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Based on medical record reviews, observation, review of policies, review of incident and accident logs and staff interviews, the facility failed to ensure that one patient (#2) was not administered a narcotic pain medication for which the patient was identified as "allergic", the facility also failed to appropriately assess and provide interventions to this patient (#2) after the patient experienced a fall, and failed to appropriately assess and follow the facility's policy regarding notification of a physician when this patient continued to exhibit low blood pressures and non-palpaple pulses. This patient subsequently died. The facility failed to ensure the facility's three crash carts contained appropriate emergency supplies to expedite an emergency situation (code blue). Additionally, the facility failed to protect four patients (Patients #1, #2 ,#4,and #5) from falls, one of which (Patient #1) suffered significant injuries including a intracerebral bleed. Although these patients were assessed and/or had suffered falls in the facility, the facility failed to implement interventions to protect and/or prevent these patients from further falls and injury.

It was determined that the above findings resulted in immediate jeopardy for 4 of 10 sampled patients (#1, #2, #4, and #5) and had the potential to affect all patients in the facility. The hospital's average daily census for January 2010 was 29, February 2010 was 29, March 2010 was 37, and April 2010 was 35.

Based on review of the medical record and staff interview (Staff B) the facility failed to assess and document a pressure sore on admission for one patient (Patient #3).

Findings include:

Review of the medical record for patient #2 found that the facility failed to acknowledge Patient #2's known allergy to a narcotic pain medication, continued administering this medication throughout the patient's hospital stay, failed to appropriately assess and provide interventions to this patient (#2) after the patient experienced a fall, and failed to continue to assess Patient #2 when the patient exhibited low blood pressures and non-palpaple pulses.

Review of the medical record revealed documentation that staff could not obtain a blood pressure and pulse or that Patient #2's vital signs were abnormal, between 7:20 AM until 4:48 PM, the latter time being when the patient was found non-responsive and subsequently died despite the facility's attempt of cardio pulmonary resusitation. Documentation showed that a physician was notified one time when the abnormal vital signs were first exhibited by Patient #2 and a physicians order for a intravenous bolus was received and given. Although patient #2 continued to exhibit abnormal vital signs, there was no further notification to the physician nor did the physician, who was on-site and three doors away from this patient, evaluate the patient throughout that time frame until the patient was found non-responsive.

Observation of the facility's crash carts revealed that although the facility identified the crash carts did not contain all necessary supplies, as of 04/08/10, items were still missing from the crash carts (3 total carts). The carts also lacked consistent inventory sheets and were observed to be dirty.

Review of the medical records for four patients (Patient #1, #2 ,#4,and #5), staff interview, and policy and procedure review found that the facility did not plan and/or implement interventions to protect and/or prevent falls, one of which (Patient #1) suffered significant injuries including a intracerebral bleed. Although these patients were assessed and/or had suffered falls in the facility the facility failed to implement interventions to protect and/or prevent these patients from further falls and injury.
Please refer to A395.
The facility failed to care plan falls interventions for patients after being identified at risk for falls.
Please refer to A396.





03245

Based on medical record reviews, review of the facility's policies and procedures, review of incident and accident logs, and staff interviews, the facility failed to ensure that one patient
(#2) did not receive a narcotic pain medication for which the patient was identified as being allergic. The facility also failed to appropriately assess and provide interventions to this same patient (#2) after the patient experienced a fall and failed to follow the facility's policy for re-notification of a physician when this patient continued to exhibit very low blood pressures and non-palpable pulses despite the administration of intravenous fluids. The facility failed to protect three other patients (Patient #1, #4 and #5) from falls. The fall for Patient #1 resulted in a serious head injury and admission to a short term acute care hospital. Patient #5 was identified at risk for falls; however, the plan of care and falls protocol were not followed for this patient. Additionally, the facility failed to ensure that three crash carts contained appropriate emergency supplies to expedite an emergency situation (code blue). Although the facility identified these missing supplies, as of 04/08/10, these items were still missing from three code carts. These three carts were also lacked consistent inventory sheets and were observed to be dirty.

It was determined these findings resulted in immediate jeopardy for 4 of 10 sampled patients (#1, #2, #4, and #5) and has the potential to affect all patients in the facility. The hospital's average daily census for January 2010 was 29, February 2010 was 29, March 2010 was 37, and April 2010 was 35.

