HospitalInspections.org

Findings include:

The Hospital was out of compliance for the Quality Assessment and Performance Improvement (QAPI) Condition of Participation.

The Hospital failed to ensure, for one (Patient #1) patient out of 10 sampled patient records, that QAPI activities were data-driven, including analysis and preventative corrective actions to prevent falls, after Patient #1 fell and required a higher level of care due to a subdural hematoma (a type of bleeding in the brain most commonly from a traumatic head injury) that resulted from the fall.

Refer to TAG: A-0273

The Hospital failed to ensure, for one patient (Patients #1) out of 10 sampled patient records, that Quality Assessment Performance Improvement (QAPI) activities were data-driven, including analysis and preventative corrective actions after Patient #1 fell and required higher level of care due to a subdural hematoma which formed as a result of the fall.

Findings include:

Review of the Hospitals Quality and Patient Safety Plan, dated March 2018, indicated that the Hospital will have continuous process improvement which must be understood, assessed and redesigned.

Patient #1 was admitted to the Hospital in 2/2020 after being brought to the Emergency Department by Emergency Medical Services due to home care providers concerns that Patient #1 had foul smelling urine, increased confusion and a new bruise on his/her forehead.

Review of the History and Physical, dated 2/14/20, indicated that the Patient had a new bruise on his/her forehead but did not recall any recent falls or trauma.

Review of the Emergency Department Physical Therapy Evaluation, dated 2/14/20, indicated that Patient #1 was referred for evaluation due to a suspected fall at home and was assessed to have impaired insight, impaired judgement, impaired problem solving, impaired safety awareness and was inconsistent with commands. Patient #1 was assessed to require contact guard, with one person assist for bed mobility and ambulation. The Physical Therapy Evaluation indicated that Patient #1 had a slight right lean while walking and did lose his/her balance slightly towards the right and caught him/herself but if he/she overshoots with feet and is leaning towards the right he/she represents a significant fall risk. The Physical Therapist recommended short term rehabilitation to maximize function, support strengthening and balance improvements to prevent further falling and increase the Patient's ability to live safely at home.

Review of the Case Management Assessment Note, dated 2/14/20, indicated that when the Case Manager spoke with the Home Care Nurse Manager she was informed that the Patient has had multiple falls over the last six months in his/her home.

While in the Emergency Department, Patient #1 had an order for 1:1 observation for safety due to high risk for falls.

Patient #1 was transferred from the Emergency Department to the medical surgical floor for treatment of an encephalopathy (a term that means brain disease, damage, or malfunction) and underlying dementia with worsening paranoia due to a urinary tract infection. Patient #1 was admitted with an order for constant observation due to safety and high risk for falls.

Review of the Fall Risk Assessment Tool, dated 2/14/20 at 11:18 P.M., indicated that Patient #1 did not have falls in the last six months, was on two or more risk drugs for falls, required assistance or supervision for mobility, transfer or ambulation, had an unsteady gait, altered awareness of immediate physical environment and lack of understanding of physical/cognitive limitations and was identified as a high risk for falls. Interventions in place were to have the bed in lowest position, brake locks on wheels, adequate lighting in the room and a toileting schedule.

Review of the Fall Risk Assessment Tool, dated 2/15/20 at 8:40 A.M., indicated that Patient #1 did not have falls within the last six months before admission, was on one risk drug for falls, required assistance or supervision for mobility, transfer or ambulation and was identified as a moderate risk for falls. Interventions in place to prevent falls were to have the bed in the lowest position, brake locks on wheels, adequate lighting in the room, bed and chair alarm.

Review of the Fall Risk Assessment Tool, dated 2/15/20 at 9:33 P.M., indicated that Patient #1 did not have falls within the last six months before admission, was on one risk drug for falls, required assistance or supervision for mobility, transfer or ambulation and was identified as a moderate risk for falls. Interventions in place to prevent falls were to have the bed in the lowest position, brake locks on wheels, adequate lighting in the room, bed and chair alarm.

Review of the Fall Risk Assessment Tool, dated 2/16/20 at 10:58 A.M., indicated that Patient #1 did not have falls within the last six months before admission, was on one risk drug for falls, required assistance or supervision for mobility, transfer or ambulation and was identified as a moderate risk for falls. Interventions in place to prevent falls were to have the bed in the lowest position, brake locks on wheels and adequate lighting in the room.

Review of the Fall Risk Assessment Tool, dated 2/16/20 at 8:49 P.M., indicated that Patient #1 did not have falls within the last six months before admission, was on one risk drug for falls, required assistance or supervision for mobility, transfer or ambulation and was identified as a moderate risk for falls. Interventions in place to prevent falls were to have the bed in the lowest position, brake locks on wheels, adequate lighting in the room, bed and chair alarm.

