HospitalInspections.org

Based on record review of the nurses notes and Medication Administration Record (MAR) and staff interview, the facility failed to provide evidence that corrective measures were implemented for safety related to a fall that resulted in harm to 1 (#8) of 10 patients reviewed.


The findings include:


1. Review of the Medication Administration Records (MARs) on the closed electronic medical record revealed Patient #8 received an anti-anxiety medication, Ativan 1 mg IV push, on 3/24/18 at 11:00 pm for anxiety. On 3/25/18 at 0554, the patient refused to take her medications. The nurse documented that the patient kept getting up from the chair to the bed every hour multiple times, no matter how drowsy she was. The staff nurse caring for the patient positioned herself outside the door to watch Patient #8 throughout the night. The nurses' notes stated that the staff nurse was called away to care for another patient and was unable to continue watching Patient #8. At approximately 6:25 am on 3/25/18, a loud noise was heard from outside the patient's room. The Nursing Assistant went into the room, found the patient lying on the floor on her right side, and called the Staff Nurse. Patient #8 remained at her baseline orientation status. The patient was alert and oriented and refused to answer any questions regarding the fall.


On 3/25/18 at 7:10 am, Patient #8 complained of a headache. Cat scan of the head was ordered immediately. The results showed the patient had an acute right subdural hematoma and was taken to the Operating Room for a craniotomy.


Interview with the family member for Patient #8 on 5/30/18 at 12:30 pm revealed prior to hospitalization, the patient was restless; that she was up and down from the bed to the chair. The complainant stated the patient's fall alarm alert was not on when Patient #8 fell on 3/25/18.


Interview with Employee B, Risk Manager on 6/1/18 at 12:29 pm during electronic record review revealed Trazodone 100 mg by mouth, a muscle relaxant, was ordered for the patient on 3/24/18. The Risk Manager reviewed the MARS with the Surveyor and stated that the patient did not receive any doses of Trazodone. Seroquel 25 mg by mouth was ordered on 3/23/18 at 8:09 pm. The Risk Manager stated that the family did not want the patient on Seroquel. Review of the Psychiatric Evaluation dated 4/26/18 at 3:19 pm revealed Patient #8 had altered mental status with the use of Seroquel. Employee B stated that upon review of the incident that ocurred on 3/25/18, the fall bundle was in place and that staff was using the bed and chair alarm. Employee B stated that the patient was assessed for fall risk. The Risk Manager stated that Patient #8 was steady on her feet and did not have any balance issues. Employee B stated that staff was switching the bed alarm box from the bed to the chair when the patient was going back and forth from the bed to the chair and from the chair to the bed. Employee B stated the nurse moved her workstation to keep an eye on the patient during the night. Employee B stated the nurse did not switch the plugs/alarm on one of those exchanges; that the alarm was not plugged into the chair where the patient was located. Employee B stated that Patient #8 stood up on her own and fell. Employee B was asked, why was a sitter not used for the patient when the patient required continuous watching? The Risk Manager responded that it was not the culture of the unit for staff to call for a sitter.


Interview with Employee F, Nurse Manager on 6/1/18 at 1:58 pm revealed there was a meeting that occurred with the three Assistant Nurse Managers after the fall, to be proactive with high-risk patients for falls. When asked, why would the nurse not request someone to watch the patient when they could no longer watch the patient or involve the House Supervisor to find a sitter, the Nurse Manager stated that staff could request a sitter. Employee F stated that prior to the fall, they did not think about requesting a sitter. Employee F stated that the mindset from talking with staff was that the sitter was just for Baker Act patients. They stated that now staff were to share restless and agitated patients with them. Employee F stated that staff felt intimidated by family; that the patient had a psychiatric consultation and family refused to have the patient on Seroquel. The Nurse Manager was asked for supportive documentation that staff was re-educated on how to manage confused patients. The Nurse Manager stated there was no documentation to review that staff was re-educated.

Based on electronic record review of nurses' notes, assessments, care plans, policy review and staff interview, the facility failed to (1) provide appropriate nursing supervision for a high risk patient for 1 (#8) of 10 patients reviewed for falls. This fall resulted in harm to Patient #8; (2) failed to implement a fall care plan and fall alarm system to Patient #2; (3) failed to develop and implement care plans specific to the needs of 2 high risk patients for falls and diabetes. (Patient #9 & Patient #10); (4) failed to administer insulin in accordance with Physicians' Orders for Patients #9 .


These cumulative failures and inability to demonstrate documentation of corrective actions to manage patients with behaviors resulted in the Condition of Participation for Nursing.

