HospitalInspections.org

Based on a review of the medical record, staff interviews, policies and procedures, incident logs, and medical service logs, it was determined that the Governing Body failed to ensure that medical consults were performed when requested for patients experiencing medical concerns or incidents when one patient (P) (P#1) of three sampled patients (P#1, P#9, P#10), had an unwitnessed fall on 9/28/22 and a medical consultation was ordered. The medical consultation was not completed and on 10/4/22, P#1 was transferred to a local acute care emergency room and admitted with left rib fractures and a pneumothorax.

The findings include:

Review of medical record for P#1 revealed a daily nursing progress note entered by RN KK on 9/28/22 at 4:00 a.m. revealed P#1 was found on the floor of her room. There was a skin tear noted on her left elbow and left hip. The House Supervisor, Nurse Practitioner, and family were notified of the incident.

Review of physician's order taken verbally by RN KK dated 9/28/22 at 4:00 a.m. revealed a medical service consultation related to P#1's injuries.

Review of physician's progress note dated 9/28/22 at 11:00 a.m. revealed P#1 was able to tell the provider about the fall she experienced earlier in the morning.

A review of the facility's Medical Service Log (Physician Consultation Book) dated from 8/25/22 to 10/17/22 failed to reveal an entry for a medical consultation to assess P#1's injuries after fall. Additional review revealed an entry dated 10/4/22, no time, with the medical consultation reason noted as gastrointestinal bleeding. Further review failed to reveal documentation by a Medical Provider to assess P#1's injuries.
Review of the facility Incident Log dated 9/2022 to 10/2022 failed to review a fall incident for P#1 on 9/28/22.

A review of the Physician's Progress Note dated 10/4/22 at 9:30 a.m. revealed P#1 complained of (c/o) abdominal pain, nausea, weakness, and mild SOB. Sending to Emergency Room (ER) for medical clearance. Family notified. Additional review revealed a Physician's Order dated 10/4/22 at 9:30 a.m. to send P#1 to the emergency room (ER) via 911 for poor oral intake, abdominal pain, shortness of breath (SOB) and weakness.

Review of the Emergency Room Evaluation form (facility's sending/receiving nursing progress note) dated 10/4/22 at 10:59 a.m. revealed P#1's reason for transfer to the ER was poor oral intake, abdominal pain, SOB, and weakness. P#1 left the facility at 10:50 a.m. Vital signs for P#1 revealed Temperature 98.1 degrees Fahrenheit (F), Pulse 86, Respirations 16, blood pressure 121/71, and oxygen saturation 96%. Family notified of transfer via voice mail message on 10/4/22 at 10:59 a.m.

An interview took place with Medical Doctor (MD) BB on 10/12/23 at 9:20 a.m. in the conference room. MD BB revealed she vaguely remembered P#1 and the incident that occurred on 9/28/22. She said P#1 had an unwitnessed fall while in her room. She said when she examined P#1 the same morning, she saw there was a skin tear on P#1's left elbow, left hip, and that vital signs were stable. She said P#1 had experienced chronic pain while at the facility and did not complain of any increased pain or pain that was worse than normal. Medical Services were consulted to further assess P#1's injuries and she ambulated without assistance. MD BB further said that the nursing staff was responsible for completing fall risk assessments for each patient.

A telephone interview took place with Registered Nurse (RN) KK on 10/12/23 at 12:04 p.m. RN KK revealed she did not remember the specifics of the incident that occurred on 9/28/22 but said generally if a patient had a fall on the unit she assessed their cognition, pain, extremity range of motion (ROM), and ensured there were no head injuries. She said patients on the Older Adult Unit experienced "sundowning" (state of confusion occurring in the late afternoon and lasting into the night) frequently and despite fall risk precautions such as instructing the patient to call for assistance before getting out of bed, ensuring that the side rails were up on the bed, and frequent patient observation, they still found ways to climb out of bed. RN KK further said that she contacted the on-call provider and received a verbal order for a medical service consultation and that she wrote the consultation in the unit's Medical Services Log. She said the medical service provider looked at the log every day when they rounded to determine which patients needed consultations.

A telephone interview took place with Registered Nurse (RN) LL on 10/12/23 at 12:29 p.m. RN LL revealed she had been employed at the facility for two years. She said she did not remember sending P#1 to the ED on 10/4/22 and had not heard about the incident that occurred on 9/28/22. She said that generally when there was a fall or medical emergency on the unit, she assessed the patient, took vital signs, and called the MD for an order. She said medical service consultations were written in the unit's "book" so that the providers who came in later in the day would know which patients needed consultations. RN LL further said that most patients on the Older Adult Unit had full blown dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities) and that fall risk precautions required patients to wear yellow slip resistant socks, one-to-one/line of sight observation by staff, and the use of walkers or wheelchairs for patients who were ambulatory.

