HospitalInspections.org

Based on staff interview and record review, the CAH (Critical Access Hospital) failed to provide care and services in accordance with established policies for 2 of 5 applicable patients in the sample. (Patients #1 and #3) Findings include:

1. Per review of CAH policy Falls - Prevention and Management last revised on 6/14, staff failed to initiate "Post-Fall Management" interventions for Patient #3 who sustained 6 falls during 42 days of hospitalization. Patient #3 was admitted on 7/1/15 with end stage Lymphoma. At the time of admission and per CAH policy, Patient #3 was assessed to be at risk for falls using the Conley's Falls Risk assessment with a score of "6" (a score of 2 or greater or a fall during hospitalization should initiate fall prevention strategies). Per Falls - Prevention and Management policy, nursing staff were to develop a Care Plan in an effort to "...eliminate or mitigate contributory factors and develop fall prevention strategies appropriate to patient's identified risk.", however a Care Plan was not developed to address Patient #3's continued falls. There was also a failure to document in the patient's record when s/he sustained falls on 7/11/15, 7/15/15, 7/27/15 and 8/1/15 as per policy. The omissions of a Care Plan for falls and nursing note documentation was confirmed by the Director of Patient Care Services on 12/ 8/15 at 2:10 PM.

2. a. Per review of the medical record for Patient #1 on 12/8/15, nursing staff failed to accurately document the reason for the use of medical restraints in accordance with the hospital's Policy/Procedure titled "Restraints", revised 1/15. The policy stated that nurses are responsible for documenting the reason for the restraint and evidence of less restrictive interventions previously attempted and ineffective. Per review of the documentation for the 3 restraint dates in July for Patient #1, nurses included incorrect reasons for the restraints, per physician orders and failed to adequately show evidence of all ineffective but previously tried interventions utilized prior to restraint application. This was confirmed with during interviews with a Charge RN (Registered Nurse) and CNO (Chief Nursing Officer)on the days of 12/8/15 and 12/9/15.
2.b. Per record review regarding a fall that occurred on 7/8/15 for Patient #1, nurses failed to document the event in the Quantros Safety Risk Management (SRM) System completely and accurately, per policy "Adverse Events and Near - Misses ", III Procedure, A.1. "When entering a report........ as much detail as possible is encouraged". Staff failed to include important information including the time of the fall, where the patient was last observed prior to the unwitnessed fall, what were contributing factors including any medications administered and what were recommendations for improvement. Inaccurate information stated that the care plan reflected fall prevention when there was no care plan for fall prevention. Factors that led to the event failed to mention that the alarm was not put on the bed after changing linens. The report was reviewed by QA and referred to the Nurse Manager for investigation, Although the Nurse Manager did provide staff re-education and follow up after the fall, inaccuracies and incomplete data were not addressed at the nursing or QA level of event follow up.
2. c. Per review, nurses failed to conduct a fall assessment as part of the admission assessment for Patient #1, who had right sided weakness after a recent stroke. Per the policy, "Falls- Prevention and Management", 6/14, II Policy, C. All inpatients at MAHHC are assessed upon admission using the Conley's Falls Assessment. D. All patients will have standard appropriate interventions initiated per the Conley"s Fall Risk Assessment." Per review of the admission assessment for the patient dated 6/19/15, there was no fall assessment completed as required and per review of the care plan, there was no written care plan for fall risk. The patient did experience a fall on 7/8/15 and there was no alarm in place at the time of the fall. These concerns were confirmed with the Charge Nurse and CNO on 12/9/15.

Based on staff interview and record review, nurses failed to develop and keep current a care plan to address the identified needs for 3 of 5 inpatients in the sample. (Patients #1, #3 and #4). Findings include:

1. Per review of the care plan for Patient #1 on 12/8/15, the plan failed to address several of the identified needs for the patient, who had experienced an acute decline in health status due to a significant stroke. The patient had ongoing pain, had a gastric feeding tube for nutritional intake, was unable to verbalize needs, experienced a fall due to body control issues and had symptoms of delirium. The care plan failed to include these issues (falls, nutrition, pain management, communication and delirium), including measurable goals and specific interventions to address these needs.

2. Per review of the care plans for Patient #3, there was a failure to address the ongoing issue of the patient's repeated falls. During hospitalization from 7/1/15 - 8/11/15, Patient #3 sustained 6 falls from a wheelchair and/or bed while experiencing periods of delirium, confusion, pain and unsteady gait. The care plan did not reflect the patient's ongoing problems related to falls or address any fall prevention interventions.

3. Per review of the care plan for Patient #4, there was a failure to revise the care plan after the patient's admission on 11/19/15. Patient #4 was admitted and initially treated for heart failure. However, after a poor response to treatment it was determined Patient #4 would be transitioned to end of life care receiving only comfort measures. There was no indication in the care plan that Patient #4 was transitioned to receive only comfort measures, including adequate symptom management and provision of family support during the patient's final days.

Based on staff interview and record review, nurses failed to assure that medical records were complete and accurately documented for 1 of 5 applicable patients in the sample. (Patient #3.) Findings include:

1. Per review of the CAH incident reporting system, the Quantros Safety Report, there were dates and times of 6 falls sustained by Patient #3 during 42 days of hospitalization from 7/1/15 - 8/11/15. There was a failure by nursing staff to document in the patient's record the actual events and circumstances associated with 4 of the 6 falls sustained by Patient #3 on 7/11/15, 7/15/15, 7/27/15 and 8/1/15. The omissions of documentation were confirmed by the Director of Patient Care Services on 12/ 8/15 at 2:10 PM.

Based on staff interview and record reviews, the hospital failed to assure a process whereby the Quality Assurance Department evaluated all patient care and services related to patient falls. This practice affected 2 of 5 patients in the applicable sample. (Patients #1 and #3). Findings include:

1. Per staff interview regarding Patient #1, Quality staff confirmed on 12/8/15 and 12/9/15 that they had not reviewed a fall event report for accuracy and thoroughness of investigation of the fall event for Patient #1. Based on review of the medical record and the Quantros Safety Report created regarding the patient's fall from bed on the evening of 7/8/15, the report was inaccurate and incompletely documented. The event review process included follow up by the Nurse Manager with nursing staff. The event review by the Manager failed to note the lack of completion of a fall assessment at the time of admission to the hospital on 6/19/15; it also failed to note the lack of a care plan to address the high risk for a fall, and to assess the quality of the investigation, and to act on the incomplete documentation on the event report itself. Per interviews with the Director of Quality on 12/8/15 and 12/9/15, the Director stated that s/he reviews all event reports and if there is a negative outcome, there is a full review of the event, including a root cause analysis. If there was no injury from a fall, the event report would be referred to the appropriate department manager to review and complete any needed follow up actions. There is no final QA department review of the event to see if all of the preventive plans had been put into place and interventions utilized regarding fall prevention. A hospital wide quarterly meeting also reviews all falls. However, this meeting includes review of all event reports, and does not provide a timely review of falls prevention and reduction actions to effect an improvement in patient quality of care.

2. Per interview on 12/9/15 with the Director of Quality, s/he confirmed that there was no follow up quality review of falls reported via the Quantros reporting system unless there was an injury or negative outcome; thus the multiple falls (6) sustained by Patient #3, who was not injured, were not reviewed by Quality to help identify the lack of appropriate post fall actions taken. Per record review, nursing staff had failed to implement the hospital's "Post Fall Management" interventions and develop a care plan to address the patient's ongoing fall risk and history of previous falls.