HospitalInspections.org

Based on document review, observation and staff interview, the director of nursing failed to ensure nursing staff labeled the medical record and provided door signage as required per policy for 2 of 2 patients identified as high risk for falls (patients #4 and #6).

Findings include:

1. Review of patient #4 medical record indicated the following:
(A) The patient was admitted to the BHU on 1/30/11.
(B) He/she was documented as a high risk for falls since admission and plan of care included fall precautions.
(C) The medical record lacked evidence of a fall risk sticker on the front of the chart per policy.

2. Review of patient #6 medical record indicated the following:
(A) The patient was admitted to the BHU on 1/26/11.
(B) He/she was made a high risk for falls after a fall on 1/27/11 and plan of care included fall precautions.

3. Facility policy titled "Falls Precaution" last reviewed/revised 3/09 states on page 1: "Behavioral Health Falls Precaution Interventions: ..........8. Label front of chart with "Fall Precautions" sticker." and "18. Place "Falling Leaves" sign at entry to patient's room."

4. During tour of the BHU at 3:15 p.m., the following was observed:
(A) Patients #4 and #6 did not have a falling leaves sign on their door as indicated in policy for high risk patients.

5. RN #1 indicated the following in interview at 3:20 p.m.:
(A) All patients on the unit are considered high risk for falls.
(B) He/she verified lack of signage on doors for patients #4 and #6 and lack of a fall risk sticker on the chart for patient #4.

Based on medical record review, the facility failed to ensure the medical record for 1 of 3 discharged patients contained complete and accurate documentation (patient #1).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) The patient was admitted to the behavioral health unit BHU on 9/23/10.
(B) A fall on 9/27/10 resulted in rib fractures and a hip fracture.
(C) Per family request, the patient was transferred to facility #2 for treatment of the hip fracture.
(D) The patients discharge summary was not accurate. The document states on page 2: "...Meanwhile, the patient was seen to be doing good and as such it was decided that the patient will be discharged *------*." The blank was not filled in and the document did not indicate that the patient had a fall resulting in fractures and was transferred to another acute care facility.

Based on document review and staff interview, the facility failed to ensure the medical staff completed the medical record within 30 days following discharge for 3 of 3 patients (patients #1-3).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) The patient was admitted to the behavioral health unit BHU on 9/23/10 and discharged on 9/29/10.
(B) His/her discharge summary was dictated on 11/11/10.

2. Review of patient #2 medical record indicated the following:
(A) The patient was admitted to the BHU on 3/1/10 and discharged on 3/19/10.
(B) His/her discharge summary had two (2) blanks that were not filled in by the physician prior to signing the document on 4/5/10.

3. Review of patient #3 medical record indicated the following:
(A) The patient was admitted to the BHU on 3/11/10 and passed away on 3/20/11.
(B) His/her discharge summary was not dictated until 5/16/10.

4. Staff member #1 verified the above at 4:45 p.m.

Based on interviews and document review, the infection control officer failed to ensure policies/procedures were developed and implemented for the cleaning/disinfection of rooms occupied by patients with Clostridium Difficile (C-diff).

Findings include:

1. Staff member #3 indicated the following in interview at 12:50 p.m.:
(A) The facility does not have a specific policy for C-diff.
(B) The facility uses Clean-cide for isolation rooms.

2. Review of MSDS sheet for Clean-cide indicated the product is a ready to use germicidal detergent. The product is EPA registered, however is not effective against C-diff.