HospitalInspections.org

Based on record review and interview the facility failed to accurately track indicators related to quality of care. This deficiency is evidenced by the failure to include two patient falls (Pt. #3, Pt.#5) in the monthly quality monitoring report of 5 ( Pt. #1, Pt. #2, Pt. #3, Pt. #4, Pt. #5) records reviewed.
Findings:

Review of hospital policy EOC-13, titled, "Patient Incident & Occurrence Reporting," effective date 01/11/2016, reveals in part," Facility staff will report all patient occurences through the use of the facility's incident reporting form...A patient incident or occurence is anything that is out of the expected norm for the patient ( ex: elopement, fall, medication error, altercation, paychiatric emergency." The policy continues, "PI coordinator or Department manager...utilizes data for performance improvement activities monthly."

Patient #3
Review of the medical record for Pt. #3 revealed a documented fall on 10/23/2021 at 9:35 p.m. at the nurses' station. The patient was taken to the emergency room for treatment after the fall.

Review of the Performance Priority Measures Report for October revealed no documented fall on 10/23/2021 at the nurses' station for Pt. #3.

Patient #5
Review of the medical record for Pt. #5 revealed an unwitnessed fall in the dining room on 12/21/2021 at 6:30 a.m. The patient was later admitted to an acute care hospital as a result of the fall.

Review of the Performance Priority Measures Report for December revealed no documentation of a fall on 12/21/2021 in the dining room for Pt. #5.

In interview on 12/20/2022 at 11:37 a.m. S3NS verified the fall for Pt. #3 was not listed on the Performance Priority Measures Report for October. S3NS verified the fall for Pt. #5 was not listed on the Performance Priority Measures Report for December.

In interview on 12/20/2022 at 2:50 p.m. S2DON verified the falls for Pt.#3 and Pt. #5 were not on the Performance Priority Measures Reports.

Based on record review and interview the registered nurse failed to supervise and evaluate the nursing care of each patient. This deficiency is evidenced by the failure of the nursing staff to moniter neurological status per hospital protocol in 2( Pt. #3, Pt. #5) of 2 ( Pt. #3, Pt. #5) patients requiring neurological evaluation.
Findings:

Review of hospital policy AS-11 titled, "Neurological Assessment," revised 12/01/2020, in part revealed:

*Upon initial finding of potential head injury/ neurological trauma, initiate Neurological Assessment Checklist.
*Neurological Assessment will be initiated immediately after an unwitnessed fall or fall with possible head injury. This included a continuation of neuro checks to be completed after return from the Emergency room due to a fall if the patient returns within 24 hours of the fall.
*Neurological Assessment Checklist will be completed as follows:
o Upon initial finding then.
o Every 15 minutes after initial assessment x 4 then,
o Every 30 minutes x 2 then,
o Every 60 minutes x 2 then,
o Once per shift for 2 days or as indicated by physician/ non-physician practitioner order

Patient #3
Medical record review for Pt. #3 revealed the patient was hit in the head on 10/19/2021at 11:40 p.m. and sustained a laceration to the side of the face.

Further review of the medical record revealed a "Neuro Flow Sheet" was not initiated for the head trauma sustained on 10/19/2021.

Medical record review revealed Pt. #3 had a witnessed fall on 10/23/2021 at 9:35 p.m. at the nurses' station and sustained a left eye laceration. The patient was subsequently transferred to the emergency room for treatment and returned to the facility on 10/24/2021 at 5:00 a.m.

Further review of the medical record revealed a "Neuro Flow Sheet" dated 10/23/2021. It documented assessments prior to transfer to the emergency room but no assessments after his return within 24 hours of the fall.

In interview on 01/20/2022 at 2:50 p.m. S2DON verified there was no "Neuro Flow Sheet" for the incident on 10/19/2021. She also verified the neurological assessment for 10/23/2021 should have continued after the patient returned to the facility from the emergency room.

Patient #5
Medical record review for Patient #5 revealed an unwitnessed fall in the dining room on 12/21/2021 at 6:30 a.m. The patient was subsequently admitted to an acute care hospital.

Further review of the medical record revealed a "Neuro Flow Sheet" initiated on 12/21/2021 at 8:00 a.m. and continued until the patient was transported to the acute care hospital.

In interview on 01/20/2022 at 1:30 p.m. S2DON verified the "Neuro Flow Sheet" was not started immediately after the fall per hospital policy.