The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PARIS REGIONAL MEDICAL CENTER 820 CLARKSVILLE ST PARIS, TX 75460 June 27, 2017
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview and record review, the facility failed to ensure mechanisms were in place and implemented to prevent potential abuse in 1 of 11 patients ( Patient #2).

This deficient practice had the likelihood to cause harm in all patients.


Findings include:


Review of the clinical record of Patient #2 revealed she was a [AGE] year old female who presented to the Emergency department (ED) on 03/24/2017 at 5:08 a.m. for a chief complaint of shortness of breath.

Review of triage notes timed 5:11 a.m., revealed Patient #2 was a nursing home patient who was yellow and had an oxygen saturation of 72 percent. Patient #2 arrived to the hospital via emergency medical services (EMS). Patient #2 was classified as being a priority level - 2 (Emergent). There was documentation that Patient #2 had no pain or discomfort.

At 5:19 a.m., there was documentation that Patient #2 was confused and had a past medical history of Alzheimer's dementia, weakness and psychosis. According to the fall assessment Patient #2 was classified as being at high risk for falls.

At 5:23 a.m., Dr. #19's medical screening revealed the following about Patient #2:

"Back: no CVA tenderness, no vertebral tenderness, normal inspection
Extremities: no evidence of injury, non-tender, normal range of motion
Psychiatric: alert, other (NONVERBAL, SEVERE DEMENTIA)"

At 0600 a.m., there was nursing documentation that the extremities were within normal limit and Patient #2 was totally dependent for care.


Review of a history and physical dictated on 03/24/2017 at 3:08 p.m. by Dr. #20 revealed he saw Patient #2 "about 10:00 a.m." Patient #2 was "totally nonverbal, lying on the bed. Very limited history. History is taken from the emergency room staff and the chart" ...


...REVIEW OF SYSTEMS: As patient is critically ill, lying on the bed, groaning and moaning, she came to the emergency room . As per the documentation, she has shortness of breath. No nausea and vomiting. The patient also has a contracted both lower extremities and has swelling into the knee area. I do not know the baseline."..

GENERAL: She is lying on the bed, groaning and moaning ...

EXTREMITIES: The patient has a significant contraction on both lower extremities with swelling on the knee area.

SKIN: Chronic ecchymotic lesion on both lower extremities.

ASSESSMENT AND PLAN:..

15. I will get an x-ray of the knee to make sure there is no any fracture into the lower extremity."

Review of physician orders dated 03/24/2017 at 3:11 p.m. revealed an order for an x-ray of bilateral knees (5 hours after the suspicion of fractures). Physician orders were also written for pain medication at this time.

Review of an x-ray dated 03/24/2017 at 4:09 p.m., of the knees revealed Patient #2 had some of the following findings:

.."Right knee:

Transverse fracture of the distal femoral metaphysis with mild to moderate medial displacement of the distal fracture fragment with mild fracture fragment impaction."..

..."Left knee:

Fracture of the medial aspect of the distal femoral metaphysis with minimal fracture fragment displacement."


Review of a facility "Occurrence Insight" report revealed the event was described as "Bilateral femur fractures and bruising under left arm and bruising both legs." The event was reported on 03/27/2017 (3 days after it was discovered).

According to the report there was documentation that there was some suspicion of abuse since Patient #2 was found to have bilateral femur fractures and bruising both legs and under left arm.

Review of the report revealed the incident was sent to the ED Director on 03/31/2017 (7 days after the occurrence). The only thing documented on the sheet was "reviewed with staff". There was no documentation to show that the nurses caring for the patient were interviewed. The completion date for the ED investigation was 06/21/2017. There was documentation on the last form of the report that the nursing home was investigated by Texas DAD and no fault was found on the nursing home. The case was closed.

During an interview on 06/26/2017 after 2:00 p.m., Staff #8 (ED Director) reported she did not remember much about the incident. She had no statements from nurses who took care of the patient.

During an interview on 06/26/2017 after 4:00 p.m. with Staff #10 and on 06/27/2017 after 11:00 a.m. with Staff #18 revealed they had taken care of Patient #2 in the ED on 03/24/2017. No one talked to them about the event.

During an interview on 06/27/2017 after 11:15 a.m., Staff #17 confirmed the missing information on the report that there was nothing stopping staff from making the report over the weekend. Staff #17 confirmed the report was not made until Monday morning (03/27/2017).


Review of the facility policy named "Administrative/Risk Management Event Reporting" dated 10/2014 revealed the following:

"DEFINITIONS

Event: An unforeseen or unusual occurrence which is, or may be, a potential cause of harm to patients, employees, visitors, volunteers, physicians, or contractors, and which take place within the facility on its property. This may include an accident, treatment event, exposure, or loss of property.

