HospitalInspections.org

Based on review of medical records, staff interview and review of policy and procedures it was determined the facility failed to ensure a registered nurse supervised and evaluated the care of each patient for two (#1, #4) of five patients sampled.

Findings included:

Review of the facility policy, "Fall Prevention Plan," states all employees are expected to participate in the reduction of patient falls. Interventions may be initiated by either clinical or non-clinical staff, as appropriate, and will include the patient and family as appropriate. Section II - Assessment/Reassessment: ...(2) the following factors should be used to determine the patient's fall risk: Auditory and/or visual impairment, congestive heart failure. Section III - Fall Prevention Interventions states patients determined to be at risk for fall will also have the following interventions implemented based on the assessment of the patient: ...(c) the patient should not be left unattended when assisting them to the bathroom, the bedside commode, or the shower; ...(f) if video-monitoring is used, bed alarms are not to be used; ...(g) Patient Safety Attendants (sitters): the use of patient safety attendants and/or use of restrictive devices (i.e., restraint, Posey bed) should be evaluated and approved by the Director/designee/House Supervisor for implementation, continuation and resources available, i.e. family, private agency, or staff.

1. Review of patient #1's Emergency Patient Record, dated 4/13/2019, indicated the patient was 95 years old, legally blind, and hard of hearing. The stated complaint included, "CHF (congestive heart failure) and SOB (shortness of breath)". Review of the subjective assessment included "trouble breathing since yesterday". Review of the nursing fall risk assessment stated the patient was not at high risk for falls.

Interview on 5/1/2019 at 11:45 a.m., with the Risk Manager, confirmed the findings and stated patient #1 should have been assessed to be at risk for falls.

2. Review of the medical record for patient #4 revealed the patient was admitted on 2/28/2019 for urological complaint. Review of the nursing fall risk assessment, dated 2/28/2019 at 5:01 am, revealed the patient was identified with generalized weakness, the patient was hard of hearing and was a high risk for falls. Nursing documentation revealed a bed exit alarm was implemented. Review of the nursing shift assessment, dated 2/28/2019 at 7:58 am, revealed nursing assessed the patient to be a high risk for falls. Documentation stated interventions in place were a bed exit alarm, diversion, and supervision/assistance with ambulation.

Review of the nursing notes, dated 2/28/2019 at 9:15 am, revealed the nurse assisted the patient to the bathroom and told the patient to call for assistance back to bed. The nurse documented she left the room to administer another patient's medication and heard a loud thud from the patient's room. Review of the policy revealed the patient should not be left unattended when assisting them to the bathroom, the bedside commode, or the shower.

The nursing note further stated the patient attempted to ambulate back to bed and slipped on a napkin and fell hitting his elbow. The patient was assessed and treatment was provided. The physician and administrator were notified. Nursing documentation at 10:00 am revealed a post-fall assessment was completed with documentation that no fall protocols were in place at the time of the fall. Review of the record revealed no additional fall interventions were implemented post-fall. Review of the policy revealed the use of patient safety attendants and/or use of restrictive devices (i.e., restraint, Posey bed) should be evaluated and approved by the Director/designee/House Supervisor for implementation, continuation and resources available.

Review of the nursing fall risk assessment on 2/28/2019 at 8:00 pm revealed the patient was identified as a high fall risk and interventions in place were supervision/assistance, bed exit alarm, and virtual sitter. Review of the policy, "Fall Prevention Plan," states the virtual sitter is a system that uses cameras, sensors and central monitoring stations to alert staff to patient movement and activities that place them at high risk for fall. If video-monitoring is used, bed alarms are not to be used. An interview was conducted with the Director of Risk Management on 5/01/2019 at 3:00 pm at which time she confirmed the patient was located on a unit that had one room with a virtual sitter but the patient was not in that room at the time of the fall.

Review of the record revealed nursing conducted fall risk assessment of the patient each shift but there were no additional fall interventions put into place other than the supervision/assistance and bed exit alarm. Review of nursing note, dated 3/01/2019 at 8:24 pm, stated the patient was educated multiple times during the shift about the need to use the call light for assistance, bed alarm in use and assistance provided with ambulation. On 3/01/2019 at 9:24 pm nursing documented the patient was non-compliant during the shift, bed exit alarming in the patient's room multiple times since the start of the shift. The patient refused to use the call light. Review of the record revealed no evidence nursing attempted any other interventions.

Review of the nursing shift assessment, dated 3/02/2019 at 8:00 am, stated the patient was a high risk for falls, he was able to comprehend and follow directions, the bed exit alarm was in place, required supervised assistance and his gait was weak and unsteady. Review of the record revealed Physical Therapy treatment was provided at 1:45 pm and documentation revealed the patient was left supine in bed with the call light in reach and the RN (Registered Nurse) was notified of the patient's status at the end of the session. Review of the nursing note, dated 3/02/2019 at 3:05 pm, stated a loud crash was heard from the patient's room, the patient was found lying of the floor and that he slipped and fell when attempting to use the bedside commode. The patient stated he hit his head and couldn't move his leg. Review of the record revealed the patient sustained injury which required surgical repair.

An interview and review of the record was conducted on 5/01/2019 at 3:00 pm with the Director of Risk Management and the Director of Quality Management at which time the above findings were confirmed.

Based on review of medical records, staff interview and review of policy and procedures it was determined the facility failed to ensure blood transfusions were administered according to approved medical staff policies and procedures for one (#5) of five patients sampled.

Findings included:

Review of the facility policy, "Informed Consent for Medical Treatment," approved by the medical staff on 7/28/2018, states consent forms are evidence the patient has been informed of the procedure to be performed on the person as stated on the consent form and that he/she agrees to the procedure by placing his/her signature on the document. The policy states (A) authorization for medical and/or surgical treatment ...(7) specific procedure consents are available, including but not limited to ones for ...blood and blood products administration; (C) process for consents requiring informed consent (1) the physician, physician assistant or advanced registered nurse practitioner obtains consent for treatment by explaining potential benefits, risks and side effects of the patients' proposed care, treatment and services; (2) the form is presented to the patient for signature; (3) signature of the physician, physician assistant or advanced registered nurse practitioner is always required.

Review of the medical record for patient #5 revealed the patient was admitted to the outpatient unit on 4/29/2019 for physician ordered administration of two units of blood. Review of the record revealed the patient received two units of blood, per physician order, and was discharged on 4/29/2019. Review of the record revealed no evidence informed consent was obtained.


Interview on 5/01/2019 at 3:45 pm with the Director of Risk Management and Director of Quality Management confirmed there was no consent obtained for administration of the blood.