HospitalInspections.org

Based on record review and interview the facility failed to


A. include the patient and patient's identified care giver in the care plan developed for 1 (Patient #1) of 13 patients.

Refer to A 0130


B. ensure the Registered Nurse provided proper assessment and nursing intervention for 1 (patient #1) of 13 patients who complained of pain in his right hip following a number of falls. Patient was ambulatory on admission and was unable to bear weight upon discharge. Patient fractured his Right hip while hospitalized and Nursing failed to provide appropriate assessment or intervention.

Refer to A 0144

Based on record review and interview, the facility failed to include the patient and patient's identified care giver in the care plan that was developed for 1 (Patient #1) of 13 patients

This deficient practice had the likelihood of affecting all patients of the hospital.


Findings:


On the morning of 7/6/2020 in the conference room, the medical record (MR) for patient (Pt/pt) #1 was reviewed. Documentation in the MR indicated that on 6/21/2020, at 9:20 PM, "Patient was found on floor in hallway by nurses station after reportedly having a seizure." The MR documentation indicated the Registered Nurse (RN) documented the following entry, "Upon assessment pt. was AAOX3 (Alert and orientated to person, place and events); vitals signs stable." Pt assisted into wheel chair by two staff members and taken to his room." "Dr. _____, (#9), physician on call, was notified as well as house Supervisor, Dr.______ (#9) ordered CT (Computed Tomography) of head; results were no acute intracranial abnormality." There was no alteration to the written care plan.

Pt #1, who previously had been an ambulatory patient, was found on the floor with no witness statement as to how he went from standing to lying on the floor. The review of the MR for this date and time revealed the RN failed to document an assessment of pt #1 post seizure status, and the RN did not document a physical evaluation of the patient's lower legs for range of motion, internal rotation or shortening of either leg which would indicate the presence fracture in the hip. No changes were entered pt #1's care plan.

Further review of the MR indicated that on 6/23/2020 at 5:12 PM, "He (pt #1) talked to wife and signed a release of information for her also." The RN did not document that pt #1's wife had been told of his seizure and unwitnessed fall 2 days earlier.

On 6/26/2020 at 8:55 AM, "Patient was at the med window when he slowly and deliberately lowered himself to the floor. He began kicking and waving his arms. He kept yelling, Please help me Jesus, I'm gonna go into a coma and die. I'm not faking this I have epilepsy. He continued moving about yelling as he was answering questions and repeating, I'm having seizure. B/P 130/84 pulse 129, oxygen saturation 97%. Patient was assisted to sitting position and encourage to slow his breathing. Dr #10 on the unit." No further assessment of post seizure status documented by the RN.

On 6/26/2020 at 1:15 PM the MR indicated, " While in the music group patient lowered himself to the ground and began to have another seizure. He was yelling out and waiving his arms stating, I'm not faking this is another seizure. I'm so embarrassed. He was assisted to a wheel chair. He stood up and continue to talk about the seizure that he was having." The RN did not document notification to the Physician of pt #1 "seizure" and did not document any assessment of pt #1's physical status after his declaration of seizure activity.

ON 6/26/2020 at 3:00 PM, "Patient was in music group and lowered himself to the floor. He began screaming that he was having a seizure and that he was not faking. He was assisted to the WC (Wheel chair) and taken to the day area. After group he was interacting (Sic) peers. Attention seeking behaviors continued. Dr. #10 notified. of behaviors and patient was placed on 1:1 for safety. Record review revealed no alterations to pt #1's medical care plan.

On 6/27/2020 at 1:30 PM, "Patient lowered himself to bathroom floor and began screaming and demanding pain medicine. PNA (Patient Nurse Aide) was there with patient and witnessed patient lowering self to the ground while holding on the sink and bathroom wall and the wheel chair. He continued to be disruptive and loud. He raised himself up and returned to the Wheelchair." The RN failed to document vital signs or any assessment or notify the physician or pt #1's ex-wife.

On 6/27/2020 at 2:00 PM, "pt is screaming and yelling saying that he is have (sic) Right hip pain. Offered patient his PRN Tylenol and he refused it saying, I want the big gun that starts with a "T" that you only give to people when they are yelling. Appears to be med seeking." The RN did not evaluate or otherwise assess pt #1 and did not act on his cry of pain or request for stronger pain medication. There were no entries identified in the medical care plan.

