HospitalInspections.org

Based on observation, document review and interview, the hospital did not ensure emergency equipment was readily available for treatment of emergency cases. Specifically, both the adult and pediatric crash carts contained expired supplies and both the adult and pediatric crash carts check list documentation was incomplete. This could cause the hospital to not be prepared for an emergency situation.

Findings include:

-- Per observation of the Medical Surgical Unit (MSU) on 2/21/2023 at 9:10 am, the adult crash cart had the following expired items:
- two (2) 0.9% Normal Saline, 500 ml bottles, expired 11/2022
- one (1) 0.9% Normal Saline, 250 ml bottle, expired 8/2022

-- Review of the adult crash cart checklist form titled "SCU (Specialty Care Unit) Equipment List" dated 12/03/2022 through 2/21/2023, revealed the adult crash cart was not checked on 1/29/2023, and other days lacked checks twice a day. (See P&P below.)

-- Review of the adult crash cart form titled "Outdate Verifications: 2021," indicated the following: Outdate verification of the M/S-SCU crash cart would be performed by the unit secretary, under direction of the 7 pm CRN (charge registered nurse) on the first of each month (as able or ASAP thereafter). Outdates will be removed and replaced as able, the CRN will validate work and replace lock per P&P. Outdate verification is for supplies only, Pharmacy performs medication outdates. The form had signatures and dates to document outdate verifications completed on the adult crash cart for 10 of 12 months in 2021. There were no outdate verifications forms for 2022 or 2023.

-- Per observation of the MSU on 2/21/2023 at 9:30 am, the pediatric crash cart had the following expired items:
- one (1) Pedi-Padz (pediatric defibrillator pads), expired 10/2022
- one (1) intraosseous needle, expired 12/2022
- one (1) neonatal electrodes, expired 10/2022
- three (3) infant catheter kits, expired 1/2023
- one (1) oximeter probe, expired 1/2023
- one (1) Jelco IV Catheter, 22-gauge, expired 12/2022

-- Review of the pediatric crash cart form titled "Outdate Verifications: 2021," and "Outdate Verifications: 2022," indicated the following: Outdate verification of the M/S-SCU crash cart would be performed by the unit secretary (under direction of the 7:00 pm CRN) on the first of each month (as able or ASAP thereafter). Outdates should be removed and replaced as able, the CRN will validate work and replace lock per policy and procedure (P&P). Outdate verification is for supplies only, Pharmacy performs medication outdates. The 2021 form had signatures and dates to document outdate verifications completed on the pediatric crash cart for 9 (nine) of 12 (twelve) months in 2021. The 2022 form had signatures and dates to document outdate verifications completed on the pediatric crash cart for 1 (one) of 12 (twelve) months in 2022. There were no forms documenting outdate verifications for 2023.

-- Review of the pediatric crash cart form titled "SCU Med/Surg Pediatric Crash Cart Checklist" dated 1/28/2023 - 2/21/2023 revealed the crash cart was not checked on 12/09/2022, 12/10/2022, 12/11/2022, 12/13/2022, 12/18/2022, 12/29/2022, 1/1/2023, 1/2/2023, 1/3/2023, 1/7/2023, 1/10/2023, 1/11/2023, 1/15/2023, 1/21/2023, 1/29/2023, 2/3/2023, 2/4/2023, 2/12/2023, 2/17/2023, 2/18/2023 and on some other days the cart was only checked once. (See P&P below.)

-- Review of the hospital's P&P titled, "Crash Cart Check," revised 2/2020, revealed that the Emergency Code Carts (crash carts) for both adults and pediatrics should be stocked and in working order at all times. Both carts should be checked twice a day at shift change and after each use by appropriate nursing staff. In addition, the crash carts should be checked the first of every month for outdates of supplies. Missing or outdated supplies should be replaced immediately. The P&P includes a form entitled "SCU Crash Cart Checklist" which should be used by staff to document the twice-daily crash cart checks.

-- During interview of Staff A, Director of Inpatient Nursing, on 2/21/2023 at 11:45 am, Staff A acknowledged the above findings.

