HospitalInspections.org

Based on hospital policy review, medical record review, incident report review, physician and staff interviews, the hospital's nursing staff failed to supervise and evaluate patient care by failing to reassess a patient's status after a fall in 3 of 3 patient fall records reviewed (Patient #2, Patient #19, Patient #20); and failed to complete nursing shift assessments in 7 of 12 patient records reviewed. (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #19, Patient #21).

Findings include:

A. Review of policy NS (Nursing Services)-Falls Prevention and Management, last revised 10/2020, revealed "Procedure: General 1. ...Basic safety interventions include, but are not limited to, the Fall Bundle, environmental assessment, and risk assessment through the Morse fall Scale. For those patients identified as a high fall risk, more in-depth prevention interventions will be implemented.... Anticipated Psychological Fall: 1. A Morse Falls Scale is used throughout (named facility) to predict patients at risk for falls.... Post Fall Follow-up 1. In the event of a fall, the RN (registered nurse) is responsible for immediately assessing the patient's condition including, but not limited to, vital signs, neurological status, and presence of new or worsening pain .... 2. The Administrative Supervisor, patient's physician, and family are notified when a fall occurs. 3. When assessing a patient post fall, staff are expected to: a. Document the assessment using the 'Post Fall Assessment' screen ....a separate note will no longer be needed. b. update Fall Risk Assessment. c.Update the Nursing Plan of Care to reflect changes in care related to the fall. 4. The licensed nurse is responsible for entering the fall occurrence in Safety Event Report."


1. Closed medical record review of Patient (Pt) #2 revealed a 28-year-old male who presented to the Emergency Department (ED) on 09/16/2022 for complaint of psychiatric evaluation. Patient #2 was placed under IVC (involuntary commitment), awaiting placement to a psychiatric facility. Review revealed Patient #2 had a 1-1 sitter for the entire ED stay. 09/21/2022 at 0736-MD (Medical Doctor) #1 documented PN (progress note) "Patient was seen and examined today during my rounds. Patient remains medically stable for behavioral health care.... Patient complains of swelling in his legs and feet...Plan: ....We will get doppler ultrasound to rule out DVT (Deep vein thrombosis, a blood clot in the leg). We will also get physical therapy evaluation....". Review of Sitter #17 notes on 09/21/2022 revealed "...12:57-fall, 1300-back in bed...." Nursing staff failed to document the 09/21/2022 fall or implement measures to prevent further falls. Review of the ED Progress Note (PN) on 09/22/2022 at 1945 by MD #2 revealed ".... Reports weakness and pain limits his ability to ambulate to the restroom. Has been evaluated by physical therapy...." Review of Sitter #15 notes on 09/22/2022 at 2145 revealed "....14. Fell in floor off BSC (bedside commode)...." Record review failed to reveal an RN assessment after a fall for Patient #2. Review of ED PN from 09/22/2022 at 2157 revealed "CT lumbar and pelvis ordered based on lower extremity complaints. CT lumbar and pelvis reviewed. No signs of foraminal stenosis fracture or mass. No signs of pelvic fracture. Patient with signs of possible proctitis..." Review of ED PN from MD #1 on 09/23/2022 at 1731 revealed "....Events of the past 24 hours include: Patient is doing well. Patient has physical therapy session today. No complaints...." Record review failed to reveal documentation of a Morse Falls Score for Patient #2. Medical record review for Patient #2 with two falls on 09/21/2022, 09/22/2022 revealed nursing staff failed to document a fall and assess Patient #2's status after a fall . Patient #2 was discharged home on 09/25/2022 at 1423.

Requested incident report for falls for Patient #2 revealed no incident report for either fall.

Interview with RN #13 (Nurse identified by facility as being the RN assigned to Patient #2 on 09/21/2022 at the time of the fall) on 01/18/2023 at 1415 revealed RN #13 stated that she normally worked as Charge Nurse in the ER and didn't take assignments. RN #13 stated she did not remember Patient #2 at all and did not remember being told about a fall with Patient #2. RN #13 stated "As charge, a fall would/should absolutely be reported to me at which time I would tell the House Supervisor and Provider on duty and fill out an incident report.

