HospitalInspections.org

Based on medical record review and staff interview, the governing body failed to ensure the medical staff assessed and followed up on the care of a patient after condition changed after a fall.

Findings were:

Review of medical record for patient #2 revealed, the patient fell in the facility the evening of 10/13/18. Post fall the patient complained of pain and went from ambulating without assistance to being non weight bearing to right leg and using a wheelchair. No documentation in the physician notes or multidisciplinary notes reveal the medical physician or the mid-level practitioners saw the patient on follow up post fall or saw the results of the x-rays that were ordered.

The psychiatrist saw the patient daily but has no documentation regarding the patient fall nor the change in the ambulatory status of the patient. The psychiatrist on the x-ray reports stated "Ordered by Medical. I did not order this."

X-rays revealed no acute fracture at time of films but stated in the Impression:
Impression: No definite acute right hip or pelvic fracture
Subtle fractures can easily remain occult on plain films.
If there is serious concern for hip fracture, would recommend CT or MRI.

There was no documentation the nursing staff or medical staff followed up with additional x-rays after the patient complained of pain in the right leg and hip and could not bear weight on right leg and was confined to a wheelchair starting the day after the fall in his room.

In an interview with staff #4 she stated on her review of the medical record for patient #2 there were no documented Multi-disciplinary team notes for 10/14/18. She stated, there was no documentation medical physician was notified of the results of the x-rays or noted the x-ray results as they had no documentation in the medical record that medical physician came in to see the patient when he had low oxygen saturation or abdominal and hip pain. She stated the psychiatrist had documented on the x-ray review of the results but she could not determine when he had seen and verified the results as there was no date/time documented on the x-ray results. She acknowledged the notation on the x-ray by the psychiatrist stated "ordered by medical" and there was no indication the physician ordered further x-rays until the family requested repeat x-rays when he continued to have pain and was in a wheelchair.

In an interview with staff #3, she stated, she had not performed a root cause analysis on the fall by patient #2 as the x-rays indicated he did not have a fracture. She stated they track falls as they are reported every morning in status meetings. She stated for any incident reported nursing does an investigation. She looks to see if investigation is complete. She stated nursing does all follow up with falls and if significant injury then it is tracked. Patient #2 did not have a fracture on his x-ray so no fracture; the incident report was closed. She stated she was unaware the discharge summary for his discharge on 10/17/18 completed by the psychiatrist on 10/25/18 documented the patient suffered a hip fracture from his fall while in the hospital.

Based on medical record review and staff interview, the facility staff did not ensure the patient was assessed by the physician when there was a change in the patient status post fall.

Findings were:

There was no documentation in the medical record that the nurse reported to the physician the patient's change in ambulation status after the fall and no further follow up with repeat x-rays was ordered until the patient's spouse asked for additional x-rays since he could not bear weight on his leg and was confined to a wheelchair.

Cross reference A0068 and A0144

Based on medical record review and staff interview, the facility failed to follow up with medical doctor on radiology reports when patient was unable to walk after a fall was sustained in the hospital.

Findings:

Patient #2 was admitted to the hospital on 10/4/18 with Unspecified Mood Disorder due to verbal and physical aggression at the nursing home. Patient on admission had no complaints of pain. Documented skin assessment by nursing on admission 10/4/18 at 2000 reveals skin warm/dry and intact with no significant findings.

Documentation in medical record revealed patient spouse expressed the following concerns to staff on patient care:

* Documentation by social services on 10/10/18 at 1300 revealed the therapist spoke to the spouse. Therapist reviewed Treatment Plan with spouse. Spouse reported concerns regarding bruising of patient hands and arms and skin tear since admission. Spouse also stated patient is cold natured and usually wears a t-shirt, regular shirt, and sweater.

* 10/13/18 1930 Nursing Fall
Patient checked on by MHT at 1925 and then MHT heard noise from patient's room. MHT found patient lying down next to bed. Patient stated "I fell, can you help me please." Patient left with another MHT and RN was notified. Pt. laying on floor. Pt. sustained skin tear to right elbow. Head to toe assessment completed. Full range of motion of extremities noted. Steri-strips applied to tear and bleeding controlled. Pt. agitated by BP cuff and pulse oximeter. VS obtained. Neuro checks WNL. Pt. baseline is confused. Q15 Neuro checks initiated.

