HospitalInspections.org

Based on record review and interview, the hospital failed to ensure:
1. Physician notification of critical lab results for one (Patient #8) of ten patients.
2. Documentation of patient falls, monitoring and assessment after a fall for three (Patients #8, #9 and #10) of ten patients.

This failed practice has the likelihood to result in unrecognized change in the clinical condition of patients and patient injury.

Critical Lab Results

Review of policy titled "Physician Notification of Critical Tests Results and Critical Values" read in part, "The RN or LPN will notify the physician of values. Appropriate documentation will include physician name, time notified, and orders received or no orders at this time if no orders are given. Critical results will be reported to the physician or his designee within 1 hour of nursing receiving report."

Patient #8

Review of a lab result dated 08/29/21 6:42 AM showed a nurse was notified of a critically low hemoglobin at 8:05 AM.

Review of the medical record showed no documentation of physician notification of the hemoglobin level by nursing.

On 10/07/21 at 10:05 AM, Staff G reviewed the medical record for Patient #8 and stated the following:
1. The nurse should have documented that he or she notified the physician.
2. A critically low hemoglobin could have put the patient at increased risk for falls or injury.

Falls

Patient #8

Review of an internal document showed the patient was found on the floor on 08/29/21 at 11:00 AM.

Review of the medical record for Patient #8 showed no documentation of the fall by nursing and no documentation of a post-fall nursing assessment.

Review of the Fall Risk Assessment dated 08/29/21 at 7:35 PM showed no update to reflect the patient had fallen in the last three months and continued to reflect a low fall risk score of 20.

Patient #9

Review of an internal document showed the patient was found on the floor which resulted in a skin abrasion on 07/01/21 at 5:45 AM.

Review of the medical record for Patient #9 showed no documentation of the fall by nursing and no documentation of a post-fall nursing assessment to include the skin abrasion.

Patient #10

Review of an internal document showed the patient was found on the floor on 07/07/21 at 11:30 PM.

Review of the medical record for Patient #10 showed no documentation of the fall by nursing and no documentation of a post-fall nursing assessment and physician notification.

On 10/06/21 at 1:00 PM, Staff B stated the hospital had no policy to address patient care after a fall.

On 10/07/21 from 10:05 AM to approximately 11:45 AM, Staff G reviewed the medical records for Patients #8, #9, and #10 and stated the following:
1. He or she could not find nursing documentation of the falls.
2. Nurses were expected to document a nurse's note, physician notification and the receipt of new orders in a patient's chart when a patient fell.