Interview with RN #12 (Director of Nursing Operations) on 01/18/2023 at 1611 revealed that the Falls Prevention and Management policy applied to all patient care areas and her expectation regarding Patient #2's fall was that the sitter communicated the fall to the nurse. RN #12 stated that sitters did not have a place in their documentation to document who they told about a fall. RN #12's expectation was that the Falls Policy was followed, and documentation of steps taken were documented in the chart. RN #12 was unable to locate RN documentation of the falls.

Telephone interview with Sitter #15 (Sitter who documented fall #1) on 01/19/2023 at 0908 revealed she remembered Patient #2. Sitter #15 stated on 09/22/2022, she got Patient #2 out of bed to use the bedside commode. "He said he couldn't do anything with me there, so I stepped outside. I had the door cracked so that I could see him. He had been getting up without help even though he was told not to. I reminded him not to get up, but he did anyway, and he slid to the floor. I notified the nurse who had him at the time. The nurses are supposed to do the documentation. Sitters only chart on the sitter sheet. He kept saying he was ok and trying to get up. I checked him over and didn't see any bruises...." Sitter #15 stated she did not remember who the nurse taking care of Patient #2 was.

Telephone interview with Sitter #17 (Sitter who documented fall #2) on 01/19/2023 at 1218 revealed that she did not remember Patient #2 until she was read her note. Sitter #17 stated Patient #2 fell trying to get out of bed to go to the bathroom. Sitter #17 stated "I know I told his nurse because she helped me get him up. I don't remember her name, but she had brown hair and glasses." Sitter #17 did not remember if Patient #2 was hurt from the fall.

Interview requests for MD #1 and MD #2 found that both were unavailable.

Interview with RN #21, CNO (Interim Chief Nursing Officer), on 01/20/2023 at 1835 revealed RN #21 expected patients to be monitored and assessed per policy. RN #21 stated sitter can intervene if a patient is about to fall as sitters are expected to stay within direct arms reach of the patients. RN #21 was unable to locate falls assessment and monitoring, per policy, in Patient #2's chart.

2. Closed medical review of Patient #19 revealed a 53-year-old male who presented to the ED (Emergency Department) on 08/03/2022 for GI (Gastrointestinal) bleeding and Hepatic Encephalopathy (a decline in brain function as a result of severe liver disease) with an acuity level of 2 (emergent). Review of EMT-P (Emergency Medical Technician-Paramedic) #25 note on 08/04/2022 at 1053 revealed "This paramedic entered pt's (patient's) room to find pt lying right lateral in floor between bed and wall. Pt was mostly undressed and would not respond to verbal or tactile stimuli. Pt noted to have stable respirations. Multiple personnel entered room and attempted to place pt in bed. Pt became combative and began screaming incoherently. Pt noted to be covered in urine. Pt was finally able to be placed in bed after linens were changed. Pt was washed and given a new gown. Monitoring equipment cleaned and placed back on pt with exception of cardiac leads due to pt repeatedly pulling them off. Pt was left in bed resting comfortably, side rails up x2, wheels locked. Safety sitter to be requested promptly." Review revealed no safety sitter order or safety sitter notes. Review revealed that at 1125- MD ordered CT head without contrast and noted AMS (Altered mental status) as the order reason for the x-ray. -1212- CT resulted- "No acute intercranial abnormality." Review of Nurses Note documented by RN #19 on 08/04/2022 at 1943 revealed "Nurse entered room this am and observed pt curled up in the floor by the foot of the bed on his right side. Bed was in low position with both side rails up. No injury noted to patient. Pt is altered and unable to voice what happened. (Named doctor) aware. Pt combative and resistive to care. Pt was soiled with urine. Staff assisted pt to bed, incontinence care provided," Review of Nurses Note by RN #20 from 08/08/2022 at 1250 revealed "Pt sustained unwitnessed fall. Pt pulled out his PICC (Thin flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) line and rectal flexa seal (tube to catch bowel movements). (Named provider) notified of incident. PT helped back to ER stretcher by ER nurse and EMT (Emergency Medical Technician). Pt remain with VS (Vital Signs) stable on monitor." Record review failed to reveal an RN assessment after a fall for Patient #19. Patient #19 was transferred to a higher level of care facility on 08/09/2022 at 1020.

