the system. The patient's room number didn't come up when I tried to enter the patient's location. I had to enter it manually. I entered the wrong location and didn't know the transport cancelled the transfer request because of the wrong entry."

The surveyor conducted a telephone interview on 03/27/2023 at approximately 12:05 PM with Employee # 31, Transporter regarding the process for cancelling transfer requests. Employee # 31 stated, "We have a phone and the transfer requests come through the phone. If I receive a request that was entered incorrectly, it's a two-step process to cancel. You have to cancel and call. You can't cancel a request without entering a reason. On 02/24, I called the CT tech to tell him the request was entered wrong, but he didn't answer, I cancelled the request and picked up my next patient; I had back-to-back transfer requests. About an hour later, I went to speak to the CT tech and entered the transport request for him, but by that time the patient was brought down by the nurses."

Employees # 33 and #31 acknowledged the findings during the time of the interviews.