HospitalInspections.org

Based on staff interview, facility policy and procedure, and medical record review the facility failed to ensure RN's (registered nurse) supervise the nursing care for 3 out of 9 patients (#7, 10, 11), evaluate patient care needs, adjust and update interventions and goals in the care planning process for 5 out of 9 patients (#10, 4, 11, 1, 2). This deficiency has the potential to effect all patients at this facility during the survey, census on 4/16/13 was 24, 4/17/13 was 21.

Findings include:

The facility nursing staff failed to provide supervision by monitoring and assessing the care provided to patients. (See A395)

The facility failed to monitor patient care needs and adjust treatment interventions/goals according to patient change in health status. (See A396)

The cumulative effect of these failures and the serious outcome in response to these failures has potential to effect the health and safety of all patients receiving care at this facility.

Based on review of medical records, facility policy and staff interview the facility nursing staff failed to supervise and evaluate the nursing care for patients in 3 out of 9 (7, 10, 11) inpatient medical records reviewed. This deficiency has the potential to affect all patients at this facility during the survey: census on 4/16/13 was 24, and on 4/17/13 was 21.

Finding include:

Per review of facility policy on 4/16/13 at 12:00 pm titled Assessment and Reassessment- Nursing 7.15, dated 1/2/13 states under Procedure: "VI. CNA's (Certified Nursing Assistants) will document on every patient every shift using the CNA Documentation form. The CNA Documentation form is to be reviewed every shift by the patients nurse to verify completion."

Per review of facility policy on 4/16/13 at 12:00 pm titled Fall Prevention and Risk Assessment 7.43, dated 12/21/12 states under "III. Procedure C. 2. All patients will have a bed alarm and chair alarm in place upon admission. The need for continuation of the bed and/or chair alarms will be reviewed at the first team conference. E. 8. Use of a "Yellow Card" on patient's wheelchair indicating that patient should never be left unattended in wheelchair in room."

Per medical record review on 4/16/13 at 9:30 am, Pt. # 10 was admitted to facility on 3/20/13 through 4/5/13 following a diagnosis of generalized weakness and lymphoma. A fall occurred on 3/23/13 at 11:45 pm when pt. was being walked with the assist of CNA when pt's right knee gave out and pt. needed to be lowered to the floor. No Injury occurred. Documentation indicated a bed and w/c alarms were initiated upon admission per policy on 3/20/13 and were discontinued per nursing documentation on 4/4/13. CNA documentation indicated the following inconsistencies: 3/28/13 am shift: bed alarm- no, w/c alarm- no. 3/29/13 pm shift: bed alarm- blank, w/c alarm- blank. 3/30/13 am shift: bed alarm- no w/c alarm- no. 3/30/13 night shift: bed alarm- no. 3/3/1/13 am shift: bed alarm- no, w/c alarm- no. 4/1/13 am shift: bed alarm- no, w/c alarm- no. 4/2/13 am shift: bed alarm- yes, w/c alarm- no. 4/2/13 pm shift: bed alarm- yes, w/c alarm- no. 4/3/13 pm shift: bed alarm- yes, w/c alarm: no. According to documentation from the team conference, alarms were discontinued on 4/4/13.

Per medical record review on 4/16/13 at 11:15 am, Pt. # 11 was admitted to facility on 3/26/13 through 4/13/13 following a diagnosis of a left hip fracture. A fall occurred on 3/26/13 at 11:00 pm when a nurse entered pt's room due to bed alarm sounding and found pt. # 11 kneeling over the bed. Patient was assessed and determined to have no injury. Physician orders reviewed and noted an order on 3/26/13 at 11:20 pm for a "1:1 sitter" . On 3/31/13 at 7:00 pm an order was noted for a "yellow card on day shift and to continue 1:1 sitter on pm and night shift". CNA documentation indicated the following inconsistencies: 3/29/13 pm shift: bed alarm- yes, w/c alarm- yes, sitter- no. 3/30/13 night shift: bed alarm- no, w/c alarm- no, sitter- no. 4/2/13 pm shift: bed alarm- yes, w/c alarm- yes, sitter- no.

Per medical record review on 4/16/13 at 1:05 pm, Pt. # 7 was admitted to facility on 1/14/13 through 3/11/13 following a diagnosis of a stroke. A fall occurred on 3/3/13 at 10:35 am when pt. attempted to self transfer from w/c to bed. Pt. # 7 stated he slid himself to the floor, denied hitting his head. Incident report or nursing documentation does not indicate that a chair alarm was sounding at the time of the fall. The care plan states that fall interventions include a chair alarm. CNA documentation indicates the following inconsistencies: 1/16/13 am shift: bed alarm- yes, chair alarm- blank, 1/19/13 pm shift: bed alarm- no, chair alarm- no, 1/28/13 am shift: bed alarm- yes, chair alarm- blank.

