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.
| LAKELAND BEHAVIORAL HEALTH SYSTEM | 440 S MARKET SPRINGFIELD, MO 65806 | May 12, 2016 |
| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on observation, interview, record review and policy review the facility failed to ensure appropriate fall prevention interventions were in place, according to facility policy, to protect 12 current patients (#3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) of 12 current patients, and one discharged patient (#49) of one discharged patient, who were at high risk for falls and or who had previously fallen on the Geriatric Behavioral Health Unit (BHU). (A395) The facility also failed to ensure that fall risk care plans were in place for six current patients (#3, #6, #7, #9, #10 and #13) of 12 current patients reviewed who were at high risk for falls on the Geriatric BHU. (A396). These failures had the potential to lead to injury and death, and could affect all patients on the Geriatric BHU. The severity and cumulative effect of these failures resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services. |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure appropriate fall prevention interventions were in place, according to facility policy, to protect 12 current patients (#3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) of 12 current patients, and one discharged patient (#49) of one discharged patient, who were at high risk for falls and or who had previously fallen on the Geriatric Behavioral Health Unit (BHU). This had the potential to lead to possible injury and death, and could affect all patients on the Geriatric BHU. The Geriatric BHU census was 12. The facility census was 118. Findings included: 1. Record review of the facility's policy titled, "Fall Assessment and Precautions," dated 01/19/15, showed that patients who scored greater than 45 were at high risk for falls and included the following precautions: - Place a fall sticker to the patient's wrist band and medical chart; - Fall mat (foam mat) on floor at bedside; - Elevate toilet seat in bathroom; - Bed alarm in place and activated when the patient is in bed; and - Ambulate the patient with a gait belt (belt type device used to transfer a person from one place to another or to assist with ambulating a person with balance problems). Record review of the facility's policy titled, "Observation, Patient Monitoring, and Precautions - Acute Services," dated 03/09/16, showed that patients on "Level II" (level of monitoring) should be visually accessible to an assigned staff member at all times. 2. Record review of the daily report sheet for the Geriatric BHU, showed that all 12 patients (#3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) on the unit were at a high risk for falls and that Patients #8 and #13 were categorized as Level II. 3. Observation on 05/10/16 at 3:10 PM with concurrent interview showed that none of the patient's in the Geriatric BHU had fall stickers placed on their wrist band. Staff C, Director of Nursing (DON), confirmed the finding and stated that staff were no longer placing the fall stickers on patient wrist bands. 4. Observation on 05/10/16 at approximately 2:45 PM, showed that Patients #3, #4, #5, #6, #8, #9, #10, #11 and #12 did not have fall mats at the patient's bedside. 5. Observation on 05/10/16 at 2:50 PM, showed that Patients #3, #4, #7, #8, #10, #11 and #12 did not have elevated toilet seats in the bathroom. 6. Observation on 05/10/16 at 1:35 PM, showed Patient #4, laying in his bed with his eyes closed. There was no fall mat in place, and the patient's bed alarm was not turned on. 7. Observation on 05/11/16 at 9:20 AM with concurrent interview, showed Patients #4, #10 and #11 lying in bed with their eyes closed. There was no fall mat in place, and the patients' bed alarms were not turned on. Staff C stated, "They're (nursing staff) not doing it (implementing fall precautions), but I didn't realize it was this bad". 8. Record review of current Patient #8's medical record showed the following: - A nursing assessment dated [DATE] documented that the patient had a history of mobility problems including unsteady gait, multiple and frequent falls resulting in injuries, two near falls while on the Geriatric BHU, and scored a fall risk score of 95 (45 or greater is considered high risk for falls). - A History and Physical Exam (H&P) dated 05/05/16, documented that the patient had multiple, frequent falls, had two "near falls" on the Geriatric BHU on 05/04/16, a history of Parkinsonism (disorder that affects movement, causing shuffling of the feet) and muscle rigidity. - A physician's order dated 05/06/16 for the patient to be placed on Level II observation. - A nursing progress note dated 05/11/16 at 2:39 PM, documented that the patient was "very unsteady in gait", required one or two staff to assist the patient, had times of "waking up jerking like she's falling in her dreams". Observation on 05/11/16 at 4:48 PM, showed Patient #8 sitting in a geriatric chair unattended and without observation. The patient woke, shook violently, and fell forward out of the geriatric chair, landing on the floor. The patient had no obvious injuries. Even though Patient #8 had a history of falls prior to admission, and two near falls on the Geriatric BHU, the facility failed to observe the patient at all times per policy, and protect the patient from falls. 9. Record review of Patient #5's Master Treatment Plan showed: - On 04/27/16, the patient's fall risk score was 60; - On 05/01/16, the patient's fall risk score was 85; and - On 05/06/16, the patient's fall risk score was 100. Record review of Patient #5's Fall Investigations showed on 05/01/16, the patient had a non-injury fall after she was medicated with Ativan (sedative) and Thorazine (antipsychotic, used to treat mental illness), was delusional, and tripped while she carried a chair, and on 05/07/16, the patient fell and struck her head, after she ambulated in the hall with her walker. Even though Patient #5's fall risk score continued to increase, the facility failed to put measures into place, such as placing the patient on Level II to protect the patient and prevent the patient from a second fall. Observation on 05/11/16 at 9:20 AM, showed Patient #5 in bed with her eyes closed. There was no fall mat in place, and the patient's bed alarm was not on. 10. Record review of current Patient #13's fall risk score showed that patient scored 115. Record review of Patient #13's Fall Investigations showed on 05/08/16, the patient had a fall after he was left alone and unobserved, when he stood up and attempted to ambulate without assistance. The patient did not sustain an injury. Even though Patient #13 had an extremely high fall risk score, and was a Level II, the facility failed to ensure the patient was observed at all times and protected from falls. 