Request for incident report for Patient #19, fall #1 revealed there was not one available.

Incident report from 08/04/2022 for Patient #19, fall #2 revealed ".... Brief Factual Description- Pt found on the floor lying on his right side at the foot of the bed. Bed was in lowest position with side rails up. Urine was observed on the floor and bed linen was also on the floor under patient .... Level of Injury as a result of Fall-No Injury .... When and Where Event Occurred-....Event Date-08/04/2022. Time-0800....Post Fall Response: Fall documented in medical record, Manager/Clinical Coordinator informed of the fall, Physician notified.

Incident report from 08/8/2022 for Patient #19, fall #3 revealed " .... Brief Factual Description-Loud thump was heard. Staff found Pt sitting on the ground. Pt is unable to verbalize any injuries or pain. MD and Charge Nurse notified .... Level of Injury as a result of Fall: No Injury .... When and Where Event Occurred-Event Date-08/08/2022. Time-1250 .... Post Fall Response: Fall documented in medical record, Manager/Clinical Coordinator informed of the fall, Physician notified.

Interview with RN #19 (Staff Nurse in ER) on 01/20/2023 at 0915 revealed RN #19 remembered Patient #19. RN #19 stated Patient #19 was confused by not violent. RN #19 stated this was her first fall event and she stated, "I'm sure I did the (policy) things, I just didn't chart them." RN #19 stated "If I notice a change in the patient, I reassess. You do a Nursing Assessment every shift so there should be one (documented) every shift."

Request for interview with Paramedic #25 revealed he was unavailable.

Phone interview with RN #20 (Staff Nurse in ER) on 01/20/2023 at 1015 revealed she did not remember Patient #19.

Phone Interview with MD #4 on 01/19/2023 at 1005 revealed MD #4 stated "It is our policy to be made aware of any fall. We don't have very many in the ED (Emergency Department). If we are made aware, we do an exam on the patient after the fall."

Review of Incident Report for Patient #20 (Fall patient identified by a facility "Fall log") from 10/31/2022, received 1/20/2023, revealed "Brief Factual Description: Patient was in the wheelchair and was brought to x-ray room in the ED. I asked the patient if he could stand for a 2-view chest x-ray. I perform a Pa chest (an x-ray to evaluate the lungs, heart, and chest) and had to repeat due to clipping the bottom of the lung. After the second exposure I walked to the room to put the patient in the lateral (side) position. He began to stumble and then fell to the ground. I asked him if he was hurt, and he said no. He said that he does that sometimes. I asked the nurse (named) to help. (Named nurse) (Named Xray student) and myself got him off the floor from a sitting position. I asked again are you ok? Do you hurt anywhere? He said no. He said that (Named Nurse) help [sic] him out of the car. We (Named Xray student) took the patient to the waiting room with his family. I told the Charge Nurse (named nurse) about the situation that I was filling out a fall report .... Level of injury as result of fall: No injury .... Immediate actions (reported): blank .... Type of safety precautions in place at time of event: None .... Follow up actions: Description- (x-ray personnel) Patient was taken from ED waiting room, no hand off. Patient did not have a fall risk bracelet ... (ED director)-After reviewing the chart, it appears that a fall risk screening wasn't completed prior to the patient going to x-ray therefore, no fall risk bracelet was applied to the patient. I will review with all nursing staff the importance of completing this portion of the triage assessment."

3. Closed medical record review on 01/19/2023 of Patient #20 revealed a 71-year-old male who presented to the ER on 10/31/2022 at 1616 for chest pain with an acuity level of 3 (Urgent, not life-threatening patient). Review revealed at 1623- RN documented Vital Signs and a focused assessment. 1630-Triage note by RN #26 revealed "Intermittent chest pain since last week especially [sic] when he raises his arms or exerts himself." Record review failed to reveal RN documentation of a fall or assessment after a fall for Patient #20. Nursing staff failed to document a fall, assess, and reassess a Patient #20's status after a fall, or implement measures to prevent further falls. Record review failed to reveal a Morse Fall Score documented for Patient #20. Patient #20 was transferred to a higher level of care facility on 11/01/2022 at 2113.

