HospitalInspections.org

Based on document review and interview, the medical staff failed to ensure the implementation of its rules and regulations regarding H & Ps (history and physicals) for 1 of 3 MICU (medical intensive care unit) medical records, Patient #2.

Findings Include:
1. Review of the medical staff rules and regulations, last approved 3/8/16, indicated in section "II. Rules Affecting All Medical Staff", in item E. "Patient Visit by Advanced Allied Health Practitioners in Place of Physician Daily Visit:...2. The attending/sponsoring physician sponsoring the Advanced AHP (allied health practitioner) must visit the patient at a minimum of every other day and is responsible for the initial visit and admitting History and Physical examination."

2. Review of three MICU medical records indicated Patient #2 was admitted to the MICU on 4/29/16, had a H & P done by an AHP, and had no physician progress notes for the remainder of their stay on that unit. The patient was moved to the 6th floor med/surg unit on 5/5/16.

3. At 4:14 PM on 6/8/16, interview with quality and accreditation staff members #50 and #59 confirmed that after a phone call with the medical staff services staff, #61 and #62:
A. The wording that a physician is "responsible for the initial visit and admitting History and Physical examination" means that the physician must do the H & P, not an AHP with the physician signing off/agreeing with the AHP's H & P.
B. With only AHP progress notes for the 6 days Patient #2 was in the MICU, the rules and regulations were not followed as a physician was to see patients at least every other day, per the rules and regulations, and there is no documentation to show that this occurred.

Based on document review and interview, nursing services failed to ensure the fall policy was implemented for 6 of 6 patients who encountered falls while hospitalized at the facility, patients #1, #2, #3, #4, #5 and #6.

Findings Include:
1. Review of the policy: Fall Prevention - Adult and Peds, no policy number, last approved 10/2015 indicated on page 3., in section F. Interventions initiated based on Fall Risk assessment score as follows: 1. Low Fall Risk: A Fall Risk score of 0 - 24...Follow Standard fall precautions...2. Moderate Fall Risk: A Fall Risk score of 25 through 44...Implement additional interventions per hospital policy (see hospital addendum). 3. High Fall Risk: A Fall Risk score of 45 or greater..(see hospital addendum)...".

2. Review of the facility addendum, page 13, indicated for "MODERATE Fall Risk: Score 25 - 44...2. Interventions: Follow Standard Fall precautions plus additional required interventions as indicated below: Initiate High Risk for Fall Care Plan Yellow wristband on patient Implement hourly fall prevention checks:...Toileting: Do not leave patient unattended during toileting. Stay within line of sight and arms reach while patient is using toilet, on bed pan, on bedside commode...Use of bed/chair alarm...HIGH Fall Risk: Score of [equal to or greater than] 45 1. Follow all interventions and communications as listed above for Moderate Fall Risk 2. CONSIDER requesting family or healthcare worker stay at bedside."

3 Review of the Fall Prevention policy in section IV. Procedure - Inpatient Fall Occurrence (page 5), indicated: A. Complete head to toe assessment, obtain vital signs and document in the patient's medical record. In addition to a full head to toe assessment, the post-fall assessment should include: 1. Skin assessment 2. Range of motion assessment 3. Pain assessment 4. Neuro assessment...".

4 Review of the medical records of 6 patients who had fallen indicated:
A. Patient #1 arrived in the ED (emergency department) at 2:46 PM on 4/29/16 and scored 75 (high risk) on the fall risk scale. The patient fell in the ED on 4/29/16 at 4:00 PM and lacked a post fall skin, pain or range of motion assessment.
B. Patient #2 was admitted to the MICU (medical intensive care unit) with a fall score of 75 (high risk) done at 1:00 AM. The patient had a fall on 4/29/16 at 3:35 PM with documentation that indicated the patient was left on the bed pan alone while nursing staff left the room to get "supplies"; the bed alarm was inactivated by nursing staff when they placed the patient on the bed pan; and the post fall flow sheet area of the EMR (electronic medical record) was not completed.
C. Patient #3 was admitted on 4/27/16 to the oncology unit and had a fall risk score of 85 (high risk). On 4/28/16 at 10:20 PM, a near miss for fall was documented as the patient was ambulating to the bathroom and fell back into the arms of a family member and then set down on the toilet. The patient had been assessed at 30 for fall risk (moderate risk) on admission, but no bed alarm was populated on the fall intervention area of the EMR until the patient scored high risk, 85, after the fall; no "alarm on" area of the fall intervention flowsheet of the EMR populated with the moderate fall scoring assessment; and no post fall flow sheet documentation was completed by the nursing staff.
D. Patient #4 was admitted to the pre op area on 4/21/16 for a colon resection after a diagnosis of colon cancer. The patient fell on 4/22/16 at 10:12 PM while a patient on the 5th floor med/surg unit. The fall review committee documented that the patient should have been on hourly rounding but "it had been about 2 hours since the nurse was in the room", per review of the EMR notes.
E. Patient #5 was admitted on 4/25/16 and had a fall score on admission of 35 (moderate risk). A fall occurred on 4/29/16 at 2:18 PM. Documentation by the fall risk review committee indicated "most fall precautions were in place except for the bed alarm, uncertain if patient had turned it off. Pt. went to restroom unassisted, the nurse call light had not been used by the patient...". The "alarm on" section of the fall intervention area of the EMR did not populate.
F. Patient #6 was admitted on 4/19/16 and scored 90 (high risk) on admission with an increase to 105 on 4/20/16 at 4:00 AM. The patient fell at 1:05 AM on 4/22/16. There was no post fall flow sheet documentation completed in the EMR, and no "alarm on" section of the EMR was populated.

5. At 3:10 PM on 6/7/16, interview with the "policy owner" of the Fall Prevention policy, staff member #53 confirmed that:
A. A moderate risk for falls score should populate the bed alarm area of the EMR flowsheet as a bed alarm is required per the addendum for patients who score moderate and high fall risk. This had not populated for patients as listed in 4. above.
B. The four assessments post fall (pain, range of motion, neuro and skin) should be done in the ED as well as on other patient med/surg units.
C. The post fall assessment flow sheet does not include the four post fall assessments that are to be done. Currently nurses must use the daily flowsheet for documentation of these assessments, or use nursing notes.

6. At 3:35 PM on 6/7/16 and 9:30 AM on 6/8/16, interview with quality and accreditation staff members #50 and #59 confirmed that:
A. Documentation, as listed in 4. above, was lacking for the 6 patients related to failing to implement the Fall Prevention policy in various ways.
B. It was just found that there was an error with the EPIC (EMR system) program in regard to the "alarm on" section of the fall intervention flow sheet not populating, and that IT (information technology) staff were working to fix the problem.