HospitalInspections.org

Based on document review and staff interview it was determined the hospital failed to immediately notify the surrogate or Medical Power of Attorney (MPOA) of a patient accident that resulted in an injury that required additional medical care and treatment. This deficient practice was found in one (1) of ten (10) medical records reviewed that had a patient fall with injury (Patient #1). Failure to notify a patient's surrogate/MPOA about an injury that occurred during a hospitalization can result in violation of their rights by not including the legal decision maker in determining any additional care and treatments the patient may need.

Findings include:

1. Review of the Medical Record for patient #1 revealed the patient was admitted on 9/30/11 with atypical chest pain. On 10/3/11 at approximately 1525 hours the patient fell out of bed with a resulting leg fracture. The patient was unable to make any health care decision and had a health care surrogate. There was no documentation in the patient's record of the surrogate being notified of the accident or consulted about need for care and treatment.

2. The Registered Nurse (RN 1) who cared for the patient on 10/3/11 was interviewed 11/28/11 at 1530. The nurse readily admitted she failed to call the patient's surrogate. She said the patient's surrogate came in the day after the fall and was informed about what happened and was very upset over not being notified. RN1 admitted not calling the patient's surrogate and indicated it was an error that was overlooked during the confusion of the fall.

Based on document review and staff interview it was determined that nursing failed to follow expectations that nursing document a full patient assessment, including vital signs, following a fall with injury. This deficient practice was found in one (1) of one (1) medical records reviewed with a fall (Patient #1). Failure to document the findings of an assessment following a fall and the care with continued monitoring can result in a patients symptoms going unnoticed with a resulting deterioration in condition and negative patient outcomes.

Findings include:

1. The Chief Nursing Officer was interviewed on 11/28/11 in the afternoon concerning nursing documentation after an accident that resulted in an injury. She stated that nursing should document a full assessment of the patient including vital signs.

2. Review of the Medical Record for patient #1 revealed the patient was admitted on 9/30/11 with atypical chest pain. A nurses note on 10/3/11 at 1525 hours documented the patient was found by the Certified Nursing Assistant (CNA) lying on the floor with head pointing toward the door. The patient was lifted back to bed and complained of right leg pain. There were no deformities noted. The record lacked documentation of vital signs that were taken immediately after the fall, the appearance of the patient's leg such as color, edema or ecchymosis and any additional care measures including positioning and pain relief measures. There were no additional nursing notes after the entry at 1525 hours until 2000 hours (4 1/2 hours after the fall) when the nurse documented the patient's lower extremity has edema and ecchymosis. There were no documented vital signs until 1800 hours over two (2) hours after the fall. (Previous vital signs were taken at 1000 hours).

3. The Chief Nursing Officer reviewed the above record on 11/29/11 in the afternoon and concurred the nurse should have documented a complete assessment of this patient including vital signs and care.