HospitalInspections.org

Based on interview and record review, it was determined the hospital failed to ensure 2 of 2 RN's (Registered Nurse) Staff #13 and Staff #14 assessed and evaluated 2 of 4 patients (Patient #1 and #2). 1) Staff #13 failed to assess and/or evaluate Patient #2 who informed Staff #13 she sustained a fall and injured both her knees which caused bruising. 2) Staff #14 failed to assess and evaluate (Patient #1) after (Patient #1) fell to the floor hitting the right hip and back of the head on the floor and therefore sustained a fractured right hip and required further medical intervention.

Findings included:

1) Patient #2's History and Physical dated 10/30/11 reflected, "The patient states she needs to detox (detoxification) from hydrocodone and chemical dependency...was placed on suboxone strip...later she became quite emotional and unable to concentrate, weeping, aching, and sometimes becoming extremely weak when she took the strip...total knee replacement on the right years ago...balance and gait normal..."

The initial nursing assessment dated 10/29/11 reflected, "bruises to the right and left lower inner arms and bruises to the bilateral lower extremities..." Patient #2's bilateral knees were not documented as bruised.

The 11/05/11 nursing note timed at 19:17 PM reflected, "Husband called from dining room...said wife worse than when she came in...said she fell out of bed and demands a physical doctor to check her out...told would schedule..." No documentation was found which indicated Patient #2's knees were assessed and/or evaluated for redness, swelling or bruising.

On 02/21/12 at 10:00 AM, Staff #2 was interviewed. Staff #2 was asked to review Patient #2's medical record. Staff #2 was asked by the surveyor if Staff #13 documented an evaluation and/or assessment was completed for Patient #2. Staff #13 stated she could not find any documentation by Staff #13 which indicated patient #2's knees were evaluated for bruising, swelling, redness and/or any changes.

2) Patient #1's discharge summary with a dictation date of 10/20/11 reflected, "85 year old...hospitalized 10/18/11 to...psychiatric hospital from the emergency room as she was found wandering in the woods...she has been aggressive with her daughter, and lives in an outhouse with her daughter....on 10/19/11 at around 6:00 PM...the patient had fallen and was complaining of pain...ordered x-ray of the hips...patient's x-ray came back with a hip fracture...sent to (medical) hospital...admitted to hospital..."

The nursing note dated 10/19/11 timed at 18:00 PM reflected, "Pt (patient) was getting agitated...patient got up from chair and fell...Dr. notified order for x-ray...patient complaining of pain on the right hip...at 18:30 PM Tylenol given for pain, haldol given for agitation...patient taken back to her room...x-ray was done...21:00 PM x-ray request back, called the on call Dr. still waiting on reply..." No documentation was found indicating a head to toe assessment and/or evaluation was completed. No documentation was found indicating Patient #1's right hip was assessed for swelling, bruising and/or redness. Additionally nothing was documented that Patient #1's neurological status was assessed after hitting her head on the floor.

The nursing note dated 10/20/11 timed at 00:50 AM reflected, "Pt (patient) transferred to...hospital for further management and evaluation...04:00 AM a call was placed to hospital to inquire about pt and was told pt has been admitted..."

On 02/16/12 at 3:45 PM Staff #2 was interviewed. Staff #2 reviewed Patient #1's medical record. Staff #2 said the nurse who cared for Patient #1 failed to document her assessment of the patient.

On 02/17/12 at 8:49 AM Staff #14 was interviewed. Staff #14 stated she did assess the patient when she fell. Staff #14 stated Patient #1 did not have swelling, bruising and/or redness. The surveyor asked Staff #14 where she documented her assessment. Staff #14 stated she thought she documented it but offered no further information.

On 02/17/12 at 1:30 PM video footage of Patient #1's fall was viewed by the surveyor. The video footage reflected, the patient fell in the hallway outside the day area. Patient #1 fell on the right side and then fell backwards on her back hitting her head on the floor. At 18:03 PM hospital staff brought a Geri-chair and placed the patient in the chair and placed Patient #1 in her room.

On 02/18/12 at 12:19 AM Staff #16 was interviewed. Staff #16 stated when she arrived on duty for the night shift Patient #1 was still on the unit. Staff #16 said she received report from the off going supervisor and found out Patient #1 had a fractured right hip. Staff #16 stated she sent Patient #1 out immediately to the hospital.

The policy entitled, "Charting in the Medical Record" with a review date of 05/10 reflected, "The clinical notes should describe each patient's behavior, attitude, symptoms, nursing interventions used, and reactions of the patient...charting should be descriptive...clinical notes must reflect the ongoing care and response of the patient..."