HospitalInspections.org

Based on medical record review and staff interview, the hospital failed to ensure the hospital staff obtains signed consent for admission and treatment to the Behavioral Sciences Center (BSC) in six (6) of ten (10) medical records (records #1A, 2, 5B, 5A, 7, 8) reviewed. This has the potential to negatively impact all patient care by patients not having necessary information to make informed consent for admission and psychiatric treatment. Findings include:

1. Review of the medical record for #1A revealed the patient was admitted on 9/2/10. There was no documented evidence of signed consent for admission and treatment by the patient and/or representative.

2. Review of the medical record for #2 revealed the patient was admitted on 8/31/10. There was no documented evidence of signed consent for admission and treatment by the patient and/or representative.

3. Review of the medical record for #5B revealed the patient was admitted on 9/10/10. There was no documented evidence of signed consent for admission and treatment by the patient and/or representative.

4. Review of the medical record for #5A revealed the patient was admitted on 8/17/10. There was no documented evidence of signed consent for admission and treatment by the patient and/or representative.

5. Review of the medical record for #7 revealed the patient was admitted on 9/6/10. There was no documented evidence of signed consent for admission and treatment by the patient and/or representative.

6. Review of the medical record for #8 revealed the patient was admitted on 9/2/10. There was no documented evidence of signed consent for admission and treatment by the patient and/or representative.

7. During an interview in the afternoon of 9/15/10 and again in the morning of 9/16/10 with the BSC Unit Manager (UM), the medical records were reviewed and the UM agreed with the above findings.

Based on document review, medical record review and staff interview, the hospital failed to ensure the Behavioral Sciences Center (BSC) patient falls are followed-up appropriately, per hospital policy, in five (5) of ten (10) medical records (record #1A, 3, 4, 5A, 8) reviewed. This has the potential to negatively impact all BSC patients by not preventing future patient falls. Findings include:

1. Beckley Appalachian Regional Hospital (BARH) BSC policy Patients at Risk for Falls, last revised 6/1/08, states in part "...If a patient does fall, in spite of preventative measures, an Incident Report must be completed...The Nurse Manager (NM) will review each incident report to determine the reason the patient fell, action taken immediately after the fall and corrective action plan to prevent further falls..."

During an interview with the BSC NM in the morning of 9/14/10, the NM stated each incident report is reviewed, however, a corrective action plan is not taken on each incident.

2. BARH Risk Management policy, Incident Reporting, last revised 12/09, states in part "...D. The incident review screen must be completed by the unit/department manager or supervisor of the area in which the incident occurred. The department manager is responsible for supplying adequate information in the event reporting system to reflect that an analysis of the event has been done and that measures have been taken to prevent recurrence and improve patient safety. A complete review by the department manager should be completed within 24 hours of the incident or event, or within 24 hours after notification of the incident. After this time, the CCRAO will review the incident report and follow-up form for completeness and recommend or conduct any further investigation which may be necessary..."

During an interview with the BSC NM in the morning of 9/14/10, the NM stated the hospital's incident reporting process does not afford an adequate system for documenting all necessary information for the NMs to appropriately follow up on patient falls.

3. Review of the incident report for the fall on 9/5/10 on record 1A revealed no documented evidence of thorough review of the patient's fall and/or recurrence prevention.

4. Review of the incident report for the fall on 9/6/10 at 1030 on record 1A revealed no documented evidence of thorough review of the patient's fall and/or recurrence prevention.

5. Review of the incident report for the fall on 9/9/10 on record 3 revealed no documented evidence of thorough review of the patient's fall and/or recurrence prevention.

6. Review of the incident report for the fall on 9/7/10 on record 4 revealed no documented evidence of thorough review of the patient's fall and/or recurrence prevention.

7. Review of the incident report for the fall on 9/5/10 at 2300 on record 5A revealed no documented evidence of thorough review of the patient's fall and/or recurrence of prevention.

