HospitalInspections.org

Based on document review, record review and interview the hospital failed to provide safe and effective nursing care by failing to ensure adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care; by failing to ensure nursing staff develop, and keep current, a nursing care plan for each patient; by failing to ensure patients were assigned nursing staff who met the needs, specialized qualifications and competencies related to falls and gait belt use; and by failing to ensure medications were administered in accordance with standards of care.

The cumulative effect of the facility's failure to provide safe and effective nursing care placed patients at risk for falls, injury, inadequate staffing, lack of care, lack of qualified/trained staff and medications that cause an unsafe outcome with physical and emotional distress.

Findings Include:

1. The hospital failed to ensure adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed for one of three patients (Patient 1). Refer to A-0392.

2. The hospital failed to ensure nursing staff develop, and keep current, a nursing care plan for each patient for one of patients (Patient 1). Refer to A-0396.

3. The hospital failed to ensure patients were assigned nursing staff who met the needs, specialized qualifications and competencies related to falls and gait belt use for one of three patients reviewed (Patient 1). Refer to A-0397.

4. The hospital failed to ensure medications were administered in accordance with accepted standards of care for one of three patients reviewed (Patient 1). Refer to A-0405.

Based on interview, document review, record review and policy review the hospital failed to ensure adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed for one of three patients (Patient 1). The hospital's failure to ensure adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients has the potential for patients to receive nursing care below the professional state and federal requirements, and experience harm, injury, disease, and poor physical and emotional outcomes.

Findings Include:

Review of the hospital's policy titled, "Staffing and Reporting Structure for Clinical Services," dated 06/04/18, showed..."staffing levels for each department shall be adjusted to accommodate patient volume and acuity. Department managers and the Chief Nursing Officer will collaborate to provide flexibility to meet patient needs. The Association of periOperative Registered Nurses (AORN), The American Society of PeriAnesthesia Nurses (ASPAN), the Joint Commission (JCAHO), and the American Nurses Association (ANA) standards of staffing will be followed".

Review of the hospital's policy titled, "Fall Prevention/Management," dated 08/08/19, showed ..."staff with patient contact are required to demonstrate competency in fall risk assessment and interventional annually...all hospital employees who have direct contact with patients have responsibility for the safety of...patients and need to assist with preventing patients from falling...should a fall occur: reassess the patient for fall risk, revise the fall prevention care plan accordingly...our staff works very hard to prevent patient falls. One patient fall is too many!"

Review of the hospital's job description for, "Chief Nursing Officer," dated 10/09/17, showed, "...ensure that patient care delivery models and standards of nursing practice are consistent with current professional standards...consults with staff, physicians, and other nursing units on nursing problems and interpretation of Hospital policies and procedures to ensure that patient needs are met ...coordinates, through clinical management personnel, the establishment of major schedules, task assignments, and allocation of manpower and equipment to ensure conformance with specified objectives and policies".

During an interview on 09/05/19 at 9:10 AM, Staff C, CNO stated that concerning the staffing policy and procedure she stated that there are no specific guidelines to follow. She stated that they try to staff with four patients to one nurse on day shift and five to six patients to one nurse for the night shift. She shared every day she meets with the managers at 8:30 AM and 3:00 PM to discuss the current staffing and plan for the next staffing needs. She clarified the policy is very vague so that they can accommodate for the acuity needs. Concerning the policy stating that they will follow guidelines by AORN, ASPAN, JCAHO and ANA, she stated that we have not retrieved those standards yet.

Review of the hospital's staffing 06/23/19 to 07/20/19 showed the following patient/nurse ratios for delivery of total patient care provided by one registered nurse (RN):

Day shift from 06/23/19 to 07/20/19 showed 40 times an RN had a ratio over the four patients to one RN for total care.
Day shift from 07/21/19 to 08/17/19 showed 53 times an RN had a ratio over the four patients to one RN for total care.
Day shift from 08/18/19 to 09/02/19 showed 30 times an RN had a ratio over the four patients to one RN for total care.

During an interview on 09/04/19 at 4:38 PM, Staff C, CNO stated that in the last six months they have had a lot of staff turnover and the census has been high. We have a few nurses who will work as needed (PRN), but we do not have a float pool. We use a total care model and on nights the model has shifted to them possibly having five to six patients per nurse. She shared they are looking at a new model to include patient care technicians (PCT's) and Licensed Practical Nurses (LPN'S) as nurse extenders. Staff C explained the CEO is behind the model and he has ultimate authority over the hospital staffing, and she then is to see that it is enforced. Staff C shared they have been doing a lot of rebuilding this summer to retain staff, keep the morale up and keep the staff safe and happy. She also shared that the CEO will make the determination when they use contracted staff. Staff C commented that concerning falls an email went out to staff to read and they had to e-sign they read the information.


