HospitalInspections.org

Based on document review,observation and interview, the hospital failed to ensure nursing staff kept care plans current and in agreement with interventions utilized/not utilized, for 7 of 7 high fall risk patients (P1, P2, P5, P6, P7, P8 and P10).

Findings include:

1. Review of hospital policies and procedures (P&P) indicated the following:
A. The policy titled Care Planning, Last Reviewed Date: 08/16/2018:
i. POLICY. 1. The RN (Registered Nurse) will initiate the IPOC (Interdisciplinary Plan of Care) within 24 hours of admission on each patient. 5. IDT (Interdisciplinary Team) will initiate all applicable interventions. 11. Updates to the IPOC are documented in the plan. Any new problems or interventions are identified and initiated. Any completed or discontinued interventions are documented.
B. The policy titled Fall Prevention Program, Last Reviewed Date: 08/16/2018:
i. POLICY. II. Fall Screening Tool. The corporation requires that all hospitals use an evidenced based risk assessment tool. The tool required for the hospital is the Morse Fall Risk Assessment. The Scoring Guidelines for the Morse Fall Risk Assessment are... Scoring Guidelines: (< or =) 45 = Standard Precautions: > 45 = Strict Fall Precautions.
ii. PROCEDURE. Fall Precaution Interventions. This list provides suggestions for fall interventions and is not intended to be a complete list or should this list be used as a substitute for clinical judgment. Effective interventions not listed below may also be incorporated into a Fall Prevention Plan.
a. Less than or equal to 45 (Morse Fall Assessment Score); Standard. The list included, but was not limited to the following: 4. Keep bed in low position. 5. Lock wheels on all wheelchairs, beds, commodes and stretchers. 10. Develop and institute regular rounding program.
b. Greater than 45 (Morse Fall Assessment Score); High Risk - (All Standard interventions should be in place). The list included, but was not limited to the following: 2. Assure supervision and assistance are provided with bathroom activities, transfers and ambulation as indicated. 5. Additionally consider a wheelchair and/or bed alarm. If wheelchair alarm is used must utilize a seal (sic) belt... 7. Regular rounding in place.
C. The policy titled Use of Restraints, Last Reviewed Date: 08/16/2018: Order/Renewal: Requires LIP (Licensed Independent Practitioner) reorder every calendar day.

