HospitalInspections.org

A. Based on medical record review and staff interview, it was determined in 4 of 8 (Pts #3, #5, #6, #7) medical records reviewed, in which the patient had a bed or a chair alarm on prior to sustaining a fall, the Critical Access Hospital (CAH) failed to ensure bed and chair alarms were maintained in operating condition.

Findings include:

1. The medical record of Pt #3 was reviewed on 6/28/11. Pt #3 was admitted to the CAH on 2/7/11 with the diagnosis Diverticulitis Colon without Hemorrhage and had a bed alarm on due to disorientation. On 2/8/11 at 1:30 PM, nursing documentation indicated Pt #3 was "found next to bed on back... unable to state what happened." There was no documentation to indicate that the bed alarm had alarmed or what brought the staff member into the patient room.

2. The medical record of Pt #5 was reviewed on 6/28/11. Pt #5 was admitted to the CAH on 5/30/11 with the diagnosis Pneumonia. On 6/5/11 at 8:05 AM, nursing documentation indicated "Slid to floor out of chair. Alarm on but didn't alarm. No injury." There was no documentation to indicate corrective action related to the nonfunctioning chair alarm was taken.

3. The medical record of Pt #6 was reviewed on 6/28/11. Pt #6 was admitted to the CAH on 10/26/10 with the diagnosis Food/ Vomit Pneumonitis and had a bed alarm on due to disorientation. On 10/29/10 at 9:51 AM, nursing documentation indicated "Physical Therapy Assistant saw Pt #6 falling." There was no documentation to indicate whether the alarm was on or off prior to the fall. There was no documentation to indicate the alarm was functioning.

4. The medical record of Pt #7 was reviewed on 6/28/11. Pt #7 was admitted to the CAH on 11/18/10 with the diagnosis Urinary Tract Infection. On 11/19/10 at 3:20 AM, nursing documentation indicated "Bed alarm on. "Heard thump" and "Help" and Pt #7 was on the floor with Foley. There was no documentation to indicate the bed alarm had alarmed.

5. During a staff interview, conducted with the Chief Executive Officer on 6/28/11 at 4:30 PM, the above findings were confirmed.

A. Based on a review of CAH policies, medical record review, and staff interview, it was determined in 3 of 8 (Pts #1, #2, #6) medical records reviewed, in which the patient sustained a fall, the CAH failed to ensure both the physician and family were notified, as per CAH policy.

Findings include:

1. The policy titled " Occurrence and Medication Error Reporting " was reviewed on 6/28/11. It indicated " Procedure: Injuries: 1. Inpatient and Outpatients: a. Notify the physician ... " The policy titled " Fall Prevention Procedure " was also reviewed. It indicated " Post Fall Follow Up: 12. Document what occurred in the medical record including: ...e. Medical provider notification. f. Medical/ nursing actions and results of the actions. g. Family notification if applicable ... 14. Notify the physician if injuries are noted. 15. Notify the patient ' s family ... "

2. The medical record of Pt #1 was reviewed on 6/28/11. Pt #1 was admitted to the CAH on 9/19/10 with the diagnoses Pneumonia and Pulmonary Fibrosis and sustained a fall on 9/21/10 at 3:00 AM. There was no documentation to indicate the physician or the family were notified.

3. The medical record of Pt #2 was reviewed on 6/28/11. Pt #2 was admitted to the CAH on 1/13/11 with the diagnosis Other Convulsions and sustained a fall on 1/14/11 at 12:00 PM. There was no documentation to indicate the family was notified.

4. The medical record of Pt #6 was reviewed on 6/28/11. Pt #6 was admitted to the CAH on 10/26/10 with the diagnosis Food/ Vomit Pneumonitis and sustained a fall on 10/29/10 at 9:51 AM. There was no documentation to indicate the family was notified.

5. During a staff interview, conducted with the Chief Executive Officer on 6/28/11 at 4:30 PM, the above findings were confirmed.


B. Based on medical record review and staff interview, it was determined in 3 of 3 (Pts #1, #4, #7) medical records reviewed, in which the patient sustained a fall with subsequent injury requiring dressing changes, the CAH failed to ensure orders for wound care were obtained.

Findings include:

1. The medical record of Pt #1 was reviewed on 6/28/11. Pt #1 was admitted to the CAH on 9/19/10 with the diagnoses Pneumonia and Pulmonary Fibrosis and sustained a fall on 9/21/11 at 3:00 AM which led to the following skin tears: 4 cm x 2 cm above the elbow that the skin is missing, and just below that a 4 cm slit in the skin that was approximated and steri-stripped. On forearm, a 15 cm x 5 cm area and 6 cm area that the skin is missing, below that a 6 cm slit in the skin that was approximated and steri- stripped. A 7 cm half moon slit in the skin that was approximated and steri-stripped. Telfa pads applied to raw areas and wrapped with Kerlix. There is a bruised area on the top of the left shoulder that was seeping, cleansed and OpSite applied to protect area from further damage. It further indicated that a similar dressing was applied at 10:24 AM that same morning. There was no physician order for the wound care.