Review of Patient 1's discharged medical record showed she was schedule for surgery on 07/15/19 for a revision laminectomy decompression foraminotomy of L3-S1 (a surgery that enlarges your spinal canal to relieve pressure on the spinal cord or nerves). On 07/16/19 at 4:10 PM, Staff J, RN documented when transferring the patient from the chair to bed with a gait belt and walker and assist when backing up to the bed she slid down the edge of the bed. The patient stated she had no pain and was assessed with no injuries to the buttocks or back. Staff N, MD was notified and when the daughter came to the hospital she was notified her verbally. On 07/17/19 at 6:16 PM, Staff J, RN documented the patient is confused at times, takes her oxygen off and desaturates without the oxygen. She takes off her telemetry wires, has a hard time holding on to items and continues to drop drinks. She still feels loopy from pain medications and gets tangled up in lead wires and oxygen tubing due to impatient impulsive movements. Staff N, MD was notified of continued weakness and intermittent confusion. Staff N, MD and Staff T, Advanced Practical Registered Nurse (APRN) were notified of unsteadiness with transfers with gait belt, and of Staff K's, Occupational Therapist, (OT) recommendation for one person transfer assist using gait belt. The patient had complained of buttock pain, no redness or bruising to buttocks.

Review of the staffing when Patient 1 had her falls on 07/16/19 and 07/17/19, showed Staff J, Registered Nurse, (RN) was providing total care for five patients. One patient over the four to one ratio.

Review of the gait belt training showed Staff J, RN completed training in 2018 and failed to initial, date and record the time she completed gait belt training for 2019.

During an interview on 09/03/19 at 7:23 PM, Patient 1 stated that she remembers one of the falls at the hospital happened when the nurse would not listen to her on 07/17/19. Patient 1 stated that she is very familiar with patient care as she was a nurse for over 40 years. She recalled sitting in a wheel chair about an hour and physical therapy (PT) came by and told the nurse she had to do something and to get her back to bed in about 30 minutes. Patient 1 remembers overhearing the nurse say she had never used a gait belt. The nurse came in about 30 minutes later and put the gait belt around me like it was a sling.

During an interview on 09/03/19 at 7:37 PM, F1, patient 1's daughter stated that her mother had back surgery on a Monday and on Tuesday a nurse said she had dropped her. F1 shared she spoke with the nurse after the fall and asked her where the gait belt was and why they did not have two people. F1 stated that the nurse told her she did not have a gait belt, she did not know what a gait belt was and she was too busy. F1 called the nurse who told her that she had dropped her mother again. F1 did not remember the nurses name, but did share she was blonde and it was the same nurse that dropped her both days. Again the nurse told F1 she did not know what a gait belt was and that her mother told her the nurse put the gait belt on like a sash around her neck and arm and that is what caused the fall. F1 stated that she has never seen anything like this and she has worked in rehab for 40 years.

During an interview on 09/04/19 at 4:14 PM, Staff J, RN stated that she remembers patient 1 and the care she gave her. Staff J remembered on 07/16/19 that PT/OT got patient 1 up to the chair and she got her back into bed using the gait belt. She remembers the patient's knees gave out, she landed on the floor, it pulled her hands down and they went under her breasts. She shared the patient had no injuries. She also remembers the daughter commenting to her that they looked like they were short staffed and asked why they did not have aides to help them. Staff J explained they only have nurses at this hospital. Staff J then explained that on 07/17/19 Staff K, OT had got patient 1 up to the chair by themselves and told her to call if she needed help to get the patient back into bed. When Staff J was ready to get the patient back into bed she called Staff K for help and was told that the patient would be going home tomorrow and needed to be an assist of one. Staff J then proceeded to transfer the patient back to bed and the patient's legs went out and they both went down to the floor. Staff J stated that she was sent to ER, they found she had a back strain. Staff J stated she remembers using a gait belt with the second fall and it was placed under the patient's breasts. She also remembered going through gait belt training at the hospital and it was good. She shared that the daughter again was very mad as the staff appeared to be short staffed and she told her they were not short staffed. Staff J was asked if having five to six patients is manageable and she stated sometimes it is and sometimes it is not.

