HospitalInspections.org

482.23 Condition of Participation: Nursing Services

Based on medical record reviews, policy review, falls data, observations and staff interviews, the hospital failed to ensure that nursing services planned and provided to Patients #10 and #12 were adequate to prevent falls. Additionally Patient #7 was placed at risk for falls due to a lack of follow through to ensure all visual cues included in the falls risk program were in place to identify those patients at risk. The hospital census was 225.

Findings include:

Please see A396 for findings.

Based on medical record reviews, policy review, review of falls data for the last six months, observations and staff interviews, two of ten patients (#10 and #12) who sustained falls during their hospitalizations did not have interventions in place which were consistent with the falls risk assessment and Patient #7 who did not fall but was at a higher falls risk than visual cues reflected. The facility's policy relating to falls prevention was not followed by staff and plans of care did not address falls prevention. The hospital census was 225.
Findings include:
Per review on 06/08/11 of the hospital's falls prevention policy, all patients are to be assessed on admission by the RN to determine the patient's falls risk. The falls assessment is to be completed daily, with a change in patient condition, with a change in level of care and after a fall occurs. In-patients are identified as a moderate or high fall risk by: a yellow fall risk sticker on the patient's name band, for moderate risk an orange leaf sign is placed on the patient's room door frame and when considered a high risk, a red leaf sign is to be placed on the patient's door frame and all patients determined to be a risk for falls are to wear yellow double sided non-skid socks. No patients were observed in the geri-psychiatric unit on 06/07/11 or 06/08/11 in yellow socks. Per interview on 06/07/11 at 11:10 AM with H, a nurse on the geri-psychiatric unit, they are no longer using just the yellow socks as they found that since the yellow non-skid socks come in one size only and did not fit every patient, the color of the sock was no longer an indicator of falls risk.
Per interview on 06/07/11 at 10:26 AM with Staff F , the quality manager and nurse responsible for the falls risk program, another part of the falls prevention program policy is that when a patient falls on any nursing unit in the hospital, a post fall SBAR form is to be completed by either the clinical manager, assistant clinical manager or nursing supervisor . Also the patient's power of attorney or family are to be notified. When copies of these SBAR forms were requested for review on 06/07/11, Staff F indicated there had been problems with nursing staff completing the forms since March 2011. During the month of April 2011, there were 28 falls and 5 SBAR forms completed for a completion rate of 17%. In May 2011, there were 12 SBAR forms for 25 falls. The SBAR form includes a description of the "situation", a description of the fall by the patient which is the "background" of the fall, the "assessment" which asks the patient why he/she thinks the fall occurred and the "recommendation" or interventions to prevent future falls. Falls data for the months of January, February, March, April and May are reported as patient falls per every 1000 patient days. The hospital's current goal was 2.5 falls/1000 patient days. In January 2011, there were 3.57 falls/1000 patient days, February 2011 there were 3.34 falls/1000 patient days, in March 2011 the rate decreased to 2.25 falls /1000 patient days, April was 4.1 falls/1000 patient days and May 2011 was 5 falls/1000 patient days. These statistics reflect an increase in patient falls.

Per medical record review on 06/09/11, Patient #12 was admitted to the geri-psychiatric unit at 05:30 PM on 05/16/11. The first falls risk assessment completed on 05/17/11 at 04:00 AM placed the patient at moderate risk for falls. At the time of Patient #12's first fall which occurred on 05/18/11 at 02:05 AM, the patient fell in the bedroom and sustained a hematoma on the right forehead. The unwitnessed fall occurred despite a bed alarm which was documented as being in place. A CT scan of the head was completed after the house physician evaluated the patient. The scan results revealed no acute intracranial injury. Per review of the incident report relating to this fall, Patient #12's family member was not notified of the fall. This was confirmed by Staff F on 06/09/11 at 11:00 AM.
Patient #12's second fall occurred on 05/18/11 at 05:55 PM in the day room and was witnessed by staff. A falls risk assessment completed on 05/18/11 at 02:00 PM revealed the patient was at high risk. While attempting to sit down the patient fell onto the floor on his/her buttocks. No harm was experienced.
Patient #12's third fall occurred on 05/22/11 at 05:50 AM while in his/her room and was unwitnessed. This time Patient #12 was found on the floor with a laceration above the left eye. An adult diaper was at the ankles and urine was on the floor. A post fall SBAR report was completed and the response to the question "Could this event been prevented?" was written "If the bed alarm had been on and functioning.'" A repeat CT scan of the head was done and the results revealed no acute intracranial abnormality. The patient's family were not notified of the fall according to documentation in the medical record and per interview with Staff F on 06/09/11 at 11:00 AM.