Review of the Fall Risk Assessment Tool, dated 2/17/20 at 8:30 A.M., indicated that Patient #1 did have a history of a fall within six months before admission, has experienced a fall during this hospitalization and there was an automatic fall risk category of high. Interventions in place to prevent falls were to have the bed in the lowest position, locks on wheels, adequate lighting and bed alarm.

Review of the Post Fall Assessment, dated 2/17/20 at 8:34 A.M., indicated that Patient #1 had a fall on 2/17/20 at 7:00 A.M. The injury assessment indicated that Patient #1 was found lying on the floor next to the bathroom and had a laceration to his/her right scalp and that Patient #1 patient was responsive.

Review of the Rapid Response Team Record, dated 2/17/20 at 7:00 A.M., indicated that Patient #1 was admitted for falls and a urinary tract infection. Patient #1 has baseline dementia. Patient #1 was ringing his/her call bell over night and the bed alarm was shut off by the nurse.

Review of the Hospital's internal investigation, dated 2/18/20, indicated that Patient #1 had a high falls risk in the ED and that, on 2/20/20, the Emergency Department Nurse Manager said Patient #1 was a high risk and all measures were implemented and documented to keep Patient #1 safe.

Record review indicated that, on 2/17/20, a head computed tomography (CT) scan was performed and demonstrated a focal left convexity frontotemporal subdural hematoma and Patient #1 was transferred to another campus. Repeat CT scans showed a large left panhemispheric acute subdural hemorrhage with left temporal intracerebral hemorrhage (bleeding into the brain).

During an interview with the Director of Nursing Operations on 3/2/20 at 2:00 P.M., the Director of Nursing Operations said that the nurses should use their assessment skills to answer the Falls Risk Assessment Tool. The Director of Nursing Operations said that the hand off communication and previous notes can also be used to identify risk.

During an interview with the Clinical Leader on 3/3/20 at 8:30 A.M., the Clinical Leader said that once a patient is deemed a high fall risk, the patient should remain a high fall risk throughout their hospitalization.

During an interview with Nurse #1 on 3/3/20 at 10:30 A.M., Nurse #1 said that, based on her own assessment, she may change a patient from high to moderate risk for falls if her assessment differed from the previous nurse's assessment. Nurse #1 said that the nurse completing the Falls Risk Assessment Tool puts in his/her own interventions for the prevention of future falls manually.

During an interview with the Accreditation Manager on 3/4/20 at 10:30 A.M., the Accreditation Manager said that the Hospital educated the staff during orientation on the Falls Risk Assessment Tool. The Accreditation Manager said that once a patient is assessed at a high risk for falls, they remain a high risk of falls throughout their hospitalization. The Accreditation Manager also said that, with the Assessment Tool, certain criteria will generate an automatic risk assessment. The Accreditation Manager said that one criteria would be, if a patient had a fall in the last six month before admission, they would automatically be a high risk for falls on admission and should stay a high risk for falls throughout hospitalization.

The Hospital failed to identify that the nursing staff were not following the Hospital protocol to maintain a patient's fall risk at the level at which they were initially assessed to be. The Hospital failed to identify that the nursing staff did not accurately and consistently assess Patient #1's level of fall risk. There was no preventative action implemented as a result of this investigation to prevent a like occurrence from happening again.

Based on records reviewed and interviews, the Hospital failed, for one (Patient #1) patient out of ten sampled patients, to ensure Quality Assessment and Performance Improvement (QAPI) activities identified opportunities for improvement after patient #1 fell and required a higher level of care as a result of the fall.

Findings include:

Review of the Hospital's Incident Reports: Sentinel Events Policy, dated 10/1/19, indicated that initial response to an event is an evaluation and immediate corrective action to obvious system failures to mitigate future risk to other patients. The Policy also indicated that the goals of the Root Cause Analysis Team are to understand how and why the event occurred and to identify process or system changes which would improve performance and prevent recurrence of the event.

Patient #1 was admitted to the Hospital in 2/2020 after being brought to the Emergency Department by Emergency Medical Services due to home care providers concerns that the Patient had foul smelling urine, increased confusion and a new bruise on his/her forehead.

Review of the History and Physical, dated 2/14/20, indicated that the Patient had a new bruise on his/her forehead today, but does not recall any recent falls or trauma.

Review of the Emergency Department Physical Therapy Evaluation, dated 2/14/20, indicated that Patient #1 was referred for evaluation due to suspected fall at home and was assessed to have impaired insight, impaired judgement, impaired problem solving, impaired safety awareness and was inconsistent with commands. Patient #1 was assessed to require contact guard , with one person assist for bed mobility and ambulation. The Physical Therapy Evaluation indicated that Patient #1 had a slight right lean while walking and did lose his/her balance slightly towards the right and caught him/herself but if he/she overshoots with feet and is leaning towards the right he/she represents a significant fall risk. The Physical Therapist recommended short term rehabilitation to maximize function, support strengthening and balance improvements to prevent further falling and increase the Patient's ability to live safely at home.

