HospitalInspections.org

Based on document review and interview, the facility failed to notify Power of Attorney (POA) and or Guardian of patient events in 3 of 10 medical records (MR) reviewed (P5, P6, P7).

Findings include:

1. Facility policy titled, Fall Prevention Program, PolicyStat ID 13554604, last revised 04/23, indicated procedure post fall included the nurse must notify POA/Guardian and/or patient's family.

2. Facility policy titled, Patient Rights and Responsibilities, PolicyStat ID 15317670, last revised 09/21, indicated a patient right was to have family and/or agent be informed of their care, in order to participate in decisions affecting care and the care plan.

3. The MR facesheet indicates P5 had a POA/Guardian. Per incident report, P5 had a fall on 10/25/23. The MR nurses notes lacked documentation of POA/Guardian notification of fall event.

4. The MR facesheet indicates P6 had a POA/Guardian and he/she was admitted 8/12/23. The MR nurses notes lacked documentation of POA/Guardian notification of P6's refusal to eat, intravenous (IV) line started, IV fluids started, and indication for IV fluids being new diagnosis of failure to thrive.

5. The MR facesheet indicates P7 had a POA/Guardian. The MR indicated P7 had a fall 8/1/23 at 5:00 pm. The MR nurses notes lacked documentation of POA/Guardian notification of fall event.

6. In interview on 10/30/23, A3 (Quality/Compliance Director [QCD]), verified notifications to providers and family are charted in the nurses notes.

Based on document review and interview, the facility failed to provide an adequate number of staff on 1 of 1 unit reviewed for staffing and failed to evaluate the nursing care for 1 of 10 patients reviewed (P6).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Nursing Services were provided in a safe manner.

Based on document review and interview, the facility failed to provide an adequate number of staff on 1 of 1 unit reviewed for staffing.

Findings include:

1. Facility policy titled, Clinical Staff (Nurse) Staffing Plan, PolicyStat ID 12279065, last revised 08/22, indicated 1 clinical staff member for every 4 patients, and at least 1 RN on every unit.

2. Review of the Staffing Pattern Worksheet (SPW) for unit 100 indicated the following:
a. Between the dates of 8/13/23 to 8/26/23, unit 100 was not staffed with any registered nurse (RN) coverage per Clinical Staff (Nurse) Staffing Plan policy on 5 of 42 shifts, including day, evening and night shifts, dates included: 8/18/23 day shift, 8/18/23 evening shift, 8/21/23 day shift, 8/21/23 evening shift, and 8/21/23 night shift.
b. Between the dates of 8/13/23 to 8/26/23, unit 100 was not staffed with expected staff to patient ratio per Clinical Staff (Nurse) Staffing Plan policy, including day, evening and night shifts on (a sampling of dates included but not limited to):
1. 8/13/23, unit census 16, Clinical Staff (Nurse) Staffing Plan policy indicates 4 staff required. SPW, night shift, indicates 3 staff.
2. 8/21/23, unit census 16, Clinical Staff (Nurse) Staffing Plan policy indicates 4 staff required. SPW, day shift, indicates 3 staff.
3. 8/21/23, unit census 16, Clinical Staff (Nurse) Staffing Plan policy indicates 4 staff required. SPW, night shift, indicates 2 staff.

3. In interview on 10/31/23, at approximately 10:15 am, A4 Director of Nursing (DON), verified SPW was correct and he/she was unaware of the staffing requirements in the Clinical Staff (Nurse) Staffing Plan policy.

Based on document review and interview, the facility failed to evaluate the nursing care for 1 of 10 patients reviewed (P6).

Findings include:

1. Facility policy titled, Assessment/Reassessment, PolicyStat ID 12386392, last revised 09/22, indicated assessments were ongoing as appropriate throughout the hospital stay.

2. Medical Record (MR) review of P6 indicated the following:
a. P6 was admitted to the facility on 8/12/23.
b. Psychiatric Progress note dated 8/15/23 indicated poor food and fluid intake.
c. Psychiatric Progress notes, dated 8/16/23 through 8/19/23, indicated poor food and fluid intake with P6 refusing to eat and drink.
d. On 8/18/23 skin turgor assessed at greater than 8 seconds, documented as reported to provider with orders received for Normal Saline 0.9% intravenous (IV) fluid to be started.
e. Medication Administration Record (MAR) and nurses notes indicated IV fluids infusing at 75 "cc" per hour from 8/18/23 at 2:30 pm until 8/18/23 at 6:30 (not indicated if am or pm, found as entry entered after 9:00 am entry on 8/18/23) when the IV was dislodged, nursing staff unable to restart IV line. Nurses notes did not indicate provider notification of no IV line or fluid administration. New IV line with fluids not restarted until 8/19/23 at 10:00 am.
f. On 8/19/23 a Complete Metabolic Panel (CMP) was collected at 7:26 am. CMP result, for specimen collected on 8/19/23 at 07:26 am, found in MR was facsimile (fax) copy of lab report. Fax date and time stamp indicated the facility received the fax on 8/19/23 at 1:24 pm. Potassium level resulted at 3.3 milimoles per liter (mmol/L), indicated as a low result with normal variance of 3.5-5.2. No provider signature noted on lab report. Nurses notes lacked documentation of lab reported to provider.
g. On 8/20/23 at 7:00 am P6 was described as unresponsive with vital signs charted as follows: blood pressure 82/59, temperature 96.8, pulse 59, respirations 18, pulse oximetry 96. Nurses notes on 8/20/23 at 7:30 am indicated P6 had hands and cheeks that were cool to the touch. MR lacked documentation of provider notification of vital signs and assessments made on 8/20/23 at 7:00 am and 7:30 am. MR lacked evidence of additional vital signs obtained after 7:00 am on 8/20/23 by facility staff. MR lacked documentation on P6's condition from 7:30 am until 8/20/23 at 9:30 am when P6 was assessed and found to have no pulse.

3. In interview on 10/31/23, at approximately 10:15 am, A4 (DON), verified providers sign the laboratory reports after they have reviewed them.

4. In interview on 10/30/23, A3 (QCD), verified that notifications to providers and family are charted in the nurses notes. A3 verified there should be every 15 minute checks for 9/20/23 from 7:00 am through transfer to ED. A3 verified he/she is unable to account for missing documentation from P6's MR.