HospitalInspections.org

Based on review of medical documentation and interview, it was determined that the facility governing body did not maintain responsibly for serviced furnished in the hospital, as evidence by failing ensure that bylaws, rules, and regulations were implemented and by the medical staff.

Findings were:

Facility policy & procedure titled Restraint Use stated, in part,
" Physician Responsibilities
1. Restraint shall be ordered by a Licensed Independent Practitioner and used only when clinically indicated. PRN Restraint orders are not accepted. "

A review of the clinical record for Patient # 1 revealed the following Physician Order, 06/19/12 at 0600, "Problem: Pulled PICC line out, IV pulled out. Attempted several times to get out of bed. May restrain for patient safety. " There was no time limit, start or stop time noted on this restraint order, making this a standing PRN restraint order.

Facility policy & procedure titled Nursing Documentation stated, in part,
"Nursing Documentation:...
2. Monitor and record the following:
? Changes in patient ' s condition "

A review of the clinic record for patient # 1 revealed a failure to properly document a fall that occurred on 06/15/12. According to documentation,"While on the floor, the patient fell, X-rays of the right lower extremity were ordered. X-rays revealed a right distal femur fracture."
? It appears the fall resulting in the fractured right femur occurred around 1500 on 06/14/12 related to the time entered on the Physician/Professional Communication sheet. According to the Physician/ Professional Communication Note dated 6/14/12 the physician was notified of a " Significant Event " at 1515. There was no description of the significant event. The actions related to the communication were, "Stat xray of hip and right knee. Will contact Dr. Badylak and call if any changes to orders. "
? There was no documented description of the significant event (fall). There was no follow up fall assessment, physical assessment, or pain assessment documented on the patient post fall.

Facility policy & procedure titled Fall Precautions stated, in part, " The Morse Fall Scale will be utilized to assess the patient ' s fall risk factors upon admission, fall, change in status and discharge or transfer to a new setting. "
? A review of the clinical record for Patient # 1 revealed a Safety Assessment including Fall Risk Assessment completed upon their admission on 6/14/12 at 1300. This initial Fall Risk Assessment scored the patient at 50 indicating a low fall risk 25-50. A Safety Assessment at 1500 indicated she was WNL (within defined limits). Another Fall Risk Assessment is not completed in the medical record until 2131. During this assessment the patient received a score of 65 indicating a high fall risk. No other fall risk assessments were completed on 6/14/12. No fall assessment was document post fall per policy. There was no follow up fall assessment documented on the patient post fall.

Facility policy & procedure titled Pain Management stated, in part, " All patients will be assessed for pain on admission and reassessed as indicated by the patient ' s condition:..
9. Frequency of assessment for pain should be determined based on individual patient needs. The patient will be assessed: ...
? Each shift ...
? After each analgesic according to onset and peak effect time.
10. Assessment and evaluation will be ongoing and consider the patient ' s history, current condition and anticipated needs. If the patient is reporting pain, the following factors should be evaluated and documented and as indicated:
? Location
? Radiation
? Intensity (0-10)
? Onset
? Duration
? Patterns
? Assessment of pain at its least and worst
? Qualitative Characteristics ...
? Response to the Intervention
? Absence or presence of unrelieved pain at peak action time
? Absence or presence of dose-limiting side effects
14. Reassessment of the patient ' s condition and response to pain medications will be made after the administration of each dose of pain medication. "