Based on review of the medical record and staff interview (Staff B) the facility failed to assess and document a pressure sore on admission for one patient (Patient #3).

Findings include:

The medical record review for Patient #2 revealed the patient was admitted on 02/23/10 via squad from Miami Valley Hospital at 7:00 PM with an extensive abdominal wound including a fistula which was draining yellowish drainage into an ostomy bag. The abdominal wound covered the entire abdomen. Further review of the medical record revealed a document titled "Fall Risk Screening Tool" that is to be completed on admission. This document was signed by the assessor however it was not dated. This assessment documented the patient as scoring a "12" which, according to the fall risk assessment tool, would place the patient as "AT RISK".

According to the medical record Patient #2 fell on 02/26/10 at 6:41 AM. The notes indicated that the "staff heard a thump as if something fell. came to room and noted patient lying on floor outside bathroom door covered in drng (drainage) from assumed abd wound" The note further indicated the patient was breathing spontaneously and had a pulse. The patient was moved to the bed by the staff on duty. Staff D stated, when interviewed on 04/09/10 at 3:30 PM, that he/she was just arriving for duty and entered the room with the staff currently on duty. Staff D further stated that Patient #2 was briefly unresponsive at that time.
The nurses notes on 02/25/10 reflect that the fall risk score was O. However, the nursing plan of care identified Patient #2 as a potential for injury related to medications (oxycodone/acetaminophen, morphine, hydromorphone) with fall risk potential. The physical therapy assessment indicates that the patient has decreased functional mobility. The nurses notes were silent to any follow up regarding the fall of this patient that occurred on 02/26/10 at 6:41 AM. The patient was listed as a fall risk on the new admission information sheet.
The 7:30 AM nursing notes on 02/26/2010 stated that the nurse was unable to obtain Patient #2's manual or electronic blood pressure. (The patient's blood pressure at admission on 02/23/10 at 8:43 PM was documented as 128/91 with a radial pulse of 122 beats per minute.) The physician and supervisor were notified. The physician ordered an intravenous (IV) fluids bolus. Documentation revealed "The patient was alert and oriented, cold, and very anxious. At 9:30 AM, the physician was notified that the IV bolus was finished. The nursing notes reflect the nurse was still unable to obtain manual blood pressure. At 11:45 AM the patient care technician notified the nurse that he/she was unable to obtain the patient's vitals including pulse, temperature, or blood pressure. The nurse checked as well. The physician and supervisor were notified. There was no documentation the physician or supervisor responded.

The nurse did not request additional assistance from specially trained staff members when a patient's condition appeared to be worsening. The nurse did not call for the Rapid Response Team. Nor did the nurse (Staff P) use the facility's Rapid Response Team Protocols which indicated if the systolic blood pressure is less than 80 place on telemetry, elevate foot of bed, and initiate 250 cc of normal saline bolus. The Rapid Response Team Policy (Titled Rapid Response Team and the policy code was PC Addendum) was reviewed on 04/08/10 at 1:00 PM. Staff A and B stated on 04/08/10 that the hospital plans to train the staff in June on Rapid Response and when to call the respiratory therapist before a code and when it is applicable. Patient #2's family members were not notified by nursing of the status change of blood pressure and pulse being low between 7:20 AM and 4:58 PM, at which time the patient coded.
Further review of documentation in Patient #2's medical record reflected that Cardio Pulmonary Resuscitation started at 4:58 PM. The patient was intubated at 5:02 PM. The physician's progress note stated: "The patient was found with no pulse and no respiration with flat line and asystole on 02/26/2010 at 4:15 PM. Cardiopulmonary resuscitation (CPR) was started on patient which lasted about 35 minutes. The patient was pronounced dead at 5:56 PM."

