HospitalInspections.org

Based on observation, interview and record review the hospital failed 1 of 1 Patient (Patient #1) the right to receive care in a safe setting.

Findings Include:

During observation of video footage Patient #1 fell out of the wheelchair to the ground in the hallway reaching for the telephone, as Patient #1 was half seated in the wheelchair.

During interview Staff #1 reported Patient #1 had multiple falls that she was made aware, but were not initally witnessed. During interview Staff #1 stated that Patient #1 was found in the hallway, but it was an unwitnessed fall.

During Record Review the 'Incident Report" provided by Staff #1 indicated this was the hospital investigation of the event. "On 12/27 at or around 2045 Patient #1 was found on the floor sitting beside bed. Patient #1 was confused and disruptive. Patient #1 was taking off clothes, throwing self out of bed and stating wanted out of bed. Patient #1 was assisted back to bed via a Hoyer lift and placed on increased fall precautions. Patient #1 denied pain at the time and Neuro checks were within baseline for patient.
On the morning of 12/28/2022 at 0900 patient was noted to be lethargic, refusing to take food or water. Refused to take medications, Staff ##7 notified, orders received for Covid test and to send out to ER for evaluation. Patient #1 was admitted to hospital for UTI and Covid symptoms. On 12/28/2022 patients son called stating patient also has a broken femur. He is requesting medical records. He is not the POA, but have the same name ...Patient admitted to hospital Covid, UTI, and broken femur ...Facts within 2 hours prior to incident: 'Patient had been quite, no signs of aggression or disruptive behavior ...Precautions Ordered prior to incident: Aggression Precautions, Fall Risk."

During record review after the first fall Patient #1's fall was witnessed by Staff #3. Staff #3 reported there was an order for Patient #1 to be placed on Q5 minute observations. The record review reflected the order written in the 'Final Ancillary Orders' (non-med) dated 12/26/2022 at 1200, reflected, "Level of Observation Q5 minute directed on 12/26/2022 at 11:37. Esigned on 12/26/22 at 11:38AM. Comments: Strict Q5 Safety Check."

During Record Review the hospital Q15 observation sheets from the time Patient #1 fell on 12/26/22 through 12/29/2022. The hospital staff failed to follow its own Policy and follow the doctors orders violating the Patient Rights of Care in Safe Setting.

During Record Review the (Q15 Minute Observation Sheets) failed to reflect the Q15 minute observations were changed to every 15 inutes to every 5 minutes.

During Record Review the hospital Nursing Notes reflected that Pateint #1's FHS Orders were reviewed prior to shift change. The medical nursing staff failed to change the level of observation.

During Interview with Staff #3 was asked if the Orders for the level of Observation were changed backed to Q15 minute cchecks. Staff #3 responded, NO!

Policy
The hospital Policy on Patient Rights dated 03/2021 reflected, "For the purposes of this policy, a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patients representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 41 CFR 489. A complaint is defined as a form of verbal communication from the patient or the patient's representative individuals dissatisfaction with services and the dissatisfaction is able to be resolved by the staff present at the time of the verbal complaint."

The hospital Policy on Abuse 04/2021 reflected, "Mayhill Hospital will maintain an environment free of abuse and neglect. All potential new employees will be screened for a history of abuse ...Screening of potential employees includes requesting information from previous and/or current employers and verifying information through background checks. Potential employees will be hired after screening has been conducted ...It is the policy of Mayhill Hospital to report alleged and suspected abuse and neglect to the Texas Department of Health and appropriate authorities in accordance with state and federal statues'. The staff members who conduct's the screening and has cause to suspect abuse has occurred is legally response for reporting ...Prevention of abuse will be communicated to families and staff. They are encouraged to report concerns, incidents, and grievances without fear of retribution and will be provided with feedback regarding the concerns that have been expressed."

The hospital policy on Nursing Services 04/2021 reflected, "Each clinical discipline maintains policies which define the process of data collection for patient assessment that guides their decision making in meeting patient care needs."

The hospital policy on Falls Prevention and Reduction 04/2021 reflected, "To prevent falls by creating a safe environment.
B. Assess patients at risk for falls and place on appropriate precautions.
b. Special signage will be used to alert staff of increased risk for falls.
c. Patients will wear shoes or non-skid socks.
d. Patient will be placed in a low bed when appropriate.
e. Patient will use bed alarms if appropriate.
D. Communication will take place informing all staff members of the level of precautions to be taken for each patient.
1. Label the patient chart for fall precautions
2. Oncoming shift staff members will be notified of fall precautions level during each change of shift report.
E. Implement interventions based on appropriate level."

The hospital Policy on Patient Observation 04/2021 reflected, "To ensure patient safety as well as, to provide a process for observing and documenting patient location and behavior."