During an interview on 09/04/19 at 11:03 PM, Staff D, RN, Manager stated that she remembers Staff J, RN was the nurse on duty when the patient first fall and the next day she was the nurse for the second fall. She recalled when the patient fell the second day Staff J had called OT for help and was told that one person could do the transfer. Staff D remembers the nurse went down with the patient after the second fall. Staff D remembers that after the first fall Staff J the nurse called the desk for help and she stated that the patient had lost her balance and fell against the nurse and slid down. She said she slid down so close to the nurse that it almost took her pants off. Staff D remembers the patient had on non-skid socks, the nurse used a gait belt, and the patient kept repeating herself. Staff D explained that concerning the second fall she was off the unit and the staff got her and said Staff J needed help. When she arrived to the room she was told Staff K, OT had put the patient into the chair by the head of the bed earlier and when the nurse went to put her back to bed she lost her balance and it took three to four people to get her up and back into bed. She sent Staff J to the ER and she had no injuries.

During an interview on 09/03/19 at 10:07 AM, Staff D, Registered Nurse (RN), Manager stated that falls decreased last year and this year have been back up again. She shared the staff were trained in gait belt use at the skills day in 2018 and I think they always need this training. Staff D stated she cannot remember contracted staff being trained on falls and gait belts. The falls were doing well until several months ago when the census went up and the staffing went down. If a patient is a fall risk they will have a yellow signage outside their door, a yellow armband and yellow socks. Staff D explained there is an issue with not enough staff and falls occurring especially with the larger patients. Staff D encourages her staff to call for help and she again stated she has seen the correlation of increased falls related to decrease staffing.

During an interview on 09/03/19 at 4:40 PM, Staff C, CNO stated that on August 20th and 27th, 2019 they had another gait belt training for all staff and this was a separate part of the annual training.

Based on interview, record review and policy and procedure review the hospital failed to ensure nursing staff develop, and keep current, a nursing care plan for each patient for one of patients (Patient 1). The hospital's failure to ensure nursing staff develops, and keeps current, a nursing care plan for each patient has the potential for patients to fail to have accurate assessments and interventions to meet their health care and recovery needs resulting in falls, harm, injury and poor outcomes.

Finding Include:

Review of the Hospital's policy titled, "Nursing Standards of Patient Care," dated 03/12/18 showed...the nurse develops a plan of care specific to the individual needs and patient rights ...the nurse will reassess the plan of care, evaluate and revise on as needed basis.

Review of the Hospital's policy titled, "Fall Prevention/Management," dated 08/08/19, showed ...has a system for identifying patients "at highest risk for falls" implementing department appropriate measures to ensure the safety of these patients. Established screening criteria, precautions, and actions have been developed to prove a safe environment ...upon admission as an inpatient to ...the RN will assess the patient for fall-related risk factors utilizing the following "Fall Risk" criteria ...upon admission as an inpatient to ...the nurse will document on the Adult Admission Assessment either a Conley Fall Risk Assessment or the Morse Fall Risk Assessment ...should a fall occur ...reassess the patient for a fall risk ...revise the fall prevention care plan accordingly ...document initial fall risk assessment upon admission using the Conley or Morse Fall Risk Assessment ...inpatient's fall risk assessment is reviewed each shift and if condition changes, or with each change of the RN caregiver and documented on the shift assessment flowsheet and purposeful and hourly rounding will be completed to ensure the patient is safe.

Review of Patient 1's discharged medical record showed on 07/15/19 at 8:40 AM, Staff Q, Registered Nurse (RN) performed an assessment prior to surgery and completed the Morse Fall Risk but failed to score it and assess if the patient was a fall risk. The medical record lacked evidence of a fall risk assessment and care plan entry after surgery on her initial nursing assessment when she was admitted to the medical/surgical floor and lacked evidence of a fall risk assessment and care plan entry after each of her falls on 07/16/19 and 07/17/19.

During an interview on 09/04/19 at 2:02 PM, Staff C, Chief Nursing Officer (CNO) stated that a comprehensive nursing assessment is required when a patient is admitted to the floor. She verified that a comprehensive assessment did not include a complete fall assessment and a plan of care for falls was not completed for Patient 1, who was admitted to the medical surgical floor on 07/15/19. She also verified that the plan of care was never opened after each of Patient 1's falls and that the Morris Fall Scale was started and not completed upon admission.

Based on interview, document review, record review and policy review the hospital failed to ensure patients were assigned nursing staff who met the needs, specialized qualifications and competencies related to falls and gait belt use for one of three patients reviewed (Patient 1). The hospital's failure to ensure patients were assigned nursing staff who met the needs, specialized qualifications and competencies related to falls and gait belt use has the potential for patients to receive harm, injuries and lack of standard nursing care.

