HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 3 (Pt.#1) clinical records reviewed for falls, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by not completing the fall risk assessments, including score every shift, as required.

Findings include:

1. The Hospital's policy titled, "Fall Prevention" (dated 5/3/2022), was reviewed on 10/18/2022, and required, "Patients will be evaluated for fall risk and interventions will be instituted and maintained to reduce the risks for falls and/or injury...In Patients: 1. Patient will be evaluated using the Morse Fall Risk Scale (MFRS) on admission, and when clinically indicated..."

2. The clinic record for Pt #1 was reviewed on 10/17/2022. Pt #1 was admitted on 12/30/2021 with a diagnosis of Right Hip Fracture s/p [status post] Hemiathroplasty [hip surgery]. Pt #1 was discharged from the Medical Surgical Unit on 1/7/2022 and re-admitted to 5-4 Rehabilitation Unit on 1/7/2022.

- Pt #1's Morse Fall Risk Score (used to determine fall risk) on admission (dated 1/7/2022), was documented at 80 (score 50 and above indicates high fall risk).

- A Nurse's Note (dated 1/14/2022 at 8:40 PM), included "1608 [4:08 PM]- Screaming heard from the patient's room and alarms sounding, writer and CNA [certified nursing assistant] enter room, patient observed laying on floor face down laying on left lateral side. VS [vital signs] taken, no open areas nor bleeding noted. Patient noted guarding LUE, grimacing. No protruding areas noted to area. [MD #2/on-call] made aware, came to assess patient. STAT x-rays were ordered ...Per results-left clavicle fracture sustained. Patient provided with ice packs and PRN Norco as requested, within 30-40 minutes patient voices a slight decrease in pain ..."

- Pt #1's Fall Risk Assessments, from 1/14/2022- 1/28/2022, were reviewed (following the fall event on 1/14/2022). Pt #1's clinical record lacked either the required 8-hour fall risk assessments or the fall risk score on: 1/16/2022 (no day and PM shift assessment); 1/17/2022 at 2:34 PM (no fall risk score); 1/18/2022 at 6:03 PM (no fall risk score); 1/19/2022 (no day shift assessment); and 1/24/2022 (no day shift assessment).

3. On 10/18/2022 at 2:40 PM, an interview was conducted with the 5-4 Rehabilitation Unit Manager (E #2). E #2 stated that the nurses are expected to do fall risk assessments (including score) every shift (8 hours).

B. Based on document review and interview, it was determined that for 1 of 3 (Pt.#1) clinical records reviewed for falls, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by not implementing new interventions after a fall, as required.

Findings include:

1. The Hospital's policy titled, "Fall Prevention" (dated 5/3/2022), was reviewed on 10/18/2022, and required, "...In the event of any patient fall: 8. Implement interventions as necessary to further reduce risk of another fall taking place..."

2. The clinic record for Pt #1 was reviewed on 10/17/2022. Pt #1 was admitted on 12/30/2021 with a diagnosis of Right Hip Fracture s/p [status post] Hemiathroplasty [hip surgery]. Pt #1 was discharged from the Medical Surgical Unit on 1/7/2022 and re-admitted to 5-4 Rehabilitation Unit on 1/7/2022.

- Pt #1's Morse Fall Risk Score (used to determine fall risk), on admission (dated 1/7/2022), was documented at 80 (score 50 and above indicates high fall risk).

3. A Hospital's Incident Report (dated 1/14/2022), regarding Pt #1, included, "Patient observed on floor. Staff immediately enters room, patient noted laying on floor in lateral position/left side. Patient assessed, VS taken, breathing easy & non-labored. Patient noted guarding LLE [left lower extremity]. MD #2 aware, came to assess patient. New orders for x-rays in order at this time. All safety measures taken, appropriate team members aware ...Last fall risk assessment score: High risk ...Type of fall safety precautions in place at time of fall ...Bed alarm ...Nature of injury ...Fracture ...Left Clavicle ..."

4. Pt #1's Post Fall Huddle Tool (utilized post-fall), dated 1/14/2022, included, " ...Follow up plan (free text new interventions to prevent further falls) ...Bed rails up x 4, frequent rounds ..." The new interventions that would be implemented as "bed rails up x 4 and frequent rounds" were not documented. The clinical record lacked documentation that the new measurable interventions following the fall with injury on 1/14/2022 were implemented.

5. On 10/18/2022 at 2:40 PM, an interview was conducted with the 5-4 Rehabilitation Unit Manager (E #2). E #2 stated that she was aware of Pt #1's fall. E #2 stated that when a patient falls, the fall prevention measures should be changed with a new intervention. E #2 stated that an example for Pt #1, could have been to have a Safety Sitter or adding more "frequent rounds". E #2 stated that more "frequent rounds" does not indicate a prescribed or specific time frame.

C. Based on document review and interview, it was determined that for 3 of 3 (Pt.#1, Pt #9, Pt #10) clinical records reviewed for pain management, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to assess and re-assess pain scores, as required.