Interview with RN #19 (nurse identified by facility as Patient #20's Nurse at time of fall) on 01/20/2023 revealed the RN #19 did not remember Patient #20. After reviewing chart, RN #19 stated that she did not work the day of Patient #20's fall and was not his nurse.

Request for interview with Xray student revealed she was unavailable.

Interview with RN #21, CNO (Interim Chief Nursing Officer), on 01/20/2023 at 1835 revealed RN #21 expected patients to be monitored and assessed per policy. RN #21 was unable to find any nursing documentation regarding a fall in Patient #21's chart.

B. Review of the hospital policy titled PC (Patient Care)-Patient Assessment and Reassessment, last approved 03/2021, applicable to all patient care areas in the (named) facility, revealed ".... (Named Healthcare) will define the patient assessment and reassessment processes to be conducted on all patients seeking care to determine the care, treatment, and services needed to meet the patient's initial and continuing needs.... Assessment/Re-Assessment Grid: ....Department ER. Initial Assessment Completion: On arrival. Re-Assessment Completion: Every 4 hours and change in patient condition...."

1. Closed medical record review of Patient (Pt) #2 revealed a 28-year-old male who presented to the Emergency Department (ED) on 09/16/2022 for complaint of psychiatric evaluation. Patient #2 was placed under IVC (involuntary commitment), awaiting placement to a psychiatric facility. Review revealed Patient #2 had a 1-1 sitter for the entire ED stay. Medical record review failed to reveal Nursing Assessments/Reassessments per policy on the following days/shifts: 09/19/2022 7am-7pm, 09/19/2022 7pm-7am, 09/20/2022 7am-7pm, 09/20/2022 7am-7pm, 09/21/2022 7am-7pm, 09/23/2022 7am-7pm, 09/25/2022 7am-7pm. Record review revealed Patient #2 had 7 of 11 shifts without a nursing shift assessment per hospital policy. Patient #2 was discharged home on 09/25/2022 at 1423.

Interview on 01/18/2023 at 1527 with the ED Nurse Manager, RN #6 revealed " ... patients would be monitored every 2 hours ..." Interview revealed the expectation for monitoring an ED patient was with hourly rounding, vital signs every 2 hours, and within one hour of discharge. Interview revealed the expectation for nursing assessments and reassessments for the ED RN " ...was once the patient was medically cleared, a nursing assessment was completed once per shift, with change in patient condition and within one hour of discharge and/or transfer. Interview revealed hospital policy for nursing assessment and reassessment was not followed. Further interview on 01/20/2023 at 0932 revealed "...an assessment by the nurse every shift was the expectation..." Interview revealed Patient #2 was missing nursing assessments on review of his electronic medical record. Interview revealed hospital policy was not followed for nursing assessments for Patient #2.

Interview on 01/20/2023 at 0955 with ED RN #19 revealed ".... focused assessments are completed every shift on all patients and reassessments with patient change in condition is what we are supposed to do..." Interview revealed there should be a nursing assessment completed each shift by the RN. Interview revealed hospital policy was not followed.

Interview on 01/20/2023 at 1130 with RN #21, the Interim Chief Nursing Officer, after review of the Patient Assessment/Reassessment policy revealed the expectation was for the ED nurse to assess patients every shift, and with a change in patient condition. Interview revealed the hospital policy for assessment/reassessment was not followed for Patient #2.

2. Closed medical review of Patient #19 revealed a 53-year-old male who presented to the ED (Emergency Department) on 08/03/2022 for GI (Gastrointestinal) bleeding and Hepatic Encephalopathy (a decline in brain function as a result of severe liver disease) with an acuity level of 2 (emergent). Review of the record failed to reveal Nursing Assessments per hospital policy for the following Dates/shifts: 08/04/2022 7pm-7am, 08/05/2022 7am-7pm, 08/06/2022 7am-7pm, 08/06/2022 7pm-7am, 08/07/2022 7am-7pm, 08/07/2022 7pm-7am, 08/09/2022 7am-7pm. Patient #19 was transferred to a higher level of care facility on 08/09/2022 at 1020.