2. Review of medical records (MR) indicated the following:
A. Patient P1 was admitted 12/24/18 and was a current inpatient. P1's admitting Morse Fall Risk Score was 60, the MR lacked documentation of a change in this score.
i. The Interdisciplinary Plan of Care (IPOC), Update Entered On: 01/02/2019, indicated the following: IPOC Update. The following reflects current patient status and plan of care update:
a. "IPOC - At Risk for Injury Rehab". Interventions included, but were not limited to:
1. Monitor elimination needs. (No frequency was indicated in this section of the IPOC)
2. Fall Risk Protocol, Constant Order, 12/24/18. The MR lacked documentation/definition of Fall Risk Protocol interventions.
b. "IPOC - Integumentary". Interventions included, but were not limited to: -Monitor urinary/fecal incontinence q2H (every 2 hours) and PRN (as needed), initiate toileting schedule/change inc. (incontinence) pad PRN.
ii. The MR lacked documentation of regular monitoring for elimination needs as evidenced by lack of documentation of q2H Toileting Status and lack of documentation of monitoring for urinary/fecal incontinence q2H as follows: Note: The following is not all inclusive.
a. Toileting Status lacked documentation of any entries/monitoring between 12/24/18 at 16:00 hours until 12/28/18 at 07:00 hours.
b. Urine Output lacked documentation of elimination and/or q2H monitoring between 12/24/18 at 16:00 hours and 12/28/18 at 07:00 hours.
c. Stool Output lacked documentation of elimination and/or q2H monitoring between 12/24/18 at 16:00 hours and 12/25/18 at 00:00 hours.
d. Rounding entries lacked documentation of monitoring for elimination needs.
B. Patient P2 was admitted 1/6/19 and was a current inpatient. P2's admitting and current Morse Fall Risk Score was 70.
i. ADL (Activities of Daily Living) Functional Status Grid, included, but was not limited to: Toilet Transfer: "MaxA" (Maximal Assistance). Basic ADL Comments: Pt (patient) has NWB (Non Weight Bearing) LLE (Left Lower Extremity) (and boot) and has difficulty maintaining NWB status during t/f's (transfers) and self care.
ii. The IPOC, Entered On: 01/06/2019, indicated the following: "IPOC - At Risk for Injury Rehab". Interventions included, but were not limited to: Monitor elimination needs (no frequency was indicated).
iii. The MR lacked documentation of regular monitoring for elimination needs as evidenced by lack of regular documentation of Toileting Status and of monitoring for urinary/fecal incontinence as follows: Note: The following is not all inclusive.
a. Toileting Status lacked documentation of any entries/monitoring for toileting.
b. Urine Output lacked documentation of elimination and/or monitoring between 1/7/19 at 04:00 hours and 1/7/19 at 23:00 hours
c. Rounding entries lacked documentation of monitoring for elimination needs.
C. Patient P5 was admitted 11/24/18 and discharged 12/7/18. P5's admitting Morse Fall Risk Score was 50. The MR lacked documentation of a change in this score.
i. The IPOC, Update Entered On: 12/04/2018, indicated the following:
a. Basic ADL documentation indicated the patient required "Sup" (support) for "Toilet Transfer"
b. "IPOC - At Risk for Injury Rehab". Interventions included, but were not limited to:
1. Monitor elimination needs. (No frequency was indicated in this section of the IPOC)
2. Reassess need for continued restraint every 24 hours.
3. Chair Alarm - 11/24/18 at 16:25 hours, Stop date 11/24/18 at 16:25 hours.
c. "IPOC - Integumentary". Interventions included, but were not limited to: -Monitor urinary/fecal incontinence q2H and PRN, initiate toileting schedule/change inc. pad PRN.
ii. The MR lacked documentation of regular monitoring for elimination needs and providing support for toilet transfer as evidenced by lack of documentation of q2H Toileting Status, lack of documentation of support provided during toileting and lack of documentation of monitoring for urinary/fecal incontinence q2H as follows: Note: The following is not all inclusive.
a. Toileting Status lacked documentation of any entries/monitoring between 11/24/18 at 15:11 hours until 12/26/18 at 20:00 hours.
b. Urine Output (UO) documentation was not in agreement with the IPOC for providing support for toilet transfer and indicated "Bladder Assistance Level Ongoing" "Ind" (Independent). The Urine Output documentation also lacked documentation of elimination and/or q2H monitoring as follows:
1. Nothing was documented for UO between 11/24/18 at 18:45 hours and 11/25/18 at 03:00 hours.
2. Nothing was documented for UO between 11/25/18 at 08:00 hours and 11/25/18 at 21:00 hours. The documentation of UO at 08:00 hours indicated the following: Urinary Elimination: "Voiding". Urine Description: Not Observed.
c. Stool Output (SO) lacked documentation of elimination and/or q2H monitoring between 11/24/18 at 16:38 hours and 11/25/18 at 08:00 hours. The documentation of SO on 11/24/18 at 16:38 hours indicated the following: Bowel Movement Last Date: 11/23/18.
d. Stool Output (SO) lacked documentation of elimination and/or q2H monitoring between 11/25/18 at 08:00 hours and 11/25/18 at 22:27 hours. The documentation of SO on 11/24/18 at 16:38 hours indicated the following: Bowel Movement Last Date: 11/24/18. MR entries for 11/24/18 lacked documentation of the patient having had a bowel movement/SO. MR SO entries lacked documentation of support provided for toileting.
e. Rounding entries lacked documentation of monitoring for elimination needs.
f. "Progress Note-Nurse", dated 12/2/18 indicated, "Requires 1 assist for toileting transfers chair alarm on bed alarm on at all times d/t (due to) pt (patient) confusion in evening." The IPOC lacked documentation of the chair alarm having been implemented as an intervention.
g. The MR lacked documentation of patient P5 having been restrained and/or of 24 hour reassessments of need for continued restraint as indicated in the IPOC.
D. Patient P6 was admitted 11/24/18 and discharged 12/6/18. P6's admitting Morse Fall Risk Score was 60. The MR lacked documentation of a change in this score.
i. The IPOC, Entered On: 11/24/2018, indicated the following: "IPOC - At Risk for Injury Rehab". Interventions included, but were not limited to: Monitor elimination needs. (No frequency was indicated)
ii. The MR lacked documentation of regular monitoring for elimination needs as evidenced by lack of regular documentation of Toileting Status and of monitoring for urinary/fecal incontinence as follows: Note: The following is not all inclusive.
a. Toileting Status lacked documentation of entries/monitoring for toileting between 11/25/18 at 09:39 hours and 11/28/18 at 10:29 hours, and between 11/28/18 at 10:29 hours and 11/29/18 at 10:30 hours.
b. Urine Output lacked documentation of elimination and/or UO monitoring between 11/24/18 at 16:20 hours and 11/24/18 at 22:04 hours. The 16:30 hours and 22:04 hours documentation indicated the following: Urinary Elimination: Disposable Brief.
c. Stool Output lacked documentation of elimination and/or SO monitoring between 11/24/18 at 16:20 hours and 11/27/18 at 08:00 hours. The 16:20 hours entry indicated the patient was incontinent of stool at that time.
d. Rounding entries lacked documentation of monitoring for elimination needs.
E. Patient P7 was admitted 12/1/18 and discharged 12/15/18. P7's admitting Morse Fall Risk Score was 95. The MR lacked documentation of a change in this score.
i. The Interdisciplinary Plan of Care (IPOC), Entered On: 12/02/2018, indicated the following:
a. "IPOC - At Risk for Injury Rehab". Interventions included, but were not limited to:
1. Monitor elimination needs. (No frequency was indicated in this section of the IPOC)
2. Fall Risk Protocol, Constant Order, 12/01/18. The MR lacked documentation/definition of Fall Risk Protocol interventions to be implemented.
b. "IPOC - Integumentary". Interventions included, but were not limited to: -Monitor urinary/fecal incontinence q2H (every 2 hours) and PRN (as needed), initiate toileting schedule/change inc. (incontinence) pad PRN.
ii. The MR lacked documentation of regular monitoring for elimination needs as evidenced by lack of documentation of q2H Toileting Status and lack of documentation of monitoring for urinary/fecal incontinence q2H as follows: Note: The following is not all inclusive.
a. Toileting Status lacked documentation of entries/monitoring between 12/3/18 at 07:00 hours and 12/4/18 at 07:00 hours.
b. Urine Output lacked documentation of elimination and/or q2H monitoring between 12/5/18 at 10:16 hours and 12/5/18 at 20:00 hours.
c. Stool Output lacked documentation of elimination and/or q2H monitoring between 12/8/18 at 06:57 hours and 12/9/18 at 08:00 hours.
d. Rounding entries lacked documentation of monitoring for elimination needs.
F. Patient P8 was admitted 12/8/18 and discharged 12/17/18. P8's admitting Morse Fall Risk Score was 60. The MR lacked documentation of a change in this score.
i. The Interdisciplinary Plan of Care (IPOC), Entered On: 12/08/2018. The "IPOC - At Risk for Injury Rehab". Interventions included, but were not limited to:
a. Monitor elimination needs. (No frequency was indicated)
b. Reassess need for continued restraint every 24 hours. The MR lacked documentation of an order for restraints and lacked documentation of implementation of restraint use.
c. Fall Risk Protocol, Constant Order, 12/01/18. The MR lacked documentation/definition of Fall Risk Protocol interventions to be implemented.
ii. The MR lacked documentation of regular monitoring for elimination needs as evidenced by lack of documentation of regular Toileting Status entries/monitoring between 12/9/18 at 11:51 hours and 12/11/18 at 20:00 hours.
iii. Progress Note-Nurse documentation indicated fall risk protocol for use of a chair alarm needed, but not implemented as follows:
a. On 12/10/18 at 18:25 hours: "He/she was impulsive sometime, he/she tried to get up by him/herself for a few times. and education, he/she promise not get up by him/herself and will use call light, he/she need chair alarm, but chair alarm was not available today."
b. On 12/11/18 at 03:28 hours: "Both myself and tech asked for chair alarm, but one is not currently available."
G. Patient P10 was admitted 12/27/18 and was a current inpatient. P10's admitting Morse Fall Risk Score was 70. The MR lacked documentation of a change in this score.
i. The Interdisciplinary Plan of Care (IPOC), Update Entered On: 01/08/2019, indicated the following:
a. The "IPOC - At Risk for Injury Rehab". Interventions included, but were not limited to:
1. Monitor elimination needs. (No frequency was indicated)
2. Patient Safety: Bed against wall.
ii. The MR lacked documentation of regular monitoring for elimination needs as evidenced by lack of documentation of regular Toileting Status entries/monitoring between 12/27/18 at 20:27 hours and 12/30/18 at 14:45 hours; between 12/30/18 at 14:45 hours and 1/2/19 at 10:00 hours.
iii. The MR lacked documentation of the patient's bed against the wall.

