HospitalInspections.org

Based on interview and record review the facility's Governing Body failed to ensure that the facility was in compliance with their policy and procedure on fall prevention, Patient Rights, and Nursing Services when

- The facility's "Fall Prevention" Policy was not utilized in the emergency room for a sedated patient, resulting in a fall with severe injuries and placing all sedated patient arriving to the ER department at risk.
- A patient, while at the facility, experienced a fall with serious injuries and was transported to a higher level of care without any notification to the family.
- The facility's medical records were being amended two days later and the staff were not identifying the entries as being late.
- A STAT CT was not completed according to the facility policy.
- The Facility's Quality Improvement Committee did not report the Safety Committee reports to the Governing Body, quarterly, as the Fall Prevention Policy required.

Findings include:

Review of the facility's Incident reports from 8/17 through 12/17 reflected,
8/17- 4 falls, 9/17- 2 falls, 10/17- 3 falls, 11/17- 4 falls and 12/17- 2 falls

The facility provided Fall Prevention policy was effective on 4/2012 and required that each department will monitor their monthly fall rate and submit their score to the Safety Committee, who reports to the Quality Improvement Committee at the quarterly meeting.

Review of the facility Governing Body meeting minutes for 2017 reflected the facility patient falls had not been reviewed or discussed except for the 4th quarter, which only indicated that patient falls were included in the agenda, the details of the discussion were not included in the meeting minutes.

During an interview on the morning of 1/29/18, Staff #2, Quality stated, "...we started tracking them in the 4th quarter."

Cross Refer to A115, A118, A144, A145, A386, A449.

Based on interview and record review the facility failed to protect and promote a patients' rights to safe care when

- The facility did not assess a sedated patient for a fall risk or put interventions in place to prevent the patient from falling in the facility's ER , resulting in severe injuries. (Patient #1)

- A CT was ordered STAT at 4:14 a.m., to rule out a subdural hemorrhage for Patient #1 after a fall in the ER; the CT was not completed until 5:03 a.m., possibly delaying treatment.

- Following a fall at Lubbock Heart Hospital (LHH) and a discovered subdural hemorrhage, Patient #1 was transported to a nearby Level 1 trauma Center, University Medical Center (UMC). LHH did not inform Patient #1's immediate family of the fall or the need for an emergency transfer.

- Patient #1's medical records did not contain a fall risk assessment for a sedated patient or a post-fall nursing assessment as the facility's fall policies required.

Findings include:

Review of patient #1 's Medical Records dated 1/3/18 reflected an 80-year-old male admitted by air transport due to chest pain....While in route Patient # 1 became combative and tried to escape from the helicopter. Patient #1 received 2 mg of Ativan (for anxiety) and 60 mg of ketamine (a short acting analgesic that induces a trance-like state, sedation and memory loss). "...Currently he is sleeping soundly. The course/duration of symptoms is fluctuating in intensity...." The transport time was approximately 30 minutes long. The helicopter report reflected, lift off from Clovis, NM at 12:56 a.m. and landed at LHH in Lubbock, TX at 1:34 a.m.

Review of Patient #1's LHH's Emergency Room Nurse's notes do not reflect Patient #1 had been identified and assessed for fall risks and that interventions had not been put in place to prevent the patient from falling.

Further review reflected "...ESI [emergency severity index]
Does the patient require immediate life-saving intervention? No
Is this a high risk situation where the patient is confused/lethargic/disoriented or in severe pain/distress?: No
How many different resources will this patient need? : Many
Recommended ESI Level 3

Glasgow Coma
Eye opening: Spontaneously
Best Verbal Response: Confused
Best Motor Response: Obeys simple commands
Glasgow Coma Score: 14
...Orientation Assessment: Disoriented X 4
General Symptoms: Confusion/Disorientation..."

Review of Patient #1's Nursing progress note dated 1/3/18 at 4:00 a.m., that was electronically written and signed on 1/5/18 at 8:06 p.m. [two and a half days after the incident], stated in part, "Pt fell after attempting multiple times to exit the bed. Pt is extremely confused and combative...." The note was not labeled as a late entry.

