HospitalInspections.org

Based on document review and interview, the facility failed to ensure adequate staffing was provided and according to staffing grid for 7 of 9 days.

Findings include:

1. Review of staffing and staffing grid indicated the following:
(A) Per the staffing grid, the facility should have three (3) licensed staff and six (6) Nursing Assistants for a census of thirty-thirty six (30-36) patients.
(B) On 2/29/16, the facility had a census of thirty four (34) patients and was short a Nursing Assistant on day shift.
(C) On 3/1/16, the facility had a census of thirty three (33) patients and was short a Nursing Assistant on night shift.
(D) On 3/3/16, the facility had a census of thirty five (35) patients and was short a Nursing Assistant on day shift.
(E) On 3/4/16, the facility had a census of 35 patients and was short a Nursing Assistant on both day shift and night shift.
(F) On 3/5/16 and 3/6/16, the facility had a census of 34 patients and was short two (2) Nursing Assistants on day shift.
(G) On 3/7/16, the facility had a census of thirty one (31) patients and was short a Nursing Assistant on day shift.

2. Staff member #3 (Assistant Director of Nursing [ADON]) verified the staffing sheet documentation in interviews beginning at 12:15 p.m. on 5/11/16.

Based on document review and interview, the facility failed to ensure a registered nurse supervised the care being provided to 5 of 10 patients (patients #1-4 and #5) by failing to adhere to physician orders for 3 of 10 patients (patients #1, 3 and 5), failing to put fall interventions in place for 4 of 10 patients (patients #1-4), failing to correctly complete fall risk assessments for 4 of 10 patients (patients #1-4) and failing to complete incident reports for 1 of 4 patients (patient #1).

Findings include:

1. Review of policy titled "INCIDENT REPORTS" with an issue date of 5/2015 states on page 1: "An Incident is defined as: any event which is not consistent with the routine operation of NeuroPsychiatric Hospital of Indianapolis and that adversely affects or threatens to affect the well-being of the Patients........" Under procedure, the policy states: "...2. An Incident Report should be completed immediately when an incident occurs by the employee who witnessed or was informed of the incident;..........4. Incident reports shall include documentation of the following elements:.........Family/legal guardian of the patient notified of incident/injury....Administrator on Call and the Director of Nursing notified of incidents involving injury....."

2. Review of policy titled "NURSING ADMISSION DATABASE" with an effective date of 5/15 indicates on page 6 of 7 that a fall risk score of 4-5 would include, but not limited to, a bed/chair alarm. A score of 6-7 would include, but not limited to, assess for 1:1 and PT consult......." The policy indicates that a history of falls would be coded as a 1 in the fall history section.

3. The "DAILY NURSING RECORD" indicates under "PRIOR FALL HISTORY" no falls would be coded as a 0, a fall before admission would be coded as a 1, and a fall during admission would be coded as a 2.

4. Review of incident reports indicated that the incident reports for patients #1-4 failed to document notifications to the Administrator, Director of Nursing, and family per policy. There was no incident report completed for fall at 9:45 p.m. on 3/3/16 and 7:00 p.m. on 3/5/16 involving patient #1.

5. Review of patient #1 medical record indicated the following:
(A) The patient was admitted to the facility on 3/2/16. Admission orders indicated under medical comorbidities that the patient had a history of falls.
(B) "DAILY NURSING RECORD" completed by staff member #6 indicated that at 0210 a.m. on 3/3/16 the patient was getting out of bed with a Certified Nursing Assistant (CNA)and the patient's leg hit the wheelchair and the patient received a "large" (no measurement) skin tear. A picture obtained at 12:02 p.m. on 3/3/16 indicated the size of the skin tear was 9.5 x 1 x .1 cm. The 0210 documentation indicated the fall risk assessment was not completed accurately. The score total was a 4 with a 0 marked under prior fall history indicating the patient had no history of falls. The admission orders indicated that the patient had a history of falls. A total score of 4-5 would require bed/chair alarms per nursing assessment policy. The only documentation of alarm use in the medical record was on day shift on 3/5/16.
(C) An order was written at 10:00 a.m. on 3/3/16 to give po (by mouth) liquid 250 ccs every 6 hours. The medical administration record (MAR) lacked evidence that this order was followed. The order was placed on the MAR, however had no initials that it was implemented.
(D) "DAILY NURSING RECORD" documented by staff member #5 on 3/3/16 indicated that at 9:45 p.m. the patient was observed on the floor in the activity room. No injuries documented. The fall risk assessment total for this shift was not complete. The assessment was completed, however the total score was not added/documented. The document had a 1 coded under the mobility section, a 1 coded under elimination section, a 1 coded under mentation section, a 2 coded under prior fall history section, and a 1 under the medication section. There was no indication in the medical record that a PT consult was obtained or that the patient was assessed for 1:1.
(E) Per the "DAILY NURSING RECORD" for day shift on 3/4/16, the patient had a fall risk score of 6. The record lacked evidence that 1:1 assessment was conducted or PT consult obtained.
(F) An order was written at 6:00 p.m. on 3/4/16 to start an IV (Intravenous) of D5 (Dextrose 5%) 1/2 Nacl (Sodium Chloride) at 60 cc/hour to be started "now". The order was on the MAR, however, there was no indication that it was started. There was no documentation of an IV being started in the narrative nurses notes.
(G) A nutritional assessment was completed on 3/4/16 with recommendation to give Ensure three times a day (tid). An order was written on 3/4/16 to give Ensure 1 can tid. The medical record lacked evidence that the Ensure was given. It was written on the MAR, however was not initialed as given.
(H) Per the "DAILY NURSING RECORD" for nightshift for 3/4/16 the patient had a fall risk score of 4. The patient had a score of 1 for falls before admission. The document indicated that a fall after admission required a score of 2. There was no score marked under medications. Based on the patient's medication regimen, the section required a score of 1.
(I) Per the "DAILY NURSING RECORD" for day shift on 3/5/16 the patient had a fall risk score of 4. The patient had a score of 0 for falls. The document indicated that a fall after admission is coded as a 2.
(J) Per the "DAILY NURSING RECORD" the patient was found on the floor at 7:00 p.m. on 3/5/16. The patient was lying face down with a pool of blood on the floor from his/her nose. The patient was sent to facility #2 via ambulance.

