HospitalInspections.org

Based on medical record review, review of facility policy Fall Prevention, interview, and observation, the facility failed to ensure patients received care in a safe setting to prevent falls for two (#1 and #2) of five patients reviewed.

The findings included:

Patient #1 was admitted to the facility on May 31, 2010, with diagnoses including Congestive Heart Failure, Chronic Renal Insufficiency, and Chronic Obstructive Pulmonary Disease.

Medical record review of the nursing assessments and progress notes dated June 3-5, 2010, revealed the patient was alert and oriented; used assistive devices for ambulating; was dizzy and/or had balance problems and/or weakness; and was receiving antihypertensives, hypoglycemics, diuretics, and sedatives/hypnotics. Continued review of the nursing assessments revealed the patient was assessed as "6+" or a high risk for falls and High Risk Interventions were implemented including "...leaf on door, fall arm band...bed alarm or personal alarm on when in bed, personal alarm on when up in chair, instruct to call for assistance with ambulation and ADL's (activities of daily living), do not leave unattended on BSC (bedside commode) or in bathroom, educate patient and family regarding safety, use gait belt for ambulation/transfer, target toileting needs..."

Review of the facility's policy Fall Prevention effective September, 2005, and revised September 1, 2010, revealed, "Purpose: The fall prevention policy is designed to ensure a safe environment for all patients and reduce the risk of patient harm resulting from falls...A score of 6+ indicates a high risk to fall. A patient meeting the following conditions will be considered an Automatic High Risk to fall...Administration of sedative/hypnotic...A Registered Nurse or Licensed Practical Nurse will complete the Fall Risk Screen every shift determining the patient's current fall risk level, making adjustments to the interventions as necessary...The following protocol for patients at high risk is implemented on admission or whenever the patient is deemed to be a high risk for fall. All low risk as well as high risk initiatives will be implemented, unless the Registered Nurse's assessment determines an initiative to be unwarranted. This determination along with rationale for variance will be documented in the Patient Care Record. 1. Place yellow armband on patient...6. Bed alarms are to be on at all times when the patient is in bed. Except...b. If the Registered Nurse assesses the patient capable and willing to call for assistance before getting out of bed, the bed alarm will be turned off. The Registered Nurse will document this decision on the Patient Care Record. If the patient refuses the bed alarm the Registered Nurse will: 1). Explain safety issues to the patient. 2). Document this discussion and the result in the nurses' progress notes...8. Place a personal alarm when the patient is up in a chair...If the Registered Nurse assesses the patient capable and willing to call for assistance before getting out of the chair, the chair alarm will not be applied. The Registered Nurse will document this decision on the Patient Care Record..."

Medical record review of the fall risk assessment for the night shift on June 6, 2010, revealed the patient scored 19 and all High Risk Interventions were to be implemented including top side rails up, fall arm band, bed alarm or personal alarm on when in bed, and personal alarm on when up in a chair.

Medical record review of the nursing progress notes dated June 6, 2010, revealed, "0010 (12:10 a.m.) Assessment completed. SR (side rails up) x 2. Call light in reach. 0115 (1:15 a.m.) Noise heard coming from pt's (patient's) room. On the arrival to the room, pt found on the floor..."

Medical record review of the orthopedic consult dated June 6, 2010, revealed, "...nondisplaced lateral malleolus fracture..." of the right ankle.

Review of the facility's investigation, medical record review, and interviews with the Chief Nursing Officer, Director of Quality, Director of Risk Management, Director of Safety, and the unit Patient Care Coordinator on November 4, 2010, from 11:15 a.m., until 12:30 p.m., in the Medical Staff Conference Room, confirmed patient #1 was assessed as high risk for falls and was to have a bed alarm or personal alarm on at all times. Further medical record and document review and interviews confirmed the alarm was not in place at the time of the fall. Continued interviews revealed the facility investigation concluded the fall was the result of a recent onset of confusion and the patient turning off the bed alarm. Continued interviews and medical record review confirmed there was no documentation the patient had ever turned off the alarms prior to the fall or at the time of the fall, and no documentation the patient reported turning off the alarm. Further interviews confirmed the medical record documentation did not support the conclusion the patient had turned off the alarm and the investigation consisted of interviews with staff who stated they thought the patient had turned off the alarm, but the patient was not witnessed ever turning off the alarms or reported turning off the alarms. Further interview confirmed there was no conclusive evidence the patient turned off the alarm.

