HospitalInspections.org

Based on interview, record review, policy review, and job description review, the provider failed to ensure nursing staff had documented:
*Neurological (neuro) assessments and vital signs after the initial fall with a head injury for one of one sampled patient (1).
*A verbal order for neuro assessments from the provider was clarified for one of one sampled patient (1) after a fall.
*Details of the falls, neuro assessments, and vitals signs for three of ten sampled patients (2, 3, and 6).
Findings include:

1. Review of the electronic medical record (EMR) for patient 1 revealed:
*She was admitted on 2/12/23 and expired on 2/17/23.
*Admission diagnoses included pneumonia, COVID-19, hypoxia, dementia, and acute kidney injury.

Review of registered nurse (RN) C nursing documentation for patient 1 on 4/17/23 revealed:
*On 4/14/24 at 2:00 a.m. staff noticed the patient's oxygen saturation no longer registered a reading on the monitor.
*Upon entering the patient's room she was found at the foot of the bed sitting on the floor.
-There was blood, water, and feces on the floor.
-There was no documentation the bed alarm had been sounding upon staff entering the room.
*Direct pressure was applied to a 3/4 inch by 1/8 inch superficial cut on the back of her head.
*A head-to-toe assessment was completed with no additional injuries identified.
*By assistance from staff she was placed on a shower chair, showered, placed on commode, and returned to bed.
*"Pt [patient] showed no signs of dizziness. Pt was awake and alert at all times. Pupils are equal and dilated bilaterally. Vitals were taken. Warming blanket placed on pt. Bed alarm is turned on. IV [intravenous] infusion restarted. O2 [oxygen] with N/C [nasal cannula] at 2L [liters] put back on pt. Provider was called."
*Certified nurse practitioner (CNP) B arrived:
-"Provider checked pt head to toe.
-Provider was shown vitals on monitor at this time (WNL's) [within normal limits].
-Provider stated the wound was already starting to scab over and would recheck in the morning.
-Provider stated to check on pt ever [every] 2 to 3 hours."

Review of CNP B's Family Medicine Progress Note dated 4/14/23 for the 2:00 a.m. fall described above revealed:
*At 2:19 a.m. she was contacted and informed a patient had a fall from her bed.
-She had been found on her bottom on the ground and was incontinent of stool.
*From the fall she had received a 0.5 centimeter superficial laceration to the posterior scalp that had stopped bleeding on its own.
*"Upon assessment, patient was alert, confused conversation but did follow commands, appeared neurologically at baseline. She denied any pain at that time. Lungs clear bilaterally, heart normal rate and rhythm. Pulses intact to all extremities, patient able to move all extremities.
*"Nursing staff was instructed to do frequent neuro assessments and call if any changes. Vital signs stable at this time."
-This instruction was contradictory from RN C's documentation at 2:00 a.m. on 4/17/23.
--In that note staff were to monitor the patient closely, there was no mention of conducting neuro assessments.

Continued review of RN C's documentation on 4/17/23 for patient 1 revealed:
*On 4/14/23 at 4:00 a.m. the patient bed alarm was sounding.
-She was found out of bed leaning on a bed table attempting to ambulate and was returned to bed.
-"Pt's mentality suddenly changes and becomes unresponsive. Vitals are taken. B/P [blood pressure] is elevated [high] and O2 has dropped off [detectable oxygen concentration in blood has decreased]. O2 is increased to 4L N/C. Provider [CNP B] is contacted. Provider [CNP B] try's to get pt to respond by verbal and physical stimuli with no response. Provider is shown vitals on monitor.
-X-ray of the pelvic/abdomen area and head CT [computed tomography] without contrast for the head ordered."
*She was transferred from her room to radiology.
*"CT shows a brain bleed" and she was taken to the in-house emergency department.
-"Pt's vitals are taken ever [every] 5 minutes. Pt's pupil's are fixed and dilated. Hydralazine (to lower B/P) and Protamine (reversal medication for Lovenox). Pt's B/P comes down. Pt is unresponsive but stable at this time."
-Cervical collar placed on patient until neck cleared of injury.
*The patient was placed on comfort care.

Review of the EMR for patient 1 on 4/12/23 revealed:
*Neuro assessments had not been ordered.
*No additional vital signs had been documented until 4:00 a.m. when the patient became unresponsive.

Review of patient 1's medication administration record revealed:
*IV (intravenous) Heparin (blood thinner) 25,000 units in 250 milliliters 0.45% normal saline was started on 4/12/23 and discontinued on 4/13/23.
*Lovenox (prevents blood clots) 0.001 milligrams subcutaneous every 12-hours was started on 4/12/23.



