HospitalInspections.org

Based on medical record review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 patients (Patient #1) who had been a patient at the CAH since 3/15/21 had an individualized and updated nursing care plan. Failure to provide an individualized and updated nursing care plan resulted in Patient #1 being bedbound for extended periods of time without any type of exercise plan or regimen to ensure Patient #1 maximized or maintained their strength and conditioning. The CAH identified an average daily census of 7.5 patients.

Findings include:

1. Review of medical records revealed:

a. On 3/15/21 Patient #1 was hospitalized after being brought to the Emergency Department (ED) by Emergency Medical Services with a chief complaint of weakness. Patient #1's past medical history included homelessness, physical deconditioning, arthritis of the hips, left hip arthritis and avascular necrosis (death of bone tissue due to the loss of blood supply to the bone.) EMS had been frequently called to Patient #1's residence to assist Patient #1with their toileting needs. Because Patient #1 continued to be unable to walk, EMS brought Patient #1 to the ED. Patient #1 reported that they walk with crutches.

b. On 3/15/21 at 5:08 PM, Physician K ordered "Activity as Tolerated".

c. Review of the nursing care plan revealed the care plan lacked a goal related to movement and activity.

d. Review of nursing documentation for Patient #1's activity from 9/1/21 to 10/31/21 revealed the nursing staff had not documented that Patient #1 had been out of bed, or done any any type of strengthening or movement activity during that two month time period:

9/1/2021 8:00 PM, RN A charted "Lying in Bed, HOB [head of bed] elevated"
9/4/2021 7:41 PM, RN B charted "Lying in Bed, HOB elevated"
9/4/2021 8:33 PM, RN B charted "Lying in Bed, HOB elevated"
9/4/2021 9:26 PM, RN B charted "Lying in Bed, HOB elevated"
9/4/2021 10:22 PM, RN B charted "Lying in Bed, HOB elevated"
9/4/2021 11:19 PM, RN B charted "Lying in Bed, HOB elevated"
9/5/2021 12:36 AM, RN B charted "Lying in Bed, HOB elevated"
9/5/2021 1:30 AM, RN B charted "Lying in Bed, HOB elevated"
9/5/2021 2:37 AM, RN B charted "Lying in Bed, HOB elevated"
9/5/2021 3:37 AM, RN B charted "Lying in Bed, HOB elevated"
9/5/2021 4:32 AM, RN B charted "Lying in Bed, HOB elevated"
9/5/2021 5:38 AM, RN B charted "Lying in Bed, HOB elevated"
9/5/2021 6:13 AM, RN B charted "HOB elevated"
9/7/2021 9:00 PM, RN A charted "Lying in Bed"
9/8/2021 7:32 AM, LPN C charted "Lying in Bed"
9/8/2021 7:27 PM, RN A charted "Lying in Bed"
9/9/2021 7:32 PM, RN A charted "Lying in Bed"
9/10/2021 8:14 PM, RN D charted "Lying in Bed"
9/13/2021 8:00 PM, RN A charted "Lying in Bed"
9/16/2021 4:00 AM, RN E charted "Lying in Bed"
9/16/2021 4:40 AM, RN E charted "Reposition"
9/29/2021 7:25 PM, RN A charted, "Lying in Bed, HOB elevated"
9/29/2021 8:00 PM, RN A charted "Lying in Bed"
9/29/2021 9:00 PM, RN A charted "Lying in Bed"
9/29/2021 10:00 PM, RN A charted "Lying in Bed"
9/30/2021 7:56 PM, LPN F charted "Lying in Bed"
10/1/2021 7:05 PM, RN D charted, "Lying in Bed"
10/2/2021 7:43 PM, RN D charted "Lying in Bed"
10/3/2021 11:49 PM, RN G charted "Reposition"
10/4/2021 9:00 PM, RN A charted "Lying in Bed"
10/5/2021 8:00 PM, RN A charted, "Lying in Bed"
10/6/2021 8:00 PM, RN A charted "Lying in Bed"
10/16/2021 7:00 PM, RN E charted "Reposition"
10/20/2021 9:00 PM, RN A charted "Lying in Bed"
10/21/2021 8:00 PM, RN A charted "Lying in Bed"
10/25/2021 7:28 PM, RN A charted "Lying in Bed"
10/26/2021 7:37 PM, RN A charted "Lying in Bed"
10/27/2021 2:00 AM, RN E charted "Reposition"
10/31/2021 8:02 PM, RN D charted "Lying in Bed"