The hospital Policy on Interdisciplinary Master Treatment Plan 02/2021 reflected, "Each patient shall have a written individualized inter-disciplinary master treatment plan facilitate the patient individualized, active treatment while at Mayhill hospital. This treatment plan will be responsive to patient specific needs, will reflect the patients participation and will address discharge criteria and discharge plan.
N. As new onset of conditions occur in a patient's treatment, Interdisciplinary Treatment Plan will be updated to reflect these changes."

Based on Record Review, Observation, and Interview the hospital failed 1 of 1 Patient (Patient #1) by failing to include any changes in the patient's condition.


Findings Include:

During record review the hospital failed to comply with the doctors orders and change the level of observation written by Staff #3. The Final Ancillary Orders (non-med) dated 12/26/2022 at 1200, reflected, "Level of Observation Q5 minute directed on 12/26/2022 at 11:37. Esigned on 12/26/22 at 11:38AM. Comments: Strict Q5 Safety Check." Prior to this order, Patient #1 was on Q15 minute observations."

During record review Patient #1 fell at a minimum of three (3) times. The hospital Progress Note on 12/26/2022, reflected, "At, 1130 in the morning, patient fell in front of the nurses station. The Hospital AM Nursing Assessment/Progress Note on 12/26/2022, "at 1555 Bernette presents alert but confused throughout the shift. She will typically e seen minimizing to self. Wandering around the unit. Patient presents loud, disruptive and impulsive this shift, difficult to redirect. Patient found laying in the hallway."The Hospital PM Nursing Assessment Progress Note on 12/27/2022 at 2130, "Bernette, awake in her room, alert and presents with confusion which is very disruptive/impulsive, patient cannot be redirected as she screaming very loud, Patient throws self on the floor and only wants to get out and keeps removing clothes."

During record review of the hospital Master Treatment Plan, The nursing Plan was not updated in accordance to the hospital Policy and Procedures.

During Interview with hopsital Staff #1, and Staff #2, were asked why the hospital nursing staff have failed to change the level of observation. Staff #1 and Staff #2 were unable to answer.

During Interview with hospital Staff #1 and Staff #2, they were shown that their hospital nursing sheet reflects verifying the review of the doctors orders on the nursing sheet. However, the level of observation was never changed to provide appropriate care for Patient #1 from Q15 minute observations to Q5 minute observations.

During observation of the hospital video footage there was no visual evidence that reflected physical abuse.

Policy

The hospital Policy on Patient Rights dated 03/2021 reflected, "For the purposes of this policy, a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patients representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 41 CFR 489. A complaint is defined as a form of verbal communication from the patient or the patient's representative individuals dissatisfaction with services and the dissatisfaction is able to be resolved by the staff present at the time of the verbal complaint."

The hospital Policy on Abuse 04/2021 reflected, "Mayhill Hospital will maintain an environment free of abuse and neglect. All potential new employees will be screened for a history of abuse ...Screening of potential employees includes requesting information from previous and/or current employers and verifying information through background checks. Potential employees will be hired after screening has been conducted ...It is the policy of Mayhill Hospital to report alleged and suspected abuse and neglect to the Texas Department of Health and appropriate authorities in accordance with state and federal statues'. The staff members who conduct's the screening and has cause to suspect abuse has occurred is legally response for reporting ...Prevention of abuse will be communicated to families and staff. They are encouraged to report concerns, incidents, and grievances without fear of retribution and will be provided with feedback regarding the concerns that have been expressed."

The hospital policy on Nursing Services 04/2021 reflected, "Each clinical discipline maintains policies which define the process of data collection for patient assessment that guides their decision making in meeting patient care needs."

The hospital policy on Falls Prevention and Reduction 04/2021 reflected, "To prevent falls by creating a safe environment.
B. Assess patients at risk for falls and place on appropriate precautions.
b. Special signage will be used to alert staff of increased risk for falls.
c. Patients will wear shoes or non-skid socks.
d. Patient will be placed in a low bed when appropriate.
e. Patient will use bed alarms if appropriate.
D. Communication will take place informing all staff members of the level of precautions to be taken for each patient.
1. Label the patient chart for fall precautions
2. Oncoming shift staff members will be notified of fall precautions level during each change of shift report.
E. Implement interventions based on appropriate level."

The hospital Policy on Patient Observation 04/2021 reflected, "To ensure patient safety as well as, to provide a process for observing and documenting patient location and behavior."

The hospital Policy on Interdisciplinary Master Treatment Plan 02/2021 reflected, "Each patient shall have a written individualized inter-disciplinary master treatment plan facilitate the patient individualized, active treatment while at Mayhill hospital. This treatment plan will be responsive to patient specific needs, will reflect the patients participation and will address discharge criteria and discharge plan.
N. As new onset of conditions occur in a patient's treatment, Interdisciplinary Treatment Plan will be updated to reflect these changes."