Telephone interview with Registered Nurse (RN) #1 on November 12, 2010, at 2:12 p.m., confirmed RN #1 was caring for patient #1 on June 6, 2010, and was the first time the RN had cared for the patient. Continued interview confirmed RN #1 went to the patient's room at 1:15 a.m., after hearing a loud noise, the patient was on the floor, and the bed alarm was turned off and not sounding. Continued interview confirmed RN #1 felt sure the alarm was turned on after completion of the assessment at 12:10 a.m., and RN #1 did not know how the alarm was turned off, or who turned it off, but assumed the patient had turned it off, even though the RN was not aware of any history of the patient turning off the alarms and the patient did not report turning off the alarm. Continued interview confirmed there was no conclusive evidence the patient had turned off the alarm.

Patient #2 was admitted to the facility on October 29, 2010, with a diagnosis of Infected Pacemaker Site.

Medical record review of the Fall Risk Assessment for night and day shift on November 3, 2010, revealed the patient was confused, scored 16 or High Risk for falls and all High Risk Interventions were to be implemented including "Fall arm band."

Observation of patient #2 on November 3, 2010, at 2:50 p.m., in the patient's room, revealed the patient was lying in bed and did not have a fall arm band on.

Observation of the patient and interview with RN #2 on November 3, 2010, at 3:15 p.m., in the patient's room, and interview with RN #3 on November 3, 2010, at 3:20 p.m., at the nursing station, confirmed patient #2 was a high risk for falls, was to have a fall risk arm band placed, and the patient did not have a fall risk arm band present.

c/o #26649

Based on medical record review, observation, review of the facility policy Isolation Precuation, and interview, the facility failed to ensure infection prevention isolation procedures were followed for one patient (#4) of five patients reviewed.

The findings included:

Patient # 4 was admitted to the facility on November 2, 2010, with Mental Status Changes and Confusion.

Medical record review of the Admission History dated November 2, 2010, revealed the patient had a history of MRSA (methicillin-resistant Staphylococcus aureus). Medical record review of the Interdisciplinary Care Plan dated November 3, 2010, revealed the patient was in contact isolation precautions.

Medical record review of a Nursing Progress Note dated November 3, 2010, at 11:16 a.m., revealed, "MRSA screen (+) MD (physician) notified remains in contact isolation pt (patient) instructed staff aware."

Observation of patient #4 on November 3, 2010, at 4:00 p.m., revealed the patient was ambulating down the hall with a staff member assisting the patient by holding a gait belt around the patient's waist, and neither patient nor staff member was wearing a gown.

Review of the facility's policy Isolation Precautions effective March, 1984, and revised September, 2009, revealed, "...Contact transmission - the most frequent mode of transmission of nosocomial infections: 1) Direct-contact transmission - a direct body surface to body surface contact and transfer of agent between a susceptible host and an infected or colonized person (such as bathing a patient). 2) Indirect-contact transmission - contact wih a susceptible host with a contaminated intermediate object, such as contaminated instruments, dressings or gloves not changed between patients...Criteria for patients requiring isolation precautions participating in physical therapy activities outside their room...Staff member dons gown for contact precautions...use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items with the patient's environment. Examples of such illnesses include: 1. Multi-drug resistant organisms (MDRO) such as MRSA (Methicillin Resistant Staphylococcus aureus)..."

Interview with the Patient Care Coordinator on November 3, 2010, at 4:00 p.m., in the hallway, confirmed the facility's isolation precautions to prevent the spread of a multi-drug resistant organism had not been followed.