Based on observation, review of nurses' notes and Medication Administration Records (MARs) and interview with staff, the facility failed to supervise and implement appropriate nursing interventions for 2 (#2 & #8 ) of 10 patients reviewed.


The findings include:


1. Review of the MARs on the closed electronic medical record revealed Patient #8 received an anti-anxiety medication, Ativan 1 mg IV push on 3/24/18 at 11:00 pm for anxiety. On 3/25/18 at 0554, the patient refused to take her medications. The nurse documented that the patient kept getting up from the chair to the bed every hour multiple times, no matter how drowsy she was. The Staff Nurse caring for the patient positioned herself outside the door to watch Patient #8 throughout the night. The nurses' notes stated that the Staff Nurse was called away to care for another patient and was unable to continue watching Patient #8. At approximately 6:25 am on 3/25/18, a loud noise was heard from outside the patient's room. The Nursing Assistant went into the room, found the patient lying on the floor on her right side, and called the Staff Nurse. Patient #8 remained at her baseline orientation status. The patient was alert and oriented and refused to answer any questions regarding the fall.


On 3/25/18 at 7:10 am, Patient #8 complained of a headache. Cat scan of the head was ordered immediately. The results showed the patient had an acute right subdural hematoma and was taken to the Operating Room for a craniotomy.


Interview with the family member for Patient #8 on 5/30/18 at 12:30 pm revealed prior to hospitalization, the patient was restless; that she was up and down from the bed to the chair and vice versa. The complainant stated Patient #8's fall alarm alert was not on in the hospital when the patient fell on 3/25/18.


Interview with Employee B, Risk Manager on 6/1/18 at 12:29 pm, during electronic record review revealed Trazodone 100 mg by mouth, a muscle relaxant, was ordered for Patient #8 on 3/24/18. The Risk Manager reviewed the MARS with the Surveyor and stated that the patient did not receive any doses of Trazodone. Seroquel 25 mg by mouth was ordered on 3/23/18 at 8:09pm. The Risk Manager stated that the family did not want the patient on Seroquel. Review of the Psychiatric Evaluation dated 4/26/18 at 3:19 pm revealed Patient #8 had altered mental status with the use of Seroquel. Employee B stated that upon review of the incident that ocurred on 3/25/18, the fall bundle was in place and that staff was using the bed and chair alarm. Employee B stated that the patient was assessed for fall risk. The Risk Manager stated that Patient #8 was steady on her feet and did not have any balance issues. Employee B stated that staff was switching the bed alarm box from the bed to the chair when the patient was going back and forth from the bed to the chair and from the chair to the bed. Employee B stated the nurse moved her workstation to keep an eye on the patient during the night. Employee B stated the nurse did not switch the plugs/alarm on one of those exchanges; that the alarm was not plugged into the chair where the patient was located. Employee B stated that Patient #8 stood up on her own and fell. Employee B was asked, why was a sitter not used for the patient when the patient required continuous watching? The Risk Manager responded that it was not the culture of the unit for staff to call for a sitter.


Interview with Employee F, Nurse Manager on 6/1/18 at 1:58 pm revealed there was a meeting that occurred with the three Assistant Nurse Managers after the fall to be proactive with high-risk patients for falls. When asked why would the nurse not request someone to watch the patient when they could no longer watch the patient or involve the House Supervisor to find a sitter, the Nurse Manager stated that staff could request a sitter. Employee F stated that prior to the fall, they did not think about requesting a sitter. Employee F stated that the mindset from talking with staff was that the sitter was just for Baker Act patients. They stated that now staff were to share restless and agitated patients with them. Employee F stated that staff felt intimidated by family; that the patient had a psychiatric consultation and family refused to have the patient on Seroquel. The Nurse Manager was asked for supportive documentation that staff was re-educated on how to manage confused patients. The Nurse Manager stated there was no documentation to review that staff was re-educated.


2. Patient #2 had a history of brain hemorrhage and was cognitively impaired. The patient did not respond to verbal stimuli. Observation of the bed in the patient's room on 5/31/18 at 9:30 am revealed the bed was in a high position. Employee M, Staff Float Nurse, who was close by was called into the room to demonstrate the bed alarm that was located on the patient's side rails. The staff nurse was unable to engage the bed alarm, as it would not activate. The staff nurse walked to the left side of the bed to check the electronic alarm. The glass covering the alarm system was broken. The staff nurse was unable to activate the alarm on the left side. Employee M checked for the alternate remote alarm system and it was not connected to the system.


