HospitalInspections.org

Based on staff interview and document review, it was determined the hospital failed to ensure all licensed nurses who provide services in the hospital adhered to hospital policies and procedures. Specifically, nursing staff failed to comply with the hospital's policy related to documentation of the inventory of patient belongings in twelve (12) of fourteen (14) medical records reviewed in the survey sample (Patient #'s 1, 2, 4, 5, 6, 8, 9, 10, 11, 12, 13, and 14); failed to comply with fall documentation requirements in one (1) of one (1) patient fall medical record reviewed in the survey sample (Patient #8); and failed to ensure nursing staff adhered to hospital policy related to providing complete and accurate information in the handoff report to a receiving facility in one (1) of six (6) medical records reviewed in the survey sample of patients who were transferred or discharged to other facilities (Patient #8).

Findings:

The hospital's policies related to Patient Belongings were reviewed. The hospital's policy, "Patient Belongings/Valuables in Non-Behavioral Health Areas," approval date 08/01/2023, states, in part:
... "I. Guideline
... Patients have the right to retain their belongings/valuables...
... the facility records an inventory of the patient's belongings/valuables...
... II. Procedure
... Inventory and securing patients belongings/valuables
... Staff will document belongings in the electronic health record (EHR)."

The facility's procedure, "Nursing Documentation Requirements," approval date 02/06/2024, was reviewed and states, in part:
... "Procedure
... I. Documentation to be completed initially:
... A. Admitted Adult Inpatient and Observation patients...
... Patient Belongings
... C. Emergency Department
... Patient Belongings.

The medical record for Patient #1 contained documentation that the patient was seen in the Emergency Department (ED) on 03/14/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #2 contained documentation that the patient was seen in the ED on 03/12/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #4 contained documentation that the patient was seen in the ED on 03/2/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #5 contained documentation that the patient was seen in the ED on 03/9/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #6 contained documentation that the patient was seen in the ED on 03/19/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #8 contained documentation that the patient was seen in the ED on 06/18/23. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #9 contained documentation that the patient was seen in the ED on 03/23/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #10 contained documentation that the patient was seen in the ED on 03/22/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #11 contained documentation that the patient was seen in the ED on 03/30/2024. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #12 contained documentation that the patient was seen in the ED on 02/15/2024 . The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #13 contained documentation that the patient was seen in the ED on 03/26/2024. The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

The medical record for Patient #14 contained documentation that the patient was seen in the ED on 03/30/2024 . The medical record failed to contain documentation that the hospital conducted an inventory of the patient's belongings.

In an interview on 04/01/2024 at 3:57 p.m. with Staff Member #9, the surveyor asked Staff Member #9 about the facility's expectation concerning the inventory of patient's belongings in the ED. Staff Member #9 responded that documentation of patient belongings is an area of opportunity for improvement in the hospital.

In an interview conducted on 04/02/2024 at 7:30 a.m., Staff Member #7 stated that ED staff do not inventory patient belongings. This information is contrary to hospital policy.


The facility's policy, Bon Secours Mercy Health Fall Prevention effective 02/09/24 was reviewed and read in part: When a patient rolls off a low bed onto a mat or is found on a surface where you would not expect to find a patient, this is considered a fall...Unobserved falls include any case when a staff member finds the patient on the floor or other surface or when a fall is reported by the patient, a family member, or visitor....Patient experiences a fall: Complete a post fall assessment including vital signs and neuro check...document description of the fall in the progress notes; communicate any changes in the plan of care related to the fall...Notifications and follow-up post fall. Patient and family education: Instruct the patient and family/guardian on the environment ,plan of care to prevent a fall, and interventions implemented to reduce the potential for falls. Document education that was provided to patient and family/guardian in the EHR.

The medical record for Patient #8 was reviewed and contained no documentation that the patient fell or was found on the floor on 06/18/23 - 06/19/23.

The MFI requested a list of falls in the facility in June 2023. Patient #8 was listed as having fallen in the ED on 06/18/23 despite there being no documentation in the medical record that the patient fell.

An interview was conducted with Staff Member # 5 on 04/01/24 at 3:30 PM. Staff member #5 stated that Patient #8 was found on the floor in the ED on 03/18/23. The nurse reported finding the patient on the floor and was unaware that a patient found on the floor under unknown circumstances should be documented and treated as a fall. Staff member #5 confirmed this event should have been logged as a fall and documented in the medical record. Staff member #2, present during the interview and record review, confirmed the absence of any documentation related to a fall in the patient's medical record.


The facility's policy, Handoff Communication Guideline, effective May 23, 2023 was reviewed and reads in part: Handoffs take place whenever a transition in care occurs, including ...when a patient moves from one setting to another or from the hospital to another facility, such as rehabilitation or skilled nursing facility....Ensure the information is current and use technology such as electronic health records (EHR) to enhance communication. Shift handoff, transfer handoff, periop handoff documentation is done on a flowsheet in EHR. The minimum patient information made available during handoff includes:...Safety issues such as fall risk or isolation...Additional patient information during handoffs from one licensed caregiver to another includes the information necessary to take over the care of the patient, such as: ...IV access, tubes, and lines; most recent labs, tests, procedures, highlighting critical results/values and abnormal, skin/dressings...plan of care needs.

Documentation in the medical record for Patient #8 indicated the patient's tracheostomy tube had fallen out during the ED stay. The physician attempted two times to replace the tube, but was unable. The tracheostomy tube was replaced on the third attempt by a respiratory therapist. The nurse documented at 2:56 AM on 06/18/24 that report was called to the receiving provider. The nurse documented, "Discharge paperwork was handed over to [name of transport agency]." The record contained no documentation of what information was included in the handoff report to the receiving LTACH. The patient's discharge documentation (After Visit Summary) was reviewed and the information failed to contain any documentation related to an unwitnessed fall (see above fall information regarding Patient #8) and/or the replacement of the tracheostomy tube.

An interview was conducted on 04/02/24 at 7:30 AM with Staff Member #7. Staff member #7 stated all relevant information should be included in the report when the patient is sent to another facility, but there was no hospital specific form, template, or documentation related to what was included in the report to the receiving facility. Staff Member #7 reported that the only the After Visit Summary is sent with the patient at discharge.


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The above noted deficiency was confirmed with Staff Member #'s 1, 2, 9, 20 and 21 at the exit conference on 04/02/2024 at 1:00 p.m.