Review of Patient #1's physician's orders dated 1/3/18 at 4:15 a.m. reflected an order for a STAT (immediately) CT of the head without contrast. Review of Patient #1's CT reflected it was taken at 5:03 a.m., 45 minutes later. The records do not reflect the time the CT technician was notified of the order.

During an interview in the afternoon of 1/29/18, in the facility's ER when asked what the expectation for the initiation of STAT orders was, Staff #6, ER MD stated, "immediately."

During an interview on the morning of 1/29/18, in the conference room, when asked about the delay in obtaining the STAT CT scan, Staff #12, Quality Director explained, the order wasn't put in the ER orders. The physician had written the order STAT in the ER but had written the order on the inpatient admission orders. The orders were not initiated until the staff, on the inpatient unit, activated the order; the Radiology tech would not see the order until then. Staff #12 confirmed this would cause a delay in implementing STAT orders and stated in part, "They should have done the CT before he went to the floor....STAT orders should not be part of an admission order set ...the nurse should be documenting when the radiology tech is notified."

Review of the LHH's Computed Tomography Radiologist interpretation note dated 1/3/18 at 6:00 a.m. reflected, "Indication: Head trauma...A large left frontal/supraorbital scalp hematoma is noted. Small amount of hemorrhage is seen in the right frontal region and appears to be within a sulcus. Hemorrhage is present in or adjacent to the occipital horn of the right lateral ventricle. There is a mild degree of ventricular dilation. Moderate periventricular centrum semiovale white matter low attenuation is present likely representing chronic small vessel disease. There is calcification in the falx. Small amount of subdural hemorrhage is suggested over the inferior right frontal lobe region in the region of the tentorium. No shift of midline."

Review of Patient #1's UMC's CT Radiologist interpretation report, dated 1/3/18 at 8:53 a.m. reflected, "Impression: Large 7.4 x 3.6 cm (centimeter) right posterior temporal, parietal and occipital lobe parenchymal hemorrhage with mass effect and intraventricular extension. Right frontal subarachnoid hemorrhage and 3 mm (millimeter) parafalcine subdural hemorrhage. Asymmetric right hemispheric parenchymal edema. No displaced clavarial fracture. Large left frontal scalp laceration with hematoma and swelling.... "

During an interview in the afternoon of 1/29/18, in the facility's ER, when asked about the facility's follow-up after Patient #1's fall, Staff #13, ER Director stated, "I trained the staff on the use of sitters and the use of restraints for confused patients...they were confused about the use of restraints....I talked to all the ER staff...." The facility was not able to provide written documentation of the training.

During an interview in the afternoon of 1/29/18, in the facility's ER, when asked about the recent training on interventions used to prevent confused patients from falling in the ER, Staff #12, Registered Nurse (RN) stated, " ...I don't remember getting the training...we haven't used a restraint in the ER in years...We don't have sitters in the ER...I don't know how to get a sitter..."

During an interview on the morning of 1/29/18, in the facility conference room, Staff #11, Quality Director stated, "...they put him (Patient #1) in room #5, it's furthest from the nurse's station...he was asleep..., at the time, they thought it was the most appropriate place for him..." When asked if the family had been informed of the fall and the need to transfer Patient #1, Staff #11 stated, "...we didn't call the son, I talked to him later and explained we most definitely want to inform the family and it is a process improvement...."

During an interview on the afternoon of 1/29/18, in the facility conference room, Staff #11, Quality Director stated, confirmed the ER nurse marked Patient #1 as being confused and disoriented and stated, "We don't have a fall prevention policy for the ER.... they don't do a fall risk assessment in the ER ...all documentation should be completed within 24 hours...it should be marked as a late entry...."

POLICIES
Review of the facility provided policy "Availability of STAT Scanning Services" (dated December 2003) reflected, "Purpose: To establish guideline for STAT scanning services. Procedure: 1. CT emergency STAT coverage is provided at all times...2. Upon notice a STAT order, the appropriate personnel will page the on-call tech...3 Estimated arrival time is to be provided to the hospital. Arrival time is to be within 30 minutes...."