Above finding confirmed with RNIC (Registered Nurse Infection Control) G on 4/16/13 from 9:30 am through 2:15 pm.

Per staff interview with DON (Director of Nursing) F on 4/17/13 at 10:00 am, DON F stated that nurses are responsible to review the content of the CNA documentation form. DON F also stated that as part of the recent plan of correction staff was re-educated on completing CNA documentation on 4/5/13 and Nurses are to be reviewing and signing the CNA documentation form.

Based on review of medical records and staff interviews the facility staff failed to ensure that care plans were kept up to date on 5 out of 9 (# 10, 4, 11, 1, 2) inpatient's medical records reviewed. This deficiency has the potential to affect all patients at this facility during the survey, census on 4/16/13 was 24, 4/17/13 was 21.

Findings Include:

Per review on 4/16/13 at 11:00 am of facility policy titled Plan of Care-Individualized and Interdisciplinary 7.59, dated 2/5/13 states under Policy: "Each patient's individualized and interdisciplinary plan of care is appropriate to the patient's individualized assessed needs, strengths, limitations and goals. The care and treatment are provided according to the plan by the interdisciplinary team, lead by a physician. The individualized plan of care is reviewed and revised based on the patient's response to treatment." Under Procedure: "III. B. Modifications are made to the plan of care an resources allocations are made based on reassessment of the patient at specific intervals and related to the following elements: 1. Progress toward goal. 2. Failure to make progress. 3. Unusual response to treatment, 4. Failure to participate. 5. Other significant data. 6. Emergent issues.

Per review of facility policy on 4/16/13 at 12:00 pm titled Fall Prevention and Risk Assessment, 7.43 dated 12/21/12 states under Procedure: "C. All patients will have a bed alarm and chair alarm in place upon admission. The need for continuation of the bed and/or chair alarm will be reiewed at the first team conference. F. Discontinuation of fall prevention interventions will occur when a patient has achieved room independence and universal fall precautions will be utilized at that point. G. 2. Documentation: In all patient records for all falls, include: a. Description of the event an ffollow up (with factual information only). b. communication with patient, physician, and family. c. Review of falls prevention interventions and modification of plan of care, including that may have been successful in the past."

Per medical record review on 4/16/13 at 9:30 am, Pt. # 10 was admitted to facility on 3/20/13 at 2:55 am through 4/5/13, following a diagnosis of generalized weakness and lymphoma. A fall occurred on 3/23/13 at 11:45 pm when pt. was being walked with the assist of CNA when pt ' s right knee gave out and needed to be lowered to the floor. Care plan was never updated indicating that a fall occurred on 3/23/13.

Per medical record review on 4/16/13 at 10:45 am, Pt. # 4 was admitted to facility on 1/3/13, following a diagnosis of a Stroke. A fall occurred on 1/10/13 at 4:45 pm when staff responded to a w/c alarm and found pt. lying on the bathroom floor with the w/c in the doorway. The care plan indicated that as of 1/3/13 a bed alarm (no chair alarm) was initiated and that on 1/10/13 a bed/chair alarms were utilized.

Per medical record review on 4/16/13 at 11:15 am, Pt. # 11 was admitted to facility on 3/26/13 through 4/13/13, following a diagnosis of a left hip fracture. A fall occurred on 3/26/13 at 11:00 pm when a nurse entered pt ' s room due to bed alarm sounding and found pt. # 11 kneeling at the side of her bed leaning over the bed. Physician orders reviewed and noted an order on 3/26/13 at 11:20 pm for a " 1:1 sitter". Care plan was not updated with fall or order for a sitter as an intervention.

Per medical record review on 4/16/13 at 11:50 am, Pt. # 1 was admitted to facility on 12/19/12 through 12/20/12, following a diagnosis of a rib fracture from a fall at home. A fall occurred on 12/20/12 at 2:50 pm when staff heard a loud thud, staff entered the pt ' s room and found pt lying on the bathroom floor on her back. Nursing admission assessment completed on 12/19/12 am shift indicates that pt. is confused/disoriented, has impaired balance, impulsive and at a high risk for falls/injury. Bed/chair alarm are indicated as interventions. Care plan indicated pt. was at risk for falls but does not list a w/c alarm as an intervention.

Per medical record review on 4/16/13 at 1:45 pm, Pt. # 2 was admitted to facility on 12/11/12 through 12/19/13, following left lower leg cellulitis. A fall occurred on 12/19/13 at 1:45 pm when the pt. was found lying on her back on the floor in her room. Nursing shift assessment dated 12/19/13 for am shift indicates that bed and w/c alarms were used for safety interventions. Care plan does not indicate the use of a bed or w/c alarm as interventions.

Above finding confirmed with Registered Nurse Infection Control (RNIC) G on 4/16/13 from 9:30 am through 2:15 pm.

