HospitalInspections.org

Based on the follow-up visit, observational tour of the Medicine/Surgery ward, record review and interview with the Infection Control Nurse (employee #5) and Director of Nursing (employee #6), it was determined that the facility failed to provide care in an environment that is considered to be a safe setting related to appropriate surveillance related to falls and failed to ensure that patients are protected in a proper and secure manner at the emergency room.

New Deficiency.

Findings include:

1. During the record review of the Medicine/Surgery ward with the Infection Control Nurse (employee #5) on 10/24/12 from 10:35 am through 11:45 am, the following was determined:

a. R.R #20 is a 78 years old female evaluated at the emergency room on 10/19/12 at 3:37 pm and admitted to the Medicine ward on 10/19/12 with a diagnosis of Acute Coronary Syndrome. The patient was placed in the bed and stayed in the emergency room until 10/19/12 in the Intensive Care Unit (ICU #2) from 10/23/12 because no rooms with telemetry were available in the medicine ward. The patient was receiving care in the emergency room and the evaluation of fall risk was performed on 10/19/12 at 3:37 pm, in accordance with the patient's evaluation, it has eight points based on the criteria, the intervention levels for this evaluation requires nursing rounds every 30 to 60 minutes, however no evidence of these nurses rounds were found. According with a nurse (employee #4) on 10/24/12 at 11:00 pm, nursing notes from 10/22/12 at 2:05 pm, the patient is disoriented and she jumps from the bed and fell down, the nurse's notes provided evidence that she placed the patient in her bed and was evaluated by the physician (employee #1) and called the physician (employee #2) and the telephone order was received (the nurse's notes did not describe the physician orders). Nursing notes provided evidence that at 2:30 pm that the patient pulled out her intravenous (IV) lines and the nurse canalized her and administered medications but did not write what kind of medications she administered according with the physicians' order. The nurse's notes on 10/22/12 at 6:00 pm provided evidence that the patient was pending to perform a CT scan and head X-ray. On 10/23/12 at 7:25 am the patient was transferred to the Cardiovascular Laboratory to perform a Left Heart Catheterism then went to the emergency room. On 10/23/12 at 9:20 pm the nurse's notes provided evidence that the patient was admitted to the Medicine Ward and continued with Tridil at 3 ml./hour, Foley catheter, oxygen at 2 liters per minutes and telemetry however, the nurse's notes provided evidence that no telemetry monitors were available and she notified the physician and he referred to place a telemetry when available.

b. The facility failed to activate "Fall Prevention Protocol" on 10/22/12.

c. On 10/14/12 at 12:05 pm the patient was visited and was observed a laceration on the right ear and right arm. The patient was interviewed and she stated: "I fell at the emergency room but I do not know how it was because I was feeling bad and was like stunned. Thanks to God I feel better". No evidence was found of the nurse's and physician's documentation related to the patient's laceration and skin treatment.

d. The patient's daughter was interviewed and she stated during the interview on 10/24/12 at 12:05 pm "When my mother fell down she was alone because I had to leave to do some personal things. When I return at 5:00 pm I saw her sleepy I ask the nurse how was my mother and she said that she was ok and we administered "Xanax" because she was taking out her IV line. Then the physician called me because they were going to perform a head study and he told me she fell".

e. No evidence was found on 10/24/12 at 1:30 pm of the incident reported at the QAPI committee to determine if the hospital is identifying the problem and performing evaluations to take measures to ensure patient's safety.