* 10/13/18 7p-7a 0115
Pt refused O2- SpO2-86% Ambulatory; Skin: Skin tear to right elbow
Pain: Yes; grimacing/unable to locate pain or describe pain; MD notified for fall, decreased O2; Med per order Tylenol #3 for pain.

* Starting on 10/14/18 patient was using a walker/wheelchair and on 10/15 started using a wheelchair.

* Patient complained of pain in his right upper leg to staff and was irritable and did not want the staff to reposition him or bother him.

* 10/14/18 0845 the patient had x-rays of the right hip, femur, and chest x-ray performed. The x-rays show the reading was done by the radiologist at 1000 on 10/14/18. There are no documented notes by the nursing staff or the medical physician staff that they were aware of the results of the x-rays. The x-rays are signed off by the psychiatrist with no documentation of the time he saw the x-rays and notation on the x-ray by the psychiatrist state "ordered by Medical". There are no notes in the psychiatrist progress notes for notation on the x-rays and the patient now being in a wheelchair when up and pain when he is moved or touched.

* 10/16/18 1630 when the spouse visited with the patient she was concerned the patient was in a wheelchair and still complained of right hip pain and refused to bear weight on his right leg. The spouse requested another x-ray to be performed on her husband.


Physician notes in the medical record after the fall occured on 10/13/18 were:

10/12: Notes by the psychiatrist

10/15: Note by the psychiatrist 1900; Patient does not complain of abdominal pain today. Report says at times he does. Pt. last bowel movement was on the 12th. Pending report on the KUB. Medical is aware. Otherwise pt. remains Stein and does not cause any behavioral outbursts.

10/16/18: Note by psychiatrist at 1350; Pt. is ready for discharge tomorrow. Pt. is compliant with meds. No behavioral outbursts. Stable for discharge. No SI, No HI, No adverse med side effects.

No physician progress notes in patient chart by medical physician or mid-level practitioners. Order written in chart by PA on 10/16/18 at 12:15 for Miralax daily. No progress notes written by the PA to indicate PA saw the X-ray reports or the patient. No notes in multidisciplinary notes to indicate PA assessed the patient for his inability to ambulate or bear weight on his right leg.


Radiology reports for patient:

Portable XR Chest 2 Views performed on 10/14/2018 @ 8:46 am
Impression: Normal chest
This report was circled and signed by psychiatrist (no date or time of his review)


Portable XR Hip 2-3 Views Unilateral with or W/O Pelvis performed on 10/14/2018 at 8:45 am
Impression: No definite acute right hip or pelvic fracture
Subtle fractures can easily remain occult on plain films.
If there is serious concern for hip fracture, would recommend CT or MRI.
This report is circled and signed by psychiatrist with no date or time of his review; note "Ordered By Medical I did not order this"


Portable XR Femur RT
Impression: No definite acute fracture of the right hip or femur.
Subtle fractures can easily remain occult on plain films.
If acute fracture of the right hip remains a serious clinical consideration, would recommend CT or MRI.
This report has psychiatrist signature on form with no date/time documented.


X-Ray abdomen one view
Impression: Findings consistent with ileus with colonic gaseous distention.
This report is signed by psychiatrist with note "ordered by Medical" no date/time when signed

These radiology reports do not indicate the medical doctor saw the x-rays or no documentation in the chart exists from the nursing staff the physician was notified of the results.

There was no documentation in the medical record the nurse reported to the physician the patient had a change in ambulation status after the fall and no further follow up with repeat x-rays was ordered until the patient's spouse asked for additional x-rays since he could not bear weight on his leg and was confined to a wheelchair.

In an interview with staff #4 she stated on her review of the medical record for patient #2 there were no documented Multi-disciplinary team notes for 10/14/18. She stated there was no documentation medical physician was notified of the results of the x-rays or noted the x-ray results as they had no documentation in the medical record that medical physician came in to see the patient when he had low oxygen saturation or abdominal and hip pain. She stated the psychiatrist had documented on the x-ray review of the results but she could not determine when he had seen and verified the results as there was no date/time documented on the x-ray results. She acknowledged the notation on the x-ray by the psychiatrist stated "ordered by medical" and there was no indication the physician ordered further x-rays until the family requested repeat x-rays when he continued to have pain and was in a wheelchair.


