HospitalInspections.org

Based on observation and interview, it was determined that the facility did not always provide care in a safe setting.

Findings were:

Facility Policy entitled "Fall Risk Program" stated in part "If a patient falls, the Nurse will complete a Fall Reassessment, Fall Report and initiate Post Fall Management protocol. The nurse will also complete a Neuro Check form if the fall included head trauma, if the fall was unwitnessed and the patient is unable to respond/recall if head trauma occurred during the fall, if patient is on anticoagulant therapy or per doctor's order ...Documentation of a fall on the appropriate forms will include:

a) Description of the fall
b) Notification of the physician
c) Notification of family (if appropriate)
d) Assessment of the patient (including vital signs and neuro checks if necessary)
e) Patient teaching (family if appropriate)
f) Safety interventions."

There was documented evidence that patient #1 was involved in an altercation with another patient on 8/6/18. Patient was hit in the forehead and reported dizziness afterwards. There was no evidence that the patient was assessed by an RN afterwards nor given neuro-checks nor follow up care. There was no report of the black eye that the patient sustained on any following 24-hour nursing assessment.

The above was confirmed in an interview with the Risk Manager on 10/2/18.

Based on review of documentation and interview, it was determined that the facility failed to always provide nursing assessment and appropriate response to injury.

Findings were:

Facility document entitled "Patient's Bill of Rights" stated that patients at Austin Lakes Hospital have the right to: "a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity.

You have the right to appropriate treatment in the least restrictive appropriate setting available. This is a setting that provides you with the highest likelihood for improvement and that is not more restrictive of you physical or social liberties than is necessary for the most effective treatment and for protections against any dangers which you might pose to yourself or others.
You have the right to be free from mistreatment, abuse, neglect and exploitation."

There was documented evidence that patient #1 was involved in an altercation with another patient on 8/6/18. Patient was hit in the forehead and reported dizziness afterwards. There was no evidence that the patient was assessed by an RN afterwards nor given neuro-checks nor follow up care. There was no report of the black eye that the patient sustained on any following 24-hour nursing assessment.

The above was confirmed in an interview with the Risk Manager on 10/2/18.

Based on review of documentation and interview, it was determined that the facility's nursing staff failed to properly assess its patients after injury.

Findings were:

Facility Policy entitled "Fall Risk Program" stated in part "If a patient falls, the Nurse will complete a Fall Reassessment, Fall Report and initiate Post Fall Management protocol. The nurse will also complete a Neuro Check form if the fall included head trauma, if the fall was unwitnessed and the patient is unable to respond/recall if head trauma occurred during the fall, if patient is on anticoagulant therapy or per doctor's order ...Documentation of a fall on the appropriate forms will include:

a) Description of the fall
b) Notification of the physician
c) Notification of family (if appropriate)
d) Assessment of the patient (including vital signs and neuro checks if necessary)
e) Patient teaching (family if appropriate)
f) Safety interventions."

Review of the medical record of patient #1 found that after sustaining a head injury, there was no documented RN assessment or follow up neuro-checks of the patient.

The above was confirmed in an interview with the Risk Manager on 10/2/18.

Based on review of documentation and interview, it was determined that the facility did not retain medical records per federal and state regulations.

Findings were:

Requested medical records were not available for review during the survey process dated 10/01/18 and 10/2/18.

The above was verified in an interview with the Risk Manager on 10/2/18.

Based on review of documentation and interview, it was determined that the facility's nursing staff failed to properly assess its patients after injury.

Findings were:

Facility Policy entitled "Fall Risk Program" stated in part "If a patient falls, the Nurse will complete a Fall Reassessment, Fall Report and initiate Post Fall Management protocol. The nurse will also complete a Neuro Check form if the fall included head trauma, if the fall was unwitnessed and the patient is unable to respond/recall if head trauma occurred during the fall, if patient is on anticoagulant therapy or per doctor's order ...Documentation of a fall on the appropriate forms will include:
a) Description of the fall
b) Notification of the physician
c) Notification of family (if appropriate)
d) Assessment of the patient (including vital signs and neuro checks if necessary)
e) Patient teaching (family if appropriate)
f) Safety interventions."

Review of the medical record of patient #1 found that after sustaining a head injury, there was no documented RN assessment or follow up neuro-checks of the patient.

The above was confirmed in an interview with the Risk Manager on 10/2/18.