8. Review of the incident report for the fall on 9/7/10 on record 8 revealed no documented evidence of thorough review of the patient's fall and/or recurrence prevention.

9. During an interview with the BSC NM in the morning of 9/14/10 the records were reviewed and the NM agreed with the above findings.

Based on medical record review and staff interview it was determined the registered nurse failed to accurately complete the fall risk assessment and fall risk interventions portions of the nursing assessments for patients who were at risk for falls or who fell during hospitalization in the Behavioral Sciences Center (BSC). This deficient practice affected seven (7) of eight (8) patients reviewed (patients #1, 2, 4, 5, 6, 7, 8). This failure has the potential to adversely impact the care of all patients who are at risk for a fall. Findings include:

1. Review of the medical record for patient #1 (visit A) revealed the Initial Nursing Assessment, completed 9/3/10 at 0215, revealed the patient was assessed as High Risk for Falls with a Total Fall Risk Score of 80. Review of the corresponding High Risk Interventions section of the Fall Risk Interventions portion of the assessment revealed it was not completed.

Review of the Nursing Reassessments, completed each twelve (12) hour shift, for patient #1 revealed the assessments were not accurately completed on the following dates:

On 9/3/10 at 1130, 9/3/10 at 2100, 9/4/10 at 0800, 9/4/10 at 1930, 9/5/10 at 1930 and 9/6/10 at 0800 the nurse documented the patient's assessment reflected the patient was High Risk for falls. The nurse then documented: "Implement bowel and bladder program to decrease urgency and incontinence" as a High Risk Intervention which was implemented in response to the patient's high fall risk. Review of the record revealed no documentation of a bowel and bladder program. In the late morning of 9/14/10 this record was reviewed and discussed with the BSC Nurse Manager. He acknowleged the record lacked any documentation to reflect a bowel and bladder program was implemented.

On 9/3/10 at 1130, 9/4/10 at 1930 and 9/5/10 at 1930 the nurse documented "Floor mats" as High Risk Interventions which were implemented in response to the patient's high fall risk.

In the late morning of 9/13/10 the BSC Nurse Manager acknowleged the BSC has no floor mats.

2. Review of the medical record for patient #2 revealed the Initial Nursing Assessment, completed 8/31/10 (untimed) was not completed. Pages #2 and 6 and the Total Fall Risk Score portion of page #4 were not completed.

Review of the Nursing Reassessments, completed each twelve (12) hour shift, for patient #2 revealed the assessments were not accurately completed on the following dates:

On 9/12/10 at 2000, 9/12/10 at 0800, 9/11/10 at 2000, 9/11/10 at 0800, 9/10/10 at 0900, 9/9/10 at 1930, 9/9/10 at 0800, 9/8/10 at 1930, 9/7/10 at 1930, 9/6/10 at 1930, 9/6/10 at 0800, 9/5/10 at 1830 and 9/4/10 at 0800 the nurse documented the patient's assessment reflected the patient was High Risk for falls. The nurse then documented: "Implement bowel and bladder program to decrease urgency and incontinence" as a High Risk Intervention which was implemented in response to the patient's high fall risk. Review of the record revealed no documentation of a bowel and bladder program.

On 9/12/10 at 0800, 9/10/10 at 0900, 9/8/10 at 1930, 9/7/10 at 1930, 9/6/10 at 1930, 9/5/10 at 1830, 9/4/10 at 1930 the nurse documented "Floor Mats" as High Risk Interventions which were implemented in response to the patient's high fall risk.

On 9/10/10 at 2100 the nursing assessment reflected the patient was assessed as High Risk for Falls with a Total Fall Risk Score of 80. There were no nursing interventions documented. On 9/3/10 at 0800 the nursing assessment reflected the patient was assessed as High Risk for Falls with a Total Fall Risk Score of 70. No high risk nursing interventions were documented. On 9/1/10 at 1930 the nursing assessment reflected the patient was assessed as Low Risk for Falls with a Total Fall Risk Score of 45. No low risk nursing interventions were documented.

