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Based on interview and document review, the facility failed to ensure a patient grievance was reviewed according to the facility's established grievance process in order to investigate and resolve the patient's concerns. The failure was identified in one of one grievances reviewed (Patient #3).

Findings include:

Facility policies:

The Patient Complaints and Grievances policy read, the purpose is to establish a process for prompt resolution of patient grievances. Grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by the patient or patient's representative regarding the patient's care. This includes a formal or informal written or verbal concern related to abuse or neglect, or patient harm.

Required actions steps: receive notification of grievance, as performed by patient care representative. Acknowledge grievance within three working days and clarify with the complainant that all concerns are understood. Begin coordination of the investigation with appropriate parties and document in the event in the online safety event reporting system, as performed by the patient care representative. Appropriate parties might include: managers, leaders, risk, quality, physicians. Ask for investigation to be complete within 72 hours, however grievances about harm or situations which endanger the patient should be reviewed immediately. Gather additional information needed for the investigation to resolve the grievance, as performed by the affected unit leader or manager. Send grievance letter within seven working days of receipt, as performed by the patient care representative.

References:

The Grievance Final Resolution Letter template, provided by the facility as a supporting document to the grievance policy, read, the letter was to include the names and titles of the leaders who completed their investigation of the event, and the results of investigation for each component of the grievance.

1. The facility failed to ensure concerns communicated by Patient #3 regarding injury as a result of restraint were managed and investigated in accordance with the facility's grievance policy.

a. Patient #3's medical record was reviewed. Patient #3 presented to the facility's Emergency Department (ED) on 12/7/21 for concerns of low blood pressure and potential alcohol withdrawal. According to the record, ED staff initiated restraints at 9:35 a.m. for combative behavior. The restraints included four locking limb restraints and a chest strap.

i. An initial nursing assessment was completed at 9:50 a.m., fifteen minutes after staff applied restraints to Patient #3. According to the HEENT (Head, Eyes, Ears, Nose, Throat) assessment, Patient #3's nose was bleeding. A bleeding nose was not previously noted in the triage assessment performed at 7:53 a.m. or the physician's examination at 9:35 a.m.

b. A grievance associated with Patient #3's medical record was reviewed. Patient #3 submitted the grievance on 12/8/21 and reported she was neglected, abused and discriminated against during her visit to the ED. According to the grievance, Patient #3 reported she was tackled and restrained by multiple staff members, and she told staff they were hurting her neck during the application of restraints however staff did not respond. The grievance further read, Patient #3 submitted photographs of bruising which she alleged was caused during the use of restraints, and additionally reported she sustained a nosebleed during her treatment.

i. The review and investigation for Patient #3's grievance was provided. According to the review, the Patient Representative (Representative) #19 forwarded the event to facility leadership for review, including the Director of the ED (Director) #16 and the Director of Clinical Risk (Director) #18.

Director #16 entered his review of the grievance on 12/13/21. The documentation read, on review of the chart the restraint application was appropriate because Patient #3 was agitated and aggressive and attempts to verbally de-escalate the patient were unsuccessful. Director #16 further documented, restraint application was the last resort which was applied for safety of the patient and staff.

Director #18 entered her review of the grievance on 12/17/21 which read, the care and staff response was appropriate to ensure the patient's and staff's safety. Representative #19 subsequently documented she mailed the final letter to the patient on 12/17/21.

ii. There was no evidence in the review of Patient #3's grievance Director #16 investigated the patient's allegations staff hurt and injured her in the course of applying restraints. There was no documentation to reflect whether Director #16's review of the medical record corroborated the patient's concerns that she sustained a nosebleed during restraint, nor was there evidence staff involved in the patient's care were interviewed to identify whether the patient was injured when restraints were applied.

Director #18's review of the grievance did not identify how the patient's concern for abuse and injury, to include alleged bruising and nosebleed as a result of restraint, as described in her grievance was investigated or resolved.

c. On 4/14/22 at 10:10 a.m., Director #16 was interviewed. Director #16 stated when a grievance was referred to him for investigation he reviewed the chart to identify whether there was documentation to corroborate the grievance or to determine the care was appropriate. He stated if he was unable to answer the concerns in the grievance with the documentation in the medical record he interviewed staff or witnesses involved in the patient's care to gather that information, which could include speaking with security or reviewing video footage. Director #16 stated once he had the information needed to address the patient's concerns he reported his findings to Representative #19, and then addressed any identified lapses in policy with the staff involved.

Director #16 stated when he reviewed Patient #3's grievance he reviewed the medical record to identify whether the patient's behavior necessitated the use of restraint, and whether the required orders and monitoring for restraint were present. However, he stated he did not investigate whether staff applied and utilized restraints in a safe manner or if the patient was injured during the course of restraint. Director #16 reviewed Patient #3's grievance and confirmed the patient alleged she had bruising as a result of her treatment; however he stated he did not investigate the event to determine whether staff actions caused the bruising because he and Director #18 did not know that the bruising actually occurred in the facility.

Director #16 stated he did not see any documentation in Patient #3's medical record which indicated an injury occurred during her treatment. He stated he did not remember Patient #3 alleging she had a nosebleed as a result of her treatment, and when he reviewed Patient #3's medical record as part of the grievance investigation he did not identify evidence of a nosebleed. Director #16 stated any time there was new bleeding or deformity it could indicate a new injury.

