HospitalInspections.org

Based on interview and record review, the facility failed to uphold the rights of Patient # 6 by not informing her designated representative (husband) of important health information.
The facility failed to inform Patient 6's husband that she sustained a fall resulting in a head laceration, forehead swelling, and black eyes.
Findings include:
TX 00213576
Record review of intake TX 00213576 revealed Patient # 6 was admitted to the facility's behavioral unit on 01-05-15. Patient # 6's husband visited her on 01-13-15 and found her with a "swollen forehead and two black eyes..no one from the facility informed the husband of any of the injuries or how they happened.."
Interview (telephone)on 04-27-15 at 5:30 p.m. with husband of Patient # 6 he He said he was his wife's 'Medical Power of Attorney' and that she had Alzheimer's. He went on to say he repeatedly asked at the facility what had happened to his wife. No one from the facility explained her injuries. His wife was transferred to a nursing home on 01-16-15.
Patient # 6
Review of Patient # 6's clinical record revealed she was an 82 year old female who initially presented to the facility ER on 01-05-15 with altered mental status and in need of adjustment of Alzheimer's medication. She was admitted to the behavioral health unit on 01-01-15. Review of nursing notes for Patient # 6 from 01-05-15 through 01-16-15 , it was consistently documented: " patient is alert and oriented to self; confused and delusional at times.."
Review of nursing notes for Patient # 6 , dated 1-12-15 ( timed 13:35; amended 15:50), read: " entering patient's room... (nurse aide) stated I think someone fell...entered patient's room and noted patient head to the floor, on knees, with buttocks in the air. upon assessment, hematoma to front of head with slight swelling..."
Record review of head CT scan, dated 01-12-15 (15:50) : " "...no evidence of hemorrhage, internal hematoma, or mass noted...soft tissue scalp hematoma and swelling is noted in the midline..."
Further review of the nursing notes for this day , as well as each note until discharge on 01-16-15, failed to reveal any documentation Patient # 6's husband was informed of the injury and treatment.
Record review of physician progress notes from 01-13-15 until 01-16-15, failed to reveal husband of Patient # 6 was informed of his wife's injury and treatment.
Record review of facility "Patient Event Form" dated 01-12-15 ( time 1328) revealed details consistent with nursing notes: "patient found with head to floor..hematoma noted to front of head." Further review of this 'event form' , as well as the follow-up investigation report, failed to reveal documentation that Patient # 6's husband was notified of her injury and subsequent treatment.
Interview on 04-28-15 at 1:40 p.m. with Chief Nursing Officer (CNO) # 2, she stated Patient #6's husband should have been informed of her fall and injury.
Review of facility policy titled "Fall Prevention" , dated 02/2014, read: "...D. Post Fall Follow-Up:... 7. Notify family or designee of fall..."
Review of nursing home 'admission assessment' documentation on 01-16-15 ( 4 days post-fall) : " resident's forehead and bilateral eye area and nose noted with bruising, greenish/ yellow discoloration.."

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) evaluated the care upon admission and on-going basis for 5 of 10 sampled patients ( Patients #2, #3, #4, #5, # 6) . Facility failed to ensure:

* RN conducted a fall risk assessment every shift per policy for Patients # 2, # 3, # 5.

* Fall risk assessments conducted for Patients # 4, # 6 documented in the electronic medical record ( EMR) were consistent with the facility Fall Prevention policy.

Findings include:

TX 00213576

Patient # 2 :

Record review on 04-28-15 of Patient # 2's clinical record revealed she was 62 years old and admitted on 04-27-15 for Depression. There was no fall risk assessment completed for Patient # 2 since admission.

Patient # 3:

Record review on 04-28-15 of Patient # 3's clinical record revealed he was 77 years old and admitted for Depression. Fall risk assessments were not documented each shift.

Patient # 5:

Record review on 04-28-15 of Patient # 5's clinical record revealed he was 50 years old and admitted on 04-27-15 for "psych." There was no fall risk assessment completed for Patient # 5 since admission.

Patient # 4:

Record review on 04-28-15 of Patient # 4's clinical record revealed she was 55 years old and admitted on 04-23-15 for Suicidal Ideation. Patient # 4 had a history of falls. Fall risk documented in the EMR was "Level 1: High Risk" in the EMR.

Review of facility Fall Prevention policy, dated 2/2014, read: "..Fall Risk Level 1 -low fall risk.."

Patient # 6:

Record review on 04-28-15 of Patient # 6's clinical record revealed she was 82 years old and admitted on 01-01-15 for Altered Mental Status, Urinary Tract Infection, and Alzheimer's Disease. Patient # 6's fall risk documented in the EMR ( 01-08-15) was "Level 2: extremely high risk." Patient # 6 sustained an actual fall on 01-12-15.

Review of facility Fall Prevention policy, dated 2/2014, read: "..Fall Risk Level 2-moderate fall risk.."

Interview on 04-28-14 at 1:15 p.m. with Chief Nursing Officer (CNO) # 2, she acknowledged the computer EMR fall risk scores and risk levels were not consistent with the facility's current Fall Prevention policy. The CNO went on to say the facility had previously worked on a fall prevention policy specific to behavioral health ; facility was unable to locate this policy.