On 6/27/2020 at 2:37 an addendum was entered into the MR, "Patient screaming and yelling saying that he is having right hip pain. Offered patient his PRN Tylenol and he refused it saying, I want the big gun that starts with a "T" that you only give to people when they are yelling. Appears to be med seeking." The RN did not evaluate or otherwise assess pt #1 and did not act on his cry of pain or request for stronger pain medication. The RN failed to document a plan of nursing intervention to address pt #1's continued complaint of pain.

On 6/27/2020 at 9:10 PM, "Pt says that he fell down on the floor this afternoon, injured his Right hip and says that he is in pain. Pt did not even ask for any pain medication, checked his right hip without bruising or discoloration noted. Demanding that he needs to have a urinary catheter because as he says that it is the only way he can urinate. Pt was told that if he needs to use the bathroom, the staff will help him then replied, OK. Pt is trying to convince writer that he needs to be (sic) seen by a doctor because he is not feeling OK, but if the MD (medical doctor) doesn't come tonight he can wait until tomorrow. Rated his depression and anxiety at 10/10 because of what happened to him today." The RN failed to record the taking of vitals signs, or any physical assessment of pt #1's right leg and hip other than looking for a bruise. The RN declined to notify the physician regarding the patient complaint of fall or pain.

The 6/28/2020 the RN documented pt #1 slept through most of the day. He refused breakfast and lunch but accepted liquids. The RN failed to clarify if the liquid was water or a liquid nutritional supplement. No notification of Physician, or family on pt #1's behalf was identified.

On 6/28/2020 at 9:10 PM Pt still complaining that he is in pain due to his right hip injury that happened a couple of days ago but pt is not asking for his PRN pain medication and no bruising or swelling noted. The RN failed to notify the physician or the family or patient #1's continued compliant of pain. There was no physical assessment of mobility on pt #1's right hip.

6/29/2020 at 8:00 AM "Pt states that he is having some right hip pain due to falling in the bathroom. Pt states that he his his hip (sic) and it hurts to stand be he had been doing better and would like a walker to use today. Pt instructed that staff will accommodate him when they get a chance."

On 6/29/2020 at 2:05 PM, "Pt given discharge instructions...Pt assisted to the entrance with staff. Pt transport to home with facility transport.

On 6/29/2020 at 4:00 PM, a late entry was documented, "Received a message from patient's ex-wife regarding fall over the weekend. Attempted to call her back and did not get an answer. Message was left explaining encouraging her to take patient to the ER (Emergency Room) if he is reporting an inability to ambulate or pain in his hip. Contact number was provided and encouraged a return call if any questions or concerns may arise.

On 6/30/2020 at 11:40 AM. "Patient's ex-wife was called back regarding message received on 6/29 regarding fall and hip pain. ... Explained to her if she did not feel comfortable transporting him she could call 911 if there is no one that can transport him."

On the morning of 7/6/2020 in the conference room both of the hospital's transport staff were interviewed (staff #7 and #8). Both staff confirmed that pt #1 was unable to bear weight on his right leg. The transferred him into a wheel chair and rolled him to the base of the stairs required to access his mobile home. Both staff were required to lift him up the stairs with Pt #1 assisting to bear weight on his left leg. He was lifted in to the home and placed on a sofa. then they exited.

Transportation staff #1 confirmed the ex-wife questioned why Pt #1 wasn't walking. He instructed her to call the hospital and gain that information as he did not know.

On 7/6/2020 a review of the Emergency Department visit on June 30, 2020, confirmed, "There is acute displaced fracture of the greater trochanter and the base of the neck that makes it difficult to exclude underlying osteolytic lesion."

On 7/7/2020 an e-mail received from staff #1 indicated documentation had been located indicating a preplanning meeting had occurred where pt #1's wife was made aware of the care plan. A request was made of staff #1 to forward documentation that supported the pt and his wife were present either in person or by phone for the care planning meeting. No documentation was received.

The facility's nursing staff chose not to act on pt #1's complaint of pain. The staff did not recognize pt #1's change in condition and failed to notify both the physician and family member of the patient's change of condition. Pt #1 was ambulatory without restrictions at admission and non weight bearing on his right leg at discharge. The planning of care by the nursing staff failed to identify and include these changes in the daily treatment for pt #1.

Based on record review and interview, Nursing failed to ensure the Registered Nurse provided proper assessment and nursing intervention for 1 (patient #1) of 13 patients who complained of pain in his right hip following a number of falls. Patient was ambulatory on admission and was unable to bear weight upon discharge. Patient fractured his Right hip while hospitalized and Nursing never provided appropriate assessment or intervention.