The clinical record review for Patient #7 was completed on 06/09/11. The clinical record review revealed the 84-year-old patient was admitted to the facility on 06/01/11 with diagnoses of dementia with psychosis. The clinical record review revealed a skilled nurse visit note dated 06/04/11 at 4:25 A.M. that stated patient had a bed alarm on. The clinical record review revealed a skilled nurse visit note dated 06/05/11 at 11:55 P.M. that stated a bed alarm is in place. The clinical record review revealed the patient was assessed on 06/07/11 at 3:00 A.M. as a low fall risk.
On 06/07/11 at 10:30 A.M., a tour of the geri-psychiatric unit was conducted with Staff A and Staff H. While on tour Patient #7's room's doorframe had a red leaf on it indicating the patient was a high fall risk. Patient #7 was observed sitting in a chair in the dining area during the tour. Neither the surveyors nor accompanying staff were able to see an easy visual cue to indicate Patient #7 was a high fall risk.
On 06/07/11 at 10:30 A.M. during the tour, Staff H was interviewed. Staff H stated patients identified as a fall risk receive a yellow sticker to their patient identification bracelet. He/she said he/she it would be best not to look at Patient #7's bracelet because that might cause the patient to become agitated.
The clinical record review revealed on 06/08/11 at 5:00 A.M. the patient was assessed as at a moderate risk for falls.
On 06/08/11 at 8:20 A.M., the surveyor observed Patient #7's room's doorframe to have no fall risk leaf.
Review of the patient's nursing care plan revealed that patient's needs to be addressed included bizarre thought content and psychomotor abnormalities. It did not include a problem statement specific to patient falls, nor did it include the usage of bed alarms mentioned in the 06/04/11 and 06/05/11 nursing notes.

The clinical record review for Patient #10 was completed on 06/09/11. The clinical record review revealed the 97-year-old patient was admitted to the facility on 06/04/11 with diagnoses of suicide ideation, dementia, anxiety, history of fall, and stroke. The clinical record review revealed the patient was assessed as a moderate fall risk on 06/07/11 at 4:00 A.M.
On 06/07/11 at 10:30 A.M., a tour of the geri-psychiatric unit was conducted with Staff A and Staff H. While on tour Patient #10's room's doorframe had an orange leaf on it indicating the patient was a moderate fall risk. Patient #10 was observed sitting in a chair in the dining area during the tour. The patient was observed to have an alarm attached so that it would sound if he/she attempted to get out of the chair.
The clinical record review revealed the patient was assessed as a high fall risk on 06/08/11.
On 06/08/11 at 8:20 A.M., the surveyor observed the patient's doorframe had an orange leaf on it indicating the patient was a moderate fall risk. The surveyor observed the patient sitting in the dining area, and was unable to notice easily any visual cue that the patient was a high fall risk.
The clinical record review revealed a care plan that identified that patient's needs included suicidality, ineffective coping skills, hopelessness, restlessness, and motivation/energy. The care plan did not indicate any interventions specific to falls, nor did it indicate the usage of an alarm to alert staff of the patient's getting out of a chair without assistance.
The clinical record review for Patient #8 was completed on 06/09/11. The clinical record review revealed the 79-year-old patient was admitted to the facility on 05/20/11 with diagnoses of Alzheimer's dementia, anxiety, depression, and suicide attempt. The clinical record review revealed a nursing progress note dated 05/25/11 at 2:08 A.M. that indicated the patient was in his/her room and a bed alarm was on. The clinical record review revealed a fall risk score dated 05/30/11 that indicated the patient was a high risk for falls. The clinical record review revealed a nursing progress note dated 05/30/11 at 7:53 P.M. that stated the patient was found on the floor in the television room. The note stated, "1st shift stated he/she fell going from chair to couch." The note stated a physician attended to the patient, found no injury, and a voice mail was left with the patient's family regarding said fall.
The clinical record review revealed a nursing care plan dated 05/23/11 that stated the patient's problems included suicide ideation and recent loss of wife. It did not address falls, nor did it speak to the use of a bed alarm written about on 05/25/11.
On 06/08/11 at 10:25 A.M. in an interview, Staff Nurse S stated he/she was found on the floor as they came out of report. He/she said he/she had been reaching for the television remote. He/she confirmed the patient did not have a falls-specific care plan.
The clinical record review for Patient #2 was completed on 06/08/11. The clinical record review revealed the patient was admitted to the facility on 06/01/11 with diagnoses of paranoid personality traits, history of longstanding schizo-affective disorder, and primary degenerative dementia with delusions.
The clinical record review revealed a patient's care plan dated 06/03/11 that stated the patient had problems of mental illness and delusional/paranoid thinking. The care plan did not address the patient's urinary elimination needs, or that the patient would urinate in improper areas such as on the floor.
On 06/07/11 at 10:30 A.M., a tour of the geri-psychiatric unit was conducted with Staff A and Staff H. While on tour Patient #2's room was examined. In the bathroom, the surveyor observed a used incontinence undergarment on the sink and smelled a urine stench.
While on tour on 06/07/11 at 10:30 A.M., Staff H was interviewed. Staff H confirmed the stench of urine from Patient #2's bathroom was because he/she doesn't urinate in the toilet. He/she said he/she urinates in corners of the bathroom and on the floor. He/she confirmed there wasn't a care plan to address the patient's improper urination.