In the late morning of 9/13/10 the BSC Nurse Manager acknowleged the BSC has no floor mats.

In the afternoon of 9/14/10 this record was reviewed and discussed with the BSC Nurse Manager. He agreed with these findings.

3. Review of the Nursing Reassessments, completed each twelve (12) hour shift, for patient #4 revealed the assessments were not accurately completed on the following dates:

On 9/7/10 at 1930, 9/8/10 at 0800, 9/8/10 at 1930, 9/9/10 at 0800, 9/9/10 at 1930, 9/10/10 at 0800, 9/10/10 at 2100, 9/11/10 at 0800, 9/12/10 at 0800 and 9/12/10 at 2100 the nurse documented the patient's assessment reflected the patient was High Risk for falls. The nurse then documented: "Implement bowel and bladder program to decrease urgency and incontinence" as a High Risk Intervention which was implemented in response to the patient's high fall risk. Review of the record revealed no documentation of a bowel and bladder program.

On 9/7/10 at 1930, 9/8/10 at 1930, 9/10/10 at 0800, 9/10/10 at 2100, 9/12/10 at 0800 and 9/12/10 at 2100 the nurse documented "Floor Mats" as High Risk Interventions which were implemented in response to the patient's high fall risk.

In the late morning of 9/13/10 the BSC Nurse Manager acknowleged the BSC has no floor mats.

In the afternoon of 9/14/10 this record was reviewed and discussed with the BSC Nurse Manager. He agreed with these findings.

4. Review of the medical record for patient #5 (B visit) revealed the Initial Nursing Assessment, completed 9/10/10 at 1930, noted the patient had a past hospitalization for Gastrostomy tube (feeding tube) placement. The nurse documented a Peg tube was in place in the abdomen. The Nutrition Screen portion of the Gastrointestinal Review of Body Systems was not completed to indicate the patient was receiving Tubefeeding (as indicated by records sent from Nursing Home on admission). As a result the assessment did not trigger a dietary consult for the patient.

On 9/12/10 (?date) at 0800, 9/12/10 at 2100, 9/12/10 0800, 9/11/10 at 2000 and 9/11/10 at 0800 the nurse documented the patient's assessment reflected the patient was High Risk for falls. The nurse documented: "Implement bowel and bladder program to decrease urgency and incontinence" as a High Risk Intervention which was implemented in response to the patient's high fall risk. Review of the record revealed no documentation of a bowel and bladder program.

On 9/12/10 at 2100 and 9/12/10 at 0800 the nurse documented "Floor Mats" as High Risk Interventions which were implemented in response to the patient's high fall risk.

In the late morning of 9/13/10 the BSC Nurse Manager acknowleged the BSC has no floor mats.

This record was discussed and reviewed with the BSC Clinical Manager in the morning of 9/15/10. She agreed with these findings.

5. Review of the Nursing Reassessments, completed each twelve (12) hour shift, for patient #6 revealed the assessments were not accurately completed on the following dates:

On 9/12/10 at 0800, 9/12/10 at 2000, 9/11/10 at 0800, 9/10/10 at 2100, 9/10/10 at 0800, 9/9/10 at 1930, 9/9/10 at 0800, 9/8/10 at 1930, 9/7/10 at 1930, 9/6/10 at 1930, 9/6/10 at 0800, 9/5/10 at 1930, 9/4/10 at 1930, 9/4/10 at 0800, 9/3/10 at 2100 and 9/2/10 at 0900 the nurse documented the patient's assessment reflected the patient was High Risk for falls. The nurse documented: "Implement bowel and bladder program to decrease urgency and incontinence" as a High Risk Intervention which was implemented in response to the patient's high fall risk. Review of the record revealed no documentation of a bowel and bladder program.

