HospitalInspections.org

Based on observation, interview, and record review, the facility failed to document patient Advance Directives for 5 (#s 6, 7, 8, 9, and 10) of 10 sampled ED (emergency department) patients. In the event of an emergency medical situation, this deficiency could cause the providers to be unaware of a patient's wishes. Findings include:

During record review on 5/7/24, patients # 6, 7, 8, 9, and 10's medical records did not show an advance directive was entered in the patient's medical record. The Emergency Department documentation did not show the patients were asked if they had an Advance Directive.

During an observation and interview on 5/8/24 at 12:10 p.m., staff member B was asked to locate the Advance Directives in the medical records for patients #6, 7, 8, 9, and 10. Staff member B was unable to locate the Advance Directives and was unable to locate documentation indicating the patients were asked if they had Advance Directives. Staff member B stated the EMR (electronic medical record) used to have a hard stop written in the system that required staff to ask patient's if they had an Advance Directive. However, after an update the hard stop disappeared. Staff member B said staff should be asking patients if they have an Advance Directive, and they should be documenting the answer. After being unable to find the Advance Directive in the EMR staff member B stated the nurses must not be answering the question or documenting it since there is no longer a hard stop in the system.

Review of a facility Policy titled, POLST/Advance Directives, dated 1/9/24, showed:
"...A patient/resident who has the capacity to make a health care decision and who withholds consent to treatment or makes an explicit refusal of treatment either directly or through an advance directive, may not be treated against his/her wishes..."

Based on review of facility video surveillance footage, interview, and record review, the facility failed to follow a patient's comprehensive care plan for 1 (#11) of 10 sampled swing bed patients. This deficient practice resulted in the patient sustaining a fall which resulted in a hip fracture. Findings include:

Review of facility video surveillance footage dated 3/13/24 at 7:03 p.m., showed patient #11 was sitting in her wheelchair in the day room. Patient #11 rose from her wheelchair and attempted to use the wheelchair to assist her with ambulating. Patient #11 took three steps and fell on her back. Patient #11 was observed hitting her head on the floor. Once on the floor, the patient used her right arm to hold her head and continued to lie on the floor until a staff member entered the room; one minute after the patient sustained the fall.

During an interview on 5/7/24 at 5:13 p.m., staff member Q stated he was one of two CNA's who worked the night shift on the swing bed unit on 3/13/24. Staff member Q stated he was in the swing bed day room with several patient's but was called to the ER prior to patient #11's fall and was not on the swing bed side of the hospital when patient #11 fell. Staff member Q stated a chair alarm was used on patient #11's wheelchair, but he did not know if it was on her chair the evening of 3/13/24.

During an interview on 5/28/24 at 11:05 a.m., staff member I stated patient #11 was in the day room of the facility on 3/13/24 and sustained a fall. Staff member I stated patient #11 was sitting in her wheelchair and stood up and proceeded to use her wheelchair to assist her with walking. While patient #11 was attempting to ambulate, she fell. Staff member I stated this was the first fall for patient #11 since her admission to the facility. Staff member I stated patient #11's wheelchair did not have an alarm on it at the time of her fall. Staff member I stated patient #11 was a high fall risk and had care plan interventions in place to always have a wheelchair alarm on while she was in her wheelchair. Staff member I stated patient #11 was assessed after her fall and transported to the ED for further evaluation. Staff member I stated patient #11 sustained a hip fracture and was transferred to another hospital.

Review patient #11's EHR, with a swing-bed admit date of 2/22/24, showed the patient had diagnoses which included: Altered mental status, unspecified, unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.

A review of patient #11's care plan, with an initiated date of 2/23/24, showed:
"Plan: Fall Prevention/Management...
Phase: Fall Prevention...
Note: bed and chair alarm in place at all times (Charted at 3/11/2024, 8:07 A.M. by [staff member T]).

Record review of patient #11's EHR showed the patient had a Morse fall score of 80, which was recorded on 3/11/24 at 6:15 p.m., by staff member R (a Morse fall score of 45 or greater is considered a high falls risk for falls).

Record review of patient #11's admission paperwork, dated 2/22/24, completed by staff member S, showed:
"84 yo female admitted for altered mental status, delirium with dementia...At high risk for falls ...Multiple bruises on extremities consistent with history of multiple cushioned fall...does require 1:1 Nursing at times." [sic]

Record review of "Discharge Documentation" for patient #11, dated 3/13/24, showed:
"Physical Exam...I was called to the day room and notified that [patient #11] had fallen. Fall was initially unwitnessed, but staff was able to view the fall on video. It appears that [patient #11] tried to walk using her wheelchair as a walker; the wheelchair seemed to get a bit ahead of her and she fell onto her left hip...Staff notes that her left leg is shortened, tender, and externally rotated at the hip concerning for a hip fx ...
Exam...Extremities; left leg is externally rotated at the hip; appears shortened..."[sic]

Review of patient #11's "Diagnostic Radiology" report, dated 3/13/2024 at 7:48 p.m., showed:
"...Report
There is a fracture of the left femoral neck with slight varus angulation. Status post right hip arthroplasty. Degenerative change in the lower lumbar spine.
IMPRESSION: 1. Fracture of the left femoral neck..."[sic]

A review of a facility policy, titled, "Comprehensive Assessment, Comprehensive Care Plan, and Discharging Planning Policy," showed:
"PURPOSE:
Comprehensive assessment, comprehensive care plan, and discharge planning policy of Mineral Community Hospital. All patients admitted to the Swing Bed Unit shall receive a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity by a qualified individual so that a plan of care, along with discharge planning can be developed to best meet the needs of patients. The assessment of the care or treatment needs of the patients will be ongoing throughout the patient's hospital stay...
A complete assessment shall include:...
C. Cognitive patterns...
H. Physical functioning and structural problems...
O. Special treatments and procedures..."