REPORTING:

1.0 All events involving patients, employees, volunteers, physicians, or contractors must be reported.

2.0 Documentation of the event must be completed as soon as possible following the occurrence, after the welfare of the visitor/patient has been established and referred. The immediate supervisor on duty will be responsible to ensure the event is reported accurately.

2.1 The event should be documented as thoroughly as possible. All sections should be completed or checked as described in the Occurrence Insight .

2.2 Additional sheets may be used for narrative, addition information, or witness statements. Information contained in the attachments should be factual, objective information. Use direct quotes of statements if possible.


FOLLOW-UP:


1.2 The department supervisor/director is responsible for reviewing and investigating the event and entering the results of the investigation into Occurrence Insight, via the "Review" associated with the event.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, and record review, the facility failed to ensure Emergency Department (ED) patients at high risk for falls and who sustained fractures of unknown origin received continual nursing supervision, fall risk reassessments and fall prevention interventions in 3 of 11 patients (Patient #'s 2, 8 and 18).

Refer to A tag 0395 for additional information.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to ensure Emergency Department (ED) patients at high risk for falls and who sustained fractures of unknown origin received continual nursing supervision, fall risk reassessments and fall prevention interventions in 3 of 11 patients (Patient #'s 2, 8 and 18).


This deficient practice had the likelihood to cause harm to all patients presenting to the ED who were at high risk for falls.


Findings included:


Review of the clinical record of Patient #2 revealed she was a [AGE] year old female who presented to the Emergency department (ED) on 03/24/2017 at 5:08 a.m. for a chief complaint of shortness of breath.

Review of triage notes timed 5:11 a.m., revealed Patient #2 was a nursing home patient who was yellow and had an oxygen saturation of 72 percent. Patient #2 arrived to the hospital via emergency medical services (EMS). Patient #2 was classified as being a priority level - 2 (Emergent). Staff documented that Patient #2 had no pain or discomfort.

At 5:19 a.m., there was documentation that Patient #2 was confused and had a past medical history of Alzheimers dementia, weakness and psychosis. According to the fall assessment Patient #2 was classified as being at high risk for falls. The high risk interventions listed were:

"Orient to surroundings, lock movable equipment, non-slip grip footwear, path free of clutter, excess equipment removed, call light/phone in reach, personal items in reach, cords/phone wires secured, bed low position/locked, floor clean/no spills, siderails up for safety, adequate lighting, sup/assist bathing, sup/assist toileting, sup/assist sitting."
These interventions were not appropriate for Patient #2.

At 5:23 a.m., Dr' #19's medical screening revealed the following about Patient #2:

"Back: no CVA tenderness, no vertebral tenderness, normal inspection. Extremities: no evidence of injury, non-tender, normal range of motion. Psychiatric: alert, other (NONVERBAL, SEVERE DEMENTIA)"

At 6:00 a.m., there was nursing documentation that the extremities were within normal limit and Patient #2 was totally dependent for care. At 654 a.m. a Foley catheter was inserted.

At 7:00 a.m. there was documentation that Patient #2 was confused and obeys commands.

At 7:30 a.m. and 1:30 p.m., Patient #2 was resting quietly and there were no signs and symptoms of distress noted.

At 3:00 p.m. a physician was at the bedside.

Review of a history and physical dictated on 03/24/2017 at 3:08 p.m., revealed Dr. #20 saw Patient #2 "about 10:00 a.m." Patient #2 was "totally nonverbal, lying on the bed. Very limited history. History is taken from the emergency room staff and the chart" ...

"...REVIEW OF SYSTEMS: As patient is critically ill, lying on the bed, groaning and moaning, she came to the emergency room . As per the documentation, she has shortness of breath. No nausea and vomiting. The patient also has a contracted both lower extremities and has swelling into the knee area. I do not know the baseline."..

GENERAL: She is lying on the bed, groaning and moaning ...

EXTREMITIES: The patient has a significant contraction on both lower extremities with swelling on the knee area.

SKIN: Chronic ecchymotic lesion on both lower extremities.

ASSESSMENT AND PLAN:..

15. I will get an x-ray of the knee to make sure there is no any fracture into the lower extremity."


Review of physician orders dated 03/24/2017 at 3:11 p.m. revealed an order for an x-ray of bilateral knees (5 hours after the suspicion of fractures). Physician orders were also written for pain medication at this time.

Review of nursing documentation at 3:45 p.m. revealed radiology was at the bedside.

Review of an x-ray dated 03/24/2017 at 4:09 p.m., of the knees revealed Patient #2 had some of the following findings:

.."Right knee:

Transverse fracture of the distal femoral metaphysis with mild to moderate medial displacement of the distal fracture fragment with mild fracture fragment impaction."..

..."Left knee:

Fracture of the medial aspect of the distal femoral metaphysis with minimal fracture fragment displacement."


Review of nursing documentation at 5:00 p.m., revealed there was no signs and symptoms of distress.

Review of the record revealed no documentation of continued fall monitoring on Patient #2.