Director #16's interview was in contrast to review of Patient #3's medical record, in which staff documented the patient's nose was bleeding 15 minutes after the application of restraints, whereas a nosebleed was not documented on two previous assessments.

Director #16 stated he did not know how many or which staff were involved in Patient #3's episode of restraint. He stated he would only know who participated in the restraint and whether anything unusual occurred during the restraint if he interviewed the staff who cared for the patient.

There was no evidence in the documented review of Patient #3's grievance the staff involved in the patient's care were interviewed in order to investigate the patient's concerns for abuse and injury during restraint.

d. On 4/14/22 at 1:11 p.m., Representative #19 was interviewed. Representative #19 stated when department leaders reviewed a grievance she expected them to speak to staff involved and review the chart to assess the care which was provided. She stated the leaders informed her of the steps they took to review the grievance and whether the care was appropriate or if there were opportunities for staff to improve. She stated department leaders should address the concerns described by the patient in the grievance. Representative #19 stated she sent a letter to the grievant to inform them of the investigation performed and any findings.

Representative #19 stated when she reviewed Patient #3's grievance the patient was concerned with injury and bruising as a result of being put in restraints and the patient sent pictures of the bruising. She stated the grievance was forwarded to Director #16 to review, and he responded the patient's care was appropriate which she related in her letter to the patient.

Representative #19 stated Director #16 reviewed the medical record and determined the patient was agitated, aggressive and needed to be restrained for safety. She stated based on his documented follow-up for the grievance, she did not know if Director #16 reviewed the chart or took other steps to address Patient #3's concerns that she was injured, to include alleged bruising and nosebleed, when staff restrained her. When asked if Patient #3 was injured or had a nosebleed during the course of restraint, and if staff followed necessary processes to prevent injury during restraint, Representative #19 stated she was not able to answer those questions based on Director #16's review of the grievance.

Representative #19 stated she also forwarded the grievance to Director #18 because the patient felt she was abused. She stated Director #18 would review the grievance to determine whether harm or injury occurred as alleged.

There was no evidence in Director #18's documented review of Patient #3's grievance the patient's concern for abuse and injury as a result of restraint was investigated or addressed.

Representative #19 stated she forwarded grievances to department leaders for investigation because she relied on their clinical judgment to determine whether a patient's care was appropriate. She stated when Director #16 responded the care provided to Patient #3 was appropriate, she assumed he had reviewed the details of the patient's concerns and took the necessary steps to determine the care was appropriate.

Representative #19's interview was in contrast to Director #16's interview and documented review of the grievance: Director #16 stated he reviewed Patient #3's chart to determine whether it was necessary for staff to restrain Patient #3, but he did not investigate the grievance to determine whether Patient #3 was injured when she was restrained; he did not identify documentation in the medical record which aligned with the patient's allegation she sustained a nosebleed during restraint; and there was no evidence staff involved in Patient #3's care were interviewed to determine whether Patient #3 was injured due to staff application of restraints.

Based on interview and document review, the facility failed to ensure staff were trained in the safe use of all types of restraint used in the facility, specifically the use of a chest strap which was used to restrain patients with aggressive or violent behavior.

Findings include:

Facility policy:

The Restraint and Seclusion policy read, the purpose is to support the limited and safe use of restraints in all clinical settings. Restraint is defined as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely. The following are examples that may be considered a restraint: wrist/ foot restraints, belt, net/enclosure beds, side rails, hand mitts, geri chairs, physical hold in a manner that restricts the patient's movement against the patient's will.

Restraint for the management of violent or self-destructive behavior is used only as an emergency measure and is reserved for those occasions where severe aggressive or destructive behavior places the patient or others in imminent danger. Restraints may be used only to protect the immediate physical safety of the patient, staff members, and others. The type of restraint shall be appropriate to the type of behavior to be managed and must take into account information obtained in the patient's initial assessment.

The process to initiate and monitor restraints read, the hospital trains staff on the use of restraint and assesses their competence at the following intervals: at orientation, before participating in the use of restraint, and on a periodic basis thereafter. Individuals providing staff training in restraint have education, training and experience in the techniques used to address patient behaviors which necessitate the use of restraints.

References:

The manufacturer's Instructions for Use (IFUs) for the Posey General Purpose Belt read, Indications for use: patients who are aggressive and attempt to "buck" up and down, risking potential self-injury or disruption of treatment; patients who need a supplemental restraint (5th point) of the thighs, pelvis, or chest and who are already restrained at all four extremities. Contraindications: DO NOT use this device on patients with ostomy, colostomy or G-tubes; hernias, severe COPD, or with post-surgery tubes, incisions or monitoring lines. These could be disrupted by the restraint. NEVER use a 5th point restraint on a patient with a pelvic fracture, supra-pubic catheter, ostomy, feeding tube or recent incision; with a history of cardiac or pulmonary disorders or thoracic fractures; to restrain the head or neck. Adverse reactions: severe emotional or physical problems may occur if the applied device is uncomfortable or severely limits movement.