A review of the Governing Board Bylaws and Constitution, adopted January 2017, revealed the following:
ARTICAL II
Purposes.
Ridgeview Institute is dedicated to providing quality mental health services in a highly ethical manner, Ridgeview Institute-Smyrna's mission is to help patients and families to reach their fullest potential by empowering intellectual, spiritual, moral and emotional growth in a safe and therapeutic environment. A full spectrum of mental health services are provided through in-patient programs, partial hospital programs, intensive out-patient program and reintegration with the community.
ARTCLE III.
Governing Board.
Section 3.1. General Powers. The affairs of Ridgeview Institute-Smyrna are managed by the Governing Board. The board is ultimately accountable for the quality of patient care, treatment, and services. The Governing Board ensures the safety of patients, staff, and others.

A review of the facility policy titled "Medical Emergencies", last reviewed 1/2023, revealed the facility would provide basic first aid, basic life support, and notification to emergency services in the event of an unexpected illness or injury in a patient, visitor, staff member, or any other person to the extent that the equipment and expertise will allow at the facility at the time of the event.
II. Procedure:
1. The staff person witnessing or receiving an initial report of an illness, accident, or injury requiring emergency response will activate the emergency by calling a "Code Blue" over the paging system.
2. The individual experiencing the medical emergency will be taken to the examination room/emergency room (ER) for first aid/treatment, as appropriate.
a. All patients will be examined in the inpatient unit, if possible.
5. Nursing and/or medical staff will determine the nature of the medical emergency and, if a patient of the hospital, contact the internal medicine group, the attending physician and/or the on-call physician for medical orders.
9. An incident report will be completed documenting details of any event.

Based on medical record reviews, staff interviews, policies and procedures, and medical service logs, it was determined that the facility failed to ensure that one patient (P) (P#1) of three sampled patients (P#1, P#9, P#10) was free from abuse, neglect (as a form of abuse) and harassment on 9/28/22 when an unwitnessed fall resulted in serious injuries. These injuries were not assessed and properly diagnosed until P#1 was transferred to Facility 2's Emergency Department (ED) on 10/4/22 and admitted to that facility in serious condition with diagnoses of multiple left-sided rib fractures and a pneumothorax (collapsed lung).

The findings include:

Review of daily nursing progress note dated 9/28/22 at 4:00 a.m., that revealed P#1 was found on the floor of her room with skin tears on her left elbow and left hip.

A physician's order dated 9/28/22 at 4:00 a.m., revealed a verbal order taken by Registered Nurse (RN) KK for a medical service consultation to assess the injuries for P#1.

Review of physician's progress note dated 9/28/22 at 11:00 a.m., revealed the provider observed skin tears on P#1's left elbow and left hip.

A review of the facility's Medical Service Log (Physician Consultation Book) dated from 8/25/22 to 10/17/22 failed to reveal an entry by the nurse for a medical consultation to assess P#1's injuries after her fall on 9/28/22, however, revealed an entry dated 10/4/22, no time, with the medical consultation reason noted as gastrointestinal bleeding.

A physician's progress note dated 10/4/22 at 9:30 a.m., revealed P#1 complained of (c/o) abdominal pain, nausea, weakness, and mild shortness of breath (SOB).

A physician's order dated 10/4/22 at 9:30 a.m., revealed instructions to send P#1 to the ED via Emergency Medical Services (EMS) for poor oral intake, abdominal pain, SOB, and weakness.
Medical record review from Facility 2 revealed P#1 was admitted to the facility on 10/4/22 with diagnoses of left-side pneumothorax (collapsed lung), left side pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest), and closed fracture of multiple ribs on the left side.

An interview with Medical Doctor (MD) BB on 10/12/23 at 9:20 a.m., in the conference room, revealed she vaguely remembered P#1 and the incident that occurred on 9/28/22. She said P#1 had an unwitnessed fall while in her room. She said when she examined P#1 the same morning, she saw there was a skin tear on P#1's left elbow, left hip, and that her vital signs were stable. She said P#1 had experienced chronic pain while at the facility and did not complain of any increased pain or pain that was worse than normal. Medical Services were consulted to further assess P#1's injuries and she ambulated without assistance. MD BB further said that the nursing staff was responsible for completing fall risk assessments for each patient.

A telephone interview with RN KK on 10/12/23 at 12:04 p.m. RN KK revealed she did not remember the specifics of the incident that occurred on 9/28/22 but said generally if a patient had a fall on the unit she assessed their cognition, pain, extremity range of motion (ROM), and ensured there were no head injuries. She said patients on the Older Adult Unit experienced "sundowning" (state of confusion occurring in the late afternoon and lasting into the night) frequently and despite fall risk precautions such as instructing the patient to call for assistance before getting out of bed, ensuring that the side rails were up on the bed, and frequent patient observation, they still found ways to climb out of bed. RN KK further revealed that she contacted the on-call provider and received a verbal order for a medical service consultation and that she wrote the consultation in the unit's Medical Services Log. She said the medical service provider looked at the log every day when they rounded to determine which patients needed consultations.

