HospitalInspections.org

Based on observation, interview and record review the facility failed to ensure Registered Nurses (RN) supervised the care needed for one (#2) current patient and one (#38) discharged patient when the staff failed to ensure a physician's order for a sitter (one staff sitting with one patient) was followed. This failure potentially increased the risk for confused, high fall risk patients to fall and sustain injuries due to lack of protective oversight. The facility census was 491.

Findings included:

1. Record review of the facility's policy titled, "Sitter Use," dated 05/2015, showed direction to facility staff to provide a competent sitter when ordered by the provider (a physician, or Licensed Practitioner with ordering privileges) to be monitored for Protective Oversight.

Record review of the facility's policy titled," Plan for Provision of Care," dated 03/2015, showed staff directive to administer treatments as prescribed by a person licensed by a state regulatory board to prescribe the treatment such as a physician.

Record review of the facility's policy titled, "Fall Risk Assessment and Prevention," dated 11/2013, showed a staff directive that a patient with a fall risk score of eight or higher could request family to stay with the patient or obtain an order from the physician for a one to one sitter.

2. Record review of the facility's undated document titled," Registered Nurse, Job Description," showed the RN would recognize patient safety needs and provide a safe environment for the patient.

3. Observation with concurrent interview on 07/13/15 at 3:50 PM showed Patient #2 sat within the nurse's station in a Geri-chair(Geri-chair, mobile recliner with a built in tray). Staff A, Charge Nurse, stated that:
- When a patient was at increased risk for falls and there was no sitter the patient was placed in a chair at the nurse's station.
- The facility does not have staff for sitters.
- The staff are to ask family to stay or consider hiring a sitter for the confused, high fall risk patient before calling a physician for an order.
- If the family was unable to do either one, the nurse obtained a physician's order for a sitter. The order would be carried out if there was enough staff for a sitter.

During an interview on 07/13/15 at 4:15 PM Staff C, RN, stated that periodically, a patient at high risk for falls and difficult to redirect (due to confusion) would be better off to be at the nurse's station in a chair (to monitor closer to keep patient from falling).

Observation on 07/14/15 at 8:30 AM showed Patient #2 sat within the nurse's station in a Geri-chair.

Record review of Patient #2's flowsheet data, showed he had a cognitive (thinking, reasoning, and remembering) sensory (conveying nerve impulses from the sense organs to the nerve centers) and mobility deficit. He was weak, confused and considered a high fall risk on 07/13/15 at 8:08 AM and at 11:47 PM and on 07/14/15 at 9:41 AM. On 07/13/15 fall assessments showed a score of 22 and on 07/14/15 the score was 24 (a high risk for falls)

Record review of Patient #2's physician's orders showed orders for a sitter at the bedside written 07/13/15 at 3:51 PM and again on 07/14/15 at 10:13 AM.

Record review of the facility's document titled, "Smart Square Staffing Board Report," dated 07/13/15 and timed from 3:00 PM to 7:00 PM and dated 07/14/15 and timed from 7:00 AM to 3:00 PM showed no sitter assigned to Patient #2;

Record review Patient #2's flowsheet data from 07/12/15 to 07/15/15 showed no documentation of a sitter at the bedside for Patient #2 on 7/13/15 from 11:00 PM to 07/14/15 at 8:13 PM.

4. Record review of discharged Patient #38's History and Physical (H&P), dated 05/26/15 showed an assessment of confusion.

Record review of Patient #38's flowsheets showed on 06/14/15 at 07:00 AM and 7:00 PM a fall risk score of 21 (this would make the patient a high fall risk).

Record review of Patient #38's Discharge Summary Notes dated 06/17/15, showed:
- He was admitted to the facility after a motor vehicle accident (MVA)
- His diagnoses included stupor (a person is dazed or nearly unconscious) from a Traumatic Brain Injury (TBI)
- He underwent a right craniotomy (surgical opening in the skull)/craniectomy (a portion of the skull bone is removed and not replaced) for a large subdural hematoma (a collection of blood outside the brain).

Record review of Patient #38's physician's orders showed an order was written for a sitter at bedside on 06/11/15 and canceled on 06/17/15 when the patient was discharged.

Record review of the facility's document titled, "Smart Square, Staffing Board Report," showed no sitter assigned to the patient on:
- 06/11/15 from 11:00 PM to 7:00 AM (the next day);
- 06/12/15 from 7:00 AM to 11:00 PM;
- 06/15/15 from 3:00 PM to 7:00 PM;
- 06/16/15 from 7:00 PM to 11:00 PM;

Record review of Patient #38's Nursing Progress Notes dated 06/14/15 at 11:22 AM, showed:
- The RN arrived in the patient's room and found the patient on the floor next to the bed and no sitter at the patient's bedside.
- The RN placed the patient back in bed.
- The patient had increased breathing effort and respirations.
- A one by three centimeter (cm, a form of measurement) laceration (deep cut in skin) on the right heal.
- It was noted that the sitter had to leave and the Charge Nurse failed to assign another sitter.
- The RN assigned a Patient Care Assistant (PCA) to stay with the patient.

