HospitalInspections.org

Based on interview, record review, and policy review it was determined Nursing failed to supervise and evaluate the nursing care for one (1) of ten (10) patients. Patient #1 sustained a fall on 10/02/17 at 6:40 PM and had a change in condition on 10/03/17 (blood pressure dropped to 87/46); however, the facility failed to ensure the patient's physician was immediately notified of the incidents.

The findings include:

1. Review of the facility's policy titled "Incident and Adverse Drug Reaction Reporting," dated 06/24/14, revealed staff were required to complete an incident report and notify the patient's physician when an unusual or potentially serious incident occurred.

Review of Patient #1's medical record revealed the facility admitted the patient on 09/30/17, after sustaining two falls. Patient #1's diagnoses included falls, facial injuries, fractured ribs, and pneumonia. Review of the nursing notes revealed Patient #1 was assessed to be at high risk for falls and Patient #1 was placed on fall precautions.

Review of an incident report dated 10/02/17 at 6:40 PM, revealed staff responded to Patient #1's bed alarm and found the patient lying on the floor. According to the incident report, Patient #1's nurse, Registered Nurse (RN) #1, assessed the patient; however, there was no documentation that the patient's physician was notified of the incident.

Interview with RN #1 on 11/08/17 at 6:40 PM, revealed the RN was assigned to provide care for Patient #1 at the time of the incident. RN #1 stated she notified the patient's family of the incident but failed to notify the physician. RN #1 stated, "I just assumed the Nurse Supervisor notified the physician."

A telephone interview was conducted with the Nurse Supervisor on 11/08/17 at 7:50 PM, the supervisor who was working on 10/02/17 when Patient #1 was found lying on the floor. The Nurse Supervisor stated the incident occurred when nurses were changing shifts and stated, "I assumed the other nurse notified the physician." According to the Nurse Supervisor, the physician should have been informed of Patient #1's fall.

2. Review of the facility's policy titled "Notification of Physician upon change in patient condition," dated 07/24/96, revealed staff were required to notify the attending physician of any significant change in the patient's condition, which included a significant change in the patient's vital signs.

Continued review of Patient #1's medical record revealed a nursing note dated 10/03/17 at 4:34 AM, that stated the patient's blood pressure dropped to 87/46 (normal blood pressure is 120/80). However, there was no documentation that the facility notified the patient's physician of the change in Patient #1's condition.

Interview with RN #3 on 11/09/17 at 10:30 AM, revealed the physician was not notified of Patient #1's low blood pressure until morning rounds (exact time unknown) on 10/03/17. According to RN #3, staff did not normally call physicians during the night when patients had a drop in blood pressure.

An interview with the Director of Nursing (DON) on 11/09/17 at 11:00 AM, revealed staff should have immediately notified the physician when Patient #1 was found lying on the floor and when Patient #1's blood pressure dropped to 87/46.

Interview with Patient #1's Attending Physician on 11/08/17 at 4:50 PM, revealed he was not immediately notified of Patient #1's fall at the facility; however, he was not the physician on call when the incident occurred.

Interview with the on-call physician who was working on 10/02/17, revealed staff did not notify the on-call physician when Patient #1 was found lying on the floor on 10/02/17 at 6:40 PM.

Based on interview and record review it was determined Nursing failed to update/revise the care plan for one (1) of ten (10) patients. Patient #1 sustained a fall at the facility on 10/02/17 at 6:40 PM; however, the facility failed to revise the patient's care plan to include the fall and interventions to prevent further falls.

The findings include:

Review of the facility's policy titled "Care Plans," revealed the facility the facility would ensure patients were assessed and would ensure care plan interventions were identified.

Medical record review revealed the facility admitted Patient #1 on 09/30/17, after sustaining two falls. Patient #1's diagnoses included falls, facial injuries, fractured ribs, and pneumonia.

Review of the nursing notes for Patient #1 revealed the facility identified the patient was at high risk for falls. A review of Patient #1's care plan revealed the facility implemented a fall precaution protocol for Patient #1 on 09/30/17, with interventions to prevent falls, which included assisting the patient with transfers and ambulation, instructing the patient to use the call light, using diversional activities as needed, providing skid-proof footwear, and keeping the bed in the lowest position.

A review of an incident report dated 10/02/17 at 6:40 PM, revealed staff responded to Patient #1's bed alarm and found the patient lying on the floor. However, further review of the care plan revealed no evidence that the facility updated/revised the patient's care plan after the patient fell.

Interviews with Licensed Practical Nurse (LPN) #1 on 11/09/17 10:50 AM and Registered Nurse (RN) #1 on 11/08/17 at 6:40 PM, revealed the staff was responsible for updating nursing care plans; however, no explanation was given as to why Patient #1's care plan was not updated/revised after Patient #1 was found lying on the floor on 10/02/17 at 6:40 PM.

Interview with the Director of Nursing (DON) on 11/09/17 at 11:00 AM, revealed Patient #1's care plan should have been updated/revised following the patient's fall on 10/02/17.