A telephone interview with RN LL on 10/12/23 at 12:29 p.m., revealed she did not remember sending P#1 to the ED on 10/4/22 and had not heard about the incident that occurred on 9/28/22. She said that generally when there was a fall or medical emergency on the unit, she assessed the patient, took vital signs, and called the MD for an order. She said medical service consultations were written in the unit's "book" so that the providers who came in later in the day would know which patients needed consultations. RN LL further revealed that most patients on the Older Adult Unit had full blown dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities) and that fall risk precautions required patients to wear yellow slip resistant socks, one-to-one/line of sight observation by staff, and the use of walkers or wheelchairs for patients who were ambulatory.

A review of the facility's policy titled, "Patient Rights", Policy Number 12, last reviewed 1/2023, revealed it is the policy of the facility to ensure that all patients receive a copy of the Patient's Bill of Rights & Responsibilities form as well as an oral explanation of those rights, both in their primary language and in simple non-technical terms.
II. Procedure
6. Patient Rights include the following rights:
a. to participate in all decisions involving the patient's care or treatment.
i. to be free from abuse and neglect.
l. care delivered by the health care entity in accordance with the needs of the patient.
n. to receive care in a safe setting.

A review of the facility's policy titled, "Patient Rights Restrictions", Policy Number: PR #13, last reviewed 1/2023, revealed it is the policy of facility to strictly observe patient rights as per the Patient Bill of Rights. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restriction.

Based on review of the medical record, staff interviews, policies and procedures, and medical service logs, it was determined that the facility failed to ensure that all licensed nurses who provided services in the facility adhered to the policies and procedures of the facility on 9/28/22, when one patient (P) (P#1) of three sampled patients (P#1, P#9, P#10) had an unwitnessed fall in their room that resulted in a serious injury.

Findings include:

Review of a daily nursing progress note entered by Registered Nurse (RN) KK on 9/28/22 at 4:00 a.m., revealed P#1 was found on the floor of her room with a skin tear on her left elbow and left hip. The House Supervisor, on-call Nurse Practitioner, and the family were notified of the incident. Additionally, there was a physician's order taken verbally by RN KK dated 9/28/22 at 4:00 a.m., for a medical service consultation to assess P#1's injuries.

A review of the facility's Medical Service Log (Physician Consultation Book) dated from 8/25/22 to 10/17/22 failed to reveal an entry by the nurse for a medical consultation. Further review failed to reveal any documentation by a Medical Provider to assess P#1's injuries following her fall.

A review of the facility's Incident Log dated from 9/2022 to 10/2022 failed to reveal an entry by the nurse for a fall incident related to P#1 on 9/28/22.

A telephone interview with RN KK on 10/12/23 at 12:04 p.m., revealed that she did not remember the specifics of the incident that occurred on 9/28/22 but said generally if a patient had a fall on the unit she assessed their cognition, pain, extremity range of motion (ROM), and ensured there were no head injuries. She said patients on the Older Adult Unit experienced "sundowning" (state of confusion occurring in the late afternoon and lasting into the night) frequently and despite fall risk precautions such as instructing the patient to call for assistance before getting out of bed, ensuring that the side rails were up on the bed, and frequent patient observation, they still found ways to climb out of bed. RN KK further revealed that she contacted the on-call provider and received a verbal order for a medical service consultation and that she wrote the consultation in the unit's Medical Services Log. She said the medical service provider looked at the log every day when they rounded to determine which patients needed consultations.

An interview with Medical Doctor (MD) BB on 10/12/23 at 9:20 a.m., in the conference room revealed she vaguely remembered P#1 and the incident that occurred on 9/28/22. She said P#1 had an unwitnessed fall while in her room. She said when she examined P#1 the same morning, she saw there was a skin tear on P#1's left elbow, left hip, and that her vital signs were stable. She said P#1 had experienced chronic pain while at the facility and did not complain of any increased pain or pain that was worse than normal. Medical Services were consulted to further assess P#1's injuries and she ambulated without assistance. MD BB further revealed that the nursing staff was responsible for completing fall risk assessments for each patient.

A review of the facility's policy titled "Medical Emergencies", last reviewed 1/2023 revealed the facility would provide basic first aid, basic life support, and notification to emergency services in the event of an unexpected illness or injury in a patient, visitor, staff member, or any other person to the extent that the equipment and expertise will allow at the facility at the time of the event.
Procedure:
1. The staff person witnessing or receiving an initial report of an illness, accident, or injury requiring emergency response will activate the emergency by calling a "Code Blue" over the paging system.
2. The individual experiencing the medical emergency will be taken to the examination room/emergency room (ER) for first aid/treatment, as appropriate. All patients will be examined in the inpatient unit, if possible.
3. Nursing and/or medical staff will determine the nature of the medical emergency and, if a patient of the hospital, contact the internal medicine group, the attending physician and/or the on-call physician for medical orders.
4. An incident report will be completed documenting details of any event.