A review of the clinical record for Patient # 1 revealed insufficient documentation of pain assessment (4 out of 7 times that pain medication was administered) on the following days:
? On 6/14/12 at 1629 " Presence of Pain: complaints of pain/discomfort " of her right knee was noted by the nurse. The nurse did not document intensity of the pain. The Pain Management Interventions indicated " single medication modality " . The Pain Response to Interventions at 1816 noted " pain improved " , this does not appropriately document the patient ' s response to pain medication, nor does it note intensity.
? On 06/15/12 at 0944 " Presence of Pain: complaints of pain/discomfort " of her right leg was noted by the nurse, rated 6/10. The Pain Management Interventions indicated " Tylenol #3 300/30mg 1 tab PO " . The Pain Response to Interventions at 1020 noted " pain at acceptable level " , this does not appropriately document the patient ' s response to pain medication, nor does it note intensity.
? On 06/19/12 at 0200 " Presence of Pain: complaints of pain/discomfort " of her right hip was noted by the nurse. The nurse did not document intensity of the pain. The note stated " Tylenol #3 given po for pain to rt hip " . No re-assessment of the patient ' s condition and response to the pain medication was documented.
? On 06/19/12 at 1015 " Presence of Pain: complaints of pain/discomfort " of her right leg was noted by the nurse, rated 10/10. The Pain Management Interventions indicated " single medication modality " . No re-assessment of the patient ' s condition and response to the pain medication was documented.
? No documented pain assessment was recorded for Patient #1 status post fall on 06/15/12.

The governing body failing to maintain responsibly for furnished services in the hospital was confirmed in an interview with the Nurse Managers on the afternoon of 7/23/12 in the facility conference room.

Based on review of medical documentation and interview it was determined that the facility failed to ensure that patient rights were maintained as evidence by the presence of a standing/PRN restraint order.

Findings were:

? A review of the clinical record for Patient # 1 revealed the following Physician Order, 06/19/12 at 0600, "Problem: Pulled PICC line out, IV pulled out. Attempted several times to get out of bed. May restrain for patient safety. " There was no time limit, start or stop time noted on this restraint order, making this a standing PRN restraint order.

Facility policy & procedure titled Restraint Use stated, in part,
" Physician Responsibilities
1. Restraint shall be ordered by a Licensed Independent Practitioner and used only when clinically indicated. PRN Restraint orders are not accepted. "

This standing PRN restraint order was confirmed in an interview with the Nurse Managers on the afternoon of 7/23/12 in the facility conference room.

Based on review of medical documentation and interview, it was determined that the facility failed to ensure that bylaws were enforced and carried out by medical staff to carry out their responsibilities.

Findings were:
Facility policy & procedure titled Restraint Use stated, in part,
" Physician Responsibilities
1. Restraint shall be ordered by a Licensed Independent Practitioner and used only when clinically indicated. PRN Restraint orders are not accepted. "

A review of the clinical record for Patient # 1 revealed the following Physician Order, 06/19/12 at 0600, "Problem: Pulled PICC line out, IV pulled out. Attempted several times to get out of bed. May restrain for patient safety. " There was no time limit, start or stop time noted on this restraint order, making this a standing PRN restraint order.

Facility policy & procedure titled Nursing Documentation stated, in part,
"Nursing Documentation:...
2. Monitor and record the following:
? Changes in patient ' s condition "

A review of the clinic record for patient # 1 revealed a failure to properly document a fall that occurred on 06/15/12. According to documentation,"While on the floor, the patient fell, X-rays of the right lower extremity were ordered. X-rays revealed a right distal femur fracture."
? It appears the fall resulting in the fractured right femur occurred around 1500 on 06/14/12 related to the time entered on the Physician/Professional Communication sheet. According to the Physician/ Professional Communication Note dated 6/14/12 the physician was notified of a " Significant Event " at 1515. There was no description of the significant event. The actions related to the communication were, "Stat xray of hip and right knee. Will contact Dr. Badylak and call if any changes to orders. "
? There was no documented description of the significant event (fall). There was no follow up fall assessment, physical assessment, or pain assessment documented on the patient post fall.

Facility policy & procedure titled Fall Precautions stated, in part, " The Morse Fall Scale will be utilized to assess the patient ' s fall risk factors upon admission, fall, change in status and discharge or transfer to a new setting. "
? A review of the clinical record for Patient # 1 revealed a Safety Assessment including Fall Risk Assessment completed upon their admission on 6/14/12 at 1300. This initial Fall Risk Assessment scored the patient at 50 indicating a low fall risk 25-50. A Safety Assessment at 1500 indicated she was WNL (within defined limits). Another Fall Risk Assessment is not completed in the medical record until 2131. During this assessment the patient received a score of 65 indicating a high fall risk. No other fall risk assessments were completed on 6/14/12. No fall assessment was document post fall per policy. There was no follow up fall assessment documented on the patient post fall.

