HospitalInspections.org

Based on document review, interview and policy review the facility failed to ensure staffing was adequate to meet the needs of the patients, resulting in the patient harm for patient #1 cared for on the unit 3 West. Findings include:

On 8/29/12 at approximately 1030 during document review for the incident describing Patient #1's fall, a document titled "Bay Regional Medical Center Fall Report/Worksheet" dated 1/17/12 revealed that on "1/17/12 at 2120 Patient #1 was found on the floor of 3 West with 3 siderails up, the bed exit alarm on, call light in reach and hospital issued yellow slippers on". Under "Other hazards that led to the fall the RN noted 'increased floor acuity and understaffed, short one nurse'". Staff unit information at time of fall revealed "# pts assigned to RN revealed 7 + 3 patients belonging to the LPN for a total of 10 patients. "# of patients assigned to nurse aide: 10". Under Number of staff call-ins not replaced for shift "one RN" was listed. A request to interview the nurse completing the incident report and assigned to Patient #1 revealed that she is not available and works the night shift. Staff I confirmed that she was one of the people responsible for debriefing after the above mentioned fall. Staff I was asked whether the unit was short staffed the night shift of 1/17/12-1/18/12, to which staff I revealed that "initially when the assignment was made out, they had 18 patients, however they had three admissions during the (night) shift for a total of 21 patients".

A review of the document titled "Staffing Matrix 3 West revealed that for a census of 18 staffing for 7pm to 7am shift should be three RNs and two PCAs and for a census of 21, staffing should be four RNs and two PCAs". According to Staff I "staffing is evaluated twice in one shift to adjust for the need for more or less staffing". Staff I was asked whether additional staffing was provided when the census was increased to 21 on 1/17/12 between 7pm and 7am shift to which she replied "no".

According to the document titled "Event Intense Analysis" dated January 25, 2012 "how was staffing" documented "there were three nurses (2 RN's and one LPN) and two aides. The nursing supervisor had also been contacted. 3 West also had two pediatric patient admitted that evening". Action items listed on the document revealed "Improve communication with nursing supervisor to ensure that any issues (staffing and safety) are communicated in a quick and efficient manner".

Based on policy review, medical record review and interview it was revealed that the registered nurse failed to implement fall prevention and post fall protocols as dictated by policy to ensure patient safety for 13 out of 13 incidents reviewed (patient #1 - #13) resulting in the potential for patient harm. Findings include:

On 8/29/12 at approximately 1500 a review of facility policy titled "Falls" dated May 2012 revealed that " ... each adult inpatient will be assessed, upon admission, and every shift thereafter, when medications are changed, when transferred to another unit or when condition changes and after a fall to determine potential for falls ". The policy revealed that "in the event that a patient falls ...the following post-fall protocol will be implemented: complete an assessment including but not limited to skin, neurologic every 2 hours for 24 hours for unwitnessed falls, fall risk and vital signs, notify physician, notify the family/next of kin, complete an improvement report. And nursing staff will document the following: vital signs neuro checks, and assessment in the event tab ... "

On 8/29/12 at approximately 1030 during record review for Patient #1 revealed that the patient was admitted on 1/12/12 at 1045. The first fall risk assessment was completed on 1/12/12 after 2000. The fall risk assessment was conducted by the 7 pm -7 am nurse, 9 hours after the patient was admitted to the floor. This was confirmed by Staff I on 8/29/12 at approximately 1035.

On 8/29/12 at approximately 1030 during record review for Patient #1 revealed that on 1/17/12 at 2120, ".....the bed alarm sounded and patient was found sitting on floor"(sic), "02 sats only 85% with 4 L N/C"(sic). "Dr. (Staff L)paged and notified of fall. See Orders, Haldol given for anxiety, fall report written". A single neurocheck was documented with the assessment at 2010. At 2120 the nurse documented, "Denied hitting head, denied pain. Assessed head to toe no bruising, cuts contusions, etc....Assessing pt. and visual very often. Will monitor". The nurse documented, " IV site OK " with a check mark at 2000, 2100, 2200, 2300, 2400, 0100, 0200, 0400, 0600, and 0700. Free form written Nursing notes resumed 1/18/12 at 0808 with, "Lab staff came to desk to inform myself that my patient was not breathing, I went into room and patient was not breathing and I could not find a pulse CPR was started....." . Staff I was asked where the documentation for post fall monitoring, neuro checks every 2 hours, vital signs and additional findings, Staff I replied, "...... it is (implied) in the checkmarks that it was completed". On 8/29/12 interview with Staff L, the physician revealed that, ".....the staff never told me that the patient had fallen, they only called me to inform of the hypoxemia".... "I am not aware that any physician was notified of the (patients) fall". Orders received on 1/17/12 after the fall include Haldol 1 mg IVP X 1 dose tonight for agitation with a time of 0035".

On 1/18/12 at 0808 nurse documented, "Pt's husband was at the bedside with patient prior (to) day shift start". The medical record did not reflect notification of the family. According to interview with Staff I, on 8/29/12 at 1045, the midnight nurse was not available for interview, however interview by Staff I with the midnight nurse after the event revealed that "she had tried to contact the patient's husband by phone however was unable to reach him". Staff I also relayed that the midnight nurse indicated to her that the husband was partially blind and shouldn't drive at night, however did not document any of her attempts to reach the husband in the medical record.



On 8/29/12 between approximately 1300 and 1515, a review of 12 closed medical records for patients who had fallen also revealed the following:
Patient #2 medical record revealed that the post fall family notification and fall reassessment was not documented. This was confirmed by Staff E on 8/29/12 at 1320.
Patient #3 medical record revealed that the post fall family notification was not documented. This was confirmed by Staff E on 8/29/12 at 1335.
Patient #5 medical record revealed that the post fall family notification and fall reassessment was not documented. This was confirmed by Staff E on 8/29/12 at 1345.
Patient #7 medical record revealed that the post fall reassessment was not documented. This was confirmed by Staff E on 8/29/12 at 1355.
Patient #8 medical record revealed that the post fall family notification was not documented. This was confirmed by Staff E on 8/29/12 at 1405.
Patient #9 medical record revealed that the post fall nursing documentation, family notification, Physician notification and fall reassessment was not documented. This was confirmed by Staff E on 8/29/12 at 1415.
Patient #10 medical record revealed that the post fall nursing documentation, family notification and fall reassessment was not documented. This was confirmed by Staff E on 8/29/12 at 1425.
Patient #11 medical record revealed that the post fall family notification and fall reassessment was not documented. This was confirmed by Staff E on 8/29/12 at 1435.
Patient #12 medical record revealed that the post fall reassessment was not documented. This was confirmed by Staff E on 8/29/12 at 1445.
Patient #13 medical record revealed that the post fall family notification and fall reassessment was not documented. This was confirmed by Staff E on 8/29/12 at 1455.
Patient #22 medical record revealed that the post fall family notification and fall reassessment was not documented. This was confirmed by Staff E on 8/29/12 at 1500.