Review of the Facility provided policy titled "Making Amendments in the Electronic Health Record" (effective date: 12-13-15) stated in part, "Policy: Providers documenting within the electronic health record must avoid indiscriminate use of amendments as a means of documentation...
Procedure:
...2. The provider should complete an addendum which includes the following information:
...d. Document that it is a late entry."

Facility policy titled "Falls Prevention" (effective date 4/2012) stated in part, "Purpose: To identify patients at risk for falls in the organization and reduce the number of incidents that occurs.
...Scope and Applicability:
The scope of this program is as follows:
1. No specific assessment/reassessment of fall risk is required of patients seen in an out-patient care settings [sic]. However, if a patient presents with obvious risk criteria such as an unsteady gait, use of assistive devices, or other obvious need, then staff will take appropriate action to assure their safety during the provision of care, treatment, and service.
...Fall Risk Reduction Strategies:
The organization has implemented the following strategies to reduce both the likelihood and severity of patient falls:
1. Each patient identified as a fall risk will have a specific plan of care developed to address his or her risk issues.
2. Visually identifying the patient as a fall risk.
3. Communicating the fall risk to members of the healthcare team.
4. Increasing the frequency of observation and assistance to the patient for care needs and ambulation.
5. Implementing actions to prevent falls or to reduce the potential severity of a fall.
6. Applying YELLOW socks and/or yellow blanket to identify patients as high-risk.
7. Placing Stars on Door: Falling star program to indicate patients at risk.
...The organization has put human factor precautions in place to reduce the likelihood of a patient fall:
1. Use of sitters if available or encourage the family to stay with patients if appropriate.
...5. Confused patients are frequently oriented to their surroundings ....
...Staff nurse is to complete post fall assessment in the patient's electronic medical record after any accidental injury or alleged fall.
...Trend Analysis:
1. Each department will monitor their monthly fall rate and submit their score to the Safety Committee, who reports to the Quality Improvement Committee at the quarterly meeting.
2. The Safety Committee will analyze the data and report any adverse trends that may be developing."

Review of the Facility provided policy titled "Restraint Policy" effective date April 2012 stated in part, "Purpose: The use of restraints is a therapeutic intervention to prevent the patient from injuring himself/herself or from injuring others...
Use of Alternatives
1. Monitoring
a. Companionship; family member, private duty nurse/attendant stay with patient.
b. Room near or visible from nursing station.
c. Close, frequent observation.
2. Environmental Measures:
...b. Place patient near nursing station.
...j. Use of bed check/chair check alarm device ...
5. Staffing:
a. Consider assessed patient needs and behavior as well as patient/staff safety when making assignments
...d. Consider use of sitter or allow family to stay with patient if possible
...Procedure:
Assessment of risk factors, interventions and alternatives to restraint
Assessment:
1. The decision to use restraints is based on an individual assessment.
2. Non-physical techniques are preferred interventions.
a. The type of physical intervention selected should take into consideration information obtained from the individual's initial assessment."

Cross refer to A118, A144, A145.

Based on interview and record review the facility failed to ensure the investigation into a complaint voiced by a patient's representative was communicated with the complainant, as the facility policy required.

Findings were:

Review of the facility provided policy titled "Patient/Representative/Grievance/Complaint" states in part, "Patient Grievance: A grievance occurs if the complaint is expressed by the patient or his/her representative.... Senior administration will provide the patient or the patient's representative with written notice of its decision in a language and manner the hospital can reasonably expect the patient/patient's representative to understand."

During an interview on the morning of 1/29/18 Staff #11, Quality Director stated the incident was not considered a grievance, the family didn't say it was a complaint or a grievance. Staff #11 further stated, "...I talked to the son-in-law, I told him we were still investigating the incident." When asked if a written notice was sent to the complainant as the facility's policy requires Staff #11 stated, "No."

Based on interview and record review the facility failed to provide care in a safe setting when,

- The facility did not assess a sedated patient for a fall risk or put interventions in place to prevent the patient from falling in the facility's ER, resulting in severe injuries. (Patient #1)

- A Computed Tomography (CT) was ordered STAT (immediately) at 4:14 a.m., to rule out a subdural hemorrhage for Patient #1 after a fall in the ER; the CT was not completed until 5:03 a.m., possibly delaying treatment.