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2. Interview on 4/24/23 at 12:40 p.m. with RN A regarding patient 1's fall revealed:
*There were two RNs schedule to work during the night shift.
*The fall happened around 2:00 a.m.
*The patient had dementia.
*Neuro assessment and vital signs had been obtained and were within normal limits.
*She and RN C had assessed the patient. The patient was bleeding from a head wound. The nurse applied pressure to the head wound and the bleeding had been stopped.
*The patient had been on an IV (intravenous) Heparin drip (blood thinner) upon admission to the hospital due to possible small blood clots in her lungs.
*Her expectation of obtaining a neuro assessment and vital signs after a patient had fallen would have been the following:
- Neuro assessments and vitals signs would have been obtained every fifteen minutes for the first hour.
-CNP B had verbally ordered neuro's every two hours.
-The nurses would follow the fall risk protocol.
-She would ensure the patient was safe.
-CNP B was in house that night and was at the patient's bedside within five minutes after the fall.
-The oxygen saturation had decreased and RN A and C entered the patient's room and the patient had become unresponsive.
-She was unsure about what had been documented in the EMR because she had not been assigned to the patient that night. She had been assisting RN C at his request.

Telephone interview on 4/24/23 at 3:50 p.m. with CNP B regarding the fall for patient 1 revealed:
*The patient had been sitting on the floor beside her bed. She was incontinent of stool and their was blood noted on the floor.
*The nursing staff had taken the patient to the shower room, showered her, and then returned her to the room.
*The nursing staff had gotten the patient back into bed.
*There had been no mental changes at that time.
*The patient was alert and could tell the CNP her name.
*She had performed a neuro assessment on the patient upon her arrival to the patient's room.
*The patient's diagnoses were COVID-19 and pneumonia.
*She thought she had verbally ordered neuro checks frequently and that had meant every 15 to 30 minutes.
*She had not written orders for the neuro checks and the vital signs.
*Physicians and CNPs were to order neuros after a patient had fallen using the neuro check intervention in the EMR.
*She should have given a detailed order for the neuro checks and vital signs.
*She had been unsure if there was a policy and procedure for neuro checks expectations for the nursing staff.
*She had not ordered a CT scan of the patients head after the fall because the patient was alert, answered simple questions, and ambulated with assist.
*She stated that in hindsight she probably should have ordered the CT scan after the fall due to the fact the patient had been on a Heparin drip that had been discontinued on 4/13/23 and had then been placed on Lovenox another blood thinning medication.
*She had been unsure if there had been a policy and procedure for neuro's that was in place for the nursing staff to have followed.

Interview on 4/24/23 at 4:10 p.m. with director of patient services E regarding patient falls revealed:
*There were no guidelines for the nursing staff to follow for neuro checks.
*The expectation was for the physician or CNP to place the order in the patients EMR for the neuro checks and vital signs after a patient had fallen.
*She would have expected the nursing staff to clarify a physician's verbal order regarding neuro checks and vital signs.
*There had been a nursing meeting the following week after patient 1 had fallen and a new policy and procedure was initiated regarding patient falls with possible head injuries.
*The frequency of neuro checks and vital signs were driven by the physician orders.

Interview on 4/24/23 at 4:45 p.m. with RN C regarding patient 1's fall revealed:
*He restated the information documented in his nursing notes on 4/17/23 with the exception for patient monitoring.
*During the interview he stated per the provider neuro checks should have been completed "every two hours."
-This contradicts the monitoring frequency instruction stated in his nurses note on 4/17/23.
-They were not good about "getting those documented or ordered."
*The patient had been admitted with diagnoses of COVID-19 and pneumonia.
*A nonrebreather mask had been initiated at first, then the patient went to a regular oxygen mask, and then to a nasal cannula for supplemental oxygen.
*The patient's condition had been improving.
*There was a bed alarm placed due to the patent's impulsive behavior to get out of bed and the patient had a diagnosis of dementia.
*He had been in patient 1's room frequently the night of 4/13/23.
*After the patient had been found sitting on the floor beside her bed around 2:00 a.m. the morning of 4/14/23.
-There was blood and incontinent stool on the floor bedside the patient.
-There was a 4 x 4 gauze placed to the back of the patient's head due to noted bleeding.
-The patient was alert and answered simple questions.
-She was assisted from the floor to the shower chair with assistance from RNs A and C. She was taken to the shower room.
-The CNP came in to see the patient.
-The CNP had given a verbal order to check neuro's and vital signs every two hours.
-RN C had been in the patient's room frequently.
-He thought he had turned the bed alarm back on once the patient had been showered and returned to bed.
-The patient had been attempting to get out of bed several times during the night and had been redirected.
-The patient had been on an IV Heparin drip upon admission but that had been discontinued and the patient had been receiving Lovenox injections.
*RN C noted the patient's blood pressure was becoming quite elevated. He went into the room and the patient was unresponsive, pupils were fixed and dilated, and there was grunting respirations heard.
-The patient was not responding to verbal stimuli and physical stimuli at that time.
-A C (cervical)-collar was placed to keep the neck in alignment.
-CT scan was ordered by CNP B and completed.
-RN C had administered an IV medication to assist in lowering the patient's blood pressure and another medication to reverse the blood thinning properties of the Lovenox.
*There were no protocols for nurses to follow for neuro's and vital signs after a patient fall.
*When a patient was in the ER neuro checks and vital signs would have been obtained every 5-15 minutes.
*He stated there had been a nursing meeting after the incident regarding the implementation of a new protocol after a patient had fallen and had a head injury for neuro checks and vital signs.