This deficient practice had the likelihood to effect all patients of the facility.

Findings:

Review of the medical record (MR) of Pt #1 indicated he was initially seen in the facility Emergency Department under an emergency detention warrant. Pt #1 voluntarily signed himself into the facility the following morning. Pt #1 was ambulatory under his own power.

During the course of Pt #1's stay, at times exhibited bizarre behavior. His admission diagnosis included, a history of falls and seizures, bipolar disorder, schizophrenia, anti-social behavior. Pt #1 presented with paranoia. His lab work was positive for Methamphetamines and Tetrahydrocannabinol (THC).

Beginning 6/21/2020 documentation in the MR related that at 9:20 PM, "Patient was found on floor in hallway by nurses station after reportedly having a seizure." The MR documentation indicated the Registered Nurse (RN) documented the following entry, "Upon assessment pt. was AAOX3 (Alert and orientated to person, place and events); vital signs stable. Pt assisted into wheel chair by two staff members and taken to his room." "Dr._______( #9), physician on call, was notified as well as house Supervisor. Dr ______(#9) ordered CT (Computed Tomography) of head; results were no acute intracranial abnormality."

Pt #1, who previously had been an ambulatory patient, was found on the floor with no witness statement as to how he went from standing to lying on the floor. The review of the MR for this date and time reflected the RN failed to document an assessment of pt #1 post seizure status, and the RN did not document a physical evaluation of the patient's lower legs for range of motion, internal rotation or shortening of either leg which would indicate the presence of a fracture in the hip.

On 6/26/2020 at 8:55 AM, "Patient was at the med window when he slowly and deliberately lowered himself to the floor. He began kicking and waving his arms. He kept yelling, Please help me Jesus, I'm gonna go into a coma and die. I'm not faking this I have epilepsy. He continued moving about yelling as he was answering questions and repeating, I'm having seizure. B/P 130/84 pulse 129, oxygen saturation 97%. Patient was assisted to sitting position and encourage to slow his breathing. Dr #10 on the unit." No further assessment of post seizure status documented by the RN.

On 6/26/2020 at 1:15 PM the MR indicated, "While in the music group patient lowered himself to the ground and began to have another seizure. He was yelling out and waiving his arms stating, I'm not faking this is another seizure. I'm so embarrassed. He was assisted to a wheel chair. He stood up and continue to talk about the seizure that he was having." The RN did not document notification to the Physician of pt #1 "seizure " and did not document any assessment of pt #1's physical status after his declaration of seizure activity.

ON 6/26/2020 at 3:00 PM, "Patient was in music group and lowered himself to the floor. He began screaming that he was having a seizure and that he was not faking. He was assisted to the WC (Wheel chair) and taken to the day area. After group he was interacting (Sic) peers. Attention seeking behaviors continued. Dr. #10 notified. of behaviors and patient was placed on 1:1 for safety. No alterations to pt #1's medical care plan.

On 6/27/2020 at 1:30 PM, "Patient lowered himself to bathroom floor and began screaming and demanding pain medicine. PNA (Patient Nurse Aide) was there with patient and witnessed patient lowering self to the ground while holding on the sink and bathroom wall and the wheel chair. He continued to be disruptive and loud. He raised himself up and returned to the Wheelchair." The RN failed to document vital signs or any assessment or notify the physician.

The written complaint, submitted by the caregiver, reported pt #1 told his caregiver when he fell in the bathroom, the staff that was with him, told him to get up, he wasn't hurt and he could get up.

On 6/27/2020 at 2:00 PM, "pt is screaming and yelling saying that he is have (sic) Right hip pain. Offered patient his PRN Tylenol and he refused it saying, I want the big gun that starts with a "T" that you only give to people when they are yelling. Appears to be med seeking." The RN did not document an evaluation or otherwise assess pt #1 and did not act on his cry of pain or assess for a need for stronger pain medication. The RN did not notify the physician.

On 6/27/2020 at 2:37 pm, an addendum was entered into the MR, "Patient screaming and yelling saying that he is having right hip pain. Offered patient his PRN Tylenol and he refused it saying, I want the big gun that starts with a "T" that you only give to people when they are yelling. Appears to be med seeking." The RN did not evaluate or otherwise assess pt #1 for his continued complaint of pain, and did not assess for a valid need for stronger pain medication. The RN did not notify the physician.