Cross Refer to A115 Patient's Rights

Based on interview and record review the facility failed to protect Patient #1 from neglect when,

- The facility did not assess a sedated patient for a fall risk or put interventions in place to prevent the patient from falling in the facility's ER, resulting in severe injuries. (Patient #1)

- A Computed Tomography (CT) was ordered STAT (immediately) at 4:14 a.m., to rule out a subdural hemorrhage for Patient #1 after a fall in the ER; the CT was not completed until 5:03 a.m., possibly delaying treatment.

Cross Refer to A0115 Patient's Rights

Based on interview and record review the facility failed to provide an organized Nursing Services when

- The facility did not assess a sedated patient for a fall risk or put interventions in place to prevent the patient from falling in the facility's ER (Emergency Room), resulting in severe injuries. (Patient #1)

- A Computed Tomography (CT) was ordered STAT (immediately) at 4:14 a.m., to rule out a subdural hemorrhage for Patient #1 after a fall in the ER; the CT was not completed until 5:03 a.m., possibly delaying treatment.

- Following a fall at Lubbock Heart Hospital (LHH) and a discovered subdural hemorrhage, Patient #1 was transported to a nearby Level 1 trauma Center, University Medical Center (UMC). LHH did not inform Patient #1's immediate family of the fall or the need for an emergency transfer.

- Patient #1's medical records contained late entries, did not contain a neurological assessment, a fall risk assessment or a post-fall nursing assessment as the facility's fall policies required.

Cross Refer to A386, A449.

Based on interview and record review the facility failed to provide an organized Nursing Services when,

- The facility did not assess a sedated patient for a fall risk or put interventions in place to prevent the patient from falling in the facility's ER (Emergency Room), resulting in severe injuries. (Patient #1)

- A Computed Tomography (CT) was ordered STAT (immediately) at 4:14 a.m., to rule out a subdural hemorrhage for Patient #1 after a fall in the ER; the CT was not completed until 5:03 a.m., possibly delaying treatment.

- Following a fall at Lubbock Heart Hospital (LHH) and a discovered subdural hemorrhage, Patient #1 was transported to a nearby Level 1 trauma Center, University Medical Center (UMC). LHH did not inform Patient #1's immediate family of the fall or the need for an emergency transfer.

- Patient #1's medical records did not contain a fall risk assessment or a post-fall nursing assessment as the facility's fall policies required.

Cross Refer to A0115 Patient's Rights

Based on interview and record review the facility failed to ensure complete and accurate medical records when Patient #1's medical records contained nurse's notes 48 hours later and did not document the entries as late entries as the facility's policy required.

Findings include:

Review of Patient #1's Nursing progress note dated 1/3/18 at 3:00 a.m., that was electronically written and signed on 1/3/18 at 5:55 a.m. stated in part, "Quiet, Sleeping, Alarms in place, Respiratory Pattern: Regular" The note was not labeled as a late entry.

1/3/18 at 4:00 a.m., that was electronically written and signed on 1/5/18 at 8:06 p.m. [two and a half days after the incident], stated in part, "Pt fell after attempting multiple times to exit the bed. Pt is extremely confused and combative...." The note was not labeled as a late entry.

1/3/18 at 4:00 a.m., that was electronically written and signed on 1/3/18 at 6:02 a.m. stated in part, "Respirations: Unlabored & Quiet, Patient Rounds: Needs met, Alarms in place; Rounding Comments: patient restless, disoriented and combative. Found him on the floor with a large hematoma above his left eye." The note was not labeled as a late entry.

During an interview on the afternoon of 1/29/18, in the facility conference room, Staff #11, Quality Director stated, "...all documentation should be completed within 24 hours....it should be marked as a late entry...."

Review of the Facility provided policy titled "Making Amendments in the Electronic Health Record" (effective date: 12-13-15) stated in part, "Policy: Providers documenting within the electronic health record must avoid indiscriminate use of amendments as a means of documentation...
Procedure:
...2. The provider should complete an addendum which includes the following information:
...d. Document that it is a late entry."