Interview with RN #19 (Staff Nurse in ER) on 01/20/2023 at 0915 revealed RN #19 remembered Patient #19. RN #19 stated "If I notice a change in the patient, I reassess. You do a Nursing Assessment every shift so there should be one (documented) every shift." Interview revealed that RN #19 was unable to locate her nursing assessments on Patient #19 in the medical record.

Phone interview with RN #20 (Staff Nurse in ER) on 01/20/2023 at 1015 revealed she did not remember Patient #19. RN #20 stated that for boarder patients (ER patients waiting on placement or transfer), she did a full head to toe assessment at least once a shift and tried to round on them at least every hour.

Interview on 01/18/2023 at 1527 with the ED Nurse Manager, RN #6 revealed ".... patients would be monitored every 2 hours ...." Interview revealed the expectation for monitoring an ED patient was with hourly rounding, vital signs every 2 hours, and within one hour of discharge. Interview revealed the expectation for nursing assessments and reassessments for the ED RN "....was once the patient was medically cleared, a nursing assessment was completed once per shift, with change in patient condition and within one hour of discharge and/or transfer." Interview revealed Patient #19 was missing nursing assessments on review of his electronic medical record. Interview revealed hospital Patient Assessment/Reassessment policy was not followed for nursing assessments for Patient #19.

Interview on 01/20/2023 at 0955 with ED RN #19 revealed " .... focused assessments are completed every shift on all patients and reassessments with patient change in condition is what we are supposed to do ...." Interview revealed hospital policy was not followed.

Interview on 01/20/2023 at 1130 with RN #21, the Interim Chief Nursing Officer, after review of the Patient Assessment/Reassessment policy revealed the expectation was for the ED nurse to assess patients every shift, and with a change in patient condition. Interview revealed the hospital policy was not followed for Patient #19.



39307

3. Open record review revealed Patient #3 presented to the hospital Emergency Department (ED) on 01/14/2023 at 1475 with a chief complaint of Drug Overdose, Suicidal Ideation (attempt at taking ones' own life). Patient #3 was Involuntary Committed (legally forced to present to the hospital for psychiatric evaluation and treatment) to the hospital. On 01/16/2023 dayshift 0700 through 1900, the ED Nursing staff failed to document a Nursing Assessment for one of six nursing shift assessments during the 3-day length of stay in the ED for Patient #3. Review revealed on 01/17/2023 at 1806 Patient #3 was discharged to an inpatient psychiatry facility.

Interview on 01/18/2023 at 1527 with the ED Nurse Manager, RN #6 revealed ".... patients would be monitored every 2 hours ...." The expectation for monitoring an ED patient was with hourly rounding, vital signs every 2 hours, and within one hour of discharge. The expectation for nursing assessments and reassessments for the ED RN "....was once the patient was medically cleared, a nursing assessment was completed once per shift, with change in patient condition and within one hour of discharge and/or transfer." Patient #3 was missing nursing assessments on review of his electronic medical record. Interview revealed the hospital Patient Assessment/Reassessment policy was not followed for nursing assessments for Patient #3.

Interview on 01/20/2023 at 1130 with RN #21, the Interim Chief Nursing Officer, after review of the Patient Assessment/Reassessment policy revealed the expectation was for the ED nurse to assess patients every shift, and with a change in patient condition. Interview revealed the hospital policy for assessment/reassessment was not followed for Patient #3.

4. Closed record review revealed Patient #4 presented to the hospital ED on 11/10/2022 at 1128 with a chief complaint of Manic Behavior (extremely elevated and excitable mood usually associated with Bipolar Disorder, [episodes of mood swings ranging from depressive lows to manic highs]). Patient #4 was Involuntary Committed (legally forced to present to the hospital for psychiatric evaluation and treatment) to the hospital. Record review during a 7 day period (11/20/2022 through 11/26/2022) revealed the ED Nursing staff failed to document a Nursing Assessment on four of fourteen nursing shift assessments for Patient #4. On 12/14/2022 at 1156 the Discharging Physician documented "Patient was seen and examined today during rounds ...Patient discharged in improved condition." Review revealed on 12/14/2022 at 1009 Patient #4 was discharged home in the company of a family member.

