HospitalInspections.org

Based on medical record review, document review, and interview, in 1(one) of 15 medical records reviewed, the facility failed to afford the patient the right to have his/her representative notified of changes in his/her health status in accordance with its policy and procedure (Patient #1).

Findings Include:

The facility policy and procedure titled "Disclosure of Unanticipated Outcome Information," last revised September 2018 states the following: "The Attending physician will speak to the patient, family or legally authorized representative along with a designated member of the Patient Relations staff...The physician should provide facts that accurately describe the chain of events ... The physician should include the following information:
The nature of the change in the health status or injury that occurred. The event that caused the change in health status. The treatment given for the injury....
The Attending physician is required to document in the medical record that a discussion occurred, the time and date of the discussion, that the patient was informed of the results of treatment and procedures, and any advice given the patient. Follow-up conversations should also be documented.
In the event that efforts made to contact the patient and/or family/significant other(s) are unsuccessful, these efforts will be documented in the medical record."

Review of medical record for Patient #1 revealed: A 93-year-old patient who was evaluated in the Emergency Department on 11/9/2019 after a fall at home. The patient was diagnosed with a left subdural hematoma (a collection of blood between the covering of the brain and the surface of the brain) but required no acute neurosurgical intervention. The patient was admitted to a Stepdown Unit.

On 11/12/2019, at 5:02 pm, the patient was found on the floor with a left periorbital hematoma (bleeding into the tissue surrounding the eye). A CT scan of patient's face revealed "multiples left maxillofacial (pertaining to the jaws and face) fractures."

There was no documented evidence that the patient's next of kin/representative was notified of the fall incident and the patient's health status.

On 01/09/2020 at 11:36 am, during an interview with Staff C (Associate Director of Critical Care) he confirmed that the patient's next of kin or a representative was not notified and stated that it was an oversight.

On 01/13/2020 at 3:30 pm, these findings were brought to the attention of facility's administrative personnel during the survey exit conference.
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Based on medical record review, document review, and interview, in 1 of 15 medical records reviewed, the facility did not ensure safety precautions implemented for a patient identified at risk for falls were effective (Patient #1).

This failure may place patients at risk for fall and injury.
Findings include:

Review of medical record for Patient #1 revealed a 93-year-old patient who was evaluated on 11/09/2019 after a fall at home and was admitted with a diagnosis of Subdural Hematoma (a collection of blood between the covering of the brain and the surface of the brain). The Initial Nursing Assessment upon admission revealed the patient was alert and oriented to place, person, time and situation. The patient was identified as a high risk for fall evidenced by a Morse Fall Risk Score of 60 (Morse Fall Score predicts the risk of falling based on personal fall history, mental status and other risk factors. A score of 50 and above indicates a high risk for fall). The fall prevention measures implemented for the patient included, placement of a yellow identification band and yellow non-skid socks, every 15 minutes visual checks and bed alarm for safety.

On 11/10/2019 at 2:50 pm, a physician ordered the patient be placed on strict bedrest.

On 11/12/2019 at 5:02 pm, the patient was found on the floor between his bed and the bathroom. The patient sustained a left periorbital hematoma (bleeding into the tissue surrounding the eye). CT scan of patient's face revealed "multiples left maxillofacial (pertaining to the jaws and face) fractures."

On 01/10/2020 at 11:36 am, during an interview with Staff C (Associate Director of Critical Care) he stated that the nurse did not respond to the patient because she did not hear the bed alarm go off.

On 01/09/2020 at 02:04 pm, during an interview with Staff E (RN, Director of Nursing, Performance Improvement), she stated that some nurses have complained that bed alarms are not loud enough and sometimes they cannot hear them. The staff acknowledged that the bed alarms have not been fixed or replaced.

Review of "Fall Risk Assessment/Prevention" policy last revised January 2019 revealed that "All patients determined to be at risk for falls will have preventive measures instituted."

There was no indication that the continued use of bed alarms as an effective fall preventive measure were evaluated.

On 01/13/2020 at 3:30 PM, these findings were brought to the attention of the facility's administrative personnel during the survey exit conference.