This deficiency substantiates an allegation contained in Complaint OH00060949.

Based on observations and staff interview, two of four nurses observed during medication administrations did not display infection control precautions for two of five patients observed. This included Patients 4 and 6 and Staff O and P. The hospitals' current census was 225.

Findings include:

Per observation on 06/08/11 at 08:26 AM, Staff O was observed to apply a pain patch on Patient 4's neck without gloves. Then Staff O donned gloves to administer an injection of an anticoagulant into the patient's abdomen. Then Staff O assisted the patient to pull himself/herself up in bed. After that, Staff O opened the individual medication packages of eight oral pills prescribed. Then Staff O poured the medication cup containing the pills onto Patient 4's blanket covering his/her lap. Then Staff O placed each pill individually into Patient 4's mouth and provided a glass of water to facilitate swallowing. Then Staff O used the scanner to scan a new one liter intravenous bag of normal saline which was spiked and hung at 08:38 AM and used the computer keyboard to enter the IV fluids.

Per observation on 06/08/11 at 08:55 AM, Staff P was observed to blow powder from the top of the medication cart and clipboard after administering a laxative powder to Patient 5, who was in the bed next to Patient 6. Patient 6 had an intravenous lock which Staff P irrigated with normal saline with ungloved hands. Then Staff P administered 5 milliliters of cough syrup to Patient 6, used the computer mouse and typed on the computer keyboard. Staff P then picked a tissue box containing disposal tissues from the floor and placed the box on Patient 6's overbed table.

These observations were discussed with Staff J and Staff K at 09:03 AM on 06/08/11 who verified the observations did not reflect appropriate infection control techniques.

This deficiency substantiates an allegation contained in Complaint OH00060949.

Based on medical record review and staff interviews, one of three discharged patients reviewed did not have all necessary patient information provided by the hospital to the nursing home where he/she was transferred to. This included Patient 11. The current patient census was 225.

Findings include:

Per electronic medical record review on 06/08/11, Patient 11 was admitted to the hospital on 05/13/11 with a primary diagnosis of recurrent depressive psychosis-severe along with syncope and collapse, kidney disease requiring dialysis and intestinal infection due to clostridium difficile. While hospitalized from 05/13/11-05/29/11, Patient 11 was in the gero-psychiatric unit from 05/13/11-05/14/11 and 05/15/11-05/18/11 and in the surgical intensive care unit from 05/14/11-05/15/11 and from 05/18/11-05/29/11 on a medical floor. Discharge/transfer to a nursing home was anticipated and occurred at approximately 12:04 AM on 05/29/11 at the patient's request. Staff Q, a case manager, was interviewed on 06/08/11 at 04:10 PM regarding what information is sent by the hospital to the receiving nursing home. That documentation included nursing notes, physician notes and assessments. Specific discharge information was documented in discharge instructions and on a "goldenrod". Review of these documents revealed no information was provided relating to the cervical collar the patient was to wear for six weeks, according to the neuro-surgeon who evaluated the patient on 05/14/11, after Patient 11 fell and sustained fractures to C4, C5 and C6. Also not addressed on the discharge information was the status of the skin breakdown, described as stage 2 pressure ulcers on 05/18/11. During Patient 11's hospitalization he/she acquired clostridium difficile in the stool on 05/24/11 when a stool specimen verified the infection. The discharge instructions included C. Diff. precautions but no information regarding the current antibiotic treatment ordered. These findings were verified on 06/09/11 at 10:57 AM by Staff F.

This deficiency substantiates an allegation contained in Complaint OH00060949.