Staff D stated that the physician was notified that the patient's condition was deteriorating. Physician's orders were given over the phone, but per Registered Nurse (RN), the Physician did not see the patient until the Code was called. Staff C stated on 04/12/10 at 1:20 PM that the physician was in a room onsite at the hospital just three doors from the patient. Review of the physician's progress notes from 02/23/10 through 02/26/10 were silent to the physician seeing the patient prior to the code. The subsequent progress notes by the physician were unreadable and illegible. Staff C verified on 04/09/10 at 1:20 PM that Patient #2's family members were not notified by nursing of the patient's status change in regard to Patient #2's blood pressure and pulse being low between 7:20 AM and 4:58 PM, at which time the patient coded.
Additional nurses notes were written after the death of Patient #2 on 02/26/10. The nurses note written at 6:36 PM stated, " Patient alert and oriented at 4:54 PM. Patient got this nurse attention by sitting up on the side of the bed. Patient requests to sit up in chair on right side of bed. Patient stood with contact guard assistance. Patient states family is coming to visit. This nurse asked if patient needs anything before leaving the room. Patient states no. Call light in reach." The next note was written at 6:45 that stated, "This nurse was notified at 4:58 PM by patient care technician that patient was nonresponsive. This nurse and staff nurse entered patient's room to find patient slumped over in chair. At the time of arrival patient's eyes were fixed and dilated, cool to the touch and unable to arouse. This nurse and staff moved patient from chair to bed to start CPR."

Patient #2's medication administration record indicated that the patient received narcotic pain medication (Morphine). The patient's admission assessment and the physician's history and physical indicated that the patient was allergic to Morphine. The patient received this medication on several occasions. The physicians, pharmacist and the nursing staff did not catch the medication error during the patient's stay. The medication error was not documented by the hospital as of 04/12/10. In addition, the nurses notes, medication administration record and the narcotic log do not match as to when the medication was given. Morphine was noted as last given at 3:01 AM and at 5:15 AM on 2/26/2010. The actual doses of morphine could not be verified from the medical record review and/or the narcotic log. Staff C on 04/09/2010 at 1:30 PM stated that there is clearly documentation problems and I'm not sure if and when the medication was actually given.


Additionally, facility documentation, interview of staff and inspection of 3 crash/emergency carts revealed that the the crash/emergency carts did not contain the necessary emergency supplies. Staff B stated he/she was present during the code for Patient #2 and the following items were identified as needed and missing: size 81/2 sterile gloves, Central Venous Line (CVL) Kit, and doppler. The surveyors checked the 3 crash/emergency carts on 04/08/10 between 11:38 AM and 12:30 PM. The 3 carts had different required supply lists and all 3 crash/emergency carts were in need of cleaning. The tops, sides and inside drawers contained visible dark dried substance and gray dust and debris. These carts still did not contain sterile gloves, CVL kits, and dopplers as identified during the code. In addition, all 12 containers of normal saline on one cart were expired (3/20/10). Two carts did not have 6 foot suction tubing. All three carts contained soiled and uncovered suction machines and did not have the required number of syringes, lab vials, needles, IV extension tubings, suction tips and ABG kits. The carts did not have code blue documentation and clip boards. The RNs (Staff D and E) who checked the carts with the surveyors were unaware of what supplies were missing from the crash/emergency carts.


03245

Medical record review conducted for Patient #1 on 04/06/10-04/07/10 revealed the patient was admitted to the facility on 02/24/10 with a diagnosis of right foot wound with an infectious organism and an an infectious organism in the sputum. During this stay, patient #1 was receiving physical therapy, occupational therapy, wound care and hemodialysis. The medical record stated the patient needed to gain nutritional and respiratory strength and return to the short term acute care hospital for a right below the knee amputation.

The pre-admission assessment by nursing (the day before admission) stated the patient was identified at risk for falls, would be placed on fall precautions, was unable to ambulate and was alert and oriented but, forgetful. The fall risk assessment dated 03/03/10 at 9:40 AM by nursing and the plan of care, stated the patient had an unstable gait/balance or requires assistance to ambulate or transfer. The total fall/risk score was 6 (below the score for additional fall risk interventions of equal to or greater than 10). Patient #1 was also administered an anti-psychotic medication on 03/03/10 for depression. The medical record was silent to nursing staff informing the responsible family member of this medication.
The nursing assessment dated 03/04/10 at 7:50 AM stated the patient had an unsteady gait, was confused, lethargic, sleepy and needs orientation to place and time. The occupational therapy assistant documented on 03/01/10 at 9:48 AM the patient required assistance to transfer from the bed to the wheelchair and exhibited fatigue when transferring, requiring assistance.