Per staff interview with DON F on 4/17/13 at 3:00 pm, DON F stated staff is responsible to update care plans with changes

Based on review of medical records, review of facility policy and staff interviews the facility staff failed to follow MD order, failed to update MD, and document pertinent information necessary to monitor patients condition in 4 out of 9 (# 4, 11, 7, 2) inpatient medical records reviewed. This deficiency has the potential to affect all patients at this facility during the survey, census on 4/16/13 was 24, and on 4/17/13 was 21.

Finding include:

Per review of facility policy on 4/16/13 at 12:00 pm titled Fall Prevention and Risk Assessment, 7.43 dated 12/21/12 states under Procedure: "C. All patients will have a bed alarm and chair alarm in place upon admission. The need for continuation of the bed and/or chair alarm will be reviewed at the first team conference. F. Discontinuation of fall prevention interventions will occur when a patient has achieved room independence and universal fall precautions will be utilized at that point. G. 2. Documentation: In all patient records for all falls, include: a. Description of the event and follow up (with factual information only). b. Communication with patient, physician, and family. c. Review of falls prevention interventions and modification of plan of care, including that may have been successful in the past."

Per review of facility policy on 4/16/13 at 12:00 pm titled Fall Prevention and Risk Assessment, 7.43 dated 12/21/12 "Appendix A-Post Fall Assessment Guidelines, under implement: 2. If patient hit head or cannot tell you that he did not hit his head and on anticoagulants, Neurological checks and vital signs now an every 1 hour x 24."

Per medical record review on 4/16/13 at 10:45 am, Pt. # 4 was admitted to facility on 1/3/13 following a diagnosis of a Stroke. A fall occurred on 1/10/13 at 4:45 pm when staff responded to a w/c alarm and found pt. lying on the bathroom floor with the w/c in the doorway. Pt. nodded head when asked if he hit his head. Bump noted on head. Per review of neurological check sheet indicated missing information: on 1/10/13 at 5:45 pm, no assessment of pupils at 6:45 pm or documentation of vital signs. On 1/11/13 at 8:15 am, 9:15 am, 10:15 am, 11:15 am, 12:15 pm, 1:15 pm, 2:15 pm, 3:15 pm- no documentation of vital signs noted. No documentation in medical record of physician being notified of fall.

Per medical record review on 4/16/13 at 11:15 am, Pt. # 11 was admitted to facility on 3/26/13 through 4/13/13 following a diagnosis of a left hip fracture. A fall occurred on 3/26/13 at 11:00 pm when a nurse entered pt's room due to bed alarm sounding and found pt. # 11 kneeling over the side of the bed. Patient was assessed and determined to have no injury. Physician order noted on 3/26/13 at 11:20 pm for a "1:1 sitter". On 3/31/13 at 7:00 pm the order was changed for a "yellow card on day shift and to continue 1:1 sitter on pm and night shift". Physician progress note dated 3/30/13 states "sitter for confusion". CNA (Certified Nursing Assistant) documentation indicated the following inconsistencies: 3/29/13 pm shift: No sitter. 3/30/13 night shift: No sitter. 4/2/13 pm shift: No sitter.

Per medical record review on 4/16/13 at 1:05 pm, Pt. # 7 was a 59 year old male admitted to facility on 1/14/13 through 3/11/13 following a diagnosis of a Stroke. A fall occurred on 3/3/13 at 10:35 am when pt. attempted to self transfer from w/c to bed. Pt. # 7 stated he slid himself to the floor, denied hitting his head. Incident report or nursing documentation does not indicate that a chair alarm was sounding at the time of the fall. Care plan states bed and w/c alarm as interventions. Nurses' documentation indicated that physician was notified of fall on 3/3/13 at 2:51 pm (4 hours and 20 minutes later).

Per interview with DON (Director of Nursing) F on 4/17/13 at 10:00 am asked DON F what her expectations were on when physician should be updated following a fall and DON F stated as soon as patient's assessment is complete and pt is safe. DON F stated that physician of pt. # 7 should have been updated sooner.

Per medical record review on 4/16/13 at 1:45 pm, Pt. # 2 was admitted to facility on 12/11/12 through 12/19/13 following left lower leg cellulitis. A fall occurred on 12/19/13 at 1:45 pm when the pt. was found lying on her back on the floor in her room. No documentation of fall noted in medical record, states "see incident report" (which is not part of permanent record).

Above findings confirmed with RNIC G on 4/16/13 from 10:45 am through 2:15 pm.

Per staff interview with DON F on 4/16/13 at 8:30 am, DON F stated that documentation of the incident should be in the medical record because the incident report is not a part of the permanent record.

Per staff interview on 4/16/13 at 3:00 pm with DON F and DCQPI (Director of Continuous Quality Performance Improvement) B, both stated that due to falls in December of 2012 and new policy was initiated that a bed and chair alarm would be utilized on all new admits until an interdisciplinary team conference. It would be determined during the meeting if alarms could be discontinued.