HospitalInspections.org

Based on review of the facility's policy and procedures, medical records (MR), and interview with staff, it was determined the facility failed to ensure an incident report was completed in a timely manner.

This deficient practice affected 1 of 1 medical records reviewed involving a fall, which included MR # 1 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy Name: Event Reporting
Policy Number: SYS RSK_021
Approved Date: March 1, 2017

Policy:

Any Hospital Staff Member who witness, discovers or has direct involvement in and/ or knowledge of a Reportable Event must complete an Event Report.

All Event Reports must be completed using MIDAS, or the Midas downtime form (when the EMR is down) ...

Procedure:
A. Time Frame for Completing Event Report
1. After providing for the needs of the individuals involved. Hospital Staff Members must complete and submit an Event Report as soon as possible. Preferably, the report should be submitted before leaving the Hospital at the end of the work shift, but no later that twenty- four (24) hours from the time the event occurred.
B.

2 a. Complete Mandatory fields and all relevant fields specific to the event. (Mandatory fields are marked).
C. Department Director/ Manager/ Supervisor Responsibilities
Each Department Director/ Manager/ Supervisor is responsible for:
1. Reviewing events that occur in their are, assigning severity, documenting the results of the review, and assigning or completing follow-up through the Hospital's Patient Safety Reporting System.

1. MR # 1 was admitted to the facility on 3/29/18 with a primary diagnosis of Metastatic Cancer To Intra- Abdominal Lymph Nodes.

Patient was discharged on 4/3/19.

Review of the Attending Physician's Orders dated 3/29/18 revealed the following orders: Admit to Inpatient, Fall Prevention, ...

Review of the Nurse Notes (NN) documented by Employee Identifier (EI) # 5, Charge Registered Nurse dated 3/31/18 at 4:30 AM revealed the following; the patient was instructed by EI # 4, Nursing Technician II, to pull the call light inside the bathroom before getting up. EI # 4 stated he/ she left the patient in the bathroom and walked out the patient's room.

Review of the NN revealed the patient fell "backwards into the shower, hitting the back of her/ his head and shoulders knocking off several shower panels/ tiles." Further review of the NN revealed patient, "sustained skin tear to right forearm, back of head, neck and some redness to upper back."

During an interview conducted on 1/17/19 at 10:13 AM with EI # 5, Registered Nurse was asked if an Incident/ Accident Report was written about the fall. EI # 5 stated " I do not recall writing an Incident Report." The surveyor asked EI # 5 who is responsible for writing an Incident Report, EI # 5 stated the he/ she is responsible for documenting the incident.

An interview was conducted on 1/17/19 at 8:35 AM with EI # 1, Chief Nursing Officer, who confirmed the staff failed to follow facility's policy and procedures on event reporting.

Based on review of medical records (MR), hospital policy and procedure, and staff interviews, it was determined the hospital staff failed to follow their own policy for informed consent. This affected 3 of 9 records reviewed including MR # 3, MR # 1, and MR # 2, and had the potential to negatively affect all patients treated at the facility.

Findings include:

Policy: Informed Consent
Policy Number: CPL 048
Effective Date: 6/14/2018

...Purpose:

To provide guidelines for obtaining informed consent from the patient/ family/ or persons legally authorized to act on the patient's behalf.

... It is the responsibility of the physician performing the procedure to explain to the patient the procedure involved (in laymen's terms)...

The patient should also be informed of:

1. The name of the physician or other practioner who has primary responsibility for the patient's care.

2. The identity and professional status of individuals responsible for authorizing and performing procedures and treatments...

After informed consent has been obtained, a consent form should be completed for the following:

1. Surgical procedures

2. Anesthesia...

6. All endoscopic procedures (i.e. EGD [Esophagogastroduodenoscopy], colonoscopy...)

7. Administration of blood and blood products...

...Procedure:

1. The nurse will complete the consent form as ordered by the physician and witness the signature of the patient or legal guardian...

1. MR # 3 was admitted to the facility on 1/11/18 with diagnoses including Diarrhea in an Adult, and Dehydration.

Review of the MR revealed a consent for anesthesia dated 1/14/18. There was no signature documented for "Person obtaining above signature..." The date and time for the witness signature was also blank.

Further review of the MR revealed a consent for an EGD dated 1/14/18. There was no name documented to identify the doctor performing the procedure.

A consent for transfusion of blood or blood products dated 1/14/18 was noted in the MR. There was no documentation of the physician's name who provided informed consent to the patient.

An interview was conducted on 1/17/19 at 1:12 PM with Employee Identifier (EI) # 2, Patient Safety Officer, who confirmed the above findings.

2. MR # 1 was admitted to the facility on 1/10/18 with diagnoses including Altered Mental Status and Sepsis UTI (Urinary Tract Infection).

Review of the MR revealed a consent for anesthesia dated 1/19/18. There was no documented time the physician signed the consent.

Review of the MR revealed a Preanesthesia Evaluation which included a consent for anesthetic plan dated 1/19/18. There was no documented time the physician signed the consent.

An interview was conducted on 1/17/19 at 12:54 PM with EI # 2, who confirmed the above findings.

3. MR # 2 was admitted to the facility on 1/8/18 with a diagnosis of Generalized Weakness.

Review of the MR revealed a consent for Lumbar Puncture dated 1/12/18. There was no physician listed to perform the procedure. There was no date or time documented for the Registered Nurse witness signature. The consent was signed by a person other than the patient, and the section, "Relationship to the patient," was blank.