Based on document review, medical record (MR) review and interview, 1) in five (5) of five (5) (Patient's #1 - #5) MRs reviewed, of patients who fell during their admission, each lacked accurate and/or consistent documentation related to fall preventative interventions and the facility's fall prevention policy and procedure (P&P) was not consistent with staffs' current practice. 2) Administrative staff identified patient falls as an area of concern, however, no performance improvement plans had been implemented at the time of this survey. 3) Incident reports for falls lacked information and were not complete. These failures may result in serious injury, serious harm, serious impairment, or death to other patients if immediate action is not taken.

Please see tag 1046 Nursing Services for Condition Level findings.

Based on document review, medical record (MR) review and interview, 1) in five (5) of five (5) (Patient's #1 - #5) MRs reviewed, of patients who fell during their admission, each lacked accurate and/or consistent documentation related to fall preventative interventions and the facility's fall prevention policy and procedure (P&P) was not consistent with staffs' current practice. 2) Administrative staff identified patient falls as an area of concern, however, no performance improvement plans had been implemented at the time of this survey. 3) Incident reports for falls lacked information and were not complete. These failures may result in serious injury, serious harm, serious impairment, or death to other patients if immediate action is not taken.

Findings regarding (1) include:

-- Review of the facility's P&P titled, "Falls: Fall Prevention Protocol," revised 10/2020, indicated all patients should be assessed for their risk to fall on admission and during each shift to meet safety needs. The registered nurse (RN) should assess each patient using the fall assessment in the MR to determine if the patient is at risk to fall. Early identification of patient risk status is essential for prevention of falls.

The Fall/Harm Risk Assessment requires staff to answer all 3 questions:
#1a - Does patient need assistance with standing, walking or toileting? No/Yes
#1b - Does patient attempt to get out of bed (OOB)/chair unassisted when assistance is needed? No/Yes
#2 - Has the patient fallen during the last 6 months or during this admission: No/Yes/This admission/Last six months/Unable to determine
#3 - Are there harm risk factors based on your nursing judgement? No/Yes/See guide below

Harm Risk Assessment Guide:
Age: Is the patient 85 years old or older?
Bones: Does the patient have a bone condition, including osteoporosis, a previous fracture, prolonged steroid use or metastatic bone cancer?
Coagulation: Does the patient have a bleeding disorder, either through the use of anticoagulants or underlying clinical conditions?
Surgery: Is this a recent post-op patient, especially a patient who has had a recent lower limb amputation, major abdominal or thoracic surgery?
Other: (No additional guidance given.)

Conclusion:
YES, to Question #1a, OR #1b, OR #2 = Risk to fall
YES, to Question #1a, OR #1b OR #2 and Question #3 = Risk to fall with injury

Interventions will appear with every answer. Place a falling leaves sign on the door to alert all care givers of risk and institute safety plan. Patient rounds every two hours or more frequently if indicated.

All patients - Normal Safety Procedures
1. Orient to call system
2. ID bracelet on
3. Call bell, assistive device, and personal items within reach
4. Non-slip footwear when patient is OOB
5. Physically safe environment - no spills, clutter, or unnecessary equipment
6. Bed in lowest position, siderails provide support without restricting, wheels locked
7. Room/bathroom lights operational
8. Asked "Is there is anything I can do for you?" before leaving room

Risk to fall standards - Patient screens YES to Question #1a OR #1b, OR YES to Question #2:
1. Provide visual clue: yellow wrist band
2. Monitor for mental status changes and reorient to person, place and time as needed
3. Monitor gait and stability
4. Normal safety procedures

Selected Fall Risk Interventions:
Check additional interventions based on patient need
1. Bed alarm
2. Chair alarm
3. Move patient closer to nurses' station
4. Hourly rounding
5. Assisted toileting using "arms reach" rule (arm's length away: to keep eyes on the patient at all times and close enough to intervene quickly if needed; including toileting and bathing) for commode or bathroom
6. Enhanced supervision
7. Education given family/patient regarding fall risk
8. Consult with provider regarding the need for PT (physical therapy)/OT (occupational therapy) consult

