HospitalInspections.org

The hospital failed 1 of 1 Patient (Patient #1) by failing the patient the right to recieve care in a safe setting.

Findings include;

During Interview with Staff #2 it was revealed that the hospital has failed to obtain proper collateral information, restricting family visitation and communication of patient status.

During Interivew it was revealed that hospital failed to scribe correct telephone number on to collateral documentation.

During record review it was discovered the hospital had open orders for 1:1 status due to fall precautions and C-Collar.

During record review it was discovered the hospital had open orders for q5 minute observations. The patient fell out of his bed on 03/09/2021.

During interview with Staff #7 it was revealed that Patient #1 was 1:1 at night.

Policy
The hospital Patient Rights Policy dated 01/11/16 reflected, "Every client shall receive a written copy of the Patient's Bill of Rights. The patient will sign the "Acknowledgement of Rights" form stating they reviewed and understand their rights."

The hospital Policy on Falls Prevention dated 04/2020 reflected, "The policy of Kindred Behavioral Health is to ensure the following;
1. Patients are screened for fall risk upon admission during admission assessment process and at as condition changes.
2. At the time the designated fall risk screen is completed, appropriate fall intervention precautions are initiated as risks are identified ...
9.Direct caregivers will complete training and/or competency validation upon hire and as needed. Re-training is completed based on facility Quality/Performance Review data."

The hospital Policy on Interdisciplinary Treatment Planning documentation dated 11/2019 reflected, "IT is the policy of the Wellbridge Hospital of Fort Worth That each patient provided with individualized planned, and appropriate interventions that are designed to meet the patient's need for treatment. Patient response to care is regularly monitored and treatment reassessed to determine effectiveness and to enable the individual to feel a sense of achievement about treatment progress."

The hospital Level of Observation and Hand off Communication dated 12/2020 reflected, "It is the policy of the facility to provide levels of observation in compliance with physician orders and prescribed protocols."

The hospital Policy on Administration/Personnel "This policy describes the process for registered nurses, other non-advanced practice healthcare professionals and non-licensed individuals employed by Kindred Medical staff physician or group medical practice. This policy does not apply to licensed independent practitioners or Allied Health Professionals (such as physician assistants and nurse practitioners). Credentialing requirements for LIPs and AHPs."

The hospital failed one of one patient (Patient #1) by not keeping current on a nursing care plan for each patient that reflect the goals and the nursing care to be provided to meet the patient's needs. Patient #1 fell and there are open orders in the MAR..

Findings include

During record review it was discovered Patient #1 fell and he had an open order for Fall Precation 1:1 for falls and C-Collar.

During record review it was discoveredPatient #1 had an open order for Q5 minute observations.

During record review there was no record to close/discontinue either medical record.

During interview hospital staff was informed that the Medication Administration Record reflected the open orders, and which order was the staff to follow when providing service. The response was "that could be confusing."

Policy
The hospital Patient Rights Policy dated 01/11/16 reflected, "Every client shall receive a written copy of the Patient's Bill of Rights. The patient will sign the "Acknowledgement of Rights" form stating they reviewed and understand their rights."

The hospital Policy on Falls Prevention dated 04/2020 reflected, "The policy of Kindred Behavioral Health is to ensure the following;
1. Patients are screened for fall risk upon admission during admission assessment process and at as condition changes.
2. At the time the designated fall risk screen is completed, appropriate fall intervention precautions are initiated as risks are identified ...
9.Direct caregivers will complete training and/or competency validation upon hire and as needed. Re-training is completed based on facility Quality/Performance Review data."

The hospital Policy on Interdisciplinary Treatment Planning documentation dated 11/2019 reflected, "IT is the policy of the Wellbridge Hospital of Fort Worth That each patient provided with individualized planned, and appropriate interventions that are designed to meet the patient's need for treatment. Patient response to care is regularly monitored and treatment reassessed to determine effectiveness and to enable the individual to feel a sense of achievement about treatment progress."

The hospital Level of Observation and Hand off Communication dated 12/2020 reflected, "It is the policy of the facility to provide levels of observation in compliance with physician orders and prescribed protocols."

The hospital Policy on Administration/Personnel "This policy describes the process for registered nurses, other non-advanced practice healthcare professionals and non-licensed individuals employed by Kindred Medical staff physician or group medical practice. This policy does not apply to licensed independent practitioners or Allied Health Professionals (such as physician assistants and nurse practitioners). Credentialing requirements for LIPs and AHPs."