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Based on interviews and documentation review the Hospital failed to ensure that: 1) a physician order was obtained prior to attempted insertion of a Foley catheter, and 2) fall prevention interventions were consistently implemented.

Findings included:

1) Nurse #4 was interviewed on 8/4/10 at 1:50 P.M. Nurse #4 said that on 7/2/10 Patient #1 was escalating due to alcohol withdrawal and was incontinent of urine. Nurse #4 reported attempting to unsuccessfully insert a Foley catheter which resulted in some bleeding.

Review of the Policy/Procedure titled Urinary Catheterization indicated that a physician order was required for catheter insertion.

Review of physician orders indicated that there was not an order to insert a Foley catheter.

Nurse #4 reported telling the Hospitalist about the catheter insertion at a later time.


2) Review of the current Policy/Procedure titled Fall Prevention Program indicated that patients identified at high risk for falls were to have a falling star magnet at the doorway, a yellow sticker on the identification bracelet and yellow socks on at all times.

A tour of the ICU/PCU was conducted with the Clinical Manager on 8/4/10. Observation determined that 6 patient doorways did not have a falling star signifying high risk for falls. Review of the medical records for the 6 patients determined that fall risk assessments were completed. Three of the 6 patients were assessed to be at high risk for falls and should have had stars which were applied during the tour. Observation of 2 randomly selected patients identified at high risk for falls indicated that 1 of 2 patients did not have a yellow dot on the name band to signify high risk. Observation of 2 randomly selected patients indicated that 1 of the patients identified as high risk did not have the yellow socks on.

Based on interviews and documentation review the Hospital failed to ensure that an attempted catheterization and complications were documented in the medical record for one of one patients (Patient #1).

Findings included:

Please See A-0395 related to catheter insertion.

Review of the medical record documentation, dated 7/1/10 and 7/2/10, indicated that Patient #1 had a platelet count of 57,000 (normal range is 130-400,000; platelets play a role in blood coagulation; the lower the platelet count, the increase in the risk of bleeding).

Nurse #4 was interviewed on 8/4/10 at 1:50 P.M. Nurse #4 reported assisting Nurse #1 who was assigned to Patient #1. Nurse #4 said Nurse #1 was busy assisting with another patient who was having a bedside procedure. Nurse #4 said the catheterization was attempted because Patient #1 was incontinent. Nurse #4 said after the catheter insertion was attempted Patient #1 had some bleeding which required application of pressure. Nurse #4 said the bleeding subsided but restarted after Patient #1 fell out of bed. Nurse #4 said pressure was applied and the bleeding again subsided.

Review of nursing and medical staff documentation, dated 7/2/10, indicated that there was no documentation regarding the attempt to catheterize Patient #1 or the subsequent bleeding.

Based on interviews and documentation review the Hospital failed to ensure that: 1) post-fall neurological assessments were documented in the appropriate area of the medical record and/or inability to perform the assessments due to Patient #1's status was noted in the medical record, and 2) CIWA scale scores were appropriately documented in the electronic medical record.

Findings included:

1) Review of medical record documentation, dated 7/1/10, indicated that Patient #1 was brought to the Hospital after experiencing a fall associated with ETOH related seizure activity. Patient #1 obtained a left-sided subdural hematoma and multiple bruises during the fall.

The Hospital's Policy/Procedure titled Fall with Possible Head Injury indicated that a baseline neurological assessment was performed. The neurological status was then monitored every 4 hours for 24 hours then every shift for 48 hours. Neurological assessment included level of consciousness, pupil size and reaction, strength and movement of extremities, and vital signs. Assessments were documented in the neurological assessment section of the electronic medical record system.

Review of the medical record documentation, dated 7/1/10 and 7/2/10, indicated that a baseline neurological assessment was performed in the Emergency Department by the physician, otherwise vital signs were monitored and documented in the vital sign section of the electronic medical record and Patient #1's level of consciousness was noted in the nursing notes. The neurological assessment section of the electronic medical record was not completed.

The following staff were interviewed: Nurse #2 was interviewed on 8/4/10 at 11:00 A.M.; Nurse #3 was interviewed on 8/4/10 at 1:40 P.M., and Nurse #4 was interviewed on 8/4/10 at 1:50 P.M. Nurse #2, Nurse #3, and Nurse #4 said that on 7/2/10 Patient #1 became increasingly confused, combative, and was attempting to get out of bed.

There was no documentation in the medical record to indicate that during this time neurological assessments could not be completed due to Patient #1's behaviors.

2) The preprinted order sheet titled Alcohol Withdrawal Protocol currently in use at the Hospital indicated that nursing was to assess and document the CIWA (Chicago Institute for Withdrawal of Alcohol) scale, indicative of the severity of withdrawal symptoms, every 2 hours for the first 24 hours then every 4 hours following each dose of medication. Medication was administered based on the scale score.

The ICU/PCU Clinical Manager was interviewed on 8/4/10 throughout the survey. The Clinical Manager said that CIWA scales were entered into the nursing assessment section of the electronic medical record.

Review of the nursing notes, electronic nursing documentation, and medication administration record indicated that CIWA scale was being performed and medication was being administered however; the actual time the scale was performed and the actual score was not documented in the medical record.

Based on interviews and documentation review, the Hospital failed to complete a timely investigation and failed to identify all opportunities for improvement for one of one patient incidents (Patient #1 .

Findings included:

The Hospital forwarded a report to the Department of Public Health on 7/26/10 indicating that on 7/2/10 Patient #1 fell and sustained a subarachnoid hemorrhage (bleeding into the arachnoid space located between 2 membranes covering the brain resulting in increased pressure. Timely identification is essential because the larger the bleed, the greater the risk of death. May require surgical intervention).

An authorized substantial allegation survey was conducted on 8/4/10. As of the survey the investigation was not completed and a review was pending.

The Clinical Manager of the Intensive/Progressive Care Unit (ICU/PCU), the Unit Patient #1 was on, was interviewed on 8/4/10 throughout the survey. The Clinical Manager reported being off at the time of Patient #1's fall and returning to work 7/6/10. The Manager reported on 7/6/10 noting there had been a fall and inquired about the fall. The Manager reported being told of Patient #1's fall but not of the outcome. The Manager said a week later a member of the falls team notified the Manager of the details of Patient #1's fall. The Manager reported reviewing the medical record and interviewing staff. The Manager reported notifying the Director of Quality Resources. The Clinical Manager reported identifying that neurological assessments were not done according to protocol and that Patient #1 should have had a 1:1 sitter.

The investigation did not identify the following: full patient assessments were not performed by nursing staff every shift; the severity of Patient #1 DT's were not assessed and/or documented as required per protocol, and nursing staff attempted to insert a Foley catheter without a physician order which resulted in bleeding.

The Director of Quality Resources, who was responsible for external reporting of incidents, was interviewed on 8/4/10 and throughout completion of the survey. The Director reported reviewing the medical record and conducting interviews with the Clinical Manager. The Director said an intensive review was initially planned for the next week but was moved to 8/5/10.

Based on interviews and documentation review the Hospital failed to ensure implement a corrective action plan to address identified opportunities for improvement in a timely manner for one of one patient incidents (Patient #1).

Findings included:

Please refer to A-0287

The Clinical Manager of the Intensive/Progressive Care Unit (ICU/PCU), the Unit Patient #1 was on, was interviewed on 8/4/10 throughout the survey. The Clinical Manager reported identifying that neurological assessments were not done according to protocol and that Patient #1 should have had a 1:1 sitter. The Clinical Manager said corrective actions related to the identified concerns were not implemented pending completion of the investigation.