Application instructions: make sure patient wears proper undergarments to protect skin. Attach wrist and ankle restraints to aggressive patients to keep the patient from self-release. Once applied, make sure it adheres securely. The belt must be snug, but not interfere with breathing. To check for proper fit, slide an open flat hand between the belt and the patient. When using over the chest, the straps should go under the arms and attach at chest level to a movable part of the bed frame. This will prevent the patient from sliding down and becoming entangled.

The Restraint Course educational content, provided by the facility, read, the objectives of the course were to identify when it is okay to use restraints, describe how to safely manage all types of restraints, and identify behavioral changes indicating a restraint is no longer necessary. Examples of restraints included soft non-locking restraints and hard locking or non-locking restraints. Restraints should be applied with safe technique in accordance with the manufacturer's instructions and per policy and annual competency, and only applied by trained staff.

1. The facility failed to ensure staff in the Emergency Department (ED) were trained in the safe use of a chest strap restraint, to include the indications for use and safe application of the device as described by the manufacturer's IFUs.

a. Medical record review revealed ED staff documented the use of a chest strap, in addition to four-point locking limb restraints, for the management of patients who exhibited aggressive or violent behavior.

i. Patient #3's medical record was reviewed. According to a flowsheet titled Restraints for Violent or Self-Destructive Use, at 9:53 a.m. staff applied restraints to include locking left and right ankle restraints, locking left and right wrist restraints, and a chest strap. At 10:32 a.m. staff documented the chest strap was removed.

ii. Patient #6's medical record was reviewed. According to the Restraints for Violent or Self-Destructive Use flowsheet, at 4:30 a.m. staff applied restraints to include locking left and right ankle restraints, locking left and right wrist restraints, and a chest strap. At 5:30 a.m. staff documented the chest strap was removed.

b. Interviews with ED staff revealed the chest strap was utilized according to nursing staff discretion as a fifth restraint point for patients who required violent restraints. However, ED staff were not able to specify the education or training they were provided in the use of the chest strap and demonstrated lack of knowledge of the device IFUs and the criteria for use of the chest strap as an optional fifth restraint point.

i. On 4/13/22 at 11:10 a.m., ED Tech (Tech) #12 was interviewed. Tech #12 stated she had worked in the Behavioral Health area of the ED where restraints were sometimes necessary for patient safety. Tech #12 stated when restraints were in use it was important to check on the patient to ensure the restraints were not too tight and did not cause signs of injury. Tech #12 stated when staff applied a chest strap restraint to a patient, staff monitored the patient in the same manner as they would monitor a patient in limb restraints.

Tech #12 stated when she monitored a patient who was in a chest strap she checked the patient to make sure the strap did not cause injury or restrict the patient's breathing. She stated the chest strap was not applied tightly enough that it could press on a patient's chest and she believed it should be possible to fit an entire arm between the strap and the patient's body. Tech #12 stated she was not sure exactly how much room should be between the strap and the patient's body and she would have to look at the instructions to know for certain.

The IFUs for the Posey General Purpose Belt read, the belt must be snug but not interfere with breathing. To check for proper fit, slide an open flat hand between the belt and the patient.

Tech #12 stated she did not know if she had seen the device IFUs for the chest strap restraint.

ii. On 4/12/22 at 12:10 p.m., RN #14 was interviewed. RN #14 stated when staff prepared to initiate violent restraints for a patient it was important to ensure the chest strap was available if it was needed. She stated staff often needed to use the chest strap if the four locking limb restraints were applied but the patient was still trying to bite or head-butt staff, or if the patient was thrashing around and could hurt themselves. RN #14 stated nursing staff had the discretion to decide whether the chest strap was initiated and it was not specified in the physician order.

iii. On 4/12/22 at 1:44 p.m., Registered Nurse (RN) #13 was interviewed. RN #13 stated when staff utilized restraints for violent behavior this typically included use of locking restraints on all four limbs. He stated the chest strap restraint was also sometimes used to prevent a patient from sitting up and attacking staff with their head and mouth, or if staff needed to perform procedures close to the patient while the patient was restrained.

RN #13 stated he had seen the chest strap applied to patients but he did not choose to use the strap. He stated he believed four locking limb restraints were enough to keep a patient safe and he should not need to use the chest strap in addition to the four limb restraints. RN #13 stated he did not know what criteria determined when the chest strap restraint should be used.

RN #13 stated his training and education for the use of restraints was included in the orientation packet to be covered by the precepting nurse. He stated he did not remember taking a specific course regarding the use of restraints.

iv. On 4/13/22 at 10:48 a.m., ED Manager (Manager) #15 was interviewed. Manager #15 stated the chest strap restraint was considered a fifth point in the violent restraints. He stated it was usually applied if four limb restraints were in place but a patient continued to struggle and was at risk for injury. He stated when violent restraints were ordered it was up to the staff's discretion whether the chest strap should be utilized as a fifth point. Manager #15 stated the chest strap had been used in the ED for several years. He stated he believed staff were educated to the use of the chest strap when they were educated on the use of other restraint types.

Manager #15 stated he was not aware of any specific risks associated with the chest strap restraint, or situations in which a patient wouldn't be able to tolerate the use of the chest strap. However, this was in contrast to the restraint IFUs, which described multiple medical conditions which would contraindicate the use of the device such as feeding tubes, incisions, cardiac or pulmonary disorders or thoracic fractures.

v. On 4/14/22 at 12:17 a.m., ED Director (Director) #16 and Manager #15 were interviewed. Manager #15 stated the criteria for use of the chest strap was to ensure patient and staff safety and was used frequently in the ED. He stated he believed in most cases where the chest strap was utilized it was obvious to staff the device was needed, however he stated there was no formal training provided to staff to educate them on the safety, indications and proper use of the chest strap. Director #16 stated he was not aware of any guidance in the hospital's restraint policy regarding the use of the chest strap restraint.