-- Review of Patient #1's MR (95-year-old female) revealed, she presented to the hospital on 10/31/2021 at 9:46 am, via emergency medical services (EMS) from a long-term care facility with a chief complaint of being unresponsive since yesterday. She was found to be hypoxic, oxygen saturation (O2 sats) in the 50's. She was placed on a non-rebreather mask and her O2 sats increased to the 90's. She was sitting, her eyes closed and arms twitching. Responded to painful stimuli saying "ouch". Past medical history (PMH) included congestive heart failure, chronic kidney disease (Stage 3), chronic obstructive pulmonary disease (COPD), anemia, depression, atrial fibrillation, pacemaker, breast cancer. Patient #1 was admitted with a diagnosis of altered mental status, hypoxia, and pneumonia.

Nursing documentation revealed the following:

On 10/31/2021 at 4:07 pm, (day of admission) patient memory impaired, disoriented to person, place, time, event/situation.

Fall / Harm Risk Assessment
Activities of daily living (ADLs) assistance required - Yes
Does patient attempt to get OOB or chair unassisted - No
History of fall in past 6 months - No
Risk to fall with harm/injury - No

Fall precautions implemented included:

- Normal safety precautions
- Risk to fall standards
- Risk to fall additional interventions - bed alarm, chair alarm, hourly rounding (these are selected by nurse)
- Risk to fall with harm standards - Monitor gait and stability, assisted toileting using "Arms Reach" rule, hourly rounding, visual cues: yellow wrist band, red socks.

Patient was not identified as a risk to fall with harm (per facility P&P). Patient was over 85 years old.

On 11/1/2021 at 7:39 am, Patient #1 drowsy, agitated, and combative. Patient was not identified as risk to fall with harm. Risk to fall additional interventions did not include bed alarm or chair alarm.

On 11/1/2021 at 7:41 pm: the fall assessment documentation was the same as noted on the previous fall risk assessment on 11/1/2021 at 7:39 am.

On 11/2/2021 at 7:15 am, report received from previous nurse. Patient #1 had been yelling all night long.

At 7:45 am, Patient #1 was on the edge of the bed and slid to a sitting position on the floor next to the bed. No injury was identified. She was assisted (with 2 staff) to standing, then to sitting position in the bedside chair with chair alarm. (The chair alarm was documented in nurses notes, not under fall risk interventions.)

At 7:53 am, Patient #1 combative, confused, memory impaired and restless. The fall assessment documentation was the same as noted on the previous fall risk assessment on 11/1/2021 at 7:39 am.

At 9:15 am, Patient #1 fell from the chair and was injured.

After Patient #1 fell and sustained injury, fall assessment documentation on 11/2/21 at 8:52 pm, 11/3/2021 at 8:00 am and 11/3/2021 at 8:15 pm were the same as noted on the previous fall risk assessment on 11/1/2021 at 7:39 am. The documentation consistently lacked use of bed/chair alarms and the patient was not identified as a risk to fall with harm.

-- Per review of documenation provided during the survey, the facility did not do a root cause analysis (RCA) of Patient #1's fall.

-- Review of Patient #2's MR (73-year-old male) revealed, he was admitted on 1/23/2023 with a diagnosis of left (L) hip pain, status post L hip repair 1/20/2023 after a fall and also L clavicle fracture with arm in a sling. Past medical history (PMH) included diabetes, dementia.

Nursing documentation revealed the following:

On 1/23/2023 at 8:37 pm (day of admission), fall risk assessment was documented:

Assistance with ADLs needed - yes
Unassisted attempts to get OOB/chair - yes
History of falls in the past 6 months - yes

Fall precautions implemented included:
- All normal safety precautions
- Risk to fall standard
- Risk to fall additional interventions - bed alarm, chair alarm, hourly rounding, enhanced supervision, education to family/patient regarding fall risk, purposeful rounding.

On 1/24/2023 at 10:36 am, bed/chair alarm were not chosen as interventions. On 1/25/2023 at 8:23 am, bed/chair alarm were not chosen as interventions and no additional risk to fall standard interventions were identified. On 1/26/23 at 12:43 pm, no risk to fall standard interventions were identified (no bed/chair alarms).