Findings Include:

Review of the Hospital's policy titled, "Fall Prevention/Management," dated 08/08/19, showed ...staff with patient contact are required to demonstrate competency in fall risk assessment and interventions annually ...all hospital employees who have direct contact with patients have the responsibility for the safety of ...patients and need to assist with preventing patients from falling.

Review of the Hospital's policy titled, "Use of Gait Belt," dated 08/08/19, showed ...gait belts will be used in a safe and effective manner ...place belt around patient's waist snugly (should be able to comfortably place two fingers between belt and waist).

Review of the Hospital's policy titled, "Staffing and Reporting Structure for Clinical Services," dated 06/04/18, showed ...if private duty nurses or agency nurses are utilized in the hospital ...shall be subject to the policies, rules, and regulations of the hospital.

Review of the hospital's undated document titled, "Gait Belt Training," showed ...gait belt technique ...with the following items listed: when to use a gait belt, application of a gait belt, factors to be considered with a gait belt application, sternal incisions, chest tubes, abdominal incisions, PICC lines, proper body mechanics when lifting, walking patient with gait belt, patients with weakness/falling while ambulating, lowering patients to the ground safely, techniques for assisting patients with sitting on edge of bed or into chair, assisting for stand/pivot transfers with gait belt, 2 person transfer with gait belt, removal of gait belt, cleaning of gait belt, storage of gait belt ...there is a column for the nurse to review, demonstrate, date and initial and another column for the competency to be validated by the trainer with their date and initials.

Review of personnel records on 09/05/19 showed:
1. Staff C, Chief Nursing Officer (CNO), Staff D, Manager lacked evidence of gait belt training for 2018
2. Staff O and P, contracted Registered Nurses (RNs) lacked evidence of 2019 gait belt training
3. Staff J, RN failed to sign and initial she completed the training
4. Staff R and S, RNs failed to have validation signatures and dates
5. Staff F, RN failed to sign and date the gait belt training form.

Review of Patient 1's discharged medical record showed she was schedule for surgery on 07/15/19 for a revision laminectomy decompression foraminotomy of L3-S1 (a surgery that enlarges your spinal canal to relieve pressure on the spinal cord or nerves). On 07/16/19 at 4:10 PM, Staff J, RN documented when transferring the patient from the chair to bed with a gait belt and walker and assist when backing up to the bed she slid down the edge of the bed. On 07/17/19 at 6:16 PM, Staff J, RN documented the patient is confused at times, takes her oxygen off and desaturates without the oxygen. Staff N, MD was notified of continued weakness and intermittent confusion and of Patient 1's unsteadiness with transfers with gait belt, and Staff K, Occupational Therapist, (OT) recommendation of one-person transfer assist using gait belt.

During an interview on 09/03/19 at 7:23 PM, Patient 1 stated that she remembers one of the falls at the hospital happened when the nurse would not listen to her on 07/17/19. Patient 1 stated that she is very familiar with patient care as she was a nurse for over 40 years. She recalled sitting in a wheel chair about an hour and physical therapy (PT) came by and told the nurse she had to do something and to get her back to bed in about 30 minutes. Patient 1 remembers overhearing the nurse say she had never used a gait belt. The nurse came in about 30 minutes later and put the gait belt around me like it was a sling.

During an interview on 09/03/19 at 1:34 PM, Staff E, RN stated that she usually applies the gait belt above the breasts and some patients also need a walker.

During an interview on 09/03/19 at 2:15 PM, Staff F, RN stated that almost all the patients need a gait belt and the placement varies for each patient depending on the type of surgery they have.

During an interview on 09/03/19 at 10:07 AM, Staff D, RN, Manager stated that staff were trained in gait belt use at the skills day in 2018 and I think they always need this training. She stated she cannot remember contracted staff being trained on falls and use of gait belts. The falls were doing well until several months ago when the census went up and the staffing went down.

During an interview on 09/03/19 at 2:33 PM, Staff G, contracted RN stated that if she uses a gait belt it is usually placed around the chest somewhere, and that she did not receive any training from the hospital.

During an interview on 09/04/19 at 11:03 PM, Staff D, RN, Manager stated that if she uses a gait belt she usually applies it under the arms or around the waist.

During an interview on 09/04/19 at 12:41 PM, Staff K, occupational therapist (OT) stated that she is one of the staff trainers regarding use of gait belts. She and two other therapists have a check list they use along with a demonstration and then have staff give a return demonstration to show competency. Staff K explained the gait belt training is hospital wide annually, and they instruct the staff that placement is different per patient depending on the surgery they had, but usually it is to be placed around the waist or under the armpits.