Facility policy & procedure titled Pain Management stated, in part, " All patients will be assessed for pain on admission and reassessed as indicated by the patient ' s condition:..
9. Frequency of assessment for pain should be determined based on individual patient needs. The patient will be assessed: ...
? Each shift ...
? After each analgesic according to onset and peak effect time.
10. Assessment and evaluation will be ongoing and consider the patient ' s history, current condition and anticipated needs. If the patient is reporting pain, the following factors should be evaluated and documented and as indicated:
? Location
? Radiation
? Intensity (0-10)
? Onset
? Duration
? Patterns
? Assessment of pain at its least and worst
? Qualitative Characteristics ...
? Response to the Intervention
? Absence or presence of unrelieved pain at peak action time
? Absence or presence of dose-limiting side effects
14. Reassessment of the patient ' s condition and response to pain medications will be made after the administration of each dose of pain medication. "

A review of the clinical record for Patient # 1 revealed insufficient documentation of pain assessment (4 out of 7 times that pain medication was administered) on the following days:
? On 6/14/12 at 1629 " Presence of Pain: complaints of pain/discomfort " of her right knee was noted by the nurse. The nurse did not document intensity of the pain. The Pain Management Interventions indicated " single medication modality " . The Pain Response to Interventions at 1816 noted " pain improved " , this does not appropriately document the patient ' s response to pain medication, nor does it note intensity.
? On 06/15/12 at 0944 " Presence of Pain: complaints of pain/discomfort " of her right leg was noted by the nurse, rated 6/10. The Pain Management Interventions indicated " Tylenol #3 300/30mg 1 tab PO " . The Pain Response to Interventions at 1020 noted " pain at acceptable level " , this does not appropriately document the patient ' s response to pain medication, nor does it note intensity.
? On 06/19/12 at 0200 " Presence of Pain: complaints of pain/discomfort " of her right hip was noted by the nurse. The nurse did not document intensity of the pain. The note stated " Tylenol #3 given po for pain to rt hip " . No re-assessment of the patient ' s condition and response to the pain medication was documented.
? On 06/19/12 at 1015 " Presence of Pain: complaints of pain/discomfort " of her right leg was noted by the nurse, rated 10/10. The Pain Management Interventions indicated " single medication modality " . No re-assessment of the patient ' s condition and response to the pain medication was documented.
? No documented pain assessment was recorded for Patient #1 status post fall on 06/15/12.

The lack of enforcement of bylaws was confirmed in an interview with the Nurse Managers on the afternoon of 7/23/12 in the facility conference room.

Based on review of medical documentation and interview it was determined that the facility failed to ensure that a registered nurse evaluated the nursing care for each patient as evidence by lack of adequate assessment and documentation of patient care.

Findings were:

Facility policy & procedure titled Nursing Documentation stated, in part,
"Nursing Documentation:...
2. Monitor and record the following:
? Changes in patient ' s condition "

A review of the clinic record for patient # 1 revealed a failure to properly document a fall that occurred on 06/15/12. According to documentation,"While on the floor, the patient fell, X-rays of the right lower extremity were ordered. X-rays revealed a right distal femur fracture."
? It appears the fall resulting in the fractured right femur occurred around 1500 on 06/14/12 related to the time entered on the Physician/Professional Communication sheet. According to the Physician/ Professional Communication Note dated 6/14/12 the physician was notified of a " Significant Event " at 1515. There was no description of the significant event. The actions related to the communication were, "Stat xray of hip and right knee. Will contact Dr. Badylak and call if any changes to orders. "
? There was no documented description of the significant event (fall). There was no follow up fall assessment, physical assessment, or pain assessment documented on the patient post fall.