2. The medical record of Pt #4 was reviewed on 6/28/11. Pt #4 was admitted to the CAH on 5/12/11 with the diagnoses Increased Weakness, Early Dementia, and Dehydration and sustained a fall on 5/13/11 at 5:00 AM which led to a 4 cm skin tear to the left hand/ wrist/ forearm. Nursing documentation indicated "Cleanse with saline and applied OpSite to areas." There was no physician order for the wound care.

3. The medical record of Pt #7 was reviewed on 6/28/11. Pt #7 was admitted to the CAH on 11/18/10 with the diagnosis Urinary Tract Infection and sustained a fall on 11/19/10 at 3:40 AM which led to a 3.8 cm by 1.0 cm skin tear left forearm. Nursing documentation indicated "Cleanse with saline and applied OpSite." On 11/19/10 at 8:33 AM, nursing documentation indicated "Allevyn left forearm." There was no physician order for either of these wound cares.

4. During a staff interview, conducted with the Chief Executive Officer on 6/28/11 at 4:30 PM, the above findings were confirmed.

C. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 3 of 3 (Pts #1, #4, #7) medical records reviewed, in which the patient sustained a fall with subsequent injury requiring dressing changes, the CAH failed to ensure wounds were measured and dressings were documented every shift, as per CAH policy.

Findings include:

1. The policy titled " Wound Management " was reviewed on 6/28/11. It indicated " 2. Skin Tear/ Abrasions: a. Monitor for changes in skin integrity every shift. b. Notify physician of tear/ abrasion and follow prescribed treatment which may include transparent dressing, antibiotic ointment, foam or gel dressings, etc. c. Document each shift: i. Location, ii. Measurement, iii Intact dressing, if present, iv. Drainage, if present, Periwound skin appearance, v. Signs of infection ... "

2. The medical record of Pt #1 was reviewed on 6/28/11. Pt #1 was admitted to the CAH on 9/19/10 with the diagnoses Pneumonia and Pulmonary Fibrosis and sustained a fall on 9/21/11 at 3:00 AM which led to the following skin tears to the left arm. Pt #1 required twice a day dressing changes to the left forearm (which also had areas with steri-strips) and had an OpSite to the left shoulder. Nursing documentation failed to include documentation of wound measurements every shift except for the time of the fall and on 9/24/10 at 7:50 AM. The presence, absence, condition of the opsite and steri strips was not documented every shift.

3. The medical record of Pt #4 was reviewed on 6/28/11. Pt #4 was admitted to the CAH on 5/12/11 with the diagnoses Increased Weakness, Early Dementia, and Dehydration and sustained a fall on 5/13/11 at 5:00 AM which led to a 4 cm skin tear to the left hand/ wrist/ forearm. Nursing documentation indicated "Cleanse with saline and applied OpSites to areas." There were no measurements after the initial injury. There was no documentation of the presence or absence of skin tears after 5/17/11.

4. The medical record of Pt #7 was reviewed on 6/28/11. Pt #7 was admitted to the CAH on 11/18/10 with the diagnosis Urinary Tract Infection and sustained a fall on 11/19/10 at 3:40 AM which led to a 3.8 cm by 1.0 cm skin tear left forearm. Nursing documentation indicated "Cleanse with saline and applied OpSites." On 11/19/10 at 8:33 AM, nursing documentation indicated "Allevyn left forearm." There was no documentation of wound measurements the shift after the fall or with the change of the dressing to the wound.

5. During a staff interview, conducted with the Chief Executive Officer on 6/28/11 at 4:30 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 1 of 8 (Pt #4) medical records reviewed, the CAH failed to ensure verbal orders were put into writing and signed by the physician.

Findings include:

1. The medical record of Pt #4 was reviewed on 6/28/11. Pt #4 was admitted to the CAH on 5/12/11 with the diagnoses Increased Weakness, Early Dementia, and Dehydration and sustained a fall on 5/13/11 at 5:00 AM. Nursing documentation indicated the physician was notified at 6:07 AM "Doctor order bed alarm at all times." There was no documentation to indicate that this order was put into writing and signed by the physician.

2. During a staff interview, conducted with the Chief Executive Officer on 6/28/11 at 4:30 PM, the above finding was confirmed.