HospitalInspections.org

Based on document review and interview, nursing services failed to notify a provider in a timely manner of a patient's injury, change of condition related to fall, new onset pain, change in mobility, decreased range of motion of an extremity in 1 of 10 medical records reviewed (P1); and failed to initiate neurological checks after a fall in 1 of 10 medical records reviewed (P1). See Tag A0395

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, the nursing staff failed to ensure care in a safe setting for 1 of 10 medical records reviewed (P1); and failed to ensure a patient's request for emergency treatment post injury for 1 of 10 medical records reviewed (P1).

Findings include:

1. The facility policy titled, "Patient Rights and Responsibilities", PolicyStat ID 13517670, last revised 09/2021, indicated under PROCEDURE: You have the right to: 9. Request or refuse treatment, to the extent permitted by law. However, you do not have the right to demand inappropriate or medically unnecessary treatment or services. You have the right to leave the hospital even against the advice of physicians, to the extent permitted by law. 29. Humane care and protection from harm.

2. Review of P1 MR indicated the following:
a. On 6/16/24 between the hours of 7:00 am - 7:00 pm indicated at approximately 4:00 pm P1 was pushed down to the floor by P2. P1 fell to the floor hitting his/her elbow. P1 also reported hitting his/her head. P1 yelled for 911 to come help him/her. P1 reported to the nursing staff of not being able to move his/her right arm after the fall.
b. On 6/16/24 between the hours of 7:00 pm -7:00 am P1 was noted to be yelling/crying during shift change at 7:00 pm, had a bruise to his/her right elbow, and he/she was requesting to be sent to the emergency room for treatment of his/her right elbow.
c. On 6/17/24 between the hours of 7:00 am -7:00 pm P1 was noted to have complaints of pain in his/her right elbow and groin area.
d. On 6/17/24 between the hours of 7:00 pm -7:00 am P1 complained of pain in the right hand, had notable bruising and swelling to the right arm.
e. On 6/18/24 between the hours of 7:00 am -7:00pm P1 complained of a headache and pain to the right elbow, was noted to have bruising and swelling to the right elbow and was noted to be guarding his/her right arm. The patient was then transferred to the emergency room for further evaluation and treatment on 6/18/24 at 11:23 am.
f. MR for P1 lacked documentation of provider notification r/t P1 verbally requesting to be sent to the emergency room post fall/ injury on 6/16/24.

3. In an interview on 6/27/24 at approximately 1:00 pm with A4 (Director of Quality & Risk) confirmed the lack of provider communication by nursing staff delayed P1's treatment for a broken right elbow. Confirmed P1's requests to call 911 post fall and/or requests to be sent to the emergency department on 6/16/24 were not honored by facility nursing staff and should have been.

Based on documentation review and interview, facility nursing staff failed to notify a provider in a timely manner of a patient's injury, change on condition related to fall, new onset pain, change in mobility, decreased range of motion of an extremity in 1 of 10 medical records reviewed (P1); and failed to initiate neurological checks after a fall in 1 of 10 medical records reviewed (P1).

Findings include:

1. The facility policy titled, "Change of Condition", PolicyStat ID 12197218, last revised 05/2021, indicated under PROCEDURE: 2. The nurse will evaluate the patient and notify the provider with the findings. 4. A sample list of possible changes in condition would include but not limited to:
a. Unexpected temperature elevation
b. Falls
c. Change in mental status
d. Drop or elevation in blood pressure outside of patient's baseline
e. Weakness in an extremity or changes in speech
f. Onset nausea/vomiting
g. Onset of diarrhea
h. Complaint of new pain
i. Change in mobility or ambulation
j. Change in skin condition, color, and/or integrity
k. Onset of edema

2. The facility policy titled, "Fall Prevention Program", PolicyStat ID, 13554604, last revised 04/2023, indicated under PROCEDURE: POST FALL EVALUATION: 1. Each time a patient falls, the patient will be assessed by the nurse directly after the fall and the nurse will notify the provider to obtain any necessary orders. 2. Interventions necessary to stabilize the patient will be completed in a timely manner. 3. If the patient is witnessed hitting their head, or is suspected of hitting their head, neurological checks are to be initiated. 4. The nurse must notify all applicable parties including but not limited to; the CEO, DON, Nursing Supervisor, Provider, POA/Guardian and/or patient's family.

3. MR for P1 was reviewed and indicated the following:
a. On 6/16/24 between the hours of 7:00 am - 7:00 pm indicated at approximately 4:00 pm P1 was pushed down to the floor by P2. P1 fell to the floor hitting his/her elbow. P1 also reported hitting his/her head. P1 yelled for 911 to come help him/her. P1 reported to the nursing staff of not being able to move his/her right arm after the fall.
b. On 6/16/24 between the hours of 7:00 pm -7:00 am P1 was noted to be yelling/crying during shift change at 7:00 pm, had a bruise to his/her right elbow, and he/she was requesting to be sent to the emergency room for treatment of his/her right elbow.
c. On 6/17/24 between the hours of 7:00 am -7:00 pm P1 was noted to have complaints of pain in his/her right elbow and groin area.
d. On 6/17/24 between the hours of 7:00 pm -7:00 am P1 complained of pain in the right hand, had notable bruising and swelling to the right arm.
e. On 6/18/24 between the hours of 7:00 am -7:00pm P1 complained of a headache and pain to the right elbow, was noted to have bruising and swelling to the right elbow and was noted to be guarding his/her right arm. The patient was then transferred to the emergency room for further evaluation and treatment on 6/18/24 at 11:23 am.
f. The MR for P1 lacked notification of a provider post fall on 6/16/24, lacked provider notification of the patient's change of condition on 6/16/24. Lacked completed post fall documentation which included provider notification and neurological checks.

4. In an interview on 6/27/24 at approximately 1:00 pm with A4 (Director of Quality & Risk) confirmed a provider was not notified in P1's change of condition after a fall related to right elbow, hip, head, and/or pelvis pain, right elbow decreased range of motion, bruising and/or swelling and should have been. Confirmed the facility's post fall evaluation procedure for P1 was not completed per policy by nursing on 6/16/24 and should have been.