HospitalInspections.org

Based on record review and interview, facility staff failed to inform patients of their Medicare discharge rights upon discharge for 1 of 4 Medicare-eligible inpatients (Patient #1).

Findings include:

Review of Patient #1's medical record revealed an admission for pneumonia on 11/28/2023 and discharge on 12/1/2023. There was no Important Message from Medicare in the medical record at discharge.

In an interview with Quality Manager A on 1/16/2024 at 1:55 PM Quality Manager A confirmed that there was not a second Important Message from Medicare.

Based on interview and record review the facility failed to ensure that patient needs are met by ongoing assessments for 1 of 2 patients (Patient #1) with extended Emergency Department wait times and boarding status.

Findings include:


Review of the facility policy titled, "Standards of Nursing Practice Policy - Emergency/Urgent Care Department" dated 11/9/2022 document ID: KT2N6QC5SZE5-3-2854 revealed, "Purpose Statement: This Standard of Practice applies to any patient requiring and seeking care at an emergency/urgent care department with MCHS (Marshfield Clinic Health System)...3.2 Vital Signs: a. All patients will have a baseline set of vital signs recorded. Frequency of vital signs will be determined by initial triage category and patient acuity: ...Triage category ESI 3: a minimum of every 1 hours (sic) after base line..."

Review of Pt. #1's medical record revealed a triage note at 1:10 PM on 11/28/2023. The next notation in the ED record is at 5:00 PM on 11/28/23 when a doctor exam is requested. Vital signs are recorded at 1:28 PM in triage and then again at 5:10 PM. Triage note revealed an ESI (Emergency Severity Index - level 1 (most urgent) to level 5 (least urgent) of 3.

On 1/16/2024 at 9:10 AM in an interview with Triage Nurse E, Nurse E stated that they try to get out and check on patients but sometimes are too busy to do so.

On 1/16/2024 at 9:05 AM in an interview with ED Manager C when asked what the expectation was for reassessment of patients in the ED waiting room Manager C stated that he expected that the reassessment policy be followed and that vital signs be taken as indicated in the policy and documented. "It appears that didn't happen with this patient. Once a patient is made an inpatient or placed in a boarder status then we need to care for them along with other ED patients until a bed is available."

The medical record revealed that Patient #1 was boarded in the ED awaiting an inpatient bed for approximately 15 hours from approximately 8:30 PM 11/28/2023 when decision to admit was made, to admission to the nursing unit on 11/29/2023 at 1:30 PM. There is no evidence that vital signs were conducted every hour per policy and no documentation of care provided from 11/28/24 at 11 PM, until 11/29/24 at 10:16 AM (11 hours and 16 minutes later) when a float nurse was assigned to the ED to care for 2 boarder patients.

Based on record review and interview, the facility failed to follow policy and procedures for removal of high fall risk interventions on 1 of 3 patients (Pt. #1) with a high fall risk score and failed to document ongoing care of a patient (#1) who was boarded overnight in the Emergency Department.

Findings include:

Review of facility policy titled, "Fall Prevention Policy - Acute Care and Emergency Department" dated 10/5/2022 Document ID: KT2N6QC5SZE5-3-2206, revealed, "...3.2 Morse Fall Prevention Measures (Adults) (used to predict a patient's likelihood of falling by evaluating individual risk factors) a. Morse Fall risk assessments occur: ...every 12 hours, after a change in clinical condition and as deemed necessary by a Registered Nurse, high fall risk interventions MAY NOT be discontinued until the adult inpatient scores less than a 45 on the Morse Fall Risk Assessment for 24 consecutive hours...for adult inpatients with a fall risk score of 45 or less interventions may be implemented based on nurses discretion..."

In the complaint received 12.28.2023 the complainant, a family member, had concerns about the fall precautions being removed too soon due to Patient #1's diagnosis of dementia.

Review of Pt. #1's medical record revealed a Morse Fall Risk assessment on 11/29/2023 upon admission to the 4th floor at 4:00 PM. The scoring revealed, "No history of past falls, secondary diagnosis, bedrest, weak gait, oriented, fall risk band applied and a score of 45.
- On 11/29/2023 at 9:30 PM the fall risk assessment revealed a score of 60, "forgets limitations" bed exit alarm is documented.
- The medical record revealed a fall risk score of 45 on 11/30/2023 at 4:00 PM with the assessment of "oriented" and "standard precautions in place". Per review of the facility Fall Prevention Policy standard precautions include, "bed in low position, nonslip footwear, call light placed within reach, floors free of clutter, adequate lighting, purposeful hourly rounding.

Review of the interview the attending RN had with Manager D on 12/27/2023 revealed, "The RN stated that she reassessed the patient in the morning and got a 45 due to the patient no longer forgetting limitations and being alert and oriented x 4 and able to follow commands. RN is unable to remember when she turned the bed alarm off but did so knowing that the patient was following commands, was a lower fall risk and had family in the room."

The high fall risk interventions should have been in place after a patient scores 45 or less for 24 consecutive hours.

On 1/16/2024 at 2:00 PM in an interview with Quality Director A, Director A confirmed that per policy the bed alarm should have remained in place for 24 hours.

Based on record review there is not any documentation to support that the patient was attended to during the nighttime hours she was in the ED waiting for an inpatient bed.

In an interview with Director of Patient Care Services B on 1/16/2024 at 2:10 PM Director B stated that nurses chart by exception so he/she wouldn't expect to see anything documented if nothing was done for the patient. "I can see how if it's not charted it didn't happen enters in though."