On 9/12/10 at 0800, 9/10/10 at 2100, 9/10/10 at 0800, 9/8/10 at 1930, 9/7/10 at 1930, 9/6/10 at 1930, 9/5/10 at 1930, 9/4/10 at 1930, 9/3/10 at 2100 and 9/2/10 at 0900 the nurse documented "Floor Mats" as High Risk Interventions which were implemented in response to the patient's high risk fall.

In the morning of 9/1510 this record was reviewed and discussed with the BSU Clinical Manager. She agreed with these findings.

6. Review of the Nursing Reassessments, completed each twelve (12) hour shift, for patient #7 revealed the assessments were not accurately completed on the following dates:

On 9/11/10 at 2000, 9/11/10 at 0800, 9/10/10 at at 2100, 9/9/10 at 1930 the nurse documented the patient's assessment reflected the patient was High Risk for falls. The nurse documented: "Implement bowel and bladder program to decrease urgency and incontinence" as a High Risk Interventions which were implemented in response to the patient's high risk fall.

On 9/10/10 at 2100 and 9/10/10 at 0900 the nurse documented "Floor Mats" as High Risk Interventions which were implemented in response to the patient's high risk fall.

In the late morning of 9/13/10 the BSC Nurse Manager acknowleged the BSC has no floor mats.

These records were reviewed and discussed with the BSC Nurse Manager around 12 noon on 9/15/10. He agreed with these findings.

7. Review of the medical record for patient #8 revealed the Initial Nursing Assessment, completed 9/2/10 at 1815, revealed the patient was assessed as High Risk for Falls with a Total Fall Risk Score of 85. Review of the corresponding High Risk Interventions section of the Fall Risk Interventions portion of the assessment revealed it was not completed.

Review of the 9/7/10 (untimed) nursing note for patient #8 revealed the staff documented the patient experienced an unwitnessed fall in the hallway.

Review of the Nursing Reassessments, completed each twelve (12) hour shift, for patient #8 revealed the assessments were not accurately completed on the following dates:

On 9/7/10 at 1930, at 9/8/10 at 0800, at 9/8/10 at 1930 and 9/9/10 at 0800 the Fall Risk Assessment was not scored correctly. The nurse incorrectly answered "NO" to the question: "History of falling; immediate or within three months?"

In the afternoon of 9/15/10 this record was reviewed and discussed with the BSC Nurse Manager. He agreed with these findings.

Based on review of medical records and staff interview it was determined the hospital failed to ensure the nursing staff developed and kept current nursing care plans for three (3) of six (6) patients who experienced falls while in the Behavioral Sciences Center (BSC) (patients #1, 2, 4). This failure creates the potential for the care of all patients who are at risk for falls to be adversely impacted. Findings include:

1. Review of the 9/3/10 Multidisciplinary Treatment Plan (MTP) for patient #1 revealed the patient's risk for falls was established as a "Nursing Problem". Review of the Treatment Plan revealed the nursing interventions implemented to decrease risk of falls were continued after the patient's second fall on 9/5/10. The nurse failed to update or revise the patient's care plan in response to the falls.

2. Review of the 8/31/10 MTP for patient #2 revealed the patient's risk for falls was established as a problem. Review of the Treatment Plan revealed the nursing interventions implemented to decrease risk of falls were continued after the patient's fall on 9/13/10. The nurse failed to update or revise the patient's care plan in response to the falls.

3. Review of the 8/31/10 MTP for patient #4 revealed the patient's risk for falls was established as a problem on 9/1/10. Review of the Treatment Plan revealed the nursing interventions implemented to decrease risk of falls included the following intervention: "Set up regular voiding schedule every 2 hours or as appropriate to patient's need." The record lacked documentation to reflect this intervention was implemented per plan.

4. In the morning of 9/15/10 these records were reviewed and discussed with the Clinical Manager. She agreed with these findings.