HospitalInspections.org

Based on observations, document review and interviews it was determined the facility failed to provide care in a safe setting on the Geriatric Unit. This failure to provide care in a safe setting has the potential to result in patient injury.

Findings include:

1. A tour conducted on 12/3/18 at approximately 1:45 p.m. on the Geriatric Unit revealed every patient did not have access to a call light system. Mobile patients may push buttons on the wall which were left from the previous call light system. Immobile patients were given silver bells which can be tapped to call for a nurse. There were ten (10) hospital beds which have a call nurse button on the upper side rails. The call nurse button was not connected to a call light system and did not work. An interview conducted with the Registered Nurse (RN) Charge Nurse #2 during the tour on 12/3/18 at approximately 1:45 p.m. revealed patients who cannot push the buttons on the wall may yell or come to the desk to call for a nurse. The staff make rounds every fifteen (15) minutes. A bed check system is also used. One part of the bed check system attaches to the patient and the other part attaches to the bed or chair so if the patient attempts to get up, it will alarm. It was revealed during the tour the patients were not always compliant with the bed check system.

2. A document review conducted on 12/3/18 revealed patient #1 had a high risk fall score of 14. In nine (9) of ten (10) shift's fall risk assessments reviewed between 10/8/18 to 10/12/18, the nursing intervention bed/chair alarm in use was documented. One (1) of ten (10) shift's fall risk assessments reviewed between 10/8/18 to 10/12/18 did not show documentation of the nursing intervention bed/chair alarm in use. During the shift the intervention was not documented that the patient fell out of bed and suffered an injury requiring transfer to a hospital emergency department for treatment.

3. A review of the facility policy titled Fall Prevention Program, last revised 3/14/18, revealed in part: " ...Patients identified as high risk for falls (7 or more points); Bed/chair alarm in use ..."

4. A review of the facility policy titled Fall Prevention Program, last revised 3/14/18, revealed in part: "Patients identified as a low risk for fall (0-2 risk points on assessment); implement as appropriate 1. Call light in reach/instructed on use ...Patients identified as high risk for falls (7 or more points) 1. All interventions for low and high risk for falls identified above; implement as appropriate ...Developing alternative to the nurse call bell system when patient unable to use it ..."

5. A document review conducted on 12/3/18 revealed a nursing note in patient #1's medical record, dated 10/13/18 at 6:50 a.m., stated another patient came to the desk and stated another patient was in the floor. Upon investigation patient was found in the floor on her back. Patient was noted to have extreme swelling above her right eye. Physician on call was notified by the oncoming CN and sent to the ER." This note was documented by the RN Charge Nurse #1.

6. An interview conducted with RN Charge Nurse #1 on 12/4/18 at approximately 2:30 p.m. revealed she was in report at the time the patient fell. She stated she received the information about the fall from the other nurses. She stated she did assess the patient after the fall.

7. A document review conducted on 12/4/18 of the Fifteen (15) Minute Check Sheet for the 7:00 p.m. to 7:00 a.m. shift on 10/12/18 to 10/13/18 revealed an S for sleep in the box under 0700 the morning of 10/13/18.

8. A review of the Behavioral Health Pavilion policy titled Observation and Special Precautions For 15-Minute Checks revealed in part: "1. 15-minute checks are defined as the visual identification and observation of the patient's location and behavior at least every 15 minutes while awake or sleeping."

9. An interview was conducted with the Clinical Nurse Manager on 12/4/18 at approximately 1:40 p.m. She concurred with the finding related to the call light system.

10. During the same interview on 12/4/18 at approximately 2:00 p.m., the Clinical Nurse Manager concurred with the finding of the fifteen (15) minute check sheet showing an S for sleep in the 7 a.m. check box on the morning of 10/13/18. This was 10 minutes after the patient had been found on the floor following a fall.

11. An interview was conducted with the Clinical Nurse Manager on 12/5/18 at approximately 10:00 a.m. She concurred with the finding the intervention of bed/chair alarm in use was not documented on the shift of the patient fall.

Based on observations, document review and interviews it was determined the facility failed to keep the patient free from all forms of neglect. This failure to ensure the patient is free from all forms of neglect has the potential to result in physical harm.

Findings include:

1. A tour conducted on 12/3/18 at approximately 1:45 p.m. on the Geriatric Unit revealed every patient did not have access to a call light system. Mobile patients may push buttons on the wall which were left from the previous call light system. Immobile patients were given silver bells which can be tapped to call for a nurse. There are ten (10) hospital beds which have a call nurse button on the upper side rails. The call nurse button was not connected to a call light system and does not work. An interview conducted with the Registered Nurse (RN) Charge Nurse during the tour on 12/3/18 at approximately 1:45 p.m. revealed patients who cannot push the buttons on the wall may yell or come to the desk to call for a nurse. The staff makes rounds every fifteen (15) minutes. A bed check system is also used. One part of the bed check system attaches to the patient and the other part attaches to the bed or chair and if the patient attempts to get up, it will alarm. It was revealed during the tour the patients were not always compliant with the bed check system.