During an interview on 09/05/19 at 9:10 AM, Staff C, CNO and Staff B, Risk Manager stated that concerning the use of a gait belt it can be placed around the upper chest or around the waist. Staff C verified the policy and procedure for gait belts stated it can only be placed around the waist snuggly. She also clarified that the staff training check off list does not clarify how or where the belt is to be placed and that they have no handouts for reference for the staff. The training she voiced is done verbally and with a demonstration then a return demonstration from the staff.

During an interview on 09/05/19 at 12:58 PM, Staff C, CNO stated that they do not have a policy and procedure for contracted staff and they do not have any documentation of RN competencies that are required. Staff C explained usually contracted staff will try to come an hour early before their shift starts and get a quick orientation of the unit and computer. She shared all the policy and procedures are on the computer and if a contracted staff wanted to view one they would talk to the charge nurse who has her own log in and find the policy.

Based on interview, document review and policy review the hospital failed to ensure medications were administered in accordance with accepted standards of care for one of three patients reviewed (Patient 1). The Hospital's failure to ensure medications were administered in accordance with accepted standards of care has the potential for patients to received medications causing over or under sedation, falls, injury and harm.

Findings Include:

Review of the Hospital's policy titled, "Medication Administration," dated 04/11/19 showed ...registered nurses will: prepare, administer and document medication administration.

Review of the Hospital's policy titled, "Patient Controlled Analgesia Abbott Plus Pump," dated 03/12/18, showed ...registered nurse is responsible for PCA pump management, and patient assessment for effectiveness of treatment ...recording totals from pump readout ...patient assessment and documentation: assess and document level of consciousness on Patient Care Flow Sheet at least every 4 hours and prn, assess and document respiratory rate, the infuser settings, and the change of medication vial and sign out the medication vial via pyxis, document on medication record the drug, concentration and total doses used at the end of each shift, document in the nurses' notes response to pain management intervention via PCA Plus Pump and changes, document use of PCA-Plus machine under equipment.

Review of Patient 1's discharged medical record showed:

1. 07/15/19 at 1:38 PM, Staff N, MD ordered Dilaudid PCA 50 ml lock out interval 15 minutes, may give patient admin bolus (mg) 0.1.
2. 07/15/19 at 8:00 PM, Staff R, Registered Nurse (RN) notes new syringe/bag/bottle for the PCA, the bag was labeled with expiration date.
3. 07/16/19 at 6:00 AM, Staff R, RN notes PCA pump read 0.6 ml infused, 6 attempts and 6 injections given, and pump was cleared
4. 07/16/19 at 10:30 AM, Staff T, Advanced Practice Registered Nurse (APRN) notes in her plan: continue with PCA and IV
5. 07/16/19 at 4:29 PM, Staff J, RN notified Staff N, MD the patient had confusion and drowsiness due to PCA use, new orders to discontinue the PCA.

Patient 1's medical record lacked evidence of nursing documentation concerning patient assessment or recording of PCA medication from 07/15/19 at 1:38 PM until 07/15/19 at 8:00 PM and then again until 07/16/19 at 6:00 AM to 07/16/19 at 4:29 PM to include the total amount of pain medication the patient used.

During an interview on 09/04/19 at 2:59 AM, Staff B, Risk Manager and Staff C, Chief Nursing Officer (CNO) stated that the medical administration record (MAR) showed the PCA order started in post-op recovery and that the order discontinued when the patient went to the medical/surgical floor. She thinks on 07/15/19 that post-op staff got a PCA from the medical/surgical floor. Staff C verified that the medical record lacked evidence of documentation of the PCA medication during and upon discontinuation. She stated, "There is no documentation on the MAR of how much she got so it looked like it never happened."

During a phone interview on 09/10/19 at 2:20 PM, Staff C, CNO stated that they have been talking about adding medication administration and use of the PCA's to the fall training, but at this time she does not have any documentation that it is covered in the annual competencies.

Further review of Patient 1's medical record showed:

1. 07/15/19 at 2:00 PM, Staff T, APRN ordered Gabapentin (nerve pain medication) 200mg, PO, three times a day (TID) routine
2. 07/15/19, documentation showed nursing staff gave this medication one time at 11:30 AM. The record failed to show the patient received the medication three times a day as ordered.
3. 07/17/19, documentation showed nursing staff gave this medication at 9:00 AM. The record failed to show nursing staff gave another dose prior to the patient's discharge to another facility (sometime after 4:44 PM).


.