Facility policy & procedure titled Fall Precautions stated, in part, " The Morse Fall Scale will be utilized to assess the patient ' s fall risk factors upon admission, fall, change in status and discharge or transfer to a new setting. "
? A review of the clinical record for Patient # 1 revealed a Safety Assessment including Fall Risk Assessment completed upon their admission on 6/14/12 at 1300. This initial Fall Risk Assessment scored the patient at 50 indicating a low fall risk 25-50. A Safety Assessment at 1500 indicated she was WNL (within defined limits). Another Fall Risk Assessment is not completed in the medical record until 2131. During this assessment the patient received a score of 65 indicating a high fall risk. No other fall risk assessments were completed on 6/14/12. No fall assessment was document post fall per policy. There was no follow up fall assessment documented on the patient post fall.

Facility policy & procedure titled Pain Management stated, in part, " All patients will be assessed for pain on admission and reassessed as indicated by the patient ' s condition:..
9. Frequency of assessment for pain should be determined based on individual patient needs. The patient will be assessed: ...
? Each shift ...
? After each analgesic according to onset and peak effect time.
10. Assessment and evaluation will be ongoing and consider the patient ' s history, current condition and anticipated needs. If the patient is reporting pain, the following factors should be evaluated and documented and as indicated:
? Location
? Radiation
? Intensity (0-10)
? Onset
? Duration
? Patterns
? Assessment of pain at its least and worst
? Qualitative Characteristics ...
? Response to the Intervention
? Absence or presence of unrelieved pain at peak action time
? Absence or presence of dose-limiting side effects
14. Reassessment of the patient ' s condition and response to pain medications will be made after the administration of each dose of pain medication. "

A review of the clinical record for Patient # 1 revealed insufficient documentation of pain assessment (4 out of 7 times that pain medication was administered) on the following days:
? On 6/14/12 at 1629 " Presence of Pain: complaints of pain/discomfort " of her right knee was noted by the nurse. The nurse did not document intensity of the pain. The Pain Management Interventions indicated " single medication modality " . The Pain Response to Interventions at 1816 noted " pain improved " , this does not appropriately document the patient ' s response to pain medication, nor does it note intensity.
? On 06/15/12 at 0944 " Presence of Pain: complaints of pain/discomfort " of her right leg was noted by the nurse, rated 6/10. The Pain Management Interventions indicated " Tylenol #3 300/30mg 1 tab PO " . The Pain Response to Interventions at 1020 noted " pain at acceptable level " , this does not appropriately document the patient ' s response to pain medication, nor does it note intensity.
? On 06/19/12 at 0200 " Presence of Pain: complaints of pain/discomfort " of her right hip was noted by the nurse. The nurse did not document intensity of the pain. The note stated " Tylenol #3 given po for pain to rt hip " . No re-assessment of the patient ' s condition and response to the pain medication was documented.
? On 06/19/12 at 1015 " Presence of Pain: complaints of pain/discomfort " of her right leg was noted by the nurse, rated 10/10. The Pain Management Interventions indicated " single medication modality " . No re-assessment of the patient ' s condition and response to the pain medication was documented.
? No documented pain assessment was recorded for Patient #1 status post fall on 06/15/12.

This lack of appropriate nursing care was confirmed in an interview with the Nurse Managers on the afternoon of 7/23/12 in the facility conference room.

Based on review of medical documentation and interview it was determined that the facility failed to ensure that all nursing notes, reports of treatment, and other information necessary to monitor the patient's condition were included in the medical record.