2. A document review conducted on 12/3/18 revealed patient #1 had a high risk fall score of 14. In nine (9) of ten (10) shift fall risk assessments reviewed between 10/8/18 to 10/12/18, the nursing intervention bed/chair alarm in use was documented. One (1) of ten (10) shift fall risk asessments reviewed between 10/8/18 to 10/12/18 did not show documentation of the nursing intervention bed/chair alarm in use. During the shift the intervention was not documented that the patient fell out of bed and suffered an injury requiring transfer to a hospital emergency department for treatment.

3. A review of the patient care policy titled Abuse, Accessing Protective Services: Identifying, Assessing, Reporting of Child/Elder Abuse/Neglect, Domestic Abuse, Physical Assault, Sexual Molestation and Rape, last revised 9/10/18, revealed in part: "Neglect: as used in this policy means an act or failure to act for a vulnerable person or their caregiver which (1) results in the inadequate provision of care of services necessary to maintain the physical and mental health of the vulnerable person and (2) places the vulnerable person in a situation that is life-threatening or can result in serious injury."

4. An interview was conducted with the Clinical Nurse Manager on 12/4/18 at approximately 1:40 p.m. She stated the decision had been made about 8 years ago not to have the call lights because of the ligature risk. She said they have had the current hospital beds for about a year. She concurred with the finding related to the call light system.

5. An interview was conducted with the Clinical Nurse Manager on 12/5/18 at approximately 10:00 a.m. She concurred with the finding the intervention of bed/chair alarm in use was not documented on the shift of the patient fall.

Based on document review and interviews it was determined the facility failed to evaluate the nursing care and nursing interventions provided to each patient. This failure to evaluate the nursing care for each patient has the potential to adversely impact patient care and could result in patient injury.

Findings include:

1. A document review conducted on 12/3/18 revealed patient #1 had a high risk fall score of 14. In nine (9) of ten (10) shifts fall risk assessments reviewed between 10/8/18 to 10/12/18, the nursing intervention bed/chair alarm in use was documented. One (1) of ten (10) shifts fall risk assessments reviewed between 10/8/18 to 10/12/18 did not show documentation of the nursing intervention bed/chair alarm in use. During the shift the intervention was not documented that the patient fell out of bed and suffered an injury requiring transfer to a hospital emergency department for treatment.

2. A review of the facility policy titled Fall Prevention Program, last revised 3/14/18, revealed in part: "...Patients identified as high risk for falls (7 or more points); Bed/chair alarm in use ..."

3. An interview was conducted with the Clinical Nurse Manager on 12/5/18 at approximately 10:00 a.m. She concurred with the finding the intervention of bed/chair alarm in use was not documented on the shift of the patient fall.

Based on observation and staff interviews it was determined the facility failed to accurately check for expired drugs and label multidose vials of medications. This failure has the potential to negatively impact any patient receiving these medications.

Findings include:

1. On a tour of the Geriatric Behavioral Health Unit medication room on 12/3/18 at approximately 2:15 p.m., one (1) bottle of Lidocaine one percent (1%) twenty (20) milliliter vial was found to be opened without being labeled with an expiration date.

2. On 12/3/18 at 2:17 p.m. it was observed that one (1) bottle of HCS Hydrogen Peroxide was found with a date opened of 2/4/18 and one (1) bottle of HCS Hydrogen Peroxide found without an expiration date label.

3. On 12/3/18 at approximately 2:20 p.m. two (2) multi dose inhalers were found to be expired in the medication room. One (1) Atrovent MDI expired 11/2018 and one (1) Flovent MDI expired 5/2018.

4. In an interview with the Lead Charge Nurse on 12/3/18 at approximately 2:25 p.m., she concurred with the above findings.

5. In an interview with the Compliance Officer on 12/3/18 at approximately 2:45 p.m., it was determined that all hydrogen peroxide bottles were for single use only.

6. A review of the facility document titled Medication Management Storage, last review date 7/9/18, states in part: "Expired medications are checked and removed from stock."

7. A review of the facility policy titled Sterile Preparations, last revision date 2/26/18, states: "If a multiple-dose vial was used in the preparations, it must be dated and may be reused for 28 days if proper storage conditions are met since it contains preservatives."