HospitalInspections.org

Based on medical record review, quality committee documention, and staff interview the facility failed to ensure each patient adverse event was documented and investigated.

Findings were:

Review of medical record for patient #1 revealed the patient experienced a fall on 8/11/19 after being assisted to the bedside commode. Documentation by the nurse reveals the physician was notified with orders for pain medication.

Review of physician notes in the patient medical record for patient #1 revealed no documentation by the physician of the patient fall.

Document titled "Safety Event Report Categories, Subcategories Generate Performance Measures" states "Event Category: Fall".

Documentation presented from "Action Cue" for "Fall Analysis" revealed no documentation for the fall for patient #1.

In an interview with staff #3 on 9/3/19 in the facility conference room he stated he did not fill out an adverse occurrence report for the patient fall as per their policy.

In an interview with the chief nursing officer, upon her review of the patient medical record, she could find no evidence of documentation of acknowledgement of the patient fall nor of the physician assessing the patient for injury.

Based on staffing schedules and staff interview the facility failed to ensure a registered nurse was scheduled and physically present on all nursing units to provide immediate nursing care.

Findings were:

Based on review of facility staffing schedules the facility did not have a registered nurse (RN) scheduled for all units providing nursing care to ensure the immediate availability of an RN to provide bedside care to a patient.
* 7 of 13 dates reviewed had the registered nurse scheduled covering the nuring unit and the emergency room.
This practice of scheduling the same RN to cover the emergency room and the inpatient nursing unit does not allow immediate availability for the RN to provide bedside care to a patient on the nursing unit and the emergency room to meet their needs.

2 of 13 dates reviewed had registered nursing staff scheduled that had no access to charting in the computer system. This practice did not allow for documentation of nursing assessment and care provided by the registered nurse to be documented in the patient medical record.

In an interview with the director of nurses on 9/3/19 she acknowledged the registered nurse being scheduled to cover the emergency room and the inpatient nursing unit at the same time. She further acknowledged the registered nurse on the inpatient nursing unit not having access to the computer system to document care and assessments of the patients during their shift.

In an interview with the CEO of the facility he acknowledged the facility did not have an approved Medicare waiver for the facility not to staff a registered nurse on every nursing unit.