HospitalInspections.org

Based on interview, medical record review, and policy and procedure review it was determined the facility failed to ensure the registered nurse supervised and implemented safety measures for impulsive patients with traumatic brain injury (A395); and failed to ensure nursing staff developed care plans based on patient assessments and needs (A396). The cumulative effects of these systemic practices resulted in the facility's inability to ensure effective nursing practice to meet patient needs and promote patient safety. The facility census was 19 patients.

Based on medical record review, staff interview, and policy review it was determined the facility failed to ensure the registered nurse supervised and implemented safety measures for impulsive patients with traumatic brain injury. This affected one ( Patient #1) of ten medical records reviewed. The active census was 19.

Findings include:

Review of the Policy and Procedure Sitter Criteria and Algorithm Number: S06-G (Revised 12/2018) is guidelines for staff for the appropriate use of sitters and to create a safe environment for patient care delivery. A physician's order is required for a sitter and must be documented in the medical record. The need for continued sitter will be assessed by the Chief Nursing Officer (CNO) or Charge Nurse/House Supervisor every shift and documented in the medical record.

1. Review of the medical record for Patient #1 revealed the patient was hospitalized on 09/18/19 as a level two trauma after riding a bicycle into a moving bus at an unknown rate of speed. The patient suffered a traumatic brain injury and on scan was found to have a left subdural hematoma, left temporal subarachnoid hemorrhage and left frontotemporal intraparenchymal hemorrhage. The patient underwent a decompressive crainiectomy on 09/19/19 and later self- extubated himself on 09/22/19. The patient did require four point restraints and a sitter at the local hospital for safety. The patient was transferred to the long term acute care facility on 10/12/19 with a primary diagnosis of traumatic brain injury.

Review of the physician documentation noted Patient #1 arrived on 10/12/19 at 5:10 PM agitated and was attempting to go outside to smoke regardless of the hospital staff objections. The patient required a one time dose of Haldol 5 mg by mouth due to aggressive behaviors. Review of the physician orders noted soft wrist restraints were ordered, however, the patient fought attempts for restraints and seemed to calm with the use of a sitter. Review of the physician assessment and plan noted the patient was to wear a helmet when out of bed and required a sitter to ensure the safety of the patient.

Review of documentation dated 10/14/19 at 10:45 AM revealed a staff member notified the Chief Nursing Officer of the patient being seen in the lobby. Patient 1's room was checked and was found to be empty. The security staff at the front desk told the Chief Nursing Officer the patient was seen in a hospital gown, pants, and shoes and the patient reported being discharged from the hospital. The physician was notified on 10/14/19 at 11:00 AM along with local law enforcement.

Review of the sitter documentation revealed on 10/12/19 a sitter was with the patient from 7:00 PM through 7:00 AM and on 10/13/19 from 7:00 AM through 7:00 PM and none thereafter. On 10/13/19 at 8:54 PM the nurse noted the patient was wandering with poor judgement. The medical record lacked evidence the nurse assessed the need to the continue the sitter and/or obtain an active physician order to start and/or discontinue the sitter.

A phone interview was conducted with Staff H on 11/25/19 at 3:50 PM who confirmed the nurse did not reassess the patient each shift as per policy for the need to continue and/or discontinue sitter services. In addition, the medical record lack evidence of a physician's order for the sitter as per policy.

Based on medical record review, staff interview, and policy review it was determined the facility failed to ensure nursing staff developed care plans that includes a risk assessment for elopement and unsafe wandering behaviors.This affected one (Patient #1) of ten medical records reviewed. The active census was 19.

Findings include:

Review of the Nursing Care Plan Policy Number: N-02N (Revised 04/17) states the care plan is used to guidelines for a pragmatic approach to the planning of care issues. To simplify the care planning for Nursing, the care plan along with relevant internal and external bundles and standard assessment formats have been incorporated into the 24 hour patient record and plan of care. This allows for nursing priorities to be maintained " top of mind" and to establish daily short-term goals to prompt critical thinking and standard approaches.

Review of the physician documentation noted Patient #1 arrived on 10/12/19 at 5:10 PM agitated and was attempting to go outside to smoke regardless of the hospital staff objections. Review of the physician orders noted soft wrist restraints were ordered, however, the patient fought attempts for restraints and seemed to calm with the use of a sitter.

Review of the sitter documentation revealed on 10/12/19 a sitter was with the patient from 7:00 PM through 7:00 AM and on 10/13/19 from 7:00 AM through 7:00 PM and none thereafter. On 10/13/19 at 8:54 PM the nurse noted the patient was wandering with poor judgement.

The medical record lacked evidence a nursing care plan was developed and implemented to meet the needs of the patient's unsafe wandering and impulsive behaviors.