Interview on 01/18/2023 at 1527 with the ED Nurse Manager, RN #6 revealed ".... patients would be monitored every 2 hours ...." The expectation for monitoring an ED patient was with hourly rounding, vital signs every 2 hours, and within one hour of discharge. The expectation for nursing assessments and reassessments for the ED RN "....was once the patient was medically cleared, a nursing assessment was completed once per shift, with change in patient condition and within one hour of discharge and/or transfer." Interview revealed Patient #4 was missing nursing assessments on review of his electronic medical record. Interview revealed hospital Patient Assessment/Reassessment policy was not followed for nursing assessments for Patient #4.

Interview on 01/20/2023 at 1130 with RN #21, the Interim Chief Nursing Officer, after review of the Patient Assessment/Reassessment policy revealed the expectation was for the ED nurse to assess patients every shift, and with a change in patient condition. Interview revealed the hospital policy for assessment/reassessment was not followed for Patient #4.

5. Open record review revealed Patient #5 presented to the hospital ED on 12/27/2022 at 2049 with a chief complaint of Altered Mental Status. Patient #5 was Involuntary Committed (legally forced to present to the hospital for psychiatric evaluation and treatment) to the hospital. Record review during a 7 day period (01/08/2022 through 01/17/2022) revealed the ED nursing staff failed to document a Nursing Assessment for three of thirteen Nursing shift assessments for Patient #5 in the ED. Record review revealed Patient #5 remained in the ED during the time frame of the survey.

Interview on 01/18/2023 at 1527 with the ED Nurse Manager, RN #6 revealed ".... patients would be monitored every 2 hours ...." The expectation for monitoring an ED patient was with hourly rounding, vital signs every 2 hours, and within one hour of discharge. The expectation for nursing assessments and reassessments for the ED RN "....was once the patient was medically cleared, a nursing assessment was completed once per shift, with change in patient condition and within one hour of discharge and/or transfer." Patient #5 was missing nursing assessments on review of his electronic medical record. Interview revealed hospital Patient Assessment/Reassessment policy was not followed for nursing assessments for Patient #5.

Interview on 01/20/2023 at 1130 with RN #21, the Interim Chief Nursing Officer, after review of the Patient Assessment/Reassessment policy revealed the expectation was for the ED nurse to assess patients every shift, and with a change in patient condition. Interview revealed the hospital policy for assessment/reassessment was not followed for Patient #5.