11. Record review of discharged Patient #49's Fall Investigation showed: - On 03/11/16, the patient fell , and was placed on line of sight observation (currently known as Level II). - On 03/12/16, the patient fell after she was assisted to the toilet and left on the toilet unattended by staff. - On 03/14/16, the patient had an unwitnessed fall, after she attempted to get out of an alarmed chair in which the batteries had been removed from the alarm. - On 03/23/16, the patient had an unwitnessed fall, after she rose from her bed, became dizzy, and fell to the floor. Patient #49 was placed on line of sight observation after the first fall, but was left unattended and unobserved, and allowed to fall three additional times. During an interview on 05/11/16 at 12:35 PM, Staff E, Registered Nurse, stated: - She didn't know why fall precautions weren't being implemented; - Staffing contributed to some of the fall issues because many of the psychiatric patients were total care (require assistance with feeding, ambulating, toileting, etc.), and it was difficult to get the staff needed to provide care for them; and - The fall risk scale was not set up for psychiatric patients because it placed everyone at high fall risk. During an interview on 05/11/16 at 12:15 PM, Staff W, Geriatric BHU Manager, stated the following: - She recently assumed the management position (six months) and was in the process of trying to get a good routine down to manage the unit as well as another unit; - She was negligent on checking on patients and staff due to increased patient volumes and increased level of care needed to provide for the patients; - She didn't review all of the Fall Investigations; and - She was aware of the issues related to staff not initiating fall precautions. |
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| VIOLATION: NURSING CARE PLAN | Tag No: A0396 | |
| Based on interview, record review and policy review, the facility failed to ensure that fall risk care plans were in place for six current patients (#3, #6, #7, #9, #10 and #13) of 12 current patients reviewed who were at high risk for falls on the Geriatric Behavioral Health Unit (BHU). This had the potential to lead to possible falls, injury or death, which could have been prevented if the care plans were put into place. The Geriatric BHU census was 12. The facility census was 118. Findings included: 1. Record review of the facility's policy titled, "Fall Assessment and Precautions," dated 01/19/15, showed that patients who scored greater than 45 were at high risk for falls, should have a fall risk treatment plan (also known as a care plan) initiated in the patient's medical record and that High Fall Risk included the following interventions: - Place a fall sticker to the patient's wrist band and medical chart; - Fall mat (foam mat) on floor at bedside; - Elevate toilet seat in bathroom; - Bed alarm in place and activated when the patient is in bed; and - Ambulate the patient with a gait belt (belt type device used to transfer a person from one place to another or to assist with ambulating a person with balance problems). 2. Record review of current fall risk scores showed: - Patient #3 scored 50; - Patient #6 scored 80; - Patient #7 scored 75; - Patient #9 scored 90; - Patient #10 scored 100; and - Patient #13 scored 115. 3. Record review of Patients #3, #6, #7, #9, #10 and #13 care plans showed no fall risk care plan had been implemented according to policy for patients assessed at high risk for falls. |
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| VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS | Tag No: A0406 | |
| Based on interview and record review the facility failed to have a system in place to ensure that physicians or assisting physician assistants (PA) authenticated (signature to substantiate) verbal orders for three current patients (#44, #45 and #46) of five patient's verbal orders, reviewed for authentication within 24 hours. The patient census was 118. Findings included: 1. Record review of the facility's policy titled, "Verbal and Written Orders," dated 06/03/14, showed that verbal orders are to be signed by the provider within 24 hours of giving the order. 2. Record review of the facility's document titled, "Medical Staff Rules & Regulations" dated 04/2015, showed that verbal orders are to be signed by the ordering physician or assisting physician assistant within 24 hours of giving the order. 3. Record review on 05/12/16 for Patient #44 showed Staff Y, Physician Assistant (PA), gave a verbal order for increased observation to a level two with suicide precautions on 05/09/16 at 11:45 PM. At the time of the record review, Staff Y had not dated, timed or signed the verbal order. 4. Record review on 05/12/16 for Patient #45 showed Staff AA, Physician, gave a verbal order dated 05/06/16 for increased observation to a level two, due to increased fall risk. At the time of the record review, Staff AA had not dated, timed or signed the order. 5. Record review on 05/12/16 for Patient #46 showed Staff Z, Physician, gave a verbal order dated 05/06/16, for frequent position changes every two hours, for pressure reduction of left foot and coccyx. At the time of the record review Staff Z had not dated, timed or signed the verbal order. During an interview on 05/12/16 at 12:16 PM, Staff U, Registered Nurse (RN) nurse manager, stated that she expected nurses to place verbal orders to be signed on the clipboard designated for Physicians and PA's. She expected PA's and Physicians to check this daily and sign within 24 hours of the order. During an interview on 05/12/16 at 12:20 PM, Staff C, Director of Nursing, stated that he expected nurses to remind providers when there were orders to authenticate. He expected providers to date, time and sign orders within 24 hours per hospital policy. |
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