On 1/26/2023 at 1:35 pm, Patient #2 fell from his chair.

The MR lacked documentation of harm risk assessment and fall related documentation was inconsistent.

-- Review of Patient #3's MR (90 year-old female) revealed, she was admitted to the hospital with chief complaint of malaise, not feeling well for 6 days, chills, increasing dyspnea. Admitted with community acquired pneumonia.

Nursing documentation revealed the following:

On 11/29/2022 at 11:00 am, fall risk assessment documentation:

Assistance with ADLs needed - yes
Unassisted attempts to get OOB - no
Falls in past 6 months - no
Fall precautions implemented included:
- All normal safety precautions
- Risk to fall standards

Per P&P patient should have been identified as risk to fall with harm. There were no additional fall interventions documented.

On 11/29/2023 at 9:07 pm, fall risk assessment documentation lacked identification as risk to fall with harm.

On 11/30/2022 at 3:47 pm, fall risk assessment documentation indicated the only risk to fall additional intervention identified was education to patient/family regarding fall risk.

On 12/1/2022 at 3:56 am, fall risk assessment documentation again lacked risk to fall with harm and no additional risk to fall interventions were identified.

Patient #3 fell from her chair at 4:50 am.

After Patient #3 fell, documentation continued to lack harm risk assessment and fall related documentation was inconsistent and inaccurate. On 12/1/2022 at 8:21 am, nursing documented Patient #3 had no falls in the past 6 months. No additional fall preventative measures were documented. On 12/2/2023 at 1:41 pm, no documentation of risk to fall additional interventions were documented.

The same lack of consistent fall related documentation was noted in MRs for Patient #4, 89-year-old male with weakness, cat bite infection, osteomyelitis and decubitus ulcer, and Patient #5, 82-year-old male with weakness and pneumonia.

--Per review of P&P titled "Falls: Fall Prevention Protocol," last revised 10/2020, place a "falling leaves" sign on the door. Per observation on 2/21/2023, fall risk rooms have yellow lights that indicate the fall risk, no falling leaves were observed. Additionally, the P&P includes a Harm Risk Assessment Guide. However, per review of fall risk assessment in Patient #1's, Patient #2's, and Patient #3's MR, no harm risk was identified. Per the P&P, Patient #1 Patient #2, and Patient #3 met these criteria.

-- Per interview of Staff A, Director of Inpatient Nursing on 2/21/2023 at 9:00 am and 2/22/2023 at 8:40 am, most beds are equipped with alarms and there are a number of chair alarms. There had been a noticeable increase in falls lately, and they have looked at care plans, alarms, bracelets.

The rooms have yellow lights outside the doors that indicate the patient is a fall risk. Staff perform hourly rounding and document it on the rounding sheets that are taped outside the doors. The rounding sheets are collected daily and given to Staff A to review. These sheets are not scanned into the MR.

There is a new electronic incident reporting system for falls, it's more efficient and now the physical therapist reviews all falls for input and suggestions. The falls committee is being re-introduced. During COVID the committee meetings had stopped because they were so busy.

Staff A stated in December there was a unit in-service (read and sign) to remind staff to mark all additional interventions for patients at risk for fall.

-- Review of the mandatory read and sign document titled "Fall Prevention," dated 12/14/2022, revealed that nursing staff (Staff B, RN, Staff C, RN, and Staff D, RN) who documented fall assessments in the above MR had not attested to completing this mandatory education.

-- Per interview of Staff E, Supervisor/Nurse Educator on 2/22/2023 at 1:45 pm, the healthcare source titled "Fall Prevention," was inadvertently omitted from the 2022 mandatory annual staff education.

-- Per interview of Staff F, Director of Physical Therapy on 2/21/2023 at 3:30 pm, Staff F reviews all incident reports to identify any areas for improvement. Staff F looks at the facility's P&P to ensure staff have followed it. The new Falls Committee meeting is scheduled for March 2023. Staff F educates new employees during orientation on fall precautions. The facility switched from placing falling leaves outside patient's rooms to having yellow lights above doors. Staff F also goes over the Morse Fall scale during orientation. (Per review of "Falls: Fall Prevention Protocol," revised 10/2020, use of the Morse Fall scale was not identified.)