41946

6. Closed medical record review revealed Patient #6, a 65-year-old male patient who presented to the hospital emergency department (ED) on 01/30/2022 at 1929 with an arrival complaint of shortness of breath, and recent diagnosis of lung cancer. Patient #6 was placed in ED room 12 at 1934. On 01/30/2022 at 1940 by Registered Nurse (RN) #5 completed an airway, breathing, and circulation focused assessment and was "Within Defined Limits." Review of the ED Provider Note of 01/30/2022 at 1943 by Physician's Assistant (PA) #3 revealed "...recent diagnosis of lung cancer, supposed to see HEME/ONC (hematology/oncology) in the coming week. Review revealed Patient Acuity: 3 (Urgent) assigned by Registered Nurse (RN) #5 for Patient #6. Review revealed an arterial blood gas (ABG) was drawn at 2213 on room air and resulted at 2214 with a pO2 (blood oxygen level) of 51 (reference range was 83-108 for normal). PA #3 revealed "...ABG on room air is done. This shows his PO2 is 51 and his O2 saturations are 88.5%. This confirms he is oxygen dependent ...2245 The patient does not require admission, he simply needs oxygen for home use ...we can keep the patient in the emergency room tonight, let him remain on oxygen and then when case management comes ...can make arrangements for home oxygen ..." Record review 01/31/2022 at 0410 revealed Patient #6 was moved from ED room 12 to Hallway -07. Review revealed Patient #6 was awaiting home oxygen to be set-up at home. Record review at 01/31/2022 at 1256 revealed a 6-minute walk test was performed by Respiratory Therapy (RT) #11 "...Pre-Walk vitals O2 (oxygen) sat (saturation): 89, HR 110 ... Minute #5 -O2 sat 87%, HR: 116 Supplemental O2 added 3 liters per min (LPM) was added ...Post-Walk Vitals O2 sat: 91, HR: 108 with supplemental O2 at 3 LPM. Review revealed due to changes in Patient #6's heart rate and oxygen while walking, supplemental oxygen of 3 LPM was given by RRT #11. Review of the ED Care Timeline documented on 1/31/2022 0700 - 1900 (day shift) for Patient #2 failed to reveal an assessment by the Nurse. Review of the ED Care Timeline documented on 1/31/2022 from 1900 to 02/01/2022 0700 (nightshift) failed to reveal an assessment for Patient #2 by RN #36. Review revealed an ED Provider Note 02/02/2022 at 1254 by Medical Doctor (MD) #2 "...Assessment and Plan: Briefly, (Named Patient) is a 64 y.o. (year old) male who presents with hypoxia and malignant lung ca (cancer). Needs Oxygen to be set up. Is a VA (veterans administration) patient, paperwork required resulting in a delay. Suspect patient will be discharged home after home oxygen support to be arranged. Diagnosis: 1. Primary malignant neoplasm of lung metastatic to other site ...2. Hypoxia. Condition: Stable. Disposition: Discharge ...to home with self-care. Review of the ED Care Timeline documented on 02/01/2022 0700 - 1600 (dayshift) failed to reveal an assessment or discharge reassessment for Patient #6 by RN #7. Medical record review revealed the ED nursing staff failed to document a nursing assessment 3 out of 4 shifts reviewed for Patient #6. Review revealed on 02/01/2022 at 1600 Patient #6 was discharged home with self-care and home oxygen.

Request on 01/18/2023 to interview ED Physician, MD #2 revealed he was unavailable for interview.

Request on 01/18/2023 to interview the ED Discharge RN #7 revealed he was unavailable for interview.

Interview on 01/19/2023 at 1511 with CNA #10 revealed he did not recall the patient. Interview revealed patients with an acuity level 3 are to be monitored every 1-2 hours with vital signs every 4 hours in the ED. Interview revealed every patient was assigned an RN and Tech (nursing technician). Interview revealed changes in a patient's condition were reported to the nurse and charge nurse.

Interview on 01/18/2023 at 1527 with the ED Nurse Manager, RN #6 revealed " ... patients would be monitored every 2 hours ..." Interview revealed the expectation for monitoring an ED patient was with hourly rounding, vital signs every 2 hours, and within one hour of discharge. Interview revealed the expectation for nursing assessments and reassessments for the ED RN " ...was once the patient was medically cleared, a nursing assessment was completed once per shift, with change in patient condition and within one hour of discharge and/or transfer. Interview revealed hospital policy for nursing assessment and reassessment was not followed. Further interview on 01/20/2023 at 0932 revealed "...an assessment by the nurse every shift was the expectation..." Interview revealed Patient #6 was missing nursing assessments on review of his electronic medical record. Interview revealed hospital policy was not followed for nursing assessments for Patient #6.

Telephone interview on 01/19/2023 at 1653 with admitting ED RN #5 revealed she did not remember the Patient #6. Interview revealed nursing assessments are completed each shift and with a change in patient condition. Interview revealed nursing assessments and reassessments should be documented. Interview revealed hospital policy for assessments and vital signs were not followed for Patient #6.

Interview on 01/20/2023 at 1130 with RN #21, the Interim Chief Nursing Officer, after review of the Patient Assessment/Reassessment policy revealed the expectation was for the ED nurse to assess patients every shift, and with a change in patient condition. Interview revealed the hospital policy for assessment/reassessment was not followed for Patient #6.