Findings were:

Facility policy & procedure titled Nursing Documentation stated, in part,
"Nursing Documentation:...
2. Monitor and record the following:
? Changes in patient ' s condition "

A review of the clinic record for patient # 1 revealed a failure to properly document a fall that occurred on 06/15/12. According to documentation,"While on the floor, the patient fell, X-rays of the right lower extremity were ordered. X-rays revealed a right distal femur fracture."
? It appears the fall resulting in the fractured right femur occurred around 1500 on 06/14/12 related to the time entered on the Physician/Professional Communication sheet. According to the Physician/ Professional Communication Note dated 6/14/12 the physician was notified of a " Significant Event " at 1515. There was no description of the significant event. The actions related to the communication were, "Stat xray of hip and right knee. Will contact Dr. Badylak and call if any changes to orders. "
? There was no documented description of the significant event (fall). There was no follow up fall assessment, physical assessment, or pain assessment documented on the patient post fall.

Facility policy & procedure titled Fall Precautions stated, in part, " The Morse Fall Scale will be utilized to assess the patient ' s fall risk factors upon admission, fall, change in status and discharge or transfer to a new setting. "
? A review of the clinical record for Patient # 1 revealed a Safety Assessment including Fall Risk Assessment completed upon their admission on 6/14/12 at 1300. This initial Fall Risk Assessment scored the patient at 50 indicating a low fall risk 25-50. A Safety Assessment at 1500 indicated she was WNL (within defined limits). Another Fall Risk Assessment is not completed in the medical record until 2131. During this assessment the patient received a score of 65 indicating a high fall risk. No other fall risk assessments were completed on 6/14/12. No fall assessment was document post fall per policy. There was no follow up fall assessment documented on the patient post fall.

Facility policy & procedure titled Pain Management stated, in part, " All patients will be assessed for pain on admission and reassessed as indicated by the patient ' s condition:..
9. Frequency of assessment for pain should be determined based on individual patient needs. The patient will be assessed: ...
? Each shift ...
? After each analgesic according to onset and peak effect time.
10. Assessment and evaluation will be ongoing and consider the patient ' s history, current condition and anticipated needs. If the patient is reporting pain, the following factors should be evaluated and documented and as indicated:
? Location
? Radiation
? Intensity (0-10)
? Onset
? Duration
? Patterns
? Assessment of pain at its least and worst
? Qualitative Characteristics ...
? Response to the Intervention
? Absence or presence of unrelieved pain at peak action time
? Absence or presence of dose-limiting side effects
14. Reassessment of the patient ' s condition and response to pain medications will be made after the administration of each dose of pain medication. "

A review of the clinical record for Patient # 1 revealed insufficient documentation of pain assessment (4 out of 7 times that pain medication was administered) on the following days:
? On 6/14/12 at 1629 " Presence of Pain: complaints of pain/discomfort " of her right knee was noted by the nurse. The nurse did not document intensity of the pain. The Pain Management Interventions indicated " single medication modality " . The Pain Response to Interventions at 1816 noted " pain improved " , this does not appropriately document the patient ' s response to pain medication, nor does it note intensity.
? On 06/15/12 at 0944 " Presence of Pain: complaints of pain/discomfort " of her right leg was noted by the nurse, rated 6/10. The Pain Management Interventions indicated " Tylenol #3 300/30mg 1 tab PO " . The Pain Response to Interventions at 1020 noted " pain at acceptable level " , this does not appropriately document the patient ' s response to pain medication, nor does it note intensity.
? On 06/19/12 at 0200 " Presence of Pain: complaints of pain/discomfort " of her right hip was noted by the nurse. The nurse did not document intensity of the pain. The note stated " Tylenol #3 given po for pain to rt hip " . No re-assessment of the patient ' s condition and response to the pain medication was documented.
? On 06/19/12 at 1015 " Presence of Pain: complaints of pain/discomfort " of her right leg was noted by the nurse, rated 10/10. The Pain Management Interventions indicated " single medication modality " . No re-assessment of the patient ' s condition and response to the pain medication was documented.
? No documented pain assessment was recorded for Patient #1 status post fall on 06/15/12.

This lack of information necessary in the medical record to monitor the patient's condition was confirmed in an interview with the Nurse Managers on the afternoon of 7/23/12 in the facility conference room.