An interview was conducted on 1/17/19 at 1:05 PM with EI # 1, Chief Nursing Officer, who confirmed the above findings.

Based on review of facility policies and procedures, medical record (MR), and interviews, it was determined the facility failed to ensure patients were cared for in an environment which promoted a safe environment to decrease the risk for falls and / or injuries.

This deficient practice affected MR # 1, 1 of 1 record reviewed related to fall and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy Name: Fall Management
Policy Number: NRS 004 (system)
Revised date: March 2015

Purpose
The purpose of this policy is to identify patients who are at risk for falling and to implement strategies to minimize the risk for falls.

Policy
In keeping with our Core Values, a program for preventing falls will be utilized for all patients. Patients will be assessed for risk of falling utilizing the tool appropriate for them and for their environment. If patient is determined to be a risk for falling, appropriate measures will be put in place to minimize the risk.

Procedure

A. Adult Inpatients (including .....) and ...
1. All adults will be assessed for the fall risk including the Modified Mores fall Risk tool in the electronic medical record (EMR)

d. Following any changes of status.

B. Fall Prevention and Management Interventions/ Protocol for Adult Patients

13. Consider room placement closer to the nurses' station.

1. MR # 1 was admitted to the facility on 3/29/18 with a primary diagnosis of Metastatic Cancer To Intra- Abdominal Lymph Nodes.

Review of EI # 7, Registered Nurse Nurse Note (NN) revealed the following documentation: Nurses Plan of Care dated 3/31/18 at 3:38 AM Problem: Safety, Goal: Free from accidental physical injury dated 3/31/18 at 3:38. ... Outcome: Progressing.

An interview with EI # 4, Nurse Technician II was conducted on 1/17/19 at 8:05 AM. EI # 4 stated the patient called and asked to go to the bathroom. EI # 4 accompanied the patient to the bathroom, instructed the patient to pull the call light before getting up, left the patient alone in the bathroom. EI # 4 further stated she/ he was outside of the patient's room when she/ he and EI # 5 heard a loud noise and found the patient on the bathroom floor and apparently knocked off some shower panels. Patient sustained skin tear to right forearm, back of head and neck. House supervisor, charge nurse and attending physician was notified. The staff failed to ensure the fall precaution policy procedures was followed.

An interview was conducted on 1/17/19 at 1:30 PM with EI # 1, Chief Nursing Officer who confirmed the above mentioned findings.

Based on review of medical records (MR), policy and procedure, and interview with staff it was determined the hospital failed to ensure an Event Report was completed per policy on delayed medication. This affected 1 of 9 records reviewed, including MR # 9, and had the potential to negatively affect all persons served by the hospital.

Findings include:

Policy: Event Reporting
Policy Number: SYS RSK_021
Date Published: March 2, 2017

Purpose:

The purposes of this policy are to:

...A. Provide a system for promptly reporting and investigating reportable events and integrating risk reduction strategies into the patient safety activities.

B. Comply with the requirements of applicable federal and state law...

C. Establish a process to validate documentation and investigation is conducted appropriately to the type and severity of reportable events; and;

D. Support a culture of share accountability for the identification, reporting and management of reportable events that may impact the quality of care provided.

...Policy:

...Any Hospital Staff Member who witnesses, discovers or has direct involvement in and/or knowledge of a Reportable Event must complete an Event Report...

Procedure:

A. Time Frame for Completing an Event Report

1. After providing for the needs of the individuals involved, Hospital Staff Members must complete and submit an Event Report as soon as possible...

D. Hospital Risk Management...

The Hospital's Risk Manager is responsible for:

1. Providing leadership... and ensuring that all staff is trained on this policy.
2. ...c. Data integrity and analysis.

H. Enforcement

All Hospital Staff Members whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy...

Definitions:

A. "Reportable Event" means an event that is not consistent with the routine operation of the Hospital or the routine care of a patient or patients.

1. MR # 9 was admitted to the hospital on 4/4/18 with a primary diagnosis of Left Upper Extremity Deep Vein Thrombosis.

Review of the MR revealed physicians orders dated 4/9/18 for Rocephin 2 g (grams) in NaCl (Sodium Chloride) 0.9 % (percent) 100 ml (milliliters) IV (Intravenous), daily.

Further review of the MR revealed the following documentation on 4/10/18 at 4:08 PM by the RN (Registered Nurse): "...I called the PICC (Peripherally Inserted Central Catheter) team this morning somewhere between 10-11 (10:00 to 11:00). I informed (name) that my patient needed an EJ (External Jugular) (access). I was told that I would need to contact the CRNA (Certified Registered Nurse Anesthetist)... She said she was on her way. Hours have gone by and no one has showed up..."

The procedure summary dated 4/10/18 at 4:41 PM revealed a peripheral IV was started in the right hand by the CRNA.

Review of the medication administration record revealed Rocephin 2 g was administered on 4/10/18 at 5:08 PM, which was delayed by 7 hours and 38 minutes.

The surveyor requested an Event Report for the medication delay, and was informed there was no report completed.

An interview was conducted on 1/17/19 at 1:05 PM with Employee Identifier # 1, Chief Nursing Officer, who confirmed there was no report completed for the delayed medication, per policy.