A nursing note dated 03/04/10 at 4:32 AM documented the patient was found up in the hall ambulating alone and the intravenous line (IV) was pulled out. The patient was assisted back to bed, oxygen was put back on and a pressure dressing was applied to the IV site. The patient was confused as to place and time and was reoriented and instructed to remain in bed. The medical record was silent to the call light status, side rails, bed alarm, mat on the floor, or other fall risk interventions.

The fall risk assessment dated 03/04/10 at 4:37 PM, stated the patient was confused/disoriented/sedated, had unstable gait/balance or requires assistance to ambulate or transfer, forgets instructions or over estimates own limits, had previous falls history and had a total fall/risk score of 20.

The nursing documentation dated 03/05/10 at 4:19 AM stated the patient was found on the floor by a visitor. When the nurse responded to the the patient's room, the patient was discovered kneeling on the floor on his/her knees with his/her head on the bedside chair. The patient's oxygen nasal cannula was not on at that time. The patient stated he/she tried to get up, reason unknown, and slid down to his/her buttocks. The patient did have red and purplish areas to the bilateral knees when found on the floor. Patient #1 was re-educated to the call light system and to use this before trying to get out of bed. The bed was in the low position when the patient was found. After this fall on 03/05/10, staff failed to follow the falls prevention policy for additional fall interventions such as a bed alarm, one side of the bed against the wall, and a mat on the floor to prevent additional falls for Patient #1.

On 03/07/10 at 12:30 AM, the nursing notes documented several nurses heard sounds coming from Patient #1's room. The patient was found in the room on the floor, face down, with blood coming from the mouth and eye. The physician was called to the room and the supervisor was notified. The patient just had vital signs taken less than 5 minutes earlier and was noted to have a low blood pressure. Further review of the medical record documented vital signs were taken on 03/07/10 at 12:13 AM, with following results: very low blood pressure of 85/47, pulse elevated at 105 per minute, respirations 14 per minute, and elevated temperature of 99.8 degrees Fahrenheit. There was no documented evidence of physician notification of the low blood pressure, elevated pulse, and elevated temperature.

During this fall on 03/07/10 at 12:30 AM, Patient #1 was assessed by a nurse, the nursing supervisor, and the physician at the time of the fall. Physician's orders were given to do vital signs hourly, neurological checks, and ice to the wounds. The physician cleaned the wound on the patient's right eye brow. The cut on the patient's eyebrow was several centimeters in size. Clotted blood was noted coming from the patient's mouth, and a cut was noted to the inner mouth as well as several small bruises on the outer mouth and cheek. The patient was assisted to bed, the cuts were cleaned and ice was applied. The patient's blood pressure at that time was low at 105/58 and pulse elevated to 102 beats per minute. The patient's family member was notified at that time of the fall. The physician ordered neurological checks and a CAT scan of the head.

The medical record documented on 03/07/10 at 8:05 AM Patient #1 was sitting on side of bed trying to stand up, and was not oriented to date or time. The patient could not keep his/her eyes open and falls asleep during conversation. The patient was not sent to the short term acute care hospital for evaluation until 03/07/10 at 9:31 AM.

A physician's discharge summary dated 03/07/10 stated "encephalopathy, initially thought to be secondary to medication with fall from the bed with head trauma with septated subdural (blood gathered in the brain as a result of head trauma). The patient had multiple falls while here, and was in a low boy bed. The night of the transfer, the patient fell on the bed initially, did not appear to have significant head trauma, and had a little bruise over the eyebrow and then subsequently a CAT scan was ordered. The patient was found to have a subdural at local trauma hospital (within 2 miles of the facility) with intracerebral bleed and was admitted to that hospital for care. The physician initially ordered the patient to have a CAT scan at the off-site hospital; however, the patient's family member insisted the patient go directly to the emergency room (ER) where the patient was assessed and the diagnosis subdural hematoma (bleed) was made. Subsequently, the trauma team was notified and this physician's understanding is that the patient was seen by neurosurgery for possible neurosurgical intervention."

Patients #4's medical record was reviewed on 04/14/10. The patient's initial nursing assessment dated 04/01/10 at 6:29 AM stated the patient was at risk for falls, was forgetful, had weakness of extremities due to prolonged bed rest, and had two toes on the right foot that were black in color. The occupational therapy plan of care dated 04/01/10 stated the patient required assistance with transfers and bed mobility. A documented note by the physical therapist on 04/01/10 stated a goal to increase the patient's sitting balance to tolerate 5-8 minutes sitting on the edge of the bed with assistance.

