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Based on medical record review, staff interview, and review of facility policies and procedures it was determined the nursing staff failed to document an incident occurrence according to the facility's policy and procedure for serious reportable events. This affected one (Patient #10) of ten medical records reviewed. The facility census at the time of the survey was 56.

Findings include:


1. Review of the medical record for Patient #10 revealed the sixty-seven year old patient was transferred to the the facility by emergency medical services on 08/19/14 at 10:54 AM due to an altered mental status. The history and physical documentation indicated Patient #10 had a stroke in 2013 with residual deficits noted to the left leg and foot that included weakness and decreased sensation. Patient #10 was assessed and treated by multiple modalities that included physical therapy, occupational therapy, and speech therapy. Review of physical therapy documentation revealed Patient #10 had bilateral footdrop with contractures. Patient #10 received home health aide services in the residence and required the use of a hoyer lift and a wheelchair. Physician's diagnoses included the patient was in septic shock likely secondary to a urinary tract infection. The patient had a peripherally inserted central catheter (PICC) line in place, a rectal tube, and a foley catheter.

Review of nursing documentation on 08/29/14 at 6:35 AM revealed the spouse stated, " The facility dropped the ball again and I'm going to have to take him/her to another hospital." The spouse insisted on signing Patient #10 out against medical advice (AMA) at 9:00 AM due to being upset with the progression of the speech therapy.

Physician documentation on 08/29/14 at 10:53 AM revealed the family was educated the patient was not medically stable for discharge. The medical record revealed the patient went against medical advice (AMA) at the insistence of the spouse on 08/29/14 at 10:10 AM.


2. An interview with Staff G on 11/04/14 at 9:52 AM revealed the spouse of the patient was unhappy with the diet interventions the hospital put into place and wanted the patient to be discharged (AMA). Staff G stated he/she was going to the patient's room on 08/29/14 and found the spouse attempting to self- transfer the patient from the side of the bed to a wheelchair. Staff G observed that the patients legs were flaccid and the patient would fall without intervention. Staff G reported being on one side of Patient #10 and the spouse on the other when Staff G "kicked " the patient's legs out in front to lower the patient to the floor. After Patient #10 was lowered, Staff G reported the patient denied injury, three additional staff were called to the room and Staff G assisted them in using a sheet to raise the patient to the wheelchair. A staff member assisted the spouse in transferring the patient to a private vehicle where the arm of the wheelchair was removed and the patient assisted to slide into the seat of the vehicle. Staff G stated the incident was not documented because Patient #10 was exiting the hospital AMA, however, confirmed the incident should have been documented.

3. An interview with Staff H on 11/04/14 at 10:40 AM defined a fall as anytime a patient was on the floor, witnessed or not, assisted or not. Staff H reported the hospital protocol for a fall included assessment of vital signs, assessment for injuries, staff to assist in getting the patient up, contacting the physician, documentation of incident to the nurse manager, post fall huddle meeting and documentation in MIDAS, the hospital incident reporting system. Any time a patient falls or lowered to the floor the protocol should be followed. Staff H reported the agency does not have a Hoyer lift for transfers, but has other devices to include: slide boards, gait belts, stretch chairs, and Hover Mat and Hover Jack.

4. An interview with Staff I on 11/04/14 at 11:00 AM revealed a fall is defined as a patient being on the floor even if witnessed and/or assisted to the floor. Staff I stated a fall must be reported to the charge nurse and an incident report comleted. The charge nurse documents the post fall huddle form and a post fall huddle meeting occurs with all staff involved immediately after a fall.

5. An interview with Staff J on 11/04/14 at 11:05 AM revealed a fall was defined as anytime a patient was on the floor even if assisted to the floor by staff. The protocol for falls included incident reporting, assessment, physician notification, post fall huddle and documentation in MIDAS. An observation at the time of the above interview revealed transferring equipment to include slide boards, hover mat and hover jack as available on the unit.

6. Review of the facility Incident/Occurrence and Serious Reportable Event Reporting Policy effective 05/07/14 revealed an incident/occurrence is broadly defined as any occurrence which is not consistent with the appropriate standards of care or routine operations of the healthcare facility. It includes any event which directly affects patients or has the potential to affect patients. The procedure to follow for an incident/occurrence included an incident report entered into MIDAS by the person who identified the incident to include facts and description of the incident. On page two the policy included instructions for documentation in the medical record. In the nursing notes, objectively document the incident, physical signs and symptoms, and any follow-up. i.e., patient fall, bruising, physician notification and visits, tests ordered/results, treatments given/procedures performed etc.