HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of 31 medical records reviewed, it was determined the facility failed to implement appropriate fall strategies to prevent the patient from falling in the ED. (Patient #2).

Findings include:

The policy titled "Fall Prevention and Management" which was last revised 7/2024 states the purpose of the policy is to implement appropriate fall prevention strategies.

Review of Medical Record for Patient #2 identified, EMS brought this patient to the ED on 9/14/24 at 2:22 PM. The patient's son convinced the patient to come to the hospital because the patient had suicidal ideation. The triage nurse documented at 2:38 PM the "patient refuses to speak." The vital signs were within normal limits. At 3:06 PM the provider ordered close supervision for suicidal ideation, which was started at 3:15 PM.
The Patient Care Technician who was providing the close supervision documented the 15-minute checks and noted the patient was awake from 5:45 AM through 10:45 AM on 9/15/24.

On 9/15/24 at 11:42 AM, the ED doctor's note documented, "at 11:05 AM I was informed that the patient while on constant observation and with siderails up was attempting to get off the end of the stretcher and got tangled in the blankets falling forward and hitting their head on the countertop." The patient's head and spinal CT-Scans were done at 11:11 AM and they were negative for fracture or trauma.

The policy titled "Observation & Management of Patients at Risk to Self Or Others," which was last revised 03/2023 states, "One staff-member must observe multiple patients in a designated area within a field of vision."

During interview with Staff A, Patient Care Technician which was conducted on 10/3/24 at 10:45 AM, Staff A stated, on 9/15/24 they were assigned to monitor this patient as well as some other patients, but they could not recall how many patients they were watching. Staff A stated they were seated at the nurses' station when the patient fell. Staff A stated they were speaking to another patient when the patient to whom they were speaking, stated Patient#1 had gotten tangled in the sheet and fallen. Staff A stated they found the patient at the foot of the bed near the garbage can.

This finding was shared with Staff A, Regional Director, Quality and Safety on 10/30/24 at approximately 3:30 PM.

Based on medical record review, document review and interview, one (1) of 16 incidents reviewed, it was determined the facility failed document and investigate a patient report of assault and failed to identify and implement measures to prevent reoccurrence. (Patient #1)

Findings include:

The policy titled "Occurrence/Serious Safety Event/Near Miss Reporting," which was last reviewed 4/2023 states, "If an event involves an allegation of harm or abuse of a patient or harm to a staff member the staff member who first becomes aware of the allegation is to: immediately provide or obtain necessary patient treatment and inform the appropriate clinical care team members. The immediate supervisor is to conduct a preliminary investigation of the incident including patient interviews and obtaining all known facts about the incident. In situations that endanger the patient, such as neglect or abuse, an investigation shall be conducted immediately, given the seriousness of the allegations and the potential for harm to the patient(s)."

Review of medical record for Patient #1, identified a patient presented to the Emergency Department (ED) on 9/30/24 at 8:08 PM for suicidal ideation. The triage nurse documented that per the police department, the patient made a call to the suicide hotline and made suicidal statements. The patient was agitated and uncooperative and the patient refused blood tests, EKG and a vital signs assessment.

The patient remained in the ED until 10/3/24 at 7:30 PM and was transferred to the Behavioral Health Unit where a nurse documented the patient arrived on the unit at approximately 8:00 PM that night, and that the patient angrily states "I was assaulted downstairs, I don't want to be here. Patient said they were assaulted downstairs, showing bruise on the inner aspect of the arm and left wrist. Patient also said they were thrown on the floor and hit their forehead. Observed with slight redness to forehead. There was slight swelling on patient's left upper eyebrow."

Review of the facility's list of incidents revealed this allegation was not listed in the incident database nor was an investigation done.

During interview with Staff A, Regional Director, Quality and Safety which was conducted on 10/24/24 at approximately 2:30 PM, Staff A confirmed the incident was not listed in the incident database (MIDAS) nor was an investigation completed.