On 6/27/2020 at 9:10 PM, "Pt says that he fell down on the floor this afternoon, injured his Right hip and says that he is in pain. Pt did not even ask for any pain medication, checked his right hip without bruising or discoloration noted. Demanding that he needs to have a urinary catheter because as he says that it is the only way he can urinate. Pt was told that is he needs to use the bathroom, the staff will help him, then replied, OK. Pt is trying to convince writer that he needs to (sic) seen by a doctor because he is not feeling OK, but if the MD (medical doctor) doesn't come tonight, he can wait until tomorrow. Rated his depression and anxiety at 10/10 because of what happened to him today." The RN failed to record the taking of vitals signs, or any physical assessment of pt #1's right leg and hip other than looking for a bruise. The RN failed to notify the physician regarding the patient request to see a Dr. or notify the Dr. of his complaint of pain.

On 6/28/2020, the RN documented pt #1 slept through most of the day. He refused breakfast and lunch but accepted liquids. The RN failed to clarify if the liquid was water or a liquid nutritional supplement. No notification of Physician, or family on pt #1's behalf was identified.

6/28/2020 at 4:20 PM, staff RN #11 documented, Patient remains 1:1. He has slept most of the day. He did wake up to take his scheduled meds. He woke up complaining that he couldn't urinate and was demanding a catheter. He then demanded the staff carry him to the bathroom because he couldn't walk. He was able to hop from the w/c (Wheel Chair) to the bathroom and was able to void without difficulty...." Again staff RN #11 failed to document an assessment of pt #1's inability to bear weight. No vital signs were recorded and no communication with the physician regarding pt #1 refusal to weight bear or complaint of pain was documented.

On 6/28/2020 at 9:10 PM, Pt still complaining that he is in pain due to his right hip injury that happened a couple of days ago but pt is not asking for his PRN pain medication and no bruising or swelling noted. The RN failed to notify the physician or the family or patient #1's continued complaint of pain. There was no physical assessment of mobility on pt #1's right hip.

6/29/2020 at 8:00 AM "Pt states that he is having some right hip pain due to falling in the bathroom. Pt states that he his his hip (sic) and it hurts to stand but he has been doing better and would like a walker to use today. Pt instructed that staff will accommodate him when they get a chance." Again no RN addressed the fact that pt #1 was no longer weight bearing on his Right leg.

On 6/29/2020 at 2:05 PM, "Pt given discharge instructions...Pt assisted to the entrance with staff. Pt transport to home with facility transport.

On 6/29/2020 at 4:00 PM, a late entry was documented, "Received a message from patient's ex-wife regarding fall over the weekend. Attempted to call her back and did not get an answer. Message was left explaining encouraging her to take patient to the ER (Emergency Room) if he is reporting an inability to ambulate or pain in his hip. Contact number was provided and encouraged a return call if any questions or concerns may arise."

On 6/30/2020 at 11:40 AM. "Patient's ex-wife was called back regarding message received on 6/29 regarding fall and hip pain. ... Explained to her if she did not feel comfortable transporting him she could call 911 if there is no one that can transport him."

On the morning of 7/6/2020 in the conference room both of the hospital's transport staff were interviewed (staff #7 and #8). Both staff confirmed that pt #1 was unable to bear weight on his right leg. The transferred him into a wheel chair and rolled him to the base of the stairs required to access his mobile home. Both staff were required to lift him up the stairs with Pt #1 assisting to bear weight on his left leg. He was lifted in to the home and placed on a sofa, then they exited.

Transportation staff #1 confirmed the ex-wife questioned why Pt #1 wasn't walking. Staff #1 instructed her to call the hospital and gain that information, as he did not know.

On 7/6/2020, a review of the Emergency Department visit on June 30, 2020, confirmed the following radiology impression, "There is acute displaced fracture of the greater trochanter and the base of the neck that makes it difficult to exclude underlying osteolytic lesion."

On 7/6/2020 in the conference room a review of the facility's assessment policy indicated:

"Assessment, General Revised August 15, 2019", Identified the introduction. "The goal of an assessment is to determine the care, treatment, and service that will meet the patient's initial and continuing needs. The depth frequency of a more detailed assessment depends on several factors, including the patient's needs and the care, treatment, and services provided. Information you obtain from the patient's first contact may indicate a need for more data or a more intensive assessment."


On 7/6/2020 an interview with the Senior Manager for the Behavior Health Department confirmed the Lippincott Nursing Practice manual was available for all staff on line and was accessible to any staff at any time. The Senior Quality Manager as well as the Senior Manager for the Behavioral Health Department confirmed the nursing staff failed to evaluate pt #1's right hip pain. He could provide no evidence the nursing staff had utilized the Lippincott Practice Manual regarding pt #1.