Manager #15's interview was in contrast to facility policy, which read the hospital trained staff on the use of restraint and assessed their competence at orientation and before participating in the use of restraint, and to the hospitals Restraint educational content, which read restraints were to be applied with safe technique in accordance with the manufacturer's instructions and per policy and annual competency, and only applied by trained staff.

vi. On 4/14/22 at 4:22 p.m., Manager #15 and the Manager of Regulatory Affairs (Manager) #17 were interviewed. Manager #17 stated there was no evidence the chest strap restraint was addressed in the facility's restraint education for staff. Manager #15 stated because the device was used often in the ED it was educated to staff during on-the-job training, however was unable to provide any evidence of "on the job" education or training for the chest strap frequently utilized in patient care.

c. The facility provided the education content for the hospital's Restraint course, which was required for all staff in the ED, along with the education and competencies for Tech #12, RN #13 and RN #14. Tech #12, RN #13 and RN #14 all completed the Restraint course. However, the Restraints course content did not include any reference, guidance or instruction related to the use of the chest strap as a fifth point restraint, nor was there evidence the use of the chest strap was reviewed as part of the staff's additional competencies or education. In addition, the facility's Restraint and Seclusion policy did not include guidance for staff's discretion to initiate the chest strap restraint in addition to locking limb restraints when violent restraints were ordered by the physician.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0395 RN SUPERVISION OF NURSING CARE A registered nurse must supervise and evaluate the nursing care for each patient. Based on observations, interviews and document review, the facility failed to ensure the registered nurse (RN) implemented fall prevention interventions for patients susceptible to falls. Specifically, nursing staff failed to implement fall risk interventions according to facility policy for four of four high fall risk patients reviewed. (Patient #1, #2, #7 and #8)

Based on observations, interviews and document review, the facility failed to ensure the registered nurse (RN) implemented fall prevention interventions for patients susceptible to falls. Specifically, nursing staff failed to implement fall risk interventions according to facility policy for four of four high fall risk patients reviewed. (Patient #1, #2, #7 and #8)

Findings include:

Facility policy:

The Patient Fall Prevention policy read, a fall prevention plan will be developed at admission and updated as indicated by the patient's condition. An appropriate Fall Risk Assessment will be performed for all patients at admission, every shift and when the patient's condition or mental status changes during the course of the shift. An individualized fall prevention plan will be developed for all fall risk patients and documented in the patient's plan of care. Staff will implement universal risk prevention/safety interventions and individualized fall risk reduction interventions for the patient.

A fall is defined as a sudden, unintentional descent to the floor.

References:

The Determine If Patient Is At-Risk For Fall read, staff, determines if the patient is at risk for falls by completing the Morse Fall Risk Scoring Tool (Morse Fall Risk Assessment) at admission, every shift and with a change in patient condition or mental status.

The Morse Fall Risk Assessment Tool determines the patient's fall risk by assigning a score to specific fall risk factors. Patients who have a history of falls receive a risk factor score of 10. Patients with more than one diagnosis at the time of admission receive a risk factor score of 15. Patient use of an ambulatory aid such as a wheelchair, crutches or a walker receives a score of 15 and patients who stabilize themselves by gripping furniture while walking receive a risk factor score of 30. Patients with intravenous lines or a heparin lock receive a risk factor score of 20. The presence of an impaired

The Morse Fall Scale assesses the patient's likelihood of falling by assigning a score to specific fall risk factors. There are six variables used to score the patient's fall risk.

The variables used to determine the fall risk score are: The first variable is used to determine a patient's fall risk score is history of falls, this variable is scored as 25 if the patient has fallen during the present hospital admission or if there was a history of falls prior to admission, if the patient has not fallen, the score is zero. The second variable used is secondary diagnosis, this variable is scored as 15 if the patient has more than one medical diagnosis listed in the patient's chart, if not there is only one diagnosis the score is zero. The third variable is the use of ambulatory aids, this variable is scored zero if the patient walks without a walking aid or assistive device. Patients who use crutches, a cane, or a walker, are assigned a score of 15 for this variable. Patients who clutch onto furniture for support when ambulating were scored a 30 for this variable. The fourth variable is active intravenous therapy, this variable is scored as 20 if the patient has an intravenous apparatus or a heparin lock. For patients not on intravenous therapy, the score is zero. The fifth variable is patient gait, patients who have difficulty rising from a chair, attempt to get up by pushing on the arms of a chair or who bounce or require several attempts to rise received a score of 20, patients with a weak gait will receive a score of 10 and patients who are able to walk without losing balance receive a score of zero. Lastly, the sixth variable is the patient mental status, patients who forget their ambulatory limitations receive a score of 15, and patients who are oriented to their ability and capability for ambulating receive a score of zero. The cumulative score of the variables determines the patient's fall risk score.