Review of nurses notes timed 6:30 p.m., revealed Patient #2 was admitted from the ED to a nursing unit. There was no accurate assessment of Patient #2's swelling to the knees or the ecchymosis to the lower legs.

A fall risk assessment was performed at 6:51 p.m. and Patient #2 was deemed to be a high risk (over 12 hours after the first fall assessment).


Review of nurses notes revealed the first thorough pain assessment performed on Patient #2 who was unable to voice her pain was at 8:00 p.m.. Nursing documented performing a FLACC (Face, Legs, Activity, Cry and Consolability) behavior pain assessment on Patient #2 and determined she had a pain level of 9 (indicating severe discomfort or pain or both). Patient #2 was given pain medication. There was documentation that Patient #2's bilateral extremities were contracted and there was a bruise/ecchymosis to the left dorsal knee. This was the first documentation by nursing of the ecchymosis and the contracted knees.

Staff #6 confirmed the assessment and fall monitoring problems in the chart.

During an interview on 06/26/2017 after 2:00 p.m., Staff #8 (emergency room Director) revealed that the ED nurses did not have the fall monitoring tool that the other floors had. There was no system for monitoring falls in the ED.

During an observation on 06/27/2017 after 10:30 a.m. at the nursing home where patient resided, Patient #2 was observed to be totally dependent, both legs contracted at the knee and the right leg wrapped in a dressing. Nursing facility staff #13 reported x-rays showed the right leg fracture was not healed.

During an interview on 06/27/2017 after 11:00 a.m., Staff #18 reported being one of the nurses that took care of Patient #2 in the ED. Staff #18 reported they did not have the fall risk tab to select when documenting like the other floors (shows monitoring).



Review of the record of Patient #8 revealed, she was a [AGE] year old female who (MDS) dated [DATE] at 7:36 a.m. for complaints of pneumonia, hypoxia, wrist fracture and a fall.

Review of a triage assessment timed 07:36 a.m. revealed Patient #8 fell from her wheelchair and complained of right knee, right hip and right wrist pain. She also had a raised area above the right eye with a small abrasion. Patient #8 was deemed to be at low risk for falls.

According to an x-ray of the right hip dated 06/26/2017 at 8:19 a.m. revealed Patient #8's bones were osteoporotic.

An x-ray of the wrist timed 8:21 a.m. revealed Patient #8 had an "impacted relatively transverse fracture of the distal radius with evident of intra-articular extension at the lunate fossa with slight depression. There is also a fracture of the ulnar styloid. Diffuse soft tissue swelling. Bones are osteopenic/osteoporotic ...." (Fractures of the bones in the lower arm)

At 9:56 a.m. a report was called to the nursing home where Patient #8 was living. The nursing home stated transportation was in the area and would be by to pick the patient up.

At 10:15 a.m., Patient #8's oxygen saturation level was 75 percent on 3 liters and the physician was notified. Which was a change in condition for Patient #8.

At 12:20 p.m. Patient #8 was assisted to the bedside commode and tolerated it well

At 1:25 p.m., Patient #8 departed from the ED (admitted on to another unit).

Review of the ED notes revealed no documentation of a reassessment of Patient #8's fall risk when it was determined she had a change in condition, had fractures and osteoporosis.






Review of the clinical record of Patient #10 revealed, he was a [AGE] year old male who (MDS) dated [DATE] at 1:16 p.m.

Review of the nursing triage assessment dated [DATE] at 1:16 p.m., revealed Patient #10 sustained a "fall on yesterday and stayed in the floor until found by family on today." Patient #10 had diagnoses which included diabetes mellitus, hypertension, congestive heart failure and sleep apnea. Patient #10 was assessed as being at high risk for falls. Patient #10 was described as having suspicion of head and neck injury, having weakness and having back pain.

According to the notes Patient #10 was transferred from the ED at 8:17 p.m. (over 7 hours later).

The facility failed to ensure staff assessed the patient every 6 hours for the presence of fall injury risk factors or document the every 4 hour toileting.


Review of a facility's policy named "Interdisciplinary Fall Risk Assessment and Intervention" dated 02/01/2017 revealed the following:

INDICATIONS FOR USE

Adult patients on inpatient units, day hospitals, and emergency department (age 18 and over) ....

1.2 Assess patient for the presence of the following fall injury risk factors on admission to the unit, every 6 hours, and PRN as the patient's condition changes:

1.2.1 Age >80

1.2.2. Bleeding risk (e.g. Bleeding Precautions Protocol)

1.2.3 Fracture risk (e.g. osteoporosis, metastatic bone disease, Vitamin D deficiency, or frail BMI < 22).."


...2.0 Fall Prevention

2.1.3 Proactive toileting schedule is started when patient deemed appropriate, and they are scored greater than 13. These patient are to be taken to the restroom by staff every 4 hours. The time patient was toileted will be documented on the hourly rounding checklist at bedside.."