HospitalInspections.org

Based on surveyor record review and interview with nursing staff, the facility failed to ensure nursing staff developed and kept current a nursing care plan that reflected and addressed the increasing needs of patient #1.

The findings include:

1. On 12/19/20 at 0920, documentation by nursing staff gave a summative Glasgow Coma Scale total of 14. Approximately two days later and two days before the patient's fall, the patient's GCS total was documented as 3.

2. A score of 14 on the Glasgow Coma Scale indicated a mild impairment. A GCS score of 3 is an indication of severe brain impairment. A drop from 14 to 3 shows a significant deterioration in patient #1's condition.

3. Patient #1's inpatient room was located at the far end of the Covid-19 inpatient holding area hallway, near the facility fire exit doors. At no time during hospitalization did patient #1's room change to a room closer to the Covid-19 patient unit nursing station.

4. Patient #1 care plan did not change to incorporate increased monitoring, despite increase confusion, agitation, and the administration of additional sedative medications.

5. After patient #1 fell, nursing staff failed to document a post-fall physical assessment addressing the potential for a head injury and possible head bleed. The patient was at an increased risk for these types of injuries due to the patient's critical low platelet count of 68/l on 12/31/20.

Findings were validated by CNO during facility tour. CNO stated, "Yes his room was the last one on this hallway."