HospitalInspections.org

Based on observation, review of facility documents and staff interview, the facility failed to ensure patients received care in a safe setting when they failed to follow facility policy and procedure for reassessment after patient falls for 5 of 12 patients reviewed (Patients #1, 8, 9, 11, 12).

Findings include:

Policy :"Neurological Assessment #: AS-11 -Assessments" partly stated,
5. Guidelines for completing Neurological Assessment Checklist:
-Document the date and time of each assessment
-Upon initial finding of potential head injury/neurological trauma, initiate Neurological Assessment Checklist
-Neurological Assessment will be initiated immediately after an unwitnessed fall or fall with possible head injury. This includes a continuation of neuro checks to be completed after return from Emergency room due to a fall if patient returns within 24 hours of the fall.
- Neurological Assessment Checklist will be completed as follows:
o Upon initial finding then,
o Every 15 minutes after initial assessment x 4 then [times 4],
o Every 30 minutes x 2 then,
o Every 60 minutes x 2 then,
o Once per shift for 2 days or an [sic] indicated by physician/non-physician practitioner order
6. All Neurological Assessments should include vital signs which will be documented in conjunction with the medical record.
*Any change in condition and/or abnormal Neurological Assessment findings must be reported immediately to physician/non-physician practitioner."

Review of the medical record for patient #1 revealed the patient was admitted on 9-13-22 and experienced two different witnessed falls; first fall on 9-13-22, Patient #1 hit her head that created a hematoma that required neurochecks. The second fall on 9-14-22 Patient #1 also hit her head and had a laceration on her right eye that also required neurochecks. No neurochecks were initiated per policy.

Review of the medical record for patient #8 revealed the patient was admitted on 9-12-22. On 9-13-22, the patient suffered an unwitnessed fall. Neurochecks were initiated, per policy, and were completed every 15 minutes after initial assessment X 5; the neurochecks did not continue and should have been completed every 30 minutes X 2 then, every 60 minutes X 2, then once per shift for 2 days.

Review of the medical record for patient # 9 was admitted on 7-12-22 and suffered an unwitnessed fall that required an immediate neurological assessment. No neurological assessment performed per policy.

Review of the medical record for patient # 11 was admitted on 8-5-22. On 8-6-22, patient suffered an unwitnessed fall that required an immediate neurological assessment. No neurological assessment was performed per policy.

Review of the medical record for patient #12 was admitted 8-5-22 and suffered an unwitnessed fall on 8-7-22 that required an immediate neurological assessment. No neurological assessment was performed per policy.

Through record review with hospital Staff #2, #6 and #12 on the morning of 9-29-22, it was verified there was no documentation of neurological assessment or regular neurological checks per policy for reported fall incidents. Staff #2 verified that the hospital staff did not follow facility policy.

Based on review of documents and staff interview, the facility failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and qualifications and competence of the nursing staff available.

Findings include:

Review of Facility-based Staffing Records for 9/12/22 through present were reviewed and compared to the census for those days. In an interview with Staff #2, Director of Nursing [DON], on the afternoon of 9/28/22, she reported she was new and did not have access to the previous DON's staffing sheets and schedules, therefore, those could not be provided.

The following days were out of the facility-based staffing grid of 6:1 MHTs [Mental Health Technician]:
9/13/22: 28 patients; there were only 4 MHTs on day shift and 4 MHTs on night shift
9/14/22: 24 patients and 1 1:1; there were only 4 MHTs on dayshift and no indication there was a 1:1 patient
9/16/22: 25 patients; there were only 4 MHTs on nightshift
9/17/22: 26 patients; there were only 4 MHTs on dayshift
9/18/22: 26 patients; there were only 4 MHTs on dayshift and 4 MHTs on nightshift

In an interview with Staff #2, DON, on the afternoon of 9/29/22, she reported they staff to acuity, which has been getting higher, so they've been looking to add another MHT to each shift. She went on to say they have a core staffing which included 2 RNs, 1 LVN and a 6:1 ratio of MHTs to patients. She reported they pull staff when they require more or a patient's level of observation increases to a 1:1 and acknowledged the staffing sheets did not reflect those changes were made. When discussed times where the sheet indicated a staff member left early, Staff #2 reported those slots were filled, as they always pool their on-call staff to ensure their ratio follows their requirements. When pointing at the provided staffing sheets and asked what happened when a MHT left at 4:45 pm, leaving them out of ratio, she stated, "The LVN is expected to help with bathing. Leadership comes in early and I can pull from other disciplines. It needs to be better documentation." She went on to say, "We have a lot of staff going through orientation right now."

Facility-based policy titled, "Staffing Plan" stated in part, "Policy: The governing Body has adopted, implemented and enforces a written Nurse Staffing policy to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed ... The facility is staffed by a prescribed matrix with nursing staff allocated based on patient population needs to accommodate increased census and special needs of the patient ...
Procedure:
Inpatient:
Factors considered in determining staffing needs:
-Patient census and staffing matrix are used to determine staffing needs.
-A core staffing pattern is utilized and adjusted every shift to meet facility and patient needs.
-Patient acuity and number of admissions and discharges are factored in daily to ensure all patient needs are met ...
Overall Staffing Plan: DON or Designee
...Retains the staffing plan and daily shift assignment sheets for six (6) years."