In an interview with staff #3 she stated she had not performed a root cause analysis on the fall by patient #2 as the x-rays indicated he did not have a fracture. She stated they track falls as they are reported every morning in status meetings. She stated for any incident reported nursing does an investigation. She looks to see if investigation is complete. She stated nursing does all follow up with falls and if significant injury then it is tracked. Patient #2 did not have a fracture on his x-ray so no fracture; the incident report was closed.

Based on medical record review and staff interview, the facility nursing staff failed to update the nursing care plan to include immobility and pain control post fall by patient.

Findings were:

During medical record review for patient #2 on 10/30/18 there was no update to the patient treatment plan post fall on 10/13/18 for pain control and change in ambulation status.

In an interview with staff #4 she acknowledged there was no update in the plan of care to address the change in ambulation status and for pain control.

Based on medical record review, policy review, and staff interview the facility failed to ensure their staff followed their own policies in authentication and retention of medical record entries.

Findings were:

Review of medical record for patient #2 revealed the psychaitrist noted on the X-Ray reports for the patient and did not date and time his entries as required by the facility policy.

Portable XR Chest 2 Views performed on 10/14/2018 @ 8:46 am
Impression: Normal chest
This report was circled and signed by psychiatrist (no date or time of his review)

Portable XR Hip 2-3 Views Unilateral with or W/O Pelvis performed on 10/14/2018 at 8:45 am
Impression: No definite acute right hip or pelvic fracture
Subtle fractures can easily remain occult on plain films.
If there is serious concern for hip fracture, would recommend CT or MRI.
This report is circled and signed by psychiatrist with no date or time of his review; note "Ordered By Medical I did not order this"

Portable XR Femur RT
Impression: No definite acute fracture of the right hip or femur.
Subtle fractures can easily remain occult on plain films.
If acute fracture of the right hip remains a serious clinical consideration, would recommend CT or MRI.
This report has psychiatrist signature on form with no date/time documented of entry.

X-Ray abdomen one view
Impression: Findings consistent with ileus with colonic gaseous distention.
This report is signed by the psychiatrist with note "ordered by Medical" no date/time when signed., time 0915, x-ray notation.

Multi-disciplinary notes for 10/14/18 are blank except for date 10/14/18, time 0915, x-ray. No further documentation for date on the multidisciplinary notes.

Medication ordered 10/4/18 on admission Acetominophen 650mgm every 4 hours PRN for pain ( no medication sheets were available in the medical chart under Medication Administration Records the medication was ever administered. The sheets were missing from the medical record.)

Pages 5, 6, 7, & 8 of MAR (Medication Administration Record) unavailable for review in the patient medical record. These pages are for PRN medications.

Facility policy titled "Retention & Destruction" states in part "The record retention policy sets forth the guidelines for the identification, retention, storage, and destruction of records, regardless of type or storage medium. It is Oceans Healthcare policy to maintain complete, accurate, and high quality records. Records are to be retained for the period of their immediate or periodic use, unless longer retention is necessary to meet contractural, legal or regulatory requirements. Medical and Facility Records: Adult Medical Records: Duration of care plus 10 years."

Facility policy titled "Authentication" states in part "This policy serves to assure that the authenticity and integrity of medical records are in compliance with federal, state, and accreditation standards. All entries in the medical record are authenticated. All entries in the patient medical record are authenticated, dated, and timed by the author by either handwritten or electronic signatures. All orders, including verbal orders, are dated, timed, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient, and who is authorized to provide orders."

In an interview with staff #4 she verified the entries on the X-Ray reports had no time or date on the signature by the psychiatrist so she could not tell when the physician saw the report and signed off on the report. She further stated upon her review of the multidisciplinary notes and physician progress notes the only X-Ray that is documented by the psychiatrist is the KUB report on the abdomen on 10/15/18. She further stated there is no documentation in the medical record of multidisciplinary notes on 10/14/18 in the patient medical record to document if any physican was notified of the results of the X-Rays of the hip and femur or chest X-Ray. She further acknowledged the patient medication administration record is not complete as the pages for PRN medications are not in the medical record.