HospitalInspections.org

Based on observation and interview, the hospital failed to protect patients' health information by leaving medical record information readily available for anyone entering the hospital to see.


Findings Include:


Review of a hospital policy titled, "Patient Rights and Responsibilities" Revised 10/21/24 showed, " ...1. Every patient admitted to a [The Hospital] hospital is given a written copy of the Patient's Bill of Rights prior to admission, and, within 24 hours of admission, each patient is given an explanation of his/her rights and responsibilities as a patient. 2. The hospital will provide an explanation of the patient's rights and responsibilities in the patient's primary language, if requested. 3. The hospital shall obtain a signed copy of the Patient's Bill of Rights from each patient or patient's family, if appropriate. The signed copy shall include a statement that the patient and or patient's family has read the document and understands the rights specified in the document. 4. The hospital shall retain a signed copy of the Patient's Bill of Rights in the patients' medical file. 5. The [The Hospital] Patient Rights and Responsibilities Poster must be placed in prominent locations within the hospital. 6. Patients' Rights: Patients have the rights to: a) Considerate and respectful care given by competent personnel and to be made comfortable. b) Respect for cultural, psychosocial, spiritual, and personal values, beliefs, and preferences ... Have personal privacy respected. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be told the reason for the presence of any individual. The patient has the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms ... Receive care in a safe setting ... The patient has the right to access protective services and advocacy services including notifying government agencies of neglect or abuse..."


Review of the hospital's QAPI meeting minutes from April 2024 through September 2024 the hospital had identified areas of non-compliance with medication carts not being locked and Patient's Health Information (PHI) being left open and unattended on computers on wheels.


During an observation of second floor north nurses' station on 10/30/24 at 10:27 AM showed three unattended computers on wheels with patient information displayed on the screen.


Further observation of the computers on wheels showed them unlocked and unattended with patient medications present in the drawers.


During an observation of the second-floor south nurses' station on 10/30/24 at 10:34 AM showed one unattended computer on wheels with patient information displayed on the screen.


Further observation of the computer on wheels showed it unlocked and unattended with patient medications present in the drawers.


During an observation of the first-floor nurses' station on 10/30/24 at 10:45 AM, one unlocked and unattended computer on wheels with patient medications present in the drawers. Surveyors observed medication cart for approximately 5 minutes and the cart did not lock automatically nor did staff attempt to lock the cart.


During an interview on 10/31/24 at 12:20 PM Staff J, RN stated that the computer on wheels have automatic locks and should lock after a few seconds. Staff J went on to state there is a computer on wheels that was broken.


During an interview on 10/31/24 at 1:27 PM Staff B, Quality Manager stated, ...I go out and do physical audits and note unlocked medication carts, broken med carts, and unattended computers with PHI...Several staff were notified and retrained regarding unattended computers with PHI open. Broken computers on wheels should be put into locked med room until the computer on wheels is replaced ...

Based on policy review, record review, and interview the hospital failed to ensure nursing care was evaluated by a registered nurse (RN) on an ongoing basis to ensure that staff were providing the appropriate assessment, care, and evaluation of patient's response to interventions for 5 (Patient 2, 3, 4, 5, and 6) of 6 patient records reviewed. These deficient practices placed the patient at risk for development of wounds, deterioration of current illness, and adverse outcomes.


Findings Include:


Review of a hospital policy titled, "Fall Prevention" Revised 03/20/24 showed, " ...To provide a guide for assessing patients who are at risk for falling and for implementing precautionary measures to reduce the probability that a patient will fall or to reduce the probability the patient will sustain a serious injury in the event of a fall ... Risk assessment tools should be utilized as a frame of reference to enhance the predictability of patient falls and the selection of prevention strategies. Patients are assessed for the presence/absence of fall risk factors and given a score that identifies them as low, moderate, or high fall risk. Nurses will conduct an initial fall risk assessment. A fall assessment will then be conducted once a shift, and/or with any change in a patient's clinical status and post-fall. Each hospital will identify low risk with a green indication outside the door, a yellow indication for moderate, and a red indication for high. The nursing fall risk assessment and interventions are based on the use of the modified Morse Fall Scale. Patients will be assessed for fall risk factors upon admission, daily, change in clinical status, transfer to a new setting, and post-fall ... POST FALL ASSESSMENT Initiate the Post Fall Algorithm Complete Post Fall Huddle Complete Fall Analysis Tool Enter the incident into the incident reporting system ... MANAGEMENT OF THE POST-FALL PATIENT ... Did patient strike head and/or on anticoagulants or platelet inhibitors? Yes/Unknown 1. Complete a thorough nursing assessment. Does the patient have any of the following: o Spinal pain or tenderness o Abnormal motor and sensory exam o Unconsciousness 2. Obtain vital signs and neuro checks, which are to occur: o Every 15 minutes, times 4 o Every 30 minutes, times 2 oEvery hour, times 4 3. Initiate High Fall Risk Interventions, as applicable for a patient. 4. Notify nursing supervisor ..."


