HospitalInspections.org

Based on medical record (MR) review, document review and interview, in 4 (four) of 5 (five) medical records, the nursing staff failed to consistently document the implemented interventions and patient responses for patients placed on Enhanced Care (EC)/Enhanced Supervision (ES) [prevention strategies for patients at risk for falls or other types of injuries that include more frequent observation/monitoring] as per hospital policy.

This lack of consistent documentation could potentially impact the continuity of patient care.

Findings included:

The facility's policy and procedure (P&P) titled "Constant Observations/Enhanced Supervision" last revised 9/9/19 stated: "... Enhanced Supervision ... [required] documentation: (1) Plan of care must include ...a safety goal with an appropriate outcome...supervision intervals on patient...(2) Documentation on patient's response must: (a) Occur a minimum of once per 12 hours, (b) State why and when the patient was placed on ES, (c) Describe the patient's behaviors while on ES, and (d) State that the patient was observed at the planned intervals throughout the shift ..."


Review of Patient #1's MR identified the following information: This 94-year old patient with a history of Vascular Dementia since 2012, was brought to the hospital on 11/30/19, after her power of attorney called 911 because the patient was increasingly confused and wandering outside.

The patient was diagnosed with Progressive Dementia. The physician History/Physical dated 11/30/19 at 6:45 PM stated the patient was "alert, oriented to person and place but unable to state the date or year." The nurse practitioner assessment note dated 12/1/19 at 2:39 PM stated Patient #1 "was confused, had difficulty concentrating...making decisions and...remembering."

The physician admitted the patient and ordered a "fall risk protocol" on 11/30/19 which the nursing staff initiated on 12/1/19. The physician then placed an order for Enhanced Supervision (ES) on 12/4/19, which was reordered on 12/5/19.

The nursing "Adult Plan of Care: Progress Summary" dated 12/2/19 at 4:16 AM stated Patient #1 was " ...disoriented to place and situation ...frequent rounding/bed alarms and Enhanced Care [EC] implemented to ensure safety as patient likes to wander and sit in the bathroom for long periods ... continue to hourly round ..."

The nursing "Adult Plan of Care: Progress Summary" dated 12/2/19 at 3:50 PM stated "...patient out of bed and ambulated ...confused and restless at times...."
but did not identify if Patient #1 was still receiving EC.

Nursing staff documentation identified Patient #1 was on EC daily on 12/3/19, 12/4/19 and 12/5/19, but no documentation of the patient's response, why/when the patient was placed on EC, the patient's behaviors during EC, or that the patient was observed at the planned intervals throughout the shift, were found.

The same lack of required EC documentation was found in the MRs for Patient #s 24, 25 and 26.

These findings were discussed with Staff A (Chief Nursing Officer) on 12/4/19 at 9:30AM.

Based on observation, medical record (MR) review and interview, in 3 (three) of 7(seven) MRs reviewed, the facility failed to consistently implement their Fall Risk Protocol.

This lack of consistent Fall Risk Protocol implementation may place patients at an increased risk for falls.

Findings included:

The facility policy and procedure (P&P) titled "Fall Prevention: Inpatient/Resident," last reviewed 1/25/17, stated "[For] all inpatients/residents who are assessed as being at risk for falls....the plan of care should be documented in the appropriate areas in the medical record..Fall Risk Interventions include 'Provide visual cues: Yellow wrist band, Red Socks, and Room Signage (Red Sock Sign)...Patient's needs: Use of alarm(s) options: bed, voice tab, chair alarm'."

Observations in the facility's 5 (five) North Unit on 12/4/19 between 10:30AM and 12:00PM, Patient #20, identified as a Fall Risk, was observed standing by the window. Bed and/or chair alarms were not triggered.

Per interview of Staff H (Nurse Manager) at the time of observation, Staff H stated that Patient #20 "gets agitated if the bed and/or chair alarms are on," therefore the alarms were not activated for this patient, but should have been.

Review of Patient #20's MR identified that staff documented the following safety interventions daily on 12/2, 12/3, and 12/4/19, "All alarm(s) activated and audible." There was no documentation stating that Patient #20 had refused the activation of alarms, or that alarms had not been activated.
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Review of Patient # 21's MR identified the following: This patient was admitted after a fall at home. The physician ordered the Fall Risk Protocol on 12/3/19 at 3:17AM while in the Emergency Room. The nursing assessment dated 12/3/19 at 8:56AM identified that a Fall Risk Assessment was completed. The nursing assessment and interventions identified that the patient was placed on Fall with Harm Risk Interventions on 12/4/19 at 2:16AM.

Observations in the facility's 5 (five) North Unit during the afternoon of 12/4/19, identified there was no Fall Risk Protocol signage posted for Patient #21.

These findings were confirmed by Staff H and Staff C (Quality Management Coordinator) at the time of observation.

Similar findings of missing fall risk signage were identified for Patient #8 during observations in the facility's 9 South Unit on 12/3/19 at 10:45AM.

This was observed in the presence Staff D (Senior Administrative Director of Nursing Services) who confirmed the findings at the time of the observation.