-- Per interview of Staff G, RN on 2/22/2023 at 10:20 am, there are yellow lights outside the room, patients have non-skid socks, chair and bed alarms are used.

There are not enough chair alarms available. Falls had been documented on paper forms, now the incident reports are done electronically. The hospitalist should evaluate the patient after the fall. Families are called at the time of the incident.

Staff are supposed to do hourly rounding, the sheets are placed outside the door. The ward clerk collects them but sometimes they are not filled out.

-- During interview of Staff A, on 2/27/2023 at 10:00 am, Staff A confirmed the above findings and stated the fall prevention P&P had not been updated.

Findings regarding (2) include:

-- Review of the Safe Patient Handling/Falls Committee Meeting minutes, dated 8/23/2022, indicated they discussed falls and ways in which to prevent a fall if possible. All falls were reviewed during meeting. Staff questioned whether or not the "fall huddle" was being utilized after each fall as was initiated in the past.

-- Review of the Safety Committee Meeting minutes, dated 8/25/2022, indicated that they are tracking patient falls monthly, however there was no documented discussion of falls.

-- Review of the Safety Committee Meeting minutes, dated 10/27/2022, indicated that they are tracking patient falls monthly, however there was no documented discussion of falls. There was an increase of 6 falls from 8/2022 to 9/2022.

-- Review of the Safe Patient Handling/Falls Committee Meeting minutes, dated 11/16/2022, indicated that both Falls and Safe Patient Handling committees need to start from ground zero once again and begin to re-educate, encourage coaching and on-time training. Information to be covered at the next falls meeting should include: inclusion of nursing supervisors in the Falls Committee and reminder to do huddles post fall. The next Falls Committee Meeting was scheduled for 1/19/2023.

-- Review of the Safety Committee Meeting minutes, dated 1/20/2023, indicated that they are tracking patient falls monthly. There was an increase of 4 falls from 11/2022 to 12/2022, however there was no documented discussion of falls.

-- Per interview of Staff A, on 2/22/2023 at 8:40 am, Staff A had been in the position for about a year, and at the time Staff A started, there was no structure for Quality Assurance. The intention is to reboot the program. The falls committee is being re-instituted.

The facility was aware of an increase in the number of falls, however, no trending or data analysis of falls had been done to determine any commonalities to help address falls. The falls committee had not met yet to address falls.

-- Review of the Falls Committee agenda, dated 1/19/2023, indicated fall incident reports/statistics to be discussed. Meeting was cancelled and was rescheduled for March 2023.

-- Review of the Medical Surgical Registered Nurse Staff Meeting PowerPoint, dated 2/22/2023, revealed it contained fall prevention highlights: Focus on identifying patients at risk for a fall, shift assessments and care plans should match. Bed alarms are preventative not for after falls. Focus on handoff reporting to include checking the alarm. Safety huddles will include patients on alarms/risk to fall.

-- Per interview of Staff A, on 4/26/2023 at 11:10 am, only RNs viewed the staff meeting, not all RNs attended or have viewed the saved meeting presentation. The facility has started to review falls for tracking and trending.

-- Review of the Falls Committee Meeting minutes, dated 3/3/2023, indicated the P&P was reviewed and updated, further discussion scheduled for 3/16/2023 meeting.

-- Review of the Falls Committee Meeting minutes, dated 3/16/2023, indicated members reviewed the incident reports for all falls occurring between December 2022 and January 2023 in detail. Members agreed that additional tracking and trending of falls is necessary. There was no documentation of the falls discussed. Additionally the P&P was reviewed and another meeting was to be scheduled before May 2023 to review and make changes. (As of onsite survey this meeting had not occurred.)

-- Per interview of Staff M, Chief Nursing Officer/Vice President of Clinical Services, on 4/26/2023 at 2:15 pm, safety huddles have been implemented daily. The facility wants to make changes to the P&P, however, the Falls Committee is still reviewing and have not made the changes yet.