During an interview on 07/14/15 at 11:00 AM, Staff YY, Nurse Manager, stated that:
- A physician's order for a sitter was not technically a physician's order.
- The facility had to provide a sitter if the sitter order was for a patient who was suicidal (the patient wants to kill themselves) or on a 96 hour hold (involuntary hospital stay by a patient).
- Patient #2 had no sitter last night.

During an interview on 07/14/15 at 2:05 PM, Staff QQ, Nursing Logistics, stated that:
- Charge Nurse's entered into the computer the number of patients that were on their unit and the staff that were assigned to the unit for the next shift at 4:30 AM and 4:30 PM each day.
- The Charge Nurse also entered into the computer if they have a physician's order for a sitter.
- If the physician's order was for a confused patient, then the Unit staff that needed a sitter covered that need, unless there was extra staff that could be assigned from the staffing office.
- The House Supervisor or the unit's Nurse Manager had to approve use of that sitter for a confused patient.
- If the physician's order was for a sitter for a suicidal or a 96 hour hold patient the staffing office had to ensure that a sitter was provided through their office or the unit.

During an interview on 07/14/15 at 2:35 PM Staff YY, stated that if the unit did not have extra staff over there staffing grid numbers they would not have a staff to sit with a confused patient. If there was not an extra staff, then the current staff would each have to take extra patients in order to provide a sitter for a confused patient. That would not be fair to the other 23 patients (this was why physician orders for a sitter were not followed).

During an interview on 07/15/15 at 10:10 PM Staff B, Physician, stated that:
- When he wrote an order he expected it to be carried out.
- When he wrote an order for a sitter for a confused, high fall risk patient, he expected the order to be carried out.
- He stated that sometimes a sitter might be sent to a higher risk situation (to sit with a suicidal or 96 hour hold patient)
- He expected to be told when staff were unable to carry out an order for a sitter.
- This was not optimal or how he would want it (not to be able to carry out his orders and provide sitters when needed)

During an interview on 07/15/15 at 1:00 PM, Staff SS, Chief Nursing Officer (CEO), stated that she was not sure if a physician's order for a sitter had to be carried out when needed for a confused patient. That could be a nursing judgement and nursing function.

Based on interview, record review and policy review the facility failed to develop Care Plans which were individualized to meet the needs of four patients (#10, #16, #7 and #9) of four patients reviewed. This deficient practice had the potential to permit inappropriate or inadequate care to be provided. The facility census was 491.
Findings included:

1. Record review of the facility's policy titled, "Interdisciplinary Care Planning," revised 12/2013, showed the directive for staff to initiate Care Plan within 12 hours of admission and it should reflect the patient's individualized needs identified during assessment including but not limited to: Medical Goals, Psychological goals. Discharge goal, and Educational goals. It should also reflect assessment goals and interventions, education, reassessment, patient's need for further care, treatment or services and achievement of the care plan goals.

2. During an interview on 07/13/15 at 3:15 PM, Patient #10 stated that he had difficulty swallowing and had not been able to eat and had nutrition by IV (through the vein). He had been bedbound for a week and needed help to get out of bed and walk to the bathroom because of his weakness.

Record review on 07/13/15 of the patients History and Physical (H&P) showed Patient #10 was admitted to the facility on 07/01/15 with abdominal pain. The patient was a diabetic (high blood sugar), had impaired swallowing with a gastrostomy tube (a tube into the stomach to provide nutrition) and was a fall risk.
Record review of the Care Plan showed no measurable individualized interventions or goals for diabetes, impaired swallowing with a gastrostomy tube or a risk for falls.

3. During an interview on 07/14/15 at 8:55 AM, Patient #16 stated that she had fallen at home and was still unable to walk. She stated staff assisted her to the commode. She stated that she believed she was pre-diabetic but had been told by hospital staff that she was a diabetic.
Record review of the Care Plan showed no interventions or goals for diabetes and no individualized interventions or goals for risk of fall.

4. Record review of Patient #7's H&P dated 07/13/15 showed the patient was admitted on the same date with severe sepsis (infection throughout the body), diabetes, and the need for Deep Vein Thrombosis (DVT, blood clots in the deep veins that can become dislodged and block the blood flow in the lungs) prophylaxis (prevention, usually by medications that thin the blood).

Record review of Patient #7's Care Plan showed no goals for sepsis, diabetes, and DVT prophylaxis.

During an interview on 07/14/15 at 10:50 AM, Staff R, Registered Nurse (RN), confirmed that the goals for sepsis, diabetes, and DVT prophylaxis should have been in the care plan and they were not.

5. Record review of Patient #9's History and Physical dated 07/10/15 showed the patient was admitted for a urinary tract infection (UTI, an infection in the kidneys, bladder, and/or urethra), diabetes, and bradycardia (abnormally slow heart action).

Record review of Patient #9's Care Plan showed no goals for UTI, diabetes and bradycardia.

During an interview on 07/14/15 at 3:10 PM, Staff R, RN, stated that goals for UTI, diabetes, and bradycardia should have been in the patient's care plan and they were not.


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