The Fall Prevention Interventions Supporting Document read, Universal Fall Precautions for patients at low/no fall risk (Morse Fall Risk Score of 0-49) were: Instruct patient and family in the use of the nurse call light, placement of the nurse call within reach of the patient, instruct the patient to wear nonskid socks/footwear when ambulating, keep bed/cart in the lowest position and locked, encourage the use of side rails, keep room/floor free of obstacles, maintain a clear path between bed/cart or chair and bathroom and keep night light/bathroom light on to maintain adequate lighting.

The following fall interventions are mandatory for high fall risk (Morse Fall Risk Score of 50 and greater) patients: Implement all measures from the Universal Fall Precautions, placement of a fall risk alert band on the patient and document under safety - "fall risk alert band on", perform "teach back" with the patient to validate their understanding of why they are a fall risk, staff is to stay with the patient in the bathroom and be within an arm ' s length away, the patient should remain close enough so staff can reach out and stabilize the patient when toileting, use of a gait belt when the patient ambulates and transfers, ensure the bed/chair alarm is in use at all times regardless of family presence or a request by family, friends or the patient for the alarm to be turned off. Additionally, update the patient's care board within the room with the following: in the Assistance/Activity box write "Fall Risk" and indicate a bed/chair alarm is to be used for the patient and indicate which assistive device/equipment (cane, walker, lift) is needed by the patient.

The following interventions will be implemented dependent on the clinical assessment of the patient: when a patient is non-compliant with calling for assistance the initiate a "Partners in Safety" contract, reinforce call light use, relocate the patient closer to the nurses' station, keep the door to the patient's room open and keep commode or urinal at the patient's bedside.

1. The facility failed to ensure nursing staff implemented fall prevention measures and interventions for patients identified to have an increased susceptibility to falls.

A. Observations, patient interviews and medical record reviews revealed nursing staff failed to implement safety interventions for patients.

a. Review of Patient #7's medical record revealed he was admitted on 4/8/22 at 12:58 p.m. He was diagnosed with acute respiratory failure with hypoxia (shortness of breath and low oxygen levels in the blood) and pneumonia (an infection of one or both of the lungs).

i. On 4/8/22 at 3:02 p.m., a fall risk assessment was performed for Patient #7. The fall risk assessment lacked a correct fall risk score for the second diagnosis variable of the assessment tool. This resulted in a fall risk score of 35 for Patient #7, which placed Patient #7 in the low fall risk range.

The fall risk score of zero for the second diagnosis variable was in contrast to the Morse Fall Risk Assessment Tool which stated patients admitted with more than one medical diagnosis received a fall risk score of 15 for the second diagnosis variable. A secondary diagnosis fall risk score of 15 would have resulted in a cumulative fall risk score of 50 not 35 for Patient #7, placing Patient #7 in the high fall risk range.

A total of 10 fall risk assessments were performed from 4/8/22 to 4/12/22 for Patient #7. Nine of the 10 fall risk assessments for Patient #7 lacked a correct fall risk score for the second diagnosis variable. Furthermore, the fall risk interventions implemented Patient #7 were in contrast with facility policy.

According to the Fall Prevention Interventions Supporting Document, a fall risk score of 50 or greater indicated the patient to be placed on high fall risk interventions. High fall risk interventions included: the activation of bed/chair exit alarms, the application of a yellow fall risk alert band and in-room patient communication board documentation of which assistive devices were used by the patient to ambulate and ensure the patient's safety.

ii. On 4/11/22 at 9:34 a.m., an observation of Patient #7 and the patient's room revealed Patient #7 was a high fall risk patient. Patient #7 had a yellow fall risk armband on his right wrist and required the use of a nasal cannula which was tethered to the wall behind his bed to continuously receive five liters of supplemental oxygen (extra oxygen).

Further observations of Patient #7's room revealed the bed exit alarm on Patient #7's bed was not activated when Licensed Practical Nurse (LPN) #1 entered Patient #7's room. The bed panel display located on the right upper side rail of Patient #7's bed read, "Bed Exit Off".

At 9:39 a.m., LPN #1 left Patient #7's room to retrieve medication for Patient #7. The bed exit alarm had not been activated by LPN #1 before he exited Patient #7's room.

At 9:42 a.m., LPN #1 returned to Patient #7's room and administered medication to the patient.

At 9:45 a.m., LPN #1 departed Patient #7's room. The bed alarm for Patient #7 was not turned on by LPN #1 and "Bed Exit Off" was visible on the display panel for Patient #7's bed.

iii. On 411/22 at 11:35 a.m., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated Patient #7 had a yellow fall risk armband on his wrist. LPN #1 stated a yellow fall risk armband was worn by high fall risk patients.

b. Medical record review of Patient #8 revealed the patient was admitted on 4/10/22 at 9:37 a.m. Patient #8 was diagnosed with aspiration pneumonia (an infection of the lungs caused by inhalation of saliva, food, liquid or small foreign objects) and required supplemental oxygen to maintain an oxygen saturation rate above 90 percent.

i. Fall risk assessments were performed for Patient #8 on 4/10/22 at 10:32 a.m. and 8:18 p.m. On 4/11/22 at 9:35 a.m., a third fall risk assessment was performed for Patient #8. The three fall risk assessments performed resulted in a fall risk score of 85 and patients with a fall risk score greater than 50 were considered high fall risk patients.