6. Review of patient #2 medical record indicated the following:
(A) He/she was admitted on 1/13/16.
(B) He/she had a fall on 1/14/16 while attempting to kick staff, hitting his/her head. He/she did not require treatment outside the facility.
(C) Per the "DAILY NURSING RECORD" documents, the fall risk scores were not completed accurately for dates including, but not limited to, 1/21/16, 1/22/16, 1/24/16, 1/25/16 and 1/26/16. The patient had a score of 0 for falls which would indicate he/she had no falls. The patient had a fall after admission and the form required a score of 2 for falls after admission. The total fall risk score should have been 6 resulting in the patient being at a high risk for falls and requiring PT eval and alarms. The medical record lacked documentation that a PT eval was requested or that alarms were used on the patient.

7. Review of patient #3 medical record indicated the following:
(A) He/she was admitted 2/26/16.
(B) An order was written at 4:25 p.m. on 2/29/16 for Healthshake twice daily. The record lacked documentation that the shake was administered on 3/1/16, 3/2/16, 3/3/16, 3/12/16 and 3/13/16. There was no documentation that it was administered evenings on 3/10/16 and 3/15/16.
(C) An order was written at 5:00 p.m. on 3/4/16 for Ensure plus twice daily. The record lacked documentation that the Ensure was administered 3/4/16 through 3/10/16.
(D) An order was written at 7:30 p.m. on 3/12/16 for Magic Cup twice daily. The record lacked documentation that the Magic Cup was administered.
(E) The patient had a fall at 9:20 a.m. on 2/29/16 with no injury. The patient's fall risk score was 4. The medical record lacked indication that alarms were utilized except for documentation of alarm use on 3/14/16 and 3/16/16.
(F) After the fall, the fall risk score on night shift 3/2/16, 3/3/16 and 3/6/16 and day shift on 3/4/16 indicated a score of 4. There was a 0 marked in prior fall history. The form required a score of 2 for a fall after admission. The record lacked evidence that the patient was assessed for 1:1 or that a PT eval was completed per policy.
(G) The patient had a fall at 2:30 a.m. on 3/12/16 with approximate 1 cm laceration to the head which did not require treatment outside the facility.

8. Review of patient #4 medical record indicated the following:
(A) He/she was admitted on 12/29/15.
(B) The patient had a fall on 1/5/16 at 8:15 a.m. with no injury. The fall risk score on day shift 1/6/16 indicated a score of 4. There was a 1 documented in the fall history section The fall risk score on night shift on 1/6/16 indicated a score of 3. There was a 0 marked in prior fall history. The form required a score of 2 for a fall after admission. The record lacked evidence that alarms were utilized except for 1/18/16, 1/19/16 and 1/20/16. The fall risk score on day shift and night shift for 1/8/16 was a 4 with a 0 marked in the fall history section. The record lacked evidence that alarms were utilized, that the patient was assessed for 1:1 or that a PT evaluation was obtained.
(C) The patient had a fall at 7:35 a.m. on 1/15/16 and received a laceration to his/her head requiring treatment at facility #2.

9. Review of patient #5 medical record indicated the following:
(A) He/she was admitted to the facility on 4/28/16.
(B) An order was written on 4/29/16 at 11:40 a.m. for Ensure Plus tid.
(C) The medical record lacked documentation that the Ensure was administered tid 4/29/16 through 5/5/16. It was documented as administered twice each day during that time period.

10. Staff member #2 (Director of Quality and Risk Management) verified in interview beginning at 11:30 a.m. on 5/11/16 that there were no incident reports completed for falls on 3/3/16 and 3/6/16 involving patient #1.

11. Staff member #3 (Assistant Director of Nursing [ADON]) verified the medical record information for each patient and the lack of documentation per policy on the incident reports in interviews beginning at 12:15 p.m. on 5/11/16.