Based on medical record review, document review and interview, in one (1) of 16 medical records reviewed, it was determined the nursing staff failed to reassess a patient's condition when bruises and swelling were noted on the patient's skin. (Patient #1).

Findings include:

The policy titled "Assessment and Reassessment of the Patient" which was last reviewed 03/2023 states, "Each patient is reassessed as necessary based on his or her plan of care or changes in his or her condition."

Review of medical record for Patient #1 identified, a patient presented to the Emergency Department (ED) on 9/30/24 at 8:08 PM, brought in by the police for suicidal ideation. The triage nurse documented that per the police department, the patient made a call to the suicide hotline and made suicidal statements. The patient was agitated and uncooperative and the patient refused blood tests, electrocardiogram (EKG) and a vital signs assessment.

The patient remained in the ED until 10/3/24 at 7:30 PM and was transferred to the Behavioral Health Unit where a nurse documented the patient arrived on the unit at approximately 8:00 PM that night and that the patient angrily states, 'I was assaulted downstairs, I don't want to be here. Patient said they were assaulted downstairs, showing bruises on the inner aspect of the arm and left wrist. Patient also said they were thrown on the floor and hit their forehead. Observed with slight redness to forehead. There was slight swelling on her left upper eyebrow."

A nurse documented on 10/3/24 at 9:22 PM there are bruises on the anterior left arm, posterior left arm, and anterior right leg. There was no documentation of the size of the bruises and swelling.

There was no further documentation in the medical record of a nursing reassessment of any of the patient's bruises, redness of the forehead or swelling on the left upper eyebrow after the patient's admission to the Behavioral Health Unit on 10/3/24.

During interview with Staff A, Regional Director, Quality and Safety which was conducted on 10/30/24 at approximately 3:30 PM, Staff A confirmed there was no documentation of a nursing reassessment of the patient's bruises, redness of the forehead or swelling on the left upper eyebrow.

Based on medical record review, document review and interview, in one (1) of 16 medical records reviewed it was determined the nursing staff failed to create a nursing care plan to address patient's bruises and swelling of the patient's skiin. Patient #1.

Findings include:

The policy titled "Initial Patient Assessment and Care Planning" which was last reviewed 03/2023 states, "Initial patient assessment and care planning shall be initiated by the Registered Nurse at time of inpatient admission and completed within twenty-four (24) hours. The collection and analysis of information during the initial assessment shall be utilized to formulate patient problem list, plan of care and begin the process of medication reconciliation."

Review of medical record for Patient #1 identified, a patient presented to the Emergency Department (ED) on 9/30/24 at 8:08 PM, brought in by the police for suicidal ideation. The triage nurse documented that per the police department, the patient made a call to a suicide hotline and made suicidal statements. The patient was agitated and uncooperative and the patient refused blood tests, electrocardiogram (EKG) and a vital signs assessment.

The patient remained in the ED until 10/3/24 at 7:30 PM and was transferred to the Behavioral Health Unit where a nurse documented the patient arrived on the unit at approximately 8:00 PM that night and that the patient angrily states "I was assaulted downstairs, I don't want to be here. Patient said they were assaulted downstairs showing bruises on the inner aspect of the arm and left wrist. Patient also said they were thrown on the floor and hit their forehead. Observed with slight redness to forehead. There was slight swelling on the left upper eyebrow."

A nurse documented on 10/3/24 at 9:22 PM, there are bruises on the patient's anterior left arm, posterior left arm, and anterior right leg.

There was no documentation in the medical record that a nursing care plan was created to address the patient's bruises, redness of the forehead or swelling on the left upper eyebrow.

During interview with Staff A, Regional Director, Quality and Safety which was conducted on 10/30/24 at approximately 3:30 PM, Staff A confirmed there was no documentation of a nursing care plan to address the patient's bruises, redness of the forehead or swelling on the left upper eyebrow.