HospitalInspections.org

Based on document and interview, the facility failed to ensure care in a safe setting in one instance (Patient # 2) See tag 0144.

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document and interview, the facility failed to ensure care in a safe setting in one instance (Patient # 2).

Findings include:

1. Review of established hospital policy titled: "Patient Rights and Responsibilites", PolicyStat ID 10359862, indicated on page 3, 18., "Receive care in a safe setting".

2. Review of Patient # 2 MR, indicated the following:
(a). Nurse note on 3/27/2023 at 9:00 am, reflected patient sent to AH # 60 (Acute Care Hospital) via ambulance, due to fall for further evaluation.
(b). Psychiatric progress note on 3/27/2023, by NP (Nurse Practitioner - Psychiatric) # 52, reflected patient was sent to ER (Emergency Room) as she/he rolled out of bed yesterday and was laying on the floor from 1 am until about 9 am. Staff was not able to get her/him off the floor. Patient was sent to the ER before she/he could be seen this morning.

3. Review of incident report dated 3/27/2023 at 1:15 am, reflected nurse heard patient shouting help; investigated by another nurse. Patient found lying in prone position on floor. No obvious bruises noted. No complaints of pain: AROM (active range of motion) present to extremities. Vitals taken. Staff members x 3 tried to assist patient back to bed, was unsuccessful; mattress placed on floor and patient assisted to mattress. NP contacted.

4. In interview on 5/24/2023 at approximately 12:03 pm, with NP # 52, confirmed the following:
A. Did not get to see the patient, patient was already out to hospital.
B. Information that patient was on floor, was received from the day nurse. Nurse said patient had rolled out of bed, on floor; put patient on mattress; monitored patient; until got additional help; called paramedics.
C. Patient on floor approximately 8 hours, according to nurse. Does not know what NP was called when incident happened. NP # 52 would have instructed staff to call for more help/support; even call 911.
D. Not acceptable to have left patient on the floor, on a mattress for length of time.

5. In interview on 5/24/2023 at approximately 12:35 pm, with A # 7 (Director of Nursing), confirmed the following:
A. Staff did not call regarding incident; when patient rolled out of bed at 1:00 am. No knowledge, until 7:00 am when S # 21 (Registered Nurse - staff) called.
B. To unit; patient on floor, on mattress; patient laying on tummy/prone.
C. Had S # 21 call 911 for assist, around 7:40 am. Attempted to use hoyer lift after medics arrived, but unsuccessful. Medics ended up taking patient to hospital.
D. Not acceptable that patient was left on floor; on mattress for extended period of time. Patient Rights policy not followed.

6. In interview on 5/25/2023 at approximately 12:05 pm, with S # 21 (Registered Nurse - staff), confirmed the following:
A. Patient on floor, not on the mattress at that time; when arrived on unit at 7:00 am. Patient face down, but able to move some. Called A # 7; after patient checked.
B. Patient was found on floor by night staff at 1:00 am; staff informed S # 21 about event. Not sure why A # 7 was not called or 911 for help with the patient.
C. Fire Department/Rescue arrived at 7:30 am; many attempts to get patient off the floor. Patient off the floor, by total of 4 Fire Department staff and S # 21; at approximately 8:45 am. Patient went out to hospital at 9:00 am.

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Assessment/Reassessment; for assessment ongoing, document findings, and for RN (Registered Nurse) job description for maintain standard of accurate and complete recording; in the patients MR (Medical Record), for 1 of 10 MR's reviewed (Patient # 2).

Findings include:

1. Review of established hospital policy titled: "Assessment/Reassessment", PolicyStat ID 12386392, indicated on page 1, under Policy, 5. "Assessment is ongoing as appropriate throughout the hospital stay, and on page 2, 7. "Nursing will re-assess each patient every shift and as warranted by the patient's medical condition and document findings". Last revised 9/2022.

2. Review of established hospital job description for "Registered Nurse", indicated on page 2, under Essential Standard job functions; point 14; RN "Maintains the standards of accurate and complete recording". No effective date noted.

3. Review of Patient # 2 MR, indicated the following:
(a). Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 3/23/2023; diagnosis Alzheimers disease & history of that included, but not limited to: Dementia, Depression, Cognitive communication deficit, and Morbid obesity.
(b). Nurse note on 3/27/2023 9:00 am, reflected patient sent to AH # 60 (Acute Care Hospital) via ambulance, due to fall for further evaluation.
(c). Nurse note on 3/27/2023 at 8:45 pm, reflected patient minimally agitated, reassessed by Doctor; orders for medications.
(d). MR lacked nursing note documentation related to patient's incident on 3/27/2023 at 1:15 am; patient's status thereafter, until next note at 9:00 am; when patient sent out to AH # 60 (Acute Care Hospital) for further evaluation. MR lacked nursing note documentation related to patient's status thereafter for patient's incident on 3/27/2023 at 7:00 pm, until next note at 8:45 pm.
(e). Not able to determine how long patient was on mattress on floor after incident at 1:15 am, nor if patient was returned to bed by staff, for incident at 7:00 pm.

4. Review of incident report dated 3/27/2023 at 1:15 am, reflected nurse heard patient shouting help; investigated by another nurse. Patient found lying in prone position on floor. No obvious bruises noted. No complaints of pain; AROM (active range of motion) present to extremities. Vitals taken. Staff members x 3 tried to assist patient back to bed, was unsuccessful; mattress placed on floor and patient assisted to mattress. NP (Nurse Practitioner) contacted.

5. Review of incident report dated 3/27/2023 at 7:00 pm, reflected patient rolled out of bed; was witnessed; no injury. Patient thinks she/he can walk and wanted to go to spouse.

6. In interview on 4/18/2023 at approximately 3:18 pm, with A # 1 (Chief Executive Officer), confirmed that not acceptable for a patient to be on mattress, on floor; with no documentation in MR, for event.

7. In interview on 4/18/2023 at approximately 1:45 pm, with A # 3 (Quality - Risk), confirmed that the MR for Patient # 2 lacked nurse documentation for incident that occurred at 1:15 am on 3/27/2023, and documentation for patient status; if returned to bed, after incident on 3/27/2023 at 7:00 pm.