Patient 2


Review of Patient 2's medical record showed a 73-year-old male that was admitted to the hospital on 06/21/24 at 5:29 PM with an admitting diagnosis of Encounter for other orthopedic aftercare. Past medical history includes history of hypertension (elevated blood pressure); Atrial fibrillation (AFib) (irregular and often very rapid heart rhythm); and obesity. Patient 4 discharged to a Skilled Nursing Facility on 07/12/24 at 2:50 PM.


Review of a document titled, "Physician's Order" showed "Original Order Start ...06/21/2024 ... Vital Signs Every 12 Hours Vitals, Request Type: Routine ...DC [Discontinue] Date 07/12/24 ..."


Review of a document titled, "Vital Signs" showed from 06/21/24 at 6:00 PM through 07/12/24 at 6:11 AM nursing staff failed to obtain Patient 2's vitals as ordered by the physician 12 of 40 times.



Patient 3


Review of Patient 3's medical record showed a 54-year-old female that was admitted to the hospital on 09/28/24 at 4:39 PM with an admitting diagnosis of Paraplegia (impairment in motor or sensory function of the lower extremities). Past medical history includes history of Acute Respiratory Failure with Hypoxia (lungs have a hard time loading your blood with oxygen or removing carbon dioxide), Adrenal Insufficiency (occurs when the adrenal glands don't produce enough hormones), Asthma- chronic obstructive pulmonary disease (COPD), overlap syndrome (mix of symptoms of both asthma and chronic obstructive pulmonary disease) Chronic Pain, Obesity, and Hypertension (elevated blood pressure). Patient 3 discharged to a skilled nursing facility on 10/18/24.


Review of Patient 3's medical record failed to show a physicians order for vital signs per policy from 09/28/24 at 4:49 PM through 10/18/24 at 3:57 PM.


Review of a document titled, "Vital Signs" showed from 09/28/24 at 4:49 PM through 10/18/24 at 3:57 PM nursing staff failed to obtain Patient 3's vitals 10 of 38 times.


Patient 4


Review of Patient 4's medical record showed a 79-year-old female that was admitted to the hospital on 09/11/24 at 9:15 PM with an admitting diagnosis of Unspecified symptoms and signs involving cognitive functions following cerebral infarction. Past medical history includes history of recurrent Cerebrovascular accident (CVA) with residual weakness and memory deficit and dementia. Patient 1 discharged home on 09/27/24.


Review of a document titled, "Nursing Admission Assessment" dated 09/11/24 at 9:15 PM showed, " ...Morse Fall Risk Assessment ... History of Falling (immediate or within 3 months) Yes (25) Secondary Diagnosis/More Than One Diagnosis Yes (15) Ambulatory Aid Crutches/cane/walker/wheelchair (15) Continuous IV Infusion or Heplock No (0) Gait Weak (10) Mental Status Overestimates or forgets limits (15) Morse Falls Screening Total Score Greater than 45: High Fall Risk Minimal Fall Prevention Interventions Maintained for ALL Patients: Fall Assessment completed, bed wheels locked, bed in low position, call light within reach, environment assessed for all risks, personal items within reach, Plan of Care updated as needed Morse Fall Risk Assessment Total Score: 80.00 ..."


Review of a document titled, "Nursing Shift Assessment" dated 09/12/2024 at 5:56 PM showed, " ...Morse Fall Risk Assessment History of Falling (immediate or within 3 months) No (0) Secondary Diagnosis/More Than One Diagnosis Yes (15) Ambulatory Aid Crutches/cane/walker/wheelchair (15) Continuous IV Infusion or Heplock No (0) Gait Weak (10) Mental Status Knows own limits (0) Morse Falls Screening Total Score 25-45: Moderate Fall Risk Minimal Fall Prevention Interventions Maintained for ALL Patients: Fall Assessment completed, bed wheels locked, bed in low position, call light within reach, environment assessed for all risks, personal items within reach, Plan of Care updated as needed Morse Fall Risk Assessment Total Score: 40.00 ..."


Review of Patient 4's medical record failed to show an appropriate Morse Fall Risk score was completed on Patient 4 on 09/12/2024 at 5:56 PM.


Review of a document titled, "Notes" showed, " ...while receiving report this 0650 [6:50 AM], pt [patient] reported had a fall in BR [bathroom] last night, and C/O [complaint of] pain on head, back and finger. Electronically Signed By: [Staff C] RN, 09/13/2024 14:47 [2:47 PM] ..."


