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.

WELLBRIDGE HEALTHCARE GREATER DALLAS 4301 MAPLESHADE LANE PLANO, TX 75093 Jan. 17, 2020
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







The Hospital failed 1 of 10 Patients (Patient #2) by the a registered nurse not supervising and evaluating the nursing care plan of each patient. Patient #2 was considered a High Fall Risk for 16 12 Hour shifts.


Findings Include;

During Record Review the hospital failed to review and place any type of precautions in place until Patient #2 had experienced her 3rd fall. The hospital Inpatient Nursing assessment dated [DATE] reflected, "a patient at High Fall Risk scores 106 to 123. Patient #2 scored 113."
The hospital Nursing Notes, dated 04/22/2019 at 0245 reflected, "Staff had just completed rounding down the unit. Night Supervisor down the hallway and heard a loud thud, coming from patient #2's room. Patient found on floor sitting up next to bed. Patient #2 fell on bottom no injuries noted, head to toe assessment completed, no hip dislocations noted. Patient #2 assisted back to bed."

The hospital Fall Risk assessment dated [DATE] reflected Patient #2 scored a 104 indicated a Fall Risk.

The hospital Fall Risk assessment dated [DATE] reflected Patient #2 scored a 102 indicated a Fall Risk.

The hospital Fall Risk assessment dated [DATE] reflected Patient #2 scored a 102 indicated a Fall Risk.

The hospital nursing notes on 04/25/19 at 0130 reflected, "Pt. found sitting on the floor by CAN. Nurse notified. Head to toe assessment done, no bruises or injuries noted ...denies pain, hitting head. Vs. stable ...MD notified, by house supervisor. Family notified."

The hospital Fall Risk assessment dated [DATE] reflected Patient #2 scored a 104 indicated a Fall Risk.

The hospital Fall Risk assessment dated [DATE] reflected Patient #2 scored a 104 indicated a Fall Risk.

The hospital Fall Risk assessment dated [DATE] reflected Patient #2 scored a 104 indicated a Fall Risk.

The hospital Fall Risk assessment dated [DATE] reflected Patient #2 scored a 104 indicated a Fall Risk.

The hospital Fall Risk assessment dated [DATE] reflected Patient #2 scored a 105 Indicated a Fall Risk.

The hospital Physician Orders dated 04/30/19 at 1120 reflected, "place on 1:1 for falls. X-ray right hand 2 views, x - ray right elbow.

The hospital Fall Risk assessment dated [DATE] reflected Patient #2 scored a 109 Indicated a High Risk for Falls.

The hospital nursing notes on 05/04/2019 at 119 reflected, "had a witnessed fall in the day room. Hitting head on the med cart. MD notified. Pt. sent out to Presby Plano per Dr. order to get a CT scan of the head. No apparent injuries, no bruising sustained from fall. Acadian Ambulance picked up at 1115 ...alert and verbal at time of transfer."

The hospital staff worked 16 12 hours shifts prior to placing Patient #2 on some type of precautions.

Policy
The hospital Patient Rights Policy dated 02/1/17 reflected, "This facility fully supports, endorses and enforces the rights of patients. This facility informs each patient, patient's guardian /or patient's family when appropriate, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. Patient rights include all federal and state requirements."

The hospital Patient Rights Abuse dated 02/1/2017 reflected, "It is the policy of the hospital to make every effort to protect the fundamental human, legal and civil rights of the patients in its care. Employees are expected to treat each patient in a respectful and considerate manner and to immediately report any concern for a patient's safety."

The hospital Policy Nursing Services Integrated assessment dated [DATE], "It is the policy of the facility to conduct a comprehensive assessment of all relevant factors contributing to the patient's current condition and goals of recovery."

The hospital Change in Patient Condition policy reflected, "It is the policy of the hospital to provide a structure for clinical decision making that takes into account the recognition and proper level of response to a change or deterioration in a patient's medical condition."

The hospital Policy on Psychiatric and Medical Evaluation dated 02/1/2017 reflected, "It is the policy of the facility for medical staff to conduct a comprehensive psychiatric evaluation history and physical in a timely manner per law, regulation and Medical staff by laws."

The hospital Policy on Quality of Care dated 02/1/2017 reflected, "A hospital shall develop, implement, and maintain an effective ongoing, hospital-wide, data driven quality assessment and performance improvement program ...Reflect the complexity of the hospital organization .... Involve all hospital departments and services, Specify the frequency and detail of data collected, Focus on high-risk, high volume, and problem prone areas."

The hospital Policy on Hand off Communication and Change in Condition Policy stated, "A nurse to nurse patient report will be conducted at each shift change and any time the nurse relinquishes or assumes the care for a patient ...The nurse will prove a report to the receiving facility for all patient's transferred to another facility ...The DON, or designee ...receive communication any time there is a significant patient event, transfer or change in condition."

The hostpital Policy on Assessing and Preventing Falls dated 02/1/2017 stated, "It is the policy of the facility to assess all patients for fall risk at admission and at regular intervals throughout hospitalization and minimize the risk for falls at every opportunity."