Interview with Employee M on 5/31/18 at 9:40 am revealed the patient had a non-working alarm; one that would not respond to touch, and one that was broken on the left side. The Staff Nurse stated that fifteen minutes ago, the patient was moved in his bed from another room closer to the nurses' station for closer observation. Employee M was asked, why was the bed high? He stated it was to allow for drainage of the urinary catheter. In the next minute, Employee M stated the bed was not high. Employee D, Risk Manager confirmed the bed was high. Employee M stated that he had trouble with his hand print. Employee O, Nursing Assistant came into the room at the same time to assist Employee M. She tried to operate the alarm system on the bed and it did not work. She turned off the power to the bed to reset the alarm system and it did not work.


Review of the electronic assessment and care plan revealed Patient #2 was assessed as a fall risk and the bed was to be in a low position.


Interview with Employee O, Nursing Assistant on 5/31/18 at 9:45 am revealed the alarm system was locked up and was not working.


.

Based on observation, record review and staff interview, the facility failed to implement the fall care plan for 1 (#2) of 7 observed patients; failed to ensure a nursing care plan or the nursing section of the interdisciplinary care plan was developed in accordance with the specific needs of each patient for 2 of 10 patients (# 9 and #10) reviewed.


The findings include:


1. Patient #2 had history of brain hemorrhage and was cognitively impaired. The patient did not respond to verbal stimuli. Observation of the bed on 5/31/18 at 9:30 am revealed the bed was in a high position. Employee M, Staff Float Nurse who was close by was called into the room to demonstrate the bed alarm that was located on the patient's side rails. The Staff Nurse was unable to engage the alarm, as it would not activate. The Staff Nurse walked to the left side of the bed to check the electronic alarm. The glass covering the alarm system was broken. The Staff Nurse was unable to activate the alarm on the left side. Employee M checked for the alternate remote alarm system and it was not connected to the system.


Interview with Employee M on 5/31/18 at 9:40 am revealed the patient had a non-working alarm; one that would not respond to touch, and one that was broken on the left side. The Staff Nurse stated that fifteen minutes ago, the patient was moved in his bed from another room closer to the nurses' station for closer observation. Employee M was asked, why was the bed high? He stated it was to allow for drainage of the urinary catheter. In the next minute, Employee M stated the bed was not high. Employee D, Risk Manager confirmed the bed was high. Review of the electronic assessment and care plan revealed Patient #2 was assessed as a fall risk and the bed was to be in a low position.


Employee M stated that he had trouble with his hand print. Employee O, Nursing Assistant came into the room at the same time to assist Employee M. She tried to operate the alarm system on the bed and it did not work. She turned off the power to the bed to reset the alarm system and it did not work.


Interview with Employee O, Nursing Assistant on 5/31/18 at 9:45 am revealed the alarm system was locked up and was not working.



34942


2. Review of the medical record for Patient #9 revealed the patient was assessed to be high risk for falls (Morse Fall Scale score of 45) and high risk for elevated blood sugar levels.

On 4/1 - 4/7/18, Patient #9 was assessed to be high risk for a falls (scored 45 on Morse fall scale) and on 4/10/18 Patient #9 had an elevated score of 80. There was no care plan developed to address the patient's risks. Patient #9 was admitted with diabetes needing insulin on 4/1/18. There was no nursing care plan related to metabolic condition diabetes and insulin. This is confirmed in an interview with the Assistant Nurse Manager on 6/1/18 at 11:50 am, adding an interdisciplinary plan of care for metabolic with related interventions should be in the medical record. It was noted the patient did experience high blood sugar levels and Nursing failed to provide insulin coverage according to the sliding scale ordered by the physician. This is confirmed in an interview with the Risk Manager on 6/1/18 at 11:30 am. The patient had experienced elevated blood sugar on 4/7/18 at 12:48 pm (blood sugar level = 306), 4/7/18 at 8:12pm (blood sugar level = 229) and 4/13/18 (blood sugar level 186). There was no required insulin medications given at greater than plus or minus one hour of the ordered time according to the Medication Administration Record (MAR) on 4/7/18 at 12:48pm, and 8:12pm on 4/13/18.


In addition, the fingerstick blood sugar checks were not performed within the time frame specified by the hospital's Medication Administration Policy. These fingersticks were performed at greater than plus or minus one hour of the ordered time (4/2/18 at 5:50am and at 22:57hrs, on 4/4/18 at 5:46am and on 4/8/18 at 5:17am).


3. Patient #10 was admitted with high blood sugar levels, diabetes needing insulin on 5/21/18. There was no Nursing Care Plan related to metabolic condition diabetes and insulin. This was confirmed in an interview with the Assistant Nurse Manager on 6/1/18 at 11:50 AM, adding an interdisciplinary plan of care for metabolic with related interventions should be in the medical record.