1. The Hospital's policy titled, "Pain" (dated 9/20/2022), was reviewed on 10/18/2022, and required, "Patients will receive safe and effective pain relief...Assess for the presence of pain and document findings...at regular intervals, after any event that produces pain, and upon any new report of pain...Evaluate and document the effectiveness of pain medication interventions using the Pain Score...Notify physician for: ineffective pain control..."

2. The clinic record for Pt #1 was reviewed on 10/17/2022. Pt #1 was admitted on 12/30/2021 with a diagnosis of Right Hip Fracture s/p [status post] Hemiathroplasty [hip surgery]. Pt #1 was discharged from the Medical Surgical Unit on 1/7/2022 and re-admitted to 5-4 Rehabilitation Unit on 1/7/2022.

3. Pt #1's Pain Assessments from 1/14/2022- 1/21/2022, were reviewed. The clinical record lacked either a pain score, pain re-assessment, or the location of the pain on the following dates:

- 1/14/2022 at 9:45 AM and 10:30 AM: pain location documented without a pain score.
- 1/15/2022 9:00 AM: pain score documented at 10/10 (10 being the worst), with no pain location. No pain re-assessment done until 12:00 PM (3 hours later)
- 1/15/2022 at 15:00 (3:00 PM): pain score documented at 10/10, with no pain location.
- 1/16/2022 at 9:00 AM; pain score 7/10, with no pain location. The pain re-assessment at 10:30 AM, included a pain location without a score.
- 1/17/2022 at 8:00 AM: no pain score
- 1/17/2022 at 8:54 AM: pain score documented at 10/10. No pain re-assessment documented until 1/18/2022 at 2:00 AM (17 hours and 6 minutes later)
- 1/18/2022 at 2:00 AM: pain score documented at 7/10, with no pain location
- 1/18/2022 at 13:45 (1:45 PM): pain location without a pain score
- 1/19/2022 at 17:00 (5: 00 PM): pain score 9/10. No pain re-assessment documented until 7:52 PM (2 hours and 52 minutes later)
- 1/21/2022 at 21:00 (9: 00 PM): pain score 8/10, with no pain location.

4. The clinical record for Pt #9 was reviewed on 10/19/2022. Pt #9 was admitted on 10/10/2022 to the Rehabilitation Unit, with a diagnosis of CVA (cerebrovascular accident/stroke).

5. Pt #9's Pain Assessments from 10/11/2022-10/18//2022, were reviewed, and indicated that pain assessments were not documented per shift on :
- 10/11/2022: Pain score documented at 0000 (midnight). The subsequent pain score assessment was on 10/12/2022 at 1:00 AM (25 hours later). Lacked a day or PM shift pain assessment.
- 10/13/2022: Pain score documented at 4:00 AM. The subsequent pain score assessment was on 10/13/2022 at 15:00 (3:00 PM/10 hours later). Lacked a day shift assessment.
- 10/14/2022: Pain score documented at 3:00 AM. The subsequent pain score assessment was on 10/14/2022 at 19:00 (7:00 PM/16 hours later. Lacked a day shift assessment.
- 10/15/2022: Pain score documented at 2:00 AM. The subsequent pain score assessment was on 10/15/2022 at 15:00 (3:00 PM/13 hours later. Lacked a day shift assessment.
- 10/16/2022 Pain score documented at 3:00 AM. The subsequent pain score assessment was on 10/16/2022 at 15:15 (3:15 PM/12 hours and 15 minutes later). Lacked a day shift assessment.

6. The clinical record for Pt #10 was reviewed on 10/19/2022. Pt #10 was admitted on 10/5/2022 to the Rehabilitation Unit, with a diagnosis of debility.

7. Pt #10's Pain Assessments from 10/11/2022-10/18//2022, were reviewed, and indicated that pain assessments lacked the pain location or a re-assessment on:
- 10/11/2022 at 14:04 (2:04 PM): Pain score documented at 8/10, with no pain location. Lacked a pain re-assessment.
- 10/12/2022 at 8:26 AM: Pain score documented at 8/10. Lacked a pain re-assessment.
- 10/13/2022 at 15:58 (3:58 PM): Pain score documented at 8/10, with no pain location.
- 10/14/2022 at 8:58 AM: Pain score documented at 10/10, with no pain location.
- 10/15/2022 at 10:59 AM: Pain score documented at 9/10, with no pain location.

8. On 10/18/2022 at 11:10 AM, an interview was conducted with the 5-4 Rehabilitation Agency RN (E #4). E #4 stated that pain assessments are done every 8 hours and re-assessments every 15-30 minutes after a pain intervention. E #4 stated that she would reach out to a MD if the patient's pain score was still 10/10 after a pain medication was given.

9. On 10/18/2022 at 2:40 PM, an interview was conducted with the 5-4 Rehabilitation Unit Manager (E #2). E #2 stated that the nurses are expected to do pain assessments every shift (8 hours).