HospitalInspections.org

Based on record review and interview the hospital failed to provide care in a safe setting. This failure is evidenced by the elopement of 1 (#2) of 1 patients with traumatic brain injury placed on one to one observation.
Findings:

Review of the medical record for Patient #2 revealed the patient was admitted on 08/19/2021 at 11:00 a.m. The history and physical dated 08/20/2021 states the patient was "not alert enough to go home." The physician expressed concern for Patient #2 signing out AMA her ability to care for herself.

Review of the orders for Patient #2 reveals an order on 08/20/2021 at 9:45 a.m. for one to one observation.

Review of nursing progress notes for Patient #2 revealed on 08/22/2021 at 6:01 p.m. "sitter at bedside." At 7:30 p.m., the patient was at the desk requesting to go home. The nurse redirected her to her room and asked the patient to stay there while the nurse brought her medication. Further review of the nurse's notes reveals at 8:15 p.m., the patient's family called reporting the patient was at her brother's house.

In interview on 09/20/2021 at 3:00 p.m., S2DON verified that the patient eloped on 08/22/2021 at approximately 7:30 p.m. based on review of video surveillance of the front door. She also verified that the nursing staff was not aware the patient left the facility until they received a call from the daughter of Patient #2. S2DON further verified the sitter noted at 6:01 p.m. was from the day shift and one to one care was not assigned for Patient #2 for the evening shift on 08/22/2021.

In interview on 09/21/2021 at 7:55 a.m., S1Adm reported there was adequate staffing for the evening of 08/22/2021 to provide one to one care for Patient #2. There were three nurses and two certified nursing assistants and 12 patients that shift.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the registered nurse failing to perform a complete nursing assessment after a fall for 1 out of 1 patient (Patient #4) documented as having fallen.

Findings:

In review of the hospital's policy titled "Neurological Assessment" revealed in part:
Purpose/Functional Effects:
1.) To establish a base line neurological assessment.
2.) To recognize neurological trends and changes in the patient's condition.
Instructions/Procedures:
6.) Assess patient's level of consciousness
10.) Notify the physician of any changes.
12.) Document date, time, and results of all neurological assessment, including:
a. Level of consciousness
b. Pupillary reaction
c. Motor and sensory function
d. Vital signs
e. Total Glasgow scale points, if appropriate
f. Description of all behavior and responses
g. All teaching done, if appropriate, and patient's level of understanding
13.) Use descriptive wording rather than generalizations. Assess neurological signs prior to any procedure when beginning a tour of duty, and before any surgical or emergency intervention. Significant changes in the patient's condition always require a more frequent assessment of regression in level of consciousness, any deterioration in patient's condition, etc.
A request was made for a post-fall policy; the facility failed to provide such policy.

Review of Occurrence Report from 09/12/2021 at 6:30 p.m. completed by S6LPN revealed the following:
Patient #4 fell from wheelchair next to nurses' station and the fall was witnessed by staff. Actions Implemented: DON was notified, family was notified, no treatment required. Staff transferred patient back to wheelchair and 1:1 sitter was instructed to bring patient back to bed.

Review of Patient #4's medical record on 09/21/2021 at 9:00 a.m. revealed no documentation of a post-fall assessment or notifying the physician of Patient #4's fall.

In an interview on 09/21/2021 at 11:16 a.m. S1Adm and S2DON confirmed the nurse should have done a post-fall assessment of Patient #4. They also confirmed the physician should have been notified of the fall.

In an interview on 09/21/2021 at 11:33 a.m. S2DON stated the facility does not have a post-fall policy.

Based on record review and interview, the hospital failed to provide adequete supervision of contract staff. This deficiency is evidenced by lack of documentation of orientation to hospital policies and procedures in 1 (S3RN) of 1 personnel records reviewed.
Findings:

Review of hospital policy titled, "Orientation and Training," issued 2015, "Human Resourses Executive is responsible for the overall development and coordination of the orientation program and for implementing the portions that cover cooperate history, philosophy, policies, benefits and new employee files and documentation."

Review of the personnel file for S3RN revealed she was an agency nurse and no documentation of orientation to hospital policies and procedures.

In interview on 09/21/2021 at 10:30 a.m., S2DON verified there was no documentation of the orientation of S3RN.

Based on record review and interview the facility failed to monitor pain and anxiolytic medications for effect. This deficiency is evidenced by the failure of the nursing staff to note medications effect in 2(#2, #4) of 5 (#1-#5) records reviewed for documentation of medication effect.
Findings:

Review of hospital policy, "Medication Management," issued 2009, reveals in part "each patient's response to their medication is monitered according to the clinical needs and addresses the patient's response to the prescribed medication and actual or potiential medication-related problems. Monitoring a medication's effect includes the following... Gathering the patient's own perceptions about the side effects...Referring to information in the patient's medical record such as lab values, clinical response, and medication profile."

Patient #2
Review of the medical record for Patient #2 revealed an order on 08/22/2012 at 7:49 a.m., for Haldol 5 milligrams intramuscular times one dose and Ativan 1 milligram intravenous or intramuscular every 6 hours as needed for agitation.

Review of the MAR revealed administration of Haldol 5 milligrams and Ativan 1 milligram on 08/22/2021 at 8:05 a.m. Further review of the MAR in the section labeled " Nurse's Medication Notes" revealed the two medications were given for agitation. There is no documentation of effect or the site the medication was administered.

Patient #4
Review of the medical record for Patient #4 revealed an order on 09/08/2021 at admission for lorazepam 2 milligrams intramuscularly every 4 hours as needed for agitation.

Review of the MAR revealed the administration of lorazepam 2 milligrams on 09/16/2021 at 3:30 p.m. Further review of the MAR in the section labeled "Nurse's Medication Notes" revealed the lorazepam was given for agitation. There is no documentation of effect or the site the medication was administered.

In interview on 09/21/2021 at 11:30 a.m., S2DON verified the MAR was incomplete. She also stated the hospital policy is for medication effect to be documented one hour after administration.

Based on observation and interview, the hospital failed to properly file and store patient records in a manner to protect them from fire or water damage as evidenced by storing paper medical records on open shelving.

Findings:

Review of the hospital's policy titled Storage of Medical Records revealed in part:
III. Storage Space Specifications
A. Storage space shall be selected and maintained to protect records from unauthorized access, loss and destruction. Storage space shall be selected to meet the following specifications: adequate lighting, controlled environment, freedom from dust, protection against fire, freedom from hazards such as flooding or damage from broken water pipes.

In an observation on 09/20/2021 at 10:21 a.m. of the medical records department, there were 6 open shelves approximately 11 feet long and 2 open shelves approximately 7 feet long. The shelves contained paper medical records. Further observation revealed the room contained sprinklers in the ceiling.

In an interview on 09/20/2021 at 10:00 a.m. with S1Adm, he said the paper medical records on the open shelving were not scanned into a computer.

In an interview on 09/21/2021 at 10:19 a.m. with S7HIM, she verified the paper medical records should have been covered in case the sprinkler had been activated.