Review of the Case Management Assessment Note, dated 2/14/20, indicated that when the Case Manager spoke with the home care nurse manager she was informed that the Patient has had multiple falls over the last six months in his/her home.

While in the Emergency Department Patient #1 had an order for 1:1 observation for safety due to high risk for falls.

Patient #1 was transferred from the Emergency Department to the medical surgical floor for treatment of an encephalopathy (a term that means brain disease, damage, or malfunction) and underlying dementia with worsening paranoia due to a urinary tract infection. Patient #1 was admitted with an order for constant observation due to safety and high risk for falls.

Review of the Fall Risk Assessment Tool, dated 2/14/20 at 11:18 P.M. indicated that Patient #1 did not have falls in the last six months, was on two or more risk drugs for falls, required assistance or supervision for mobility, transfer or ambulation, had an unsteady gait, altered awareness of immediate physical environment and lack of understanding of physical/cognitive limitations and was identified as a high risk for falls. Interventions in place were to have the bed in lowest position, brake locks on wheels, adequate lighting in the room and a toileting schedule.

Review of the Fall Risk Assessment Tool, dated 2/15/20 at 8:40 A.M. indicated that Patient #1 did not have falls within the last six months before admission, was on one risk drug for falls, required assistance or supervision for mobility, transfer or ambulation and was identified as a moderate risk for falls. Interventions in place to prevent falls were to have the bed in the lowest position, brake locks on wheels, adequate lighting in the room, bed alarm, chair alarm.

Review of the Fall Risk Assessment Tool, dated 2/15/20 at 9:33 P.M., indicated that Patient #1 did not have falls within the last six months before admission, was on one risk drug for falls, required assistance or supervision for mobility, transfer or ambulation and was identified as a moderate risk for falls. Interventions in place to prevent falls were to have the bed in the lowest position, brake locks on wheels, adequate lighting in the room, bed alarm and chair alarm.

Review of the Fall Risk Assessment Tool, dated 2/16/20 at 10:58 A.M., indicated that Patient #1 did not have falls within the last 6 months before admission, was on one risk drug for falls, required assistance or supervision for mobility, transfer or ambulation and was identified as a moderate risk for falls. Interventions in place to prevent falls were to have the bed in the lowest position, brake locks on wheels and adequate lighting in the room.

Review of the Fall Risk Assessment Tool, dated 2/16/20 at 8:49 P.M., indicated that Patient #1 did not have falls within the last six months before admission, was on one risk drug for falls, required assistance or supervision for mobility, transfer or ambulation and was identified as a moderate risk for falls. Interventions in place to prevent falls were to have the bed in the lowest position, brake locks on wheels, adequate lighting in the room, bed alarm and chair alarm.

Review of the Fall Risk Assessment Tool, dated 2/17/20 at 8:30 A.M., indicated that Patient #1 did have a history of a fall within six months before admission, has experienced a fall during this hospitalization and there was an automatic fall risk category of high. Interventions in place to prevent falls were to have the bed in the lowest position, locks on wheels, adequate lighting and bed alarm.

Review of the Post Fall Assessment, dated 2/17/20 at 8:34 A.M., indicated that Patient #1 had a fall on 2/17/20 at 7:00 A.M. The injury assessment indicated that Patient #1 was found lying on the floor next to the bathroom and had a laceration to his/her right scalp and was responsive.

Review of the Hospital's investigation indicated that Nurse #1 shut off Patient #1's bed alarm on the evening of 2/17/20. The interventions in place at the time of the fall included a bed alarm.

During an interview with the Director of Nursing Operations on 3/2/20 at 2:00 P.M., the Director of Nursing Operations said that other than the termination of Nurse #1, there has been no formal education or corrective actions put into place to prevent a like occurrence from happening again. The Director of Nursing Operations said that the Hospital was having a staff meeting on 3/5/20 and would be addressing Patient #1's fall at that time.

During an interview with the Clinical Leader on 3/3/20 at 8:30 A.M., the Clinical Leader said that although they have discussed Patient #1's fall during huddle, they will educate the nursing staff at the case study this week. The Clinical Leader said that she was not clear as to whether there would be system wide education related to Patient #1's fall to prevent a like occurrence in the future.

During an interview with Nurse #2 on 3/3/20 at 10:30 A.M., Nurse #2 said that she has not received education on falls or on the prevention of a like occurrence from happening again. Nurse #2 said that she did participate in the post fall huddle and Root Cause Analysis but there have been no changes that she is aware of at this time.

During an interview with the Accreditation Manager on 3/4/20 at 10:30 A.M., the Accreditation Manager said that the Hospital did identify that the fall risk assessments have inconsistencies and the Hospital anticipated educating staff members on Fall Risk Assessments in March 2020.

The Hospital failed to identify and implement corrective actions to prevent a like event from occurring in the future.