Medical record review revealed the fall interventions implemented for Patient #8 were supervised ambulation, gait belt use and activation of bed/chair alarm.

ii. On 4/11/22 at 10:19 a.m., RN #2 was observed providing care to Patient #8. Observations revealed Patient #8 wore a yellow fall risk armband on his right wrist and a walker (a medical device used to assist with ambulation) was present in Patient #8's room.

iii. At 10:20 a.m., the bed panel display located on the right upper side rail of Patient #8's bed displayed "Bed Exit Off".

At 10:26 a.m., RN #2 exited Patient #8's room. RN #2 did not activate the bed exit alarm on before she left Patient #8's room. "Bed Exit Off" was visible on the bed panel display of Patient #8's bed after RN #2 exited Patient #8's room.

iv. On 4/11/22 at 10:53 a.m., an interview was conducted with Registered Nurse (RN) #2. RN #2 stated patients with a yellow fall risk armband meant patients were at risk for falls. RN #2 stated the nurse caring for the patient determined which fall prevention interventions were implemented for the patient. RN #2 stated patients were assessed for weakness and their level of assistance by the nurse to determine the fall precautions to be implemented for the patient.

v. An interview was conducted with Patient #8 on 4/11/22 at 10:30 a.m. Patient #8 stated he was admitted to the facility on 4/9/22. Patient #8 stated he was unstable on his feet and experienced weakness in his legs when standing and ambulating. Patient #8 stated he needed assistance getting in and out of bed, when standing from a seated position and when he walked (ambulated).

Patient #8 stated he experienced a fall at the nursing home and was found on the floor in his room. Patient #8 stated the fall occurred because he became dizzy and weak when he stood up and lost his balance.

Patient #8 stated after being admitted to the hospital he was provided a walker to when he ambulated. Patient #8 stated he found it difficult to use the walker in his room because he felt unsteady and weak on his feet.

B. Medical record review and staff interviews revealed nursing staff failed to implement fall prevention interventions for patients with increased susceptibility to falls.

a. On 12/19/21 at 6:57 a.m., Patient #2 was admitted to the facility. Patient #2 was diagnosed with severe anemia (low levels of red blood cells) and alcoholic hepatitis (inflammation of the liver caused by drinking alcohol).

i. Medical record review revealed on 12/21/21 at 3:37 p.m., fall prevention interventions were implemented for Patient #2. Supervised ambulation, gait belt use when the patient ambulated and was transferred out of bed, and the bed alarm for Patient #2 was activated and remained in place.

ii. On 12/22/21 the Clinical Notes entered by RN #4 stated, during the nursing hand-off report performed at Patient #2's bedside she was informed Patient #2 was independent, and able to ambulate without assistance, furthermore, the bed alarm had not been activated for Patient #2. However, Patient #2 later advised RN #4 he had fallen on 12/21/21. Patient #2 explained he fell as he ambulated to the restroom by himself. RN #4 documented Patient #2 had a bruise on his lip and on his right hip. Furthermore, Patient #2 had a visibly unsteady gait when he walked.

This was in contrast to the Nursing's Shift Summary Note entered on 12/21/21 at 6:55 p.m. which read, a bed alarm was in place and activated for Patient #2.

iii. An interview was conducted with RN #4 on 4/12/22 at 3:13 p.m. RN #4 stated she had cared for Patient #2 on 12/22/21. RN #4 stated Patient #2 was actively withdrawing from alcohol and experienced alcohol withdrawal symptoms. RN #4 stated Patient #2 appeared unsteady when he walked and had mental and cognitive delays when he communicated. RN #2 stated she activated the bed alarm for Patient #2 after the patient stated he had fallen. RN #2 stated prior to Patient #2 disclosing he fell fall precautions had not been implemented for Patient #2.

iv. On 4/12/22 at 12:24 p.m., an interview was conducted with Physician #9. Physician #9 stated Patient #2 experienced a fall at the facility after he was admitted. Physician #2 stated after Patient #2 fell he had a large hematoma (a severe bruise that causes blood to collect and pool under the skin) on his right hip. Physician #9 stated Patient #2 experienced increased bleeding due to the hematoma as his anemia worsened. Physician #2 stated multiple blood transfusions were administered for Patient #2 as a result of the increased bleeding he experienced after he fell.

Physician #9 stated anemic patients experienced dizziness, confusion and weakness.

b. On 1/10/22 at 10:52 a.m., Patient #1 was admitted to the facility. Patient #1 was diagnosed with dementia (the loss of cognitive functions such as thinking, remembering, and reasoning). The fall risk assessment performed after Patient #1 was admitted revealed Patient #1 had an increased risk for falls. Patient #1's fall risk assessment score was 100 at the time she was admitted.

i. On 1/11/22 at 2:21 p.m., Clinical Notes entered by the physician caring for the patient read Patient #1 was confused she experienced several falls prior to her admission to the facility.

On 1/13/22 at 4:46 a.m. the Clinical Notes entered by the RN who cared for Patient #1 stated an unwitnessed fall occurred. Additionally, Patient #1 had a history of falls and instability when ambulating.

ii. Medical record review for Patient #1 revealed a total of six fall risk assessments were performed for Patient #1 when she had been admitted to the facility and the following fall risk interventions were to be implemented for the patient: supervised ambulation, gait belt use when ambulating, assistance when transferred out of bed and the activation of the bed and/or chair alarm for the patient.