The medical record documented that Patient #4 was found sitting on the floor by the bed side on 04/09/10 at 12:15 PM. Staff heard a thud, entered the patient's room and found the patient sitting on the floor. The patient stated he/she slipped after trying to sit on the side of the bed. The patient was found to have reddened buttocks at that time.

On 04/10/10 at 3:46 AM the medical record documented a physician's order for a low boy bed as soon as possible. Observation of this patient on 04/14/10 at 12:36 PM with Staff F and R revealed the patient's bed was not in the low position. A falling leaf was observed on the door (falls risk identification). The patient #4's room is located farthest from the nurses's station and the privacy curtain was pulled so the patient could not be readily viewed from the hallway. During an observation and interview with Staff R it was observed and verified that the patient's bed was not in a low position and verified the patient is a fall risk. Staff R stated the patient can control the height of the bed with the controller. Staff R walked away and failed to lower the bed in accordance with physician's orders and the falls protocol. Staff A was immediately made aware of the patient's bed not being in a low position and intervened to lower the bed, and lock the bed into the lowest position.

A review of this patient's (#4) care plan revealed there were no interventions in place to lower the bed, raise 2 siderails and keep the call light and personal items in place. This was verified with Staff B on 04/14/10 at 4:55 PM.

Medical record review was conducted for Patient #5 on 04/15/10. The patient was admitted on 04/13/10 with pneumonia. The nursing assessment on 04/14/10 at 8:08 AM stated the patient has an unsteady gait, requires 2 siderails up, a low bed, call light and personal items within reach and an identification band on to identify the patient as being a falls risk.

Observation of this patient (#5) on 04/14/10 at 12:25 PM with Staff F revealed the patient was wearing a yellow wrist band, which stated falls risk. There was no falling leaf or identification of the patient being at risk for falls in the room or on the doorway. Staff F stated the patient is a fall risk and should have a falling leaf on the door.

During an interview conducted with Staff B on 04/14/10 at 4:55 PM it was revealed that staff are not using the falls risk assessment tool properly in accordance with facility policy. The policy is for the assessment to be conducted at the time of admission, then every two weeks, or with a status change. This employee stated the tool is being used on each shift by nurses and assessments are being done for the patient in that moment and not of their overall status.

The review of the hospital's monthly fall reports for January, February, March, and April 2010 revealed the hospital incurred the following falls:
-In January 2010 three falls occurred from bed, one with injuries,
-In February 2010 a total of 5 falls. Four of the falls were from bed and one while ambulating unassisted.
-In March 2010 a total of 8 falls, seven were from bed, and one with a significant injury resulting in short term acute hospitalization.

A review of the nature of event totals by shift report for date ranges of 01/01/2010-04/06/2010 revealed the following:
-one fall with injury and three falls without injuries occurred between 7:00 PM and 11:00 PM,
-two falls with injuries and four without injuries occurred between 11:00 PM and 3:00 AM,
and one fall with injuries and four without injuries occurred between 3:00 PM and 7:00 AM.
This report revealed the number of falls increased between January and March 2010 with twelve of these falls occurring from bed.

An interview with Staff C on 04/07/10 at 10:12 AM revealed these falls are discussed in Quality Council meetings, and are reviewed for trending and patterns. This employee stated the facility has not identified any patterns for these falls between January-April 2010.

On 04/09/10 at 3:00 PM, a review of facility Fall Prevention policy H-PC 05-016 for falls states the following interventions:
1. On admission the patient is screened by the admitting nurse for fall risk using the Fall Risk Screening Tool or the Electronic Medical Record (EMR) Fall/Risk Assessment.
2. The standard fall prevention interventions will be followed on all patients as follows:
a) All patients and/or family members will be given the Fall Prevention Education Tool.
b) The patient's bed is kept in the lowest position whenever unattended by hospital
personnel.
c) The patient will be oriented to the environment, location of bathroom, bathroom
emergency call light cord, bed controls, and call bell.
d) All patients will be instructed to call for assistance, as appropriate.
e) A light will be left on in the bathroom at night, as indicated.
f) All patients will be instructed to wear non-skid slippers and to avoid wet floors.
g) Frequently used personal items will be within easy reach at all times (telephone,
eyeglasses, etc.).
h)Evaluate patient's perception of temperature and provide blankets, etc. as needed.
i) Evaluate whether use of side rails will increase potential for patient to climb over.
j) Frequent offering of toileting and staff monitoring patient while in bathroom.