Review of the MAYO CLINIC.org/diseases-conditions
Definition of "Seizures: Focal seizures without loss of consciousness" revealed the following:

"Focal seizures without loss of consciousness. These seizures may alter emotions or change the way things look, smell, feel, taste or sound, but you don't lose consciousness. These seizures may also result in the involuntary jerking of a body part, such as an arm or leg, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights.

Symptoms of focal seizures may be confused with other neurological disorders, such as migraine, narcolepsy or mental illness.

Nursing care plan goals for patients with seizure includes maintaining a patent airway, maintaining safety during an episode, and imparting knowledge and understanding about the condition. The nurse should monitor the patient for signs of toxicity: nystagmus, ataxia, lethargy, dizziness, slurred speech, nausea, and vomiting."

Based on record review and interview, the facility failed to establish a discharge plan that met the needs of both the patient and the caregiver. The facility failed to carry out a safe discharge for 1 of 13 (#1) patients

This deficient practice had the likelihood to effect all patients of the facility.


Findings:


On the morning of 7/6/2020 in the conference room, the medical record for patient (Pt/pt) was reviewed. The record indicated that on 6/20/2020, pt #1 was received to the behavioral unit on an Emergency Detention Warrant for safety. Pt #1 voluntarily signed himself into the behavioral unit afterward. Pt #1 had a history of falls and seizures, bipolar disorder, Schizophrenia, anti-social behavior. Pt #1 presented with paranoia. His lab work was positive for Methamphetamines and Tetrahydrocannabinol (THC).


On the morning of 7/6/2020 in the conference room, the Client Rights Advocate, staff #5, described confusion over whether the woman pt #1 called his wife was in fact his legal wife. She did not go by his name and the woman had told staff they were divorced. The hospital had neither marriage certificate nor divorce documents. The case management and nursing staff were confused as to weather they could release information to her.

On 6/23/2020, pt #1 signed the document titled, "Authorization to verbally disclose protected health information to family, other relatives, or friends involved in my care". Pt #1 documented the name of his wife/ex-wife as the person to release information to.

A review of the MR for pt #1 found at no time had the person, who pt #1 requested information to be given to, been notified of his fall or sudden loss of mobility and non-weight bearing status. An interview with pt #1's Ex-wife confirmed, "she could get no information as to why he wasn't discharge on the original discharge date. She could only find out what was happening if she was able to speak with Pt #1. She further indicated that another patient (Pt #2) who had knowledge of pt #1's complaint of pain, had called her to let her know the reason she had not heard from pt #1 was because he had fallen and was injured. Pt #1 was saying he was in pain."

Pt #1's ex-wife confirmed she was not given an opportunity for input into Pt #1's ultimate discharge and was simply notified he was being discharged and could she come get him. She told the staff, no, she could not.

Pt #1 had in fact fallen and fractured his hip likely on 6/27/2020. Documentation identified in the MR indicated an incident in his bathroom resulting in him being on the floor. Pt #1 told his wife/ex-wife he fell in the bathroom and an unidentified staff member told him to get up, he wasn't hurt and he could get up. The tech reported to the Registered Nurse the patient lowered himself to the floor while holding to the sink, wheel chair and wall. The Registered Nurse failed to evaluate pt #1 after the fall and failed to document the physician had been notified that something occurred in the patient's bathroom which caused pt #1 to cry out in pain. Subsequent shifts with Registered Nurses failed to evaluate pt #1 even when he could no longer ambulate without assistant and began using a wheel chair. The discharging physician may not have been aware of pt #1 non-weight bearing status, his pain level, or that he had request to see the physician after his fall.

On the morning of 7/6/2020 an interview with social worker, staff #6, confirmed she had not communicated with the ex-wife because she was the ex-wife and not family. She was unaware pt #1 had signed the document permitting his ex-wife to have his health information. She agreed it would be difficult for the ex-wife to continue the plan or care after pt #1 had been discharge, if she was unaware of the plan.

Pt #1 had been discharge with an undiagnosed acute displaced fracture of the right neck of the trochanter. The staff didn't listen to the complaint of Pt #1. Neither the patient nor the ex-wife had resources to take pt #1 to the Emergency Department after he returned home in pain, and without the ability to weight bear. The Ex-wife called 911 for transport to the local hospital, where x-rays were taken and a formal diagnosis was documented.