Patient #1 and Patient #2 exhibited the following fall risks: unsteady or impaired gait confusion, cognitive delays and weakness, both were to have the bed alarms activated and were required to have staff present to assist when the patient ambulated. Patient #1 and Patient #2 experienced unwitnessed falls while in their patient rooms although the bed alarm was documented as activated for both patients.

iii. On 04/13/22 at 9:44 a.m., an interview was conducted with Clinical Manager (Manager) #10. Manager #10 stated the bed exit alarm should have been activated for Patient #1 and Patient #2. Manager #10 reviewed the fall risk assessments and interventions implemented for both patients. Manager #10 stated the nursing staff caring for each patient documented a bed alarm was activated; however, if patients were documented as being on bed alarms the alarms were expected to be on consistently and staff needed to check to ensure the alarms were on prior to leaving the patient's room. Manager #10 stated the bed alarm should have been activated as both patients were high fall risk patients. Manager #10 stated high fall risk patients should always have bed exit alarms activated.

Based on interviews and document review, the facility failed to ensure nursing staff administered medications according to the patient's condition, facility protocols and physician order to correct a patient's hypoglycemia (low blood sugar) in one of one medical records reviewed for patients on a hypoglycemia protocol (Patient #4).

Findings include:

Facility policies:

The Medication Management policy read, medications are ordered by licensed physicians, residents, physician assistants and advanced practice nurses. Medication orders must include the drug name, strength, dosage, frequency, route of administration, and indication. All PRN orders require an indication.

The required action steps for Medication Administration, as performed by the Registered Nurse (RN), include the following. Obtain medication. Administer medications within the appropriate time frame. Medication administration to the patient must be observed, completed and documented by the responsible personnel in real time. If there are any questions regarding prioritization of medications due at the same time, clarify with the authorized prescriber. Documentation is expected to occur during actual administration of the medication to the patient. Document the patient response and other data as appropriate. Notify the physician if the patient's symptoms are not relieved by the highest dose ordered.

References:

The facility's Medical Staff Rules and Regulations read, medications must be administered in accordance with an order by a Practitioner. For PRN orders, an indication for use is required.

The facility's Hypoglycemia Treatment Guidelines read, if blood glucose result is 50 - 70, for patients who are NPO or are unconscious, give 12.5 grams of IV dextrose and recheck the blood glucose 5 minutes after dextrose is administered. For blood glucose less than 50, give 25 grams of IV dextrose and recheck the blood glucose 5 minutes after dextrose is administered. Repeat every 15 minutes until glucose is greater than 70 or the patient is no longer symptomatic.

The Lippincott Guidance for Dextrose, provided by the facility, read, for hypoglycemia in adults: administered 10 to 25 grams IV infusion. May need to repeat doses in severe cases. Determine blood glucose level before injecting; in an emergency situation promptly administer without waiting for pretreatment test results.

1. The facility failed to ensure nursing staff administered medications to treat hypoglycemia according to physician order and the facility's hypoglycemia protocol.

a. Patient #4's medical record was reviewed. According to the History and Physical (H&P) completed on 3/6/22, Patient #4 was admitted for treatment of sepsis (a potentially life-threatening response to an infection) and a consult with gastroenterology for bloody stools.

i. On 3/6/22 at 7:10 a.m., a physician order was entered and authorized by Provider #7 which read, Hypoglycemia Protocol: for any blood glucose less than 70 initiate hypoglycemia protocol. Always treat prior to or at the same time as contacting the provider. For glucose between 50 and 70, give dextrose (a form of glucose which is injected intravenously to treat low blood sugar)
12.5 grams, which was calculated as 250 ml of dextrose 5%. For glucose less than 50, give dextrose 25 grams, which was calculated as 500 ml of dextrose 5%. Check glucose level on the arm without the IV 15 minutes after dextrose administration is complete. Repeat intervention every 15 minutes until glucose is greater than 70 or symptoms resolve.

A medication order was entered at the same time for a bolus of intravenous (IV) dextrose 5% 250 ml. The administration instructions read, for blood glucose 50 - 70 give dextrose 12.5 grams, and for blood glucose less than 50 give dextrose 25 grams.

ii. According to the laboratory results for Patient #4, at 7:04 a.m. the patient's blood glucose was 39. At 7:18 a.m. Registered Nurse (RN) #5 administered IV dextrose 5% and rechecked Patient #4's blood glucose according to the hypoglycemia protocol.

Review of the medical record revealed at 11:59 a.m. Patient #4's blood glucose again was low at 31, which was indicated in the medical record as a critically low value. The RN performed a repeat blood glucose test and at 12:03 p.m. Patient #4's blood glucose was 61, which was indicated as a low value.

Nursing assessments completed at 11:00 a.m. and again at 12:48 a.m. revealed Patient #4 was drowsy, disoriented to place and situation, confused, forgetful, and exhibited garbled slurred speech. During this time period the RN also documented Patient #4 required medical restraints due to confusion, agitation and restlessness.