Review of a document titled, "Nursing Serial Neuro Assessment" dated 09/13/24 at 9:15 AM showed, " ...Reason for Neurological Assessment: Post-Fall Assessment ...Glasgow Coma Scale Total Score: 15.00 ..." Initiated two hours post patient fall.


Review of Patient 4's medical record failed to show the post fall assessment was completed per policy by failing to initiate neurological checks immediately following Patient 4's fall.


Review of a document titled, "Patient Incident Report" showed, " ...Incident Date: 9/13/2024 Incident Time: 02:32 PM ... Follow Up/Resolution: There is no report of bed alarm sounding at the time of the patient getting out of fall, no physical evidence of all on the patient's person. Patient had dementia and is forgetful...The patient report was treated as an unwitnessed fall ...Morse Fall risk assessment was completed in shift assessment, Neuro checks were completed by day nurse ...with the frequency: q 15 [every 15] min [minutes] x 4 [times 4], q 30 [every 30] min x2 [minutes times 2], Q [every] 1 hr [hour] x4 [times 4 hours]. However, the first neuro check was completed at 0915 [9:15 AM] about two hours after the patient reported the fall to the nurse ..."


During an interview on 10/29/24 at 1:28 PM Staff C, RN stated that the process when a patient has an unwitnessed fall is to immediately report to charge nurse, start vitals, neuro checks, notify physician, if complaint of hitting head request x-ray and computed tomography (CT). When a patient is a high fall risk implement yellow wrist bands, fall risk signs on door, bed alarm, chair alarms, and non-slip socks.


Review of a document titled, "Physician's Order" showed "Original Order Start ...09/12/24 ... Vital Signs Every 12 Hours Vitals, Request Type: Routine ...DC [Discontinue] Date 09/27/24 ..."


Review of a document titled, "Vital Signs" showed from 09/11/24 at 10:PM through 09/27/24 at 10:17 AM nursing staff failed to obtain Patient 4's vitals as ordered by the physician 3 of 26 times.


During an interview on 10/29/24 at 1:28 PM Staff C, RN stated that vital signs are to be done every shift.


Patient 5


Review of Patient 5's medical record showed a 69-year-old female that was admitted to the hospital on 09/04/24 at 3:30 PM with an admitting diagnosis of Ataxia following cerebral infarction. Patient 5's medical record showed patient was dependent on all cares and a high fall risk during entire hospital stay. Patient 5 remained inpatient until her time of discharge on 09/18/24 at unknown time.


Review of a document titled, "Patient Incident Report" showed, ...Incident Date:09/06/24 Incident Time: 12:51 AM ... Follow Up/Resolution: This was in the early morning hours, Usually not a very busy time of the shift. Reminded staff to respond to fall alarms in a timely manner. Review of post fall documentation showed that (a) Morse Fall Risk Assessment was not completed post fall -education given to Staff L, nurse for the patient at the time of the fall (b) The patient is on Plavix, a blood thinner and needed neuro checks completed post fall per fall algorithm stated in Fall policy. Neuro checks were completed with the frequency Q 21 min x 1, q 15 min x 2, q 30 min x2, q 1 hour x 4."


Review of Patient 5's medical record failed to show the post fall assessment was completed per policy by failing to initiate neurological checks immediately following Patient 5's fall.


Review of document titled, "Order Listing Report For 09/04/24 to 10/28/24" showed, "All Order Status For Patient 5 ...Vital Signs Every 12 Hours Vitals Start Date & Time 9/04/23 19:30 End Date & Time 9/18/24 10:18* Ordering Clinician ..."


Review of Patient 5's medical record failed to show any blood pressure readings completed per policy by failing to initiate vital signs every 12 hours on 09/04/24- 09/07/24, 09/09- 09/13/24, 09/15/24 and 09/17/24.

Review of Patient 5's medical record failed to show any blood pressure readings completed for 24 hours per policy by failing to initiate a nursing assessment with vitals every shift on 09/08/24 and 09/14/24.


Patient 6


Review of Patient 6's medical record showed an 82-year-old female that was admitted to the hospital on 10/09/24 at 5:40 PM with an admitting diagnosis of other specified myopathies, multiple recurrent wounds. Patient 6's medical record showed patient was dependent on most cares during entire hospital stay. Patient 6 remained inpatient until her time of discharge on 10/25/24 at an unknown time.


Review of document titled, "Order Listing Report For 10/09/24 to 10/28/24" showed, "All Order Status For Patient 6 ...Vital Signs Every 12 Hours Vitals Start Date & Time 10/09/24 19:30 End Date & Time 10/25/24 14:06* Ordering Clinician ..."


Review of Patient 6's medical record failed to show blood pressure readings completed per policy by failing to initiate vital signs every 12 hours on 10/10/24, 10/13/24, 10/21/24, and 10/23/24.