It was noted the patient did experience high blood sugar levels and nursing failed to provide insulin coverage according to the sliding scale ordered by the physician. This was confirmed in an interview with the Risk Manager on 6/1/18 at 11:30 AM. The patient had experienced elevated blood sugar on 5/21/18 at 5:21pm (blood sugar level was 373) and at 7:33pm (blood sugar level = 381). There were no required insulin medications given at greater than plus or minus one hour of the ordered time, according to the Medication Administration Record on 5/21/18 at 5:21 pm and 7:33 pm. The Risk Manager reviewed the medical records on 6/1/18 at 11 am. She concurred with the findings.


There was also no care plan to address the patient's risk for falls. On 5/22/18, Patient #10 was assessed to be high risk for a falls (scored 45 on Morse fall scale); no fall assessment was completed on 5/23/18 and on 5/25/18 patient had an elevated score of 50. There was no care plan developed to address the patient's risk for falls. The Risk Manager reviewed the medical records on 6/1/18 at 11:00 am. She concurred with the findings.


The Assistant Nurse Manager stated on 6/1/18 at 11:45 am, "The plan of care (IPOC) is utilized as a source to communicate information to the interdisciplinary team (IDT). It is a way for IDT to track care and it also prompts the caregiver."


Review of the Interdisciplinary Plan of Care Policy #7.02.01, effective date August 2017 revealed, "Every in-patient should have an interdisciplinary POC initiated by an RN within 24-hours.

Based on medical record review and interviews, the facility failed to administer insulin (medication to treat high blood sugar) subcutaneous in accordance with the physician's order for the treatment of diabetes (high blood sugar) for 2 of 10 patients reviewed. (Patient #9 and #10).


The findings include:


Review of the medical record for Patient #9 revealed the patient was assessed to be high risk for elevated blood sugar levels. Patient #9 was admitted with diabetes-needing insulin on 4/1/18. There was no Nursing Care Plan related to metabolic condition diabetes and insulin. This is confirmed in an interview with the Assistant Nurse Manager on 6/1/18 at 11:50 am, adding an interdisciplinary plan of care for metabolic with related interventions should be in the medical record. It was noted the patient did experience high blood sugar levels and nursing failed to provide insulin coverage according to the sliding scale ordered by the physician. This is confirmed in an interview with the Risk Manager on 6/1/18 at 11:30 am. The patient had experienced elevated blood sugar on 4/7/18 at 12:48 pm (blood sugar level = 306), 4/7/18 at 8:12 pm (blood sugar level = 229) and 4/13/18 (blood sugar level 186). There was no required insulin medications given at greater than plus or minus one hour of the ordered time according to the Medication Administration Record (MAR) on 4/7/18 at 12:48 pm, and 8:12 pm on 4/13/18. No documentation was found in the medical record to support the reason insulin coverage was not given as ordered by the physician. The Risk Manager on 6/1/18 at 11:30 am explained that according to the patient's blood sugar level, insulin should have been administered per the sliding scale.


In addition, the fingerstick blood sugar checks were not performed within the time frame specified by the hospital's Medication Administration Policy. These fingersticks were performed at greater than plus or minus one hour of the ordered time (4/2/18 at 5:50am and at 22:57hrs, on 4/4/18 at 5:46am and on 4/8/18 at 5:17am).


A review of Patient # 10's medical record revealed chief complaint: "High Blood Sugar." Patient #10 was admitted with high blood sugar levels, diabetes-needing insulin on 5/21/18. There was no nursing care plan related to metabolic condition diabetes and insulin. This was confirmed in an interview with the Assistant Nurse Manager on 6/1/18 at 11:50 am, adding an interdisciplinary plan of care for metabolic with related interventions should be in the medical record. It was noted the patient did experience high blood sugar levels and nursing failed to provide insulin coverage according to the sliding scale ordered by the physician. This is confirmed in an interview with the Risk Manager on 6/1/18 at 11:30 am. The patient had experienced elevated blood sugar on 5/21/18 at 5:21 pm (blood sugar level was 373) and at 7:33 pm (blood sugar level = 381). There was no required insulin medications given at greater than plus or minus one hour of the ordered time according to the MAR on 5/21/18 at 5:21pm and 7:33pm. The Risk Manager reviewed the medical records on 6/1/18 at 11:00 am. She concurred with the findings. No documentation was found in the medical record to support the reason insulin coverage was not given as ordered by the physician. The Risk Manager on 6/1/18 at 11:30 AM, explained that according to the Patient's blood sugar level insulin should have been administered per the sliding scale order.