According to Provider #7's order and the hypoglycemia protocol, if the patient's blood glucose was 50 - 70 the actions were to administer 250 ml of dextrose 5% and recheck the patient's blood glucose 15 minutes after dextrose was administered. These actions were to be repeated every 15 minutes until the patient's blood glucose was greater than 70 or the patient's symptoms resolved.

iv. At 12:52 p.m. the RN entered a note which read, while the RN was at bedside the patient became unresponsive and her heart rate dropped to 30. The patient did not have a pulse and a rapid response was called.

v. There was no evidence the RN administered IV dextrose between 11:59 a.m. when Patient #4's blood sugar was 31 and 12:52 p.m. when a Rapid Response was called due to the patient's deteriorating condition. In addition, the patient's blood glucose was not checked again until 12:54 p.m. after a Rapid Response had already been called in response to a decline in Patient #4's condition.

b. Interviews revealed the facility's hypoglycemia protocol and standards of practice warranted prompt administration of IV dextrose to treat Patient #4's low blood sugar, and further revealed the RN did not administer the medication in accordance with the patient's condition and the physician's order.

i. On 4/13/22 at 1:08 p.m., RN #5 was interviewed. RN #5 stated if a patient was on the hypoglycemia protocol, the nurse was to administer IV dextrose if a patient's blood glucose was below 70. She stated after dextrose was administered the nurse rechecked the blood sugar, and may need to give additional dextrose if the patient's blood sugar did not improve.

RN #5 stated she admitted Patient #4 when the patient arrived to the inpatient unit. She stated when she checked the patient's blood glucose it was 39 and the patient was intermittently confused. She stated she called the physician and obtained the order for the hypoglycemia protocol so she could administer dextrose to the patient. RN #5 stated it was important to administer dextrose to a hypoglycemic patient in order to quickly increase the patient's blood sugar. RN #5 stated a different nurse assumed care of Patient #4 for the day shift of 3/6/22, and she did not have any knowledge of why dextrose was not administered when the patient's blood sugar dropped later in the day.

ii. On 4/14/22 at 10:39 a.m., Charge Nurse (Charge) #6 was interviewed. Charge #6 stated an order for the hypoglycemia protocol was placed so the RN could administer IV dextrose if the patient's blood sugar became low. She stated it was placed as a standing order so if dextrose was needed the RN could administer the medication without taking time to call the physician.

Charge #6 reviewed Patient #4's medical record. She stated when the patient's blood glucose was 31 at 11:59 a.m. and was 61 when it was rechecked four minutes later, these results warranted an intervention to address the patient's condition. She stated if a patient's glucose was below 70 and the patient could not eat or drink the RN would administer IV dextrose.

Charge #6 confirmed on review of the medical record there was no evidence the RN administered IV dextrose after the patient's blood glucose test results were 31 and 61. She stated from the documentation in the patient's record she did not know why the medication was not given and she could not think of any reason why IV dextrose would be held or contraindicated for a patient with hypoglycemia.

Charge #6 stated if a patient's blood sugar was low it was important to administer dextrose as soon as possible, especially if a patient exhibited symptoms such as unresponsiveness or obtundation (an altered level of alertness or consciousness). According to Patient #4's medical record, in the hour before and after the low blood glucose results of 31 and 61 Patient #4 was disoriented, drowsy, forgetful and confused.

iii. On 4/14/22 at 1:44 p.m., Provider #7 was interviewed. Provider #7 stated when Patient #4 was admitted she was hypoglycemic and he placed her on the hypoglycemia protocol. He stated the protocol included giving a bolus of IV dextrose to the hypoglycemic patient.

Provider #7 reviewed Patient #4's medical record. He stated when Patient #4's blood glucose was 31 and then 61 on a recheck, the protocol would warrant dextrose to be administered based on the second result of 61. He stated for a blood glucose of 61 the RN was to administer 250 ml of dextrose 5%. Provider #7 confirmed that according to the medical record the RN did not administer any dextrose in response to the patient's blood glucose of 61.

Provider #7 stated he did not know why the nurse did not administer dextrose according to the hypoglycemia protocol. He stated he did not have any conversations with the nurse regarding holding the medication or difficulties administering the medication, nor did the nurse notify him she was unable to administer the dextrose as ordered.

iv. On 4/14/22 at 4:00 p.m., the Chief Nursing Officer (CNO) #8 was interviewed. CNO #8 stated when a nurse needed to administer medications for a low blood glucose, the nurse was to use their professional judgment to determine how quickly to administer the medication. She stated she expected a medication for hypoglycemia to be administered within 30 minutes of the low glucose result, and she stated an hour was too long to wait to administer the medication. CNO #8 stated the standard of practice for treating hypoglycemia was to treat it quickly, and if it took an hour or longer to administer a medication for hypoglycemia she would want to review the case and understand why it took so long.

CNO #8 then provided a document, the Lippincott guidance for administration of IV dextrose, which she said outlined the nursing standards of care for the intervention. She stated the guidelines read dextrose should be administered promptly, and she expected the timeframe to be within 30 minutes to address the patient's low blood sugar.

CNO #8's interview was in contrast to the medical record for Patient #4. Patient #4's blood glucose level was low at 11:59 a.m. and 12:03 p.m. and according to the ordered hypoglycemia protocol warranted administration of IV dextrose; however, there was no evidence the dextrose was administered in the 49 minutes which elapsed between the second low blood glucose result and 12:52 p.m. when a Rapid Response was called.