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Based on medical record review and staff interview, in 1 of 10 medical records reviewed, it was determined that the medical staff did not provide adequate care consistent with prevailing standard of practice. Specifically, the medical staff did not conduct a patient assessment in a timely manner after a patient fall. The untimely assessment of the patient resulted in the diagnostic delay of the patient injury.

Findings include:

A review of Patient MR #1 revealed this ninety-nine year old patient presented to the facility on 7/18/2015 with a complaint of shortness of breath on exertion. The patient had a previous medical history of a fall and hypertension. The patient was alert and oriented to person and place but disoriented to time. The patient was admitted with diagnoses of Pneumonia, Congestive Heart Failure (CHF) and Acute Kidney Failure/Acute Kidney Injury.
On 7/20/2015 at 11:02 PM, the nurse documented that Patient #1 was found on the floor by a patient care assistant; patient stated she was trying to go to the bathroom. The nurse noted contusion to the patient's right occipital/temporal area of the head, and a new bruise to the patient's right flank/lateral chest wall. The nurse noted that the nursing supervisor informed Staff A (Attending Physician) and was awaiting an order for a Computerized Tomography (CT) of the head.
CT scan of the head ordered by Staff A, on 7/20/2015, at 10:55 PM and completed on 7/21/15 at 09:47 AM, revealed no evidence of trauma to the patient's right side of the scalp.

On 7/21/2015, at 11:30 AM, approximately twelve hours after the fall incident, Staff B (another attending physician) evaluated the patient and noted, "Patient was more lethargic than her baseline but arousable, tenderness to right shoulder, ecchymosis over right shoulder and generalized weakness." The Right Clavicle X-ray ordered by the Staff B, was completed 2:15 PM, 7/21/15 and revealed "complete mildly displaced fracture through the middle third of the right clavicle."

There was no evidence that the patient was promptly evaluated by a member of the Medical Staff after the fall incident which occurred on 7/20/2015 at 11:02 PM.

During interview with Staff C (staff nurse) on 12/02/2015, at 3:00 PM, Staff C acknowledged that there was no immediate assessment by a physician after the fall incident.

The above findings were confirmed with the Clinical Analyst on 12/02/2015 at 2:30 PM.

Based on medical record review and staff interview, in 1 of 10 medical records reviewed,
it was determined that the nursing staff did not: (1) implement its policy to ensure safety of patients; (2) report changes in patient's condition to a physician in order to facilitate timely physician assessment of the patient; (3) notify the patient's next of kin immediately after the fall incident. (Patient MR#1)


Findings include:

1. A review of Patient MR #1 revealed; the patient presented to the facility on 7/18/15 with a complaint of shortness of breath on exertion. The patient was oriented to person and place, but was disoriented to time. The patient's admitting diagnoses included Pneumonia and CHF, for which she was treated with Lasix (diuretic) and oxygen therapy via a nasal cannula. Based on the initial nursing admission assessment on 7/18/15, the patient was identified to be at high risk for falls. This required an assistance of the staff with the patient's mobilization.
On 7/20/15, at 11:02 PM, the patient's nurse documented that the patient was found on the floor, patient stated she was trying to go to the bathroom. The nurse noted contusion to the patient's right occipital/temporal regions of the head. The nurse also noted a new bruise to the patient's right flank/lateral chest wall.

There was no documented evidence that the patient was offered assistance to the bathroom after she last voided on 7/20/15 at 04:35 PM. The nursing assessment of the patient's need and intervention documented on 7/20/15 at 08:31 PM, excluded an assessment of the "4Ps" which denotes "pain, potty, position, and placement."

As per facility's "Fall Risk Assessment" policy, revised 11/13, initiating a toileting protocol to prevent falls indicated that a member of staff is required to "assist the patient to void every two (2) hours while awake."

During interview on 12/02/15 at 02:00 PM, Staff #4 (Clinical Analyst) stated that it is the facility's policy to conduct hourly rounds; and, during each round, the nurse should ask the patient about the above described "4Ps." Staff #4 acknowledged that the hourly assessment and interventions were not consistently documented.

2. On 7/21/15 at 08:30 PM, Patient #1 complained of the pain in her right shoulder. There was no documented evidence that the patient's complaint of pain after the fall incident approximately nine hours prior, was immediately brought to the attention of the medical staff. Patient #1 was assessed by the attending physician at 11:30 AM, four hours after the patient complaint. X-ray of the patient's Right Clavicle that was ordered by the attending physician revealed "complete mildly displaced fracture through the middle third of the right clavicle."

On 12/02/15 at 02:30 PM, Staff #4, (Clinical Analyst) verified these findings.


3. On 07/20/2015, at 11:02 PM, the patient was found on the floor. The case review showed no evidence that the patient's next of kin listed in the Health Care Proxy, was immediately notified of the fall. During interview, Staff #5 (Assistant Director of 5th, 6th, and 7th floors), stated she spoke to the patient's daughter "the following day" after the fall when the daughter called the facility, and since then, she was interacting with the patient's daughter daily.
There is no documented evidence of interactions with the patient's next of kin listed in the Health Care Proxy.

On 12/02/15 at 11:00 am, during the interview, the VP for Legal Risk and Regulatory Affairs and Chief Legal Officer, confirmed that notification of a person listed in Health Care Proxy for the patient is a commonly accepted standard practice.