HospitalInspections.org

Based on review of records and interview with staff, the facility failed to track indicators, including adverse patient events, for 1 of 1 patient whose record was reviewed. Patient #1 fell and fractured left arm and this event was not reported per hospital policy.

Findings were:

The facility policy entitled, Occurrence Reporting stated, "I. Policy: It is the policy of Green Oaks to (1) formally report all occurrences through Meditech Notification Program (2) restrict the circulation of occurrence reports to internal administrative channels only as described in this policy and (3) to promote a culture of non-punitive error reporting. " III. Definitions stated, "A1. Occurrence- any happening out of the ordinary course of treatment which results in a potential for injury, or actual injury or damage to the following: patient ..." Further review of this policy stated, "IV. Procedures: C. Reporting Patient, Visitor, Occurrences, 1a. When a patient is involved in an occurrence which may result in injury or complaint, the staff in charge of the involved department must see that the information is relayed to the appropriate health care personnel. 1b. The Occurrence Report should be filled out as soon as possible after occurrence, reviewed by the Department Director or designee and the Risk Manager as soon as possible. The Occurrence report will be maintained by the Risk Manager." There was no Incident Report on file for Patient #1's fall, which happened in the quiet room on 7/09/2011, and therefore, no follow-up to facilitate changes to improve patient safety.

An in-person interview was conducted with the Chief Nursing Officer and the Quality Director, on 7/28/2011 in a facility office. The facility did not provide to the surveyors at the time of the investigation a copy of the Incident Report. The above was confirmed.

Based on review of records and interview with staff, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 patient whose record was reviewed, as Patient #1 fell and fractured left arm. The Registered Nurse failed to reassess Patient#1 after the fall, as per hospital policy.

Findings were:

The facility policy entitled, Falls: Prevention Guidelines stated, "I. Purpose: To provide for identification and ongoing assessment of patients who are at risk of falling during hospitalization. To establish minimal safety interventions to be implemented for the at-risk patient. To provide for communication of pertinent information about patient's fall risk status. To establish interventions to be followed in the event that a fall occurs." Further review of this policy stated, "IV. Procedure: A.2. All inpatients and PES patients will be assessed on admission by a Registered Nurse to identify those who are at risk for falling using the fall risk assessment tool. All patients will be reassessed each day, when the patient's condition changes, or immediately after a fall. G. In the event a patient does fall, the Registered Nurse will: 1. Assess patient and record assessment findings in the Post Fall assessment toll. Assessment Elements Include: a) VS b) Neurological Assessment c) Motor Strength d) Musculoskeletal e) Skin Integrity f) Pain." The Registered Nurse failed to reassess Patient#1 after the fall.

An in-person interview was conducted with the Chief Nursing Officer and the Quality Director, on 7/28/2011 in a facility office. The facility did not provide to the surveyors, at the time of the investigation, documentation in the patient medical record where the Registered Nurse reassessed the patient after the fall. The above was confirmed.

Based on review of records and interview with staff, the facility failed to track indicators, including adverse patient events, for 1 of 1 patient whose record was reviewed. Patient #1 fell and fractured left arm and this event was not reported per hospital policy.

Findings were:

The facility policy entitled, Occurrence Reporting stated, "I. Policy: It is the policy of Green Oaks to (1) formally report all occurrences through Meditech Notification Program (2) restrict the circulation of occurrence reports to internal administrative channels only as described in this policy and (3) to promote a culture of non-punitive error reporting. " III. Definitions stated, "A1. Occurrence- any happening out of the ordinary course of treatment which results in a potential for injury, or actual injury or damage to the following: patient ..." Further review of this policy stated, "IV. Procedures: C. Reporting Patient, Visitor, Occurrences, 1a. When a patient is involved in an occurrence which may result in injury or complaint, the staff in charge of the involved department must see that the information is relayed to the appropriate health care personnel. 1b. The Occurrence Report should be filled out as soon as possible after occurrence, reviewed by the Department Director or designee and the Risk Manager as soon as possible. The Occurrence report will be maintained by the Risk Manager." There was no Incident Report on file for Patient #1's fall, which happened in the quiet room on 7/09/2011, and therefore, no follow-up to facilitate changes to improve patient safety.

An in-person interview was conducted with the Chief Nursing Officer and the Quality Director, on 7/28/2011 in a facility office. The facility did not provide to the surveyors at the time of the investigation a copy of the Incident Report. The above was confirmed.

Based on review of records and interview with staff, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 patient whose record was reviewed, as Patient #1 fell and fractured left arm. The Registered Nurse failed to reassess Patient#1 after the fall, as per hospital policy.

Findings were:

The facility policy entitled, Falls: Prevention Guidelines stated, "I. Purpose: To provide for identification and ongoing assessment of patients who are at risk of falling during hospitalization. To establish minimal safety interventions to be implemented for the at-risk patient. To provide for communication of pertinent information about patient's fall risk status. To establish interventions to be followed in the event that a fall occurs." Further review of this policy stated, "IV. Procedure: A.2. All inpatients and PES patients will be assessed on admission by a Registered Nurse to identify those who are at risk for falling using the fall risk assessment tool. All patients will be reassessed each day, when the patient's condition changes, or immediately after a fall. G. In the event a patient does fall, the Registered Nurse will: 1. Assess patient and record assessment findings in the Post Fall assessment toll. Assessment Elements Include: a) VS b) Neurological Assessment c) Motor Strength d) Musculoskeletal e) Skin Integrity f) Pain." The Registered Nurse failed to reassess Patient#1 after the fall.

An in-person interview was conducted with the Chief Nursing Officer and the Quality Director, on 7/28/2011 in a facility office. The facility did not provide to the surveyors, at the time of the investigation, documentation in the patient medical record where the Registered Nurse reassessed the patient after the fall. The above was confirmed.