HospitalInspections.org

Based on interview and document review, it was determined that the facility failed to provide care in a safe setting by not respecting the Patient's and Patient Advocate's health concerns for one (1) of five (5) Patients, Patient (P) # 1.

The findings include:

On August 17, 2023, a Clinical Record review for P# 1 revealed the following:

Progress Note dated July 1, 2023 signed by Staff Member (SM) # 7 with attestation by SM # 8 reads in part "No acute overnight events reported."

Progress Note dated July 2, 2023 signed by SM # 7 with attestation by SM # 8 reads in part "No acute overnight events reported."

Progress Note dated July 3, 2023 signed by SM # 10 reads in part "No acute events overnight. Per [Family], Patient was noted having decreased movement with right hand since yesterday."

A review of Nursing Assessment flowsheets revealed
"June 30, 2023 at 11:03 p.m. - R Hand grip - weak, L Hand grip - weak"
This three (3) to four (4) hour assessment remained the same until July 2, 2023.
"July 2, 2023 at 8:30 p.m. - "R Hand grip - absent, L Hand grip - absent".
There was no documented Nursing note of report of this change to the Nurse Practitioner (NP) or Physician. SM # 5, whom was assisting with the Clinical record review, confirmed that there was no documentation that the change was reported.

CT (Computed Tomography imaging technique) Head wo (without) contrast dated July 3, 2023 impression reads in part "New regions of hypodensity suggesting subacute ischemia in the left occipital lobe, and a small region of hypodensity in the left parietal lobe. No hemorrhage."

A review of the facility's Brain attack alert process map revealed "Sudden change reported by family or staff would trigger a brain attack alert."

The findings were discussed on August 17, 2023 with SM # 1, # 3, # 6 and # 13 during the exit interview.

Based on interview and document review, it was determined that the facility failed to provide nursing staff to meet Patient needs by not reporting changes in Patient condition for one (1) of five (5) Patients, Patient (P) # 1.

The findings include:

On August 17, 2023, a review of Nursing Assessment flowsheets for P #1 revealed
"June 30, 2023 at 11:03 p.m. - R Hand grip - weak, L Hand grip - weak"
This three (3) to four (4) hour assessment remained the same until July 2, 2023.
"July 2, 2023 at 8:30 p.m. - "R Hand grip - absent, L Hand grip - absent".
There was no documented Nursing note of report of this change to the NP or Physician. SM # 5, whom was assisting with the Clinical record review, confirmed that there was no documentation that the change was reported.

On August 17, 2023 at 12:15 p.m., an interview with SM # 4 revealed "There was no complaint or grievance filed with the facility regarding P # 1. There was a discussion concerning communication issues between staff and family. The Nurse Manager spoke with staff and family to resolve the issue."

On August 17, 2023 at 12:45 p.m., an interview with SM # 1 revealed "Based on the documentation reviewed, process was not followed."

The Nursing Manager was unavailable for interview during the time of the survey.

On August 17, 2023 at 1:45 p.m., an interview with SM # 6 revealed "the Nurse Manager spoke with staff and family concerning P # 1. SM # 9 stated changes were reported to the Physician. There was no documentation that changes were reported. The Nurse Manager provided re-education to all staff starting July 8, 2023. The education included, brain attack protocol which included nurses can call brain attack with waiting for Physician approval."

On August 17, 2023 at 2:00 p.m., an interview with SM # 12 revealed "If changes in Patient persist after nursing has ruled out other causes such as medications and sedation, would expect this to be reported to Physician the day of occurrence."

A review of grievances revealed no deviation from facility policy.

A review of the facility's Brain attack alert process map revealed "Sudden change reported by family or staff would trigger a brain attack alert."

The findings were discussed on August 17, 2023 with SM # 1, # 3, # 6 and # 13 during the exit interview.