HospitalInspections.org

Based on observation, it was determined that the governing body was not responsible for services provided in the hospital in that staff failed to follow established facility policy and procedure in the care of a patient. The facility also failed to follow established requirements set forth in 25 TAC 133.41 (o).

Findings were:

Facility policy & procedure titled " Early Intervention Process " stated, in part, " The EIP will occur through interdisciplinary collaboration when an acute change (calling criteria) in a patient ' s condition has been identified. "
Per this policy,
" 1. Patient experiencing an acute change is identified ( " calling criteria " ). Acute changes may include the following:
a. Heart Rate
b. Respiratory Rate
c. Blood Pressure
d. Mental Status
e. Sustained SpO2 of < 85%
f. Low urinary output
g. Seizures
h. Significant Bleeding
i. Concerns about condition (gut feeling)
...3. During the EIP process patient will be assessed, support will be provided and communication with the physician will occur utilizing Situation, Background, Assessment, and Recommendation (SBAR). "

A review of the clinical record for Patient # 1 revealed a significant change in patient output documented in the Patient Care Record:

Documentation of patient bowel movements in the Patient Care Record revealed:

? On 12-4-11 the patient had 9 bowel movements: four large stools (1100, 1200, 1400, and 2000), two medium stools (2100 and 2300) and three small stools (0100, 0300, and 0500). No consistency note for these bowel movements. Nursing note on 12-4-11 at 1530 labeled as a late enter stated, " Patient requested Questran which she had refused earlier because she has diarrhea. "
? On 12-5-11 the patient had 5 bowel movements (0700, 0900, 1200, 1600, and 1700). No size or consistency noted for these bowel movements. Nursing notes indicate the patient received 3 doses of Imodium p.r.n. related to complaints of diarrhea. A nursing note on 12-5-11 at 1200 also stated, " Charge nurse notified of continued diarrhea and patients and daughter requesting Questran be started like patient took it at home (BID). "
? On 12-6-11 the patient had 7 bowel movements (0700, 0900, 1000, 1100, 1200, 1500, and 1600). No size or consistency was noted for these bowel movements. Nursing notes indicate diarrhea.

The clinical record of Patient # 1 contained no documentation of physician notification regarding the change in patient condition or requests to restart Questran until 12-6-11.

Facility policy & procedure titled " Warm Springs Fall Risk Assessment " stated, in part, " Upon admission the charge RN and Physical Therapist will complete the Fall Risk Assessment Form ... " Per this policy, " b. High Risk Fall Precautions: If a patient scores greater than 50 on the Fall Risk Assessment, the patient will be placed on High Risk Fall Precautions. In addition to the standard Low Risk Precautions, the precautions are also taken: documented one hour checks ... "

A review of the clinical record for Patient # 1 revealed that she was not monitored as indicated related to her fall risk status.

The " Warm Springs System Fall Risk Assessment " completed by a nurse on 11-29-11 scored Patient # 1 a 45 which is rated as a low risk with standard fall risk. The nurse completing the assessment noted in the comments, " Recommend FIPP precautions. " This indicated the need to monitor the patient hourly per policy. A second Fall Risk Assessment completed on 12-2-11 by the physical therapist scored Patient # 1 at 80 which indicated a high fall risk requiring hourly monitoring.

A review of documentation of safety observations in the Patient Care Record revealed that Patient # 1 was not monitored every hour per the recommendation of the Fall Injury Precaution Program (FIPP). The area to indicate every 1 hour observations per the FIPP was missing documentation and initials over several days:

? On 11-30-11 at 1800.
? On 12-1-11 at 1700 and 1800.
? On 12-5-11 at 1700 and 1800.
? On 12-6-11 several hours were not documented and initialed: 0800, 1000, 1200, 1400, 1600-1800, 2000, 2200, 2400, 0200, 0400, and 0600.

The above was confirmed in an interview with the Nurse Manager and the Director of Quality on the afternoon of 3-20-12 in the facility conference room.

Based on observation, it was determined that the facility failed to complete medical records within 30 days following discharge as evidenced by a chart review which was incomplete as of survey date 3-20-12. Patient # 1 had been discharged to another facility on 12-7-11. The chart remained incomplete as it was missing necessary initials and forms had not been completed. The chart was considered by the facility to be closed and complete record.

Findings were:

A review of the clinic record for Patient # 1 revealed:

? The documentation of safety observations in the Patient Care Record revealed that Patient # 1 was not monitored every hour per the recommendation of the Fall Injury Precaution Program (FIPP). The area to indicate every 1 hour observations per the FIPP was missing documentation and initials over several days: On 11-30-11 at 1800. On 12-1-11 at 1700 and 1800. On 12-5-11 at 1700 and 1800. On 12-6-11 several hours were not documented and initialed: 0800, 1000, 1200, 1400, 1600-1800, 2000, 2200, 2400, 0200, 0400, and 0600.

The above was confirmed in an interview with the Nurse Manager and the Director of Quality on the afternoon of 3-20-12 in the facility conference room.