HospitalInspections.org

Based on document review and interview it was determined that for one (Pt. #1) of 3 clinical records reviewed for patients on fall prevention, the Facility failed to provide a safe care environment to the patient.

Findings include:

1. The Hospital's policy titled, "Falls Prevention" dated 06/2019 was reviewed. The policy included, "Patients are screened for fall risk upon admission ...at a minimum weekly interval thereafter ...5. Patients are subsequently re-screened for fall risk with a change in cognition, and/or change in medication(s) that could affect fall risk, and weekly ...patient outcomes related to the fall(s) and fall risks are monitored by the Facility Quality Program ...xi ...or changes needed in staffing ...d. Interdisciplinary interventions will be added to the care plan as each discipline identifies specific needs ..."

2. On 03/03/2020 clinical of Pt. #1 was reviewed. Pt. #1 was admitted to the Facility on 01/30/2020 at 9:20 PM with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (COPD).

-The nursing admission note dated 01/30/2020 at 10:15 PM, included, "...Fall Risk screening... Total fall risk score: 5 (moderate risk). Patient confused and disoriented...Interventions include: bed in low position, bed alarm, floor mat, identifcation bracelet, signage on the door, and call light within reach."

-The nursing notes from 2/4/2020 to 2/26/2020 were reviewed. Pt. #1 had multiple falls during the hospitalization:

i. On 2/4/2020 at 6:15 PM, Patient discovered on floor of the room.
ii. On 2/13/2020 at at 10:45 AM, Patient fell, and has bump on forehead, new order for CT scan of head.
iii. On 2/23/2020 at 1:05 AM, Patient was confused and trying stand up and fell out of bed.
iv. On 2/26/2020 at 11:00 AM, Patient was found sitting on the floor.

3. On 03/04/2020 at approximately 11:30 AM, an interview was conducted with the Registered Nurse (E #10). E #10 stated, "This patient (Pt #1) had fallen several times. We place the signage on the door, room close to the nurses' station, bed in low position, floor mat, bed alarm and call light within reach of the patient. On 02/23/2020 she (Pt. #1) was found sitting on the floor. I notified the nursing supervisor and asked for a sitter for close observation to prevent further falls. But, no staff was provided to sit with the patient. The nursing assistant on the unit watches the patient for couple of hours. It is essential to have a sitter for the safety of the patient."

4. On 03/04/2020 at approximately 11:40 AM, an interview was conducted with the Registered Nurse (E #12). E #12 stated, "The patient had a fall during my shift on 02/13/2020. While I was taking care of another patient, the physical therapy left the patient in the room on a wheelchair. Patient tried to get up from the wheelchair, stood up and fell with her face down. This patient has fallen before couple of times, nothing can be done."

5. On 03/04/2020 at approximately 1:10 PM, an interview was conducted with the Nursing Supervisor (E #11). E #11 stated, "This patient (Pt. #1) was very impulsive, forgetful and had fallen several times. Probably, if we had a sitter we could have avoided her falls. We are short of nursing assistants, we lack staff. We call agency if we need nursing assistants."

Based on document review and interview, it was determined that for 1 of 1 patient (Pt #3) in the Medical-Surgical Unit (3 West) reviewed for restraint usage, the Hospital failed to ensure that a physician's order was obtained for the application of restraints immediately after the restraint was applied.

Findings include:

1. On 3/3/2020 at approximately 10:10 AM, the clinical record of Pt #3 was reviewed. Pt #3 was admitted to the Hospital on 2/28/2020 with the diagnosis of Lymphoma. The clinical record indicated that Pt #3 required that mittens be applied to upper extremities on 2/28/2020 at 8:00 PM. The Nurse obtained a physician's order on 2/29/2020 at 2:45 PM (18 hours and 45 minutes) after application of the mittens.

2. The Hospital's policy titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion (Dated 12/2019), was reviewed on 3/3/2020, and included, "4. Phsyical Restraint Devices: b. Hand mittens or mitts ...Initial restraint order from the attending physician or other licensed practitioner (LP) is required immediately or within a few minutes from initiating restraints ..."

3. On 3/3/2020 at approximately 11:30 AM, the findings were discussed with the Nursing Supervisor (E #13). E #13 stated that when restraints are applied for violent or non-violent behavior, staff must obtain an order from a physician or licensed practioner right away. E #13 stated that for Pt #3, the order was not obtained in a timely manner.

Based on document review and interview it was determined that for one (Pt. #1) of 4 clinical records reviewed for patients on restraints, the Hospital failed to ensure that trained staff monitored the patient while on restraints.

Findings include:

1. The Hospital's policy titled, "Core: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated 12/2019 was reviewed. The policy included, "b. Clinical /Nursing Staff Responsibilities - A Registered Nurse (RN) will perform assessment/reassessment at established intervals as needed... Ongoing safety checks and monitoring at least every two hours or as noted on the designated forms ...visually observe the patient at least every 2 hours for safety needs..."

2. On 03/03/2020 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Facility on 01/30/2020 at 9:20 PM with a diagnosis of acute exacerbation of the chronic obstructive pulmonary disease (COPD).

-The physician's restraint order dated 02/04/2020 at 6:30 PM, included, "Limb restraints to both left and right wrist. The nursing restraints flowsheets did not include the documentation of every two hours assessment from 02/04/2020 at 8:00 PM to 02/06/2020 until 12:00 PM.

3. On 03/05/2020 at approximately 8:45 AM, an interview was conducted with the Director of Quality (E #7). E #7 stated, "The patient (Pt. #1) went for scanning of head to another Hospital on 02/04/2020, but when she came back on 02/05/2020, they should have continued with the documentation of every 2 hour assessment in the restraints flowsheet. It is part of our policy and most importantly, patient safety is our priority."