This policy stated those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls. The At Risk for Fall Interventions may include, but are not limited to:
a) Use of a "risk for falls" sign/device to communicate risk to all caregivers (Falling Leaves, Falling Stars, bracelets, etc).
b) Use of a "remember to call for help" sign posed in patient's in patient's room to remind patient to call for assistance before getting out of bed.
c) Use of Bed Alarms/Chair alarms.
d) Turn (or Position) bed with one side to the wall and place floor mat along entry/exit side of bed.
e) Avoid use of full-length side rails.
f) Move patient closer to Nurses Station.
g) Rehab evaluation and treatment as appropriate for conditioning/strengthening options/use of assistive devices.
h) Pharmacy review of medications for fall risk potential.
i) Use of low bed.
j) Select suitable chairs that have armrest or another appropriate geriatric chair.
k) Consider family staying, or changes needed in staffing.
In the event that a patient fall occurs, regardless of the score of the Initial Fall Risk screen, he/she will be automatically considered at risk for falls, additional interventions will be considered, and the Care Plan revised to reflect increased risk. Documentation requirements stated the facility should complete an investigation after each fall using the Fall Investigation Worksheet.

Medical record review conducted for Patient #3 revealed the patient was admitted on 12/04/09 with a pressure sore on the left shoulder and sacrum that was community acquired. There was no mention of a pressure sore on the left heel at that time. Nursing documentation dated 03/08/10 by the wound care nurse (Staff K) stated the patient had a community acquired pressure ulcer on the left heel measuring 4 centimeters (cm) long by 4 cm wide by 0.2 centimeters deep, listing the open area as a Stage II (partial thickness skin loss involving epidermis and/or dermis). A nursing note dated 04/13/10 by Staff K stated the left heel open area had declined to a Stage III (full thickness skin loss involving damage or necrosis of subcutaneous tissue). The documentation was silent to measurements of this ulcer.

An interview conducted with Staff B on 04/12/10 at 4:55 PM revealed an interview with Staff K was conducted regarding this left heel pressure ulcer. Staff B stated staff failed to address the left heel pressure ulcer at the time of admission, stating the first time it was assessed and documented was on 03/03/10; however, the patient was admitted to the facility on 12/04/09 and had not left the facility since admission.

Based on medical records review and staff interview, the failed failed to develop a nursing care plan for 2 of 10 sampled patients (#4 and #5). The hospital's average daily census for January 2010 was 29, February 2010 was 29, March 2010 was 37, and April 2010 was 35.

Findings include:

Patient #4's medical record was reviewed on 04/14/10. The patient's initial nursing assessment dated 04/01/10 at 6:29 AM stated the patient was at risk for falls, was forgetful, had weakness of extremities due to prolonged bed rest, and had two toes on the right foot that were black in color. This medical record documented the patient was found sitting on the floor by the bed side on 04/09/10 at 12:15 PM. Staff heard a thud, entered the patient's room and found the patient sitting on the floor. The patient stated he/she slipped after trying to sit on the side of the bed.

A review of this patient's (#4) care plan revealed there were no identified interventions in place to lower the bed, raise 2 siderails, keep the call light and personal items in place, or to keep the patient's bed in a low position. This was verified with Staff B on 04/14/10 at 4:55 PM, at which time it was revealed falls interventions were placed on the patient's care plan.

Medical record review was conducted for Patient #5 on 04/15/10. The patient was admitted on 04/13/10 with pneumonia. The nursing assessment on 04/14/10 at 8:08 AM stated the patient has an unsteady gait, requires 2 siderails up, a low bed, call light and personal items within reach and an identification band on to identify the patient as being a falls risk. Observation of this patient on 04/14/10 at 12:25 PM with Staff F revealed the patient was wearing a yellow wrist band, which stated falls risk. There was no falling leaf or identification of the patient being at risk for falls in the room or on the doorway. Staff F stated the patient is a fall risk and should have a falling leaf on the door.