HospitalInspections.org

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Based on interview, record review and review of policies and procedures, the hospital failed to ensure nursing staff implemented its policies and procedures for measuring vital signs and performing neurological checks after patient falls for 3 of 4 medical records reviewed (Patients #1201, #1202, and #1203).

Failure to measure vital signs and perform neuro checks following patient falls risks delays in care or treatment and places patients at risk for serious harm or death.

Findings included:

1. The hospital's policy titled, "Fall Prevention," policy ID 10063023, approved 03/17, showed that after a patient fall, nursing staff will measure and document vital signs every hour for 4 hours. If there is any evidence of head trauma or unwitnessed fall, monitor and document neurologic assessments every hour for 4 hours, and then as ordered by the provider.

2. On 03/04/22 at 10:45 AM, Investigators #12 and #19 and the Clinical Informatics Nurse Manager (Staff #1201) reviewed the medical records of 4 patients who fell while hospitalized. The record review showed the following:

a. On 02/01/22 at 10:25 AM, Patient #1201 had an unwitnessed fall in the patient room, and nursing staff found the patient in between the bed and the bathroom lying on the floor in a puddle of urine. Patient #1201 admitted to hitting his head as a result of the fall, but no visible trauma was noted. Staff documented vital signs at 10.39 AM, 11:07 AM, 1:00 PM, and 3:00 PM. Staff documented a neuro assessment at 10:39 AM. The next neuro assessment documented by staff occurred at 8:02 PM.

b. On 01/20/22 at 3:50 PM, Patient #1202 had an unwitnessed fall while returning to bed after using the bathroom. At 3:53 PM and 3:54 PM, staff documented the patient's blood pressure, pulse and oxygen saturation. No other vital signs were documented until 7:48 PM. The first neuro check after Patient #1202's fall occurred on 01/20/22 at 8:02 PM.

c. On 02/25/22 at 1:00 AM, Patient #1203 experienced an unwitnessed fall while attempting to get out of bed without assistance. Staff obtained vital signs at 1:08 AM and 7:00 AM. Staff did not perform neuro checks post fall or every hour for 4 hours as required by hospital policy.

3. At the time of the document review, Staff #1201 confirmed the investigators' findings that nursing staff did not measure and document patient vital signs and neuro checks following unwitnessed falls or falls with head trauma as required by hospital policy.
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Based on document review and interview, the hospital failed to ensure that unvaccinated staff with an approved exemption completed required COVID-19 education for 2 of 23 unvaccinated exempt staff reviewed (Staff #1701 and #1702).

Failure to have exempt staff complete required education on COVID-19 precautions and vaccination risks unsafe practices that could lead to patient and staff infection.

Findings included:

1. Record review of clinical education files showed that 2 staff (Staff #1701 and #1702) that had approved exemptions from COVID-19 vaccination had not completed the required training course titled, "Swedish COVID-19 and Vaccination Education 2021."

2. On 03/04/22 at 1:30 PM, Investigator #17 interviewed the Regional Director of Accreditation (Staff #1703) about the required education. Staff #1703 stated that the education was required for unvaccinated exempt staff and confirmed that Staff #1701 and #1702 had not completed the required education at the time of review.