3. On 1/8/19 between approximately 4:00 p.m. and 5:00 p.m., patient P10 was observed up in a WC sitting next to his/her bed. The bed was observed to be positioned away from the wall.

4. The following was indicated in interview(s):
A. On 1/8/19 between approximately 11:00 a.m. and 11:30 a.m., A4, CMA, Certified Medical Assistant, indicated that he/she would expect to see documentation of elimination monitoring in the rounding or I&O (Intake and Output) section of the MR. A4 also indicated elimination monitoring may be indicated in the toileting section, but did not believe that section was used often.
B. On 1/8/19 A2, Nurse Manager indicated the following:
i. Between approximately 10:45 a.m. and 11:45 a.m., A2, indicated that monitoring of elimination needs should be set on a schedule of frequency. A2 indicated if a frequency was not documented, monitoring should be documented at regular intervals at times of rounding. A2 verified that the "Rounding" section of the EMRs (Electronic Medical Record) did not show, or offer as an electronic selection for, monitoring of elimination needs. A2 also indicated that documentation of a patient with an incontinence brief did not indicate or substitute for monitoring of elimination needs. A2 verified the MRs for patients P1 and P2 lacked documentation of regular monitoring of elimination.
ii. Between approximately 1:15 p.m. and 4:00 p.m., A2 verified patients P1, P2, P4, P5, P6, P7, P8 and P10 were scored as high fall risks during time of MR review.
iii. Between approximately 3:00 p.m. and 3:30 p.m., A2 indicated the hospital does not use restraints and verified the MRs for patients P5 and P8 lacked documentation of a restraint order or use.