7. Open medical record review of Patient #21, an 18-year-old male who presented to the hospital emergency department (ED) on 01/17/2023 at 1850 with arrival complaint of anxiety. Review of the Triage Note Addendum 01/17/2023 at 1852 by Registered Nurse (RN) #28 revealed "Pt. (patient) with a c/c (chief complaint) of anxiety. Pt. stated he felt anxious after eating dinner and believed someone (family) may have poison him [sic]. Father with pt states pt has been non-compliant on behavior meds ..." Review of the ED Care Timeline revealed Patient #21 was assigned a patient acuity level of 3 (urgent) by RN #28. Review of the ED Notes dated 01/17/2023 at 1922 by RN #29 revealed "...Pt. states that he began to feel anxious tonight around dinner time. Pt. states he felt like he was starting to have trouble breathing and was going to pass out. Pt. calm and cooperative ..." Review of the ED Provider Notes of 01/17/2023 at 1922 by MD #2 revealed "...ED Assessment/Plan Condition: Stable Disposition: Transfer ...Patient states that he started feeling short of breath some altered mental status [sic] after eating food prepared by his parents. Parents are concerned for increasing delusional characteristics. Parents state that is seems that he is eating less and less and having significant weight loss. Has been non-compliant with psychiatric meds. They feel he is poisoning himself. Patient does have a recent psychiatric inpatient evaluation patient reports he stopped taking his abilify (medication given for major depressive disorder) and related medications because he felt

Based on observation, Adult and Pediatric Crash Cart Daily Checklist review and staff interviews, the hospital nursing staff failed to complete the Crash Cart Daily Checklists on the Medical Floor for the Adult and Pediatric crash carts from December 15, 2022-January 16,2023.

Findings included:

Observation on 01/17/2023 at 1230 during tour of the Medical Unit revealed the Pediatric crash cart was found to be unlocked. Review of the Pediatric Crash Cart Daily Checklist, during the unit tour, for December 15-31, 2022, and January 1-16, 2023, revealed there was no documentation of an emergency cart check on December 15th, 16th, 20th, 21st, 22nd, 24th, 26th, 29th, 30th and 31st (10 of 17 days reviewed) and for January 2nd, 5th, 6th, 7th, 8th, 9th, 11th, 12th, 13th and 15th (10 of 16 days reviewed).

Review of the Adult Crash Cart Daily Checklist for December 15-31, 2022, and January 1-16, 2023, revealed there was no documentation of an emergency cart check on December 15th, 16th, 20th, 21st, 22nd, 24th, 26th, 29th, 30th and 31st (10 of 17 days reviewed) and for January 1st, 2nd, 5th, 6th, 7th, 8th, 9th, 12th and 13th (9 of 16 days reviewed).

Interview on 01/17/2023 at 1457 with the Nursing Unit Manager of the Medical Unit, RN #35 revealed the expectation was for the code carts to be locked at all times. Interview revealed in the event a code cart was unlocked for patient use, or for inventory the code carts would be returned to pharmacy for a new cart. Interview revealed the expectation was for the code carts to be checked daily by the night nursing staff. Interview revealed RN #35 had conducted a meeting with the Medical Unit staff on the importance of daily crash cart checks on December 13 and 15, 2022. Interview revealed the expectation for checking the Pediatric/Adult Cart Daily Checklists for December 15, 2022, through January 16, 2023, had not been met.

Interview on 01/17/2023 at 1457 with the Director of Nursing Operations, RN #12 revealed "...the night shift nursing staff are responsible for completing the crash cart daily checklists. (Named Nursing Unit Manager) had a staff meeting 2 weeks ago and discussed the importance of checking the code carts daily. The expectation was for nursing staff to complete the code cart checks daily on night shift. I will assign this today and recheck in the morning that it was done..." Interview revealed in December 2022 missing crash cart daily checks had been identified and discussed with Medical Unit nursing staff on 12/13/2022 and 12/15/2022. Interview revealed RN #12 would assign nursing staff to complete the Crash Cart Daily Checklists for Adult/Pediatric code carts. Interview revealed the expectation for checking the Pediatric/Adult Crash Cart Daily Checklists for December 15, 2022, through January 16, 2023, had not been met.

Interview on 01/20/2023 at 1830 with the Chief Nurse Officer, RN #21 revealed "...the expectation was the Crash Cart Daily Checklists were to be completed daily..." Interview revealed the Nurse Unit Manager, RN #35 was to assign a nurse daily to be responsible for checking the Adult/Pediatric code carts, and any non-compliance would follow the human resource process.
NC00194676 NC00195577 NC00185655