3. Review of the EMR for patients 2, 3, and 6 revealed the following:
*Patient 2 had a fall on 12/21/23 and bumped his head on the heating register in his room.
-He had another fall on 1/20/23 that had resulted in a large bump to the left side of his forehead when he was found on the floor at his bedside.
-There was no documentation regarding the events of his fall, no neuros and vital signs were found in the EMR.
*Patient 3 had a fall on 4/2/23 and there had been no documentation found of the fall and no neuro's and vital signs.
*Patient 6 had a fall on 2/17/22. There had been no documentation related to the fall in the EMR.
*Each of the patients had a fall risk assessment completed by the nurse but there had been no further documentation found related to the falls.

Interview on 4/25/23 at 11:00 a.m. during the review of the above patient EMRs with director of patient services E regarding the missing documentation revealed that there was no documentation in their EMRs related to the fall for patients 2, 3, and 6.

4. Interview on 4/25/23 at 12:05 p.m. with medical director F regarding patient falls with head injuries revealed:
*CT scan would have been ordered to rule out bleeding on the brain, or if there was a positive neurological exam.
*Patient 1 was alert and following commands after the fall.
*There was no protocol in place for ordering a CT scan. It would have been dependent on the clinical evaluation of the patient.
*The medical provider should have specified the time frequency for the neuro checks and vital signs.
*There had been no reeducation provided to CNP B since the incident occurred with patient 1.
*There would be education provided to the CNPs for the frequency of the neuro checks and the reason for ordering a CT scan versus not ordering a CT scan after a patient fall.

5. Review of the provider's revised April 2023 Fall Risk and Screen policy and procedure revealed:
*The purpose of the policy was to decrease the number of falls and the severity of injury related to those patient falls.
*The areas of revision related to a fall during hospitalization were the following:
-"Assess the patient for any sign of injury, such as broken bones, skin tear, etc; assess neuro status if patient may have hit his/her head;obtain VS [vital signs]".
-Provide urgent care appropriate to the injury.
-Notify the physician.
-Document the facts of the incident in the patient notes.
-Complete an occurrence report and forward to the nurse manger.
-Designate patient at higher fall risk and implement interventions as appropriate.
-Perform necessary measure to relive patient's pain (IE: Ice, Analgesics, Positioning)."

Review of the undated provider's Fall Follow-Up Tips sheet revealed to document the following:
*The description of the fall in the intervention.
*The fall risk assessment in the intervention.
*Any fall risk interventions that had been implemented by the nurse.
*Communication with the provider and family in the fall intervention.
*Adjust frequencies of the interventions as needed based on the patient's assessment.

Review of the provider's July 2009 RN Position Description revealed:
*The RNs purpose was to have provided quality nursing care to the patients and to supervise the staff working with the RN to coordinate care with ancillary staff, and to communicate effectively with the physician to ensure patient care.
*Assesses physical condition and nursing needs of inpatients, outpatients, and ER [emergency room] patients.
*Maintains records of medical and nursing treatments and related services executed by the nursing staff through appropriate and accurate documentation and utilization of the electronic medical record.

Review of the provider's February 2015 Certified Nurse Practitioner Position Description revealed the CNP:
*Assumed the responsibility for the provision of primary care ad medical management of patients at the hospital in collaboration with a physician.
*Performed necessary diagnostic and therapeutic procedures according to written, approved protocols developed with and under the supervision of the physician sponsor.
*Used the appropriate diagnostic tests in accordance with protocols and procedures approved by the appropriate licensing and administrative authorities.
*"Documents the processes of care delivery."
*"Recognizes and reacts appropriately to environmental safety factors related to patient care. Understands, applies, and supports practice policies, procedures, goals, and standards. Follows at all times procedures, policies and standards as outlines by the Flandreau Medical Clinic."