e. On 11/8/21 at 11:58 AM Case Manager documented Patient #1 had been working with Physical Therapy and had increased the distance they walk. Patient #1 was unable to get up and down from the bed and chair and is unable to take care of their own bathroom needs. Patient #1 will never be able independently transfer from the bed to a chair and toilet themself independently.

3. During an interview on 11/16/21 at 11:30 AM, the Case Manager explained that CAH is unable to place Patient #1 despite many efforts by CAH. Case Manager revealed that the goal of care is to increase Patient #1's strength so they can be transferred to a more appropriate setting.

4. During an interview on 11/15/21 at 4:00 PM, the Director of Rehab Services explained that Patient #1 had some sort of car accident previously which caused their right hip to fix so that the joint cannot flex; the left hip is quite a bit shorter and has avascular necrosis. Patient #1 also has arthritis. Patient #1 is able to get out of bed with assistance and Physical Therapy (PT) staff tried to walk with Patient #1 once a week. The Director of Rehab Services acknowledged that the biggest problem was finding time to try to walk Patient #1, as it takes 2 people and they only have 3 people in the department to cover all services. The Director of Rehab services indicated that Patient #1 is now walking farther than they were 8 months ago, and getting Patient #1 up is easier with the lift chair. The goal of therapy is a big question because the CAH staff are not sure where Patient #1 will discharge, but Patient #1 has to be able to get up and move before they can discharge to another facility. The nursing staff try to get Patient #1 up and moving, but Patient #1 is not a small person and there is fear of staff injury. There are some nurses that will help Patient #1 into a chair. Director of Rehab Services acknowledged that Patient #1 is in bed quite a bit.

5. During an interview on 11/16/21 at 11:00 AM, Physical Therapy Assistant (PTA) H explained that it takes 2 people to get Patient #1 out of bed to walk, so PTA H assists PT staff. PT staffing and case load limit their interactions with Patient #1. PTA H indicated they got a lift chair for Patient #1 in June.

6. During an interview on 11/16/21 at 10:00 AM, RN I confirmed that nursing staff does not get Patient #1 out of bed. RN I revealed that they have tried to get Patient #1 out of bed, but it is very difficult because Patient #1 was in a car accident and has a hip that is chronically dislocated, so it is painful and physically difficult for Patient #1 to bend at the waist and sit on the edge of the bed. The 1 time they tried to get Patient #1 out of bed, it did not go well, and it put a strain on the nurse's backs.

7. During an interview on 11/15/21 at 3:00 PM, RN J explained the goal is to transfer Patient #1 to a nursing home. Lately PT are the only ones that get Patient #1 up out of bed and walking. Occasionally the nursing staff will scoot Patient #1 from the bed over to the lift chair, but Patient #1 does not stay there very long. RN J thought Patient #1 got up in the chair once a week, or once every other week. The nursing staff does not walk with Patient #1, because it usually takes a male PT to get Patient #1 up and out of bed, and PT does not want the nursing staff to walk Patient #1.

8. During an interview on 11/30/21 at 8:15 AM, the Quality Manager confirmed that Patient #1's nursing care plan lacked an activity goal and a plan to ensure Patient #1 maximized their strength and conditioning to the best of their ability. Quality Manager also acknowledged that from 9/1/21 to 10/31/21 the medical record lacked any documentation that nursing staff had gotten Patient #1 out of bed, or perfromed any type of strengthening exercises or activity.