-- During interview of Staff N, RN on 4/27/2023 at 10:25 am, Staff N was not aware of the prior Department of Health (DOH) visit and concerns pertaining to patient falls.

Findings regarding (3) include:

-- Review of P&P titled "Incident Reporting," revised 1/2023, a fall incident is entered, investigation is completed, an alert is sent to Nursing Administration for review, investigation and follow up action as needed. An alert is also sent to the Director of Rehabilitation for analysis at falls committee.

-- Per review of nine (9) incident reports of falls dated 12/1/2022 - 1/30/2023, all were incomplete and many did not adequately address the fall. Incident report #316, revealed a patient fell on 1/26/2023. Not all of the questions were addressed and Staff F documented "with patient's history of dementia and poor safety awareness, chair and bed alarms should have been in place. Not sure why chair alarm not sounding. Need to clarify if not working or more education on alarm usage." Additionally, Staff A documented that this should be referred to the fall prevention committee. There is no documentation that shows this was followed up in any way.

Incident report #238 a patient fell on 12/1/2022. The incident report was not complete and lacked documentation of an investigation into the fall.

Incident report #319 revealed a patient fell on 1/30/23. the incident report was not complete. Staff A documented:
1. Documentation reveals patient set off alarm 3 times during the 7:00 pm shift. Education: discussion should occur with CNS/RN and CRN and SUP about 1:1 sitter.
2. Patient had an indwelling Foley catheter. Education: should the catheter have been removed sooner. Patient noted to want her underwear on, that caused her to reach for clothing (lead to fall).
3. Chair alarm not connected to call bell outlet to promote alarm ringing to call bell system but was connected to standard alert. Education: if patients are in a closed room for COVID, chair alarms should be wired to call bell system as fan noise and closed door obstruct alarms. Education for RN/CNA. Refer to Fall prevention committee.
There is no documentation that this education occurred.

The facility did not complete these fall investigation incident reports.

Based on medical record (MR) review, document review, and interview, in four (4) of four (4) surgical patients (Patient #1, Patient #6, Patient #7, and Patient #8) MRs reviewed, two different informed consent forms for surgical procedures were available for patient use. The informed consent forms lacked either the date and/or time the consents were obtained by the provider or patient. Also, Patient #6's informed consent form describing the procedure (in the patient's own words) and the procedure identified by the provider did not match. Additionally, the hospital's policy and procedure (P&P) only addressed one of the informed consent forms currently in use and lacked instruction to staff to have the provider and patient include the date and time the informed consent was obtained. This could lead to improperly executed consent forms.

Findings include:

-- Per review of Patient #1's MR, date of service 1/20/2023, his informed consent form lacked the time the surgeon obtained the consent.

-- Per review of Patient 6's MR, date of service 2/2/2023, the informed consent form lacked the date and time the patient signed the consent form and the time the surgeon obtained the consent.

-- Per review of Patient #7's MR, date of service 2/8/2023, the informed consent form titled "Consent for Operative, Invasive or Diagnostic Procedure," revised 2/2017, listed a surgical procedure for "left hand incision and drainage, left great toe" in the patient's own words. The surgeon documented the surgical procedure as "Left toe amputation aspiration sampling of left wrist joint fluid." The consent form lacked the date and time the patient signed the consent form.

-- Per review of Patient #8's MR, date of service 2/16/2023, the informed consent form titled "Surgical or Invasive Procedure Consent," revised 1/2022, obtained on 1/10/2023, lacked the date and time the patient signed the consent form and the time the provider obtained the consent form.

-- Per review of the hospital's P&P titled "Patient Consent," last reviewed 1/2023, it only addressed "Consent for Operative, Invasive or Diagnostic Procedure," revised 2/2017, and not "Surgical or Invasive Procedure Consent," revised 1/2022. The P&P does not instruct staff to obtain the date and time consents are obtained

-- During interview of Staff A, Director of Inpatient Nursing, on 2/22/2023 at 3:00 pm, Staff A acknowledged the above findings.