HospitalInspections.org

Based on record review and interview the facility staff failed to complete documentation of a nursing physical assessment following a patient fall in 3 of 14 falls (Patient # 5, 6, 9); failed to complete post fall documentation for 2 of 14 falls (Patient #5 (for 2 falls)); failed to evaluate and revise the care plan with appropriate interventions and goals to reflect patient care needs in 4 of 10 patient falls (Patient #5, 6, 9, 11); failed to ensure established fall interventions were utilized correctly by staff for 2 of 10 Patients (Patient #1 and 5) in a total sample of 10 medical records reviewed; and failed to ensure that contract agency staff are trained and demonstrate competency in patient transfer and transfer equipment for 2 of 2 agency Certified Nursing Assistants (CNA) (CNA R, CNA S) in a total of 10 personnel files reviewed.

Findings include:

Facility staff failed to document nursing physical assessments and failed to complete post fall documentation after patient falls. See tag A-0395

Facility staff failed to follow facility policy to update the Plan of Care following a patient fall and failed to ensure falls interventions were utilized per recommendations. See tag A-0396

Facility staff failed to ensure contract/agency staff are trained and demonstrate competency in patient transfers and transfer equipment. See tag A-0397.

Based on record review and interview, the staff failed to document the nursing physical assessment following a patient fall after 3 of 14 patient falls involving Patient (#5, 6, 9); and failed to complete a post fall documentation for 2 of 14 falls (Patient #5 for 2 falls) in a total sample of 10 medical records reviewed.

Findings include:

A review of policy titled, "Patient Falls Program" Version 2 dated 09/05/2023 revealed, "Documentation in the Medical Record: Patients assessed/reassessed as a risk for fall shall have said assessment/reassessment documented in their medical record. The medical record should also reflect documentation of interventions deployed to prevent a fall. If a fall occurs; Assess the patient for injury prior to moving. Notify physician and notify family member. Document the physical assessment and events in the chart and complete the post-fall assessment in the EMR. Conduct post fall assessment or consider debrief with team members to determine immediate/root cause of the fall within 15 minutes of the fall and plan further interventions. An incident report should be completed and turned in to the quality department."

Nursing physical assessments of the patient following a fall not completed:

A review of Patient #5's medical record revealed an admission date of 03/20/2024 following a CVA (Cerebral Vascular Accident). Patient #5 remains a current patient at the facility.

A review of facility falls log for month of March, April, and May 2024 revealed Patient #5 had 5 falls since admission (03/25/2024, 04/07/2024, 04/21/2024, 04/23/2024, and 05/01/2024).

A review of the "Incident Report" for Patient #5 revealed "Incident Date: 04/23/2024 Incident Time: 1:00 AM Report Date: 04/24/2024" revealed, "On 04/24/2024 day shift, the patient reported to therapy that she had a fall the night before. DQM (Director of Quality Management) followed up with the patient and she reported a girl came in to take her to the bathroom. The girl placed the wheelchair in front of the patient, and not at the side as they usually do. Additionally, the patient stated the girl did not use a gait belt. The patient reports the girl was trying to transfer patient and the patient slid to the floor and landed on her buttocks. The patient denies any injury or pain. The patient reports "[RN V] came in to help the girl." They put the patient into bed."

A review of Patient #5's medical record was completed. There was no documentation of Patient #5 having a fall on 04/23/2024, or a physical assessment following the fall in the medical record.

A review of Patient #6's medical record revealed an admission date of 04/19/2024 following weakness. Patient #6 remains a current patient at the facility.

A review of the facility falls log for month of March, April, and May 2024 revealed Patient #6 had 2 falls since admission (05/02/2024 and 05/04/2024).

A review of the "Incident Report" for Patient #6 revealed "Incident Date: 05/02/2024 Incident Time: 8:15 AM Report Date: 05/02/2024" revealed, "Pt found sitting on the floor in front of the recliner. Pt. complains of back and knee pain. Pt. states she was trying to get up and did not push call light to notify staff. Chair alarm in place and grip socks on prior to fall. Staff notified and asked to anticipate patient's needs where possible to help prevent additional falls. Staff agrees."

A review of Patient #6's medical record was completed. There was no documentation of Patient #6 having a fall on 05/02/2024, or a physical assessment following the fall in the medical record.

A review of Patient #9's medical record revealed an admission date of 03/07/2024 following a CVA. Patient #9 was discharged from the facility on 04/06/2024.

A review of the facility falls log for month of March, April, and May 2024 revealed Patient #9 had 2 falls since admission (03/09/2024 and 04/05/2024).

A review of the "Incident Report" for Patient #9 revealed "Incident Date: 04/05/2024 Incident Time: 3:15 PM Report Date: 04/05/2024" revealed, "Patient's chair alarm sounded- CNA (Certified Nursing Assistant), CNO (Chief Nursing Officer), & nursing supervisor entered pt's room to find pt. kneeling on floor in front of wheelchair; pt reported needing to have a bowel movement- had not utilized call light."

A review of Patient #9's medical record was completed. There was no documentation of Patient #9 having a fall on 04/05/2024, or a physical assessment following the fall in the medical record.

During an interview on 05/06/2024 at 2:00 PM the medical record review findings were discussed with and confirmed by DQM (Director of Quality Management) C who stated, "When a patient has a fall the staff are expected to document the fall and the physical assessment in the medical record."

Nursing post fall review and root cause analysis not completed:

A review of Patient #5's medical record revealed an admission date of 03/20/2024 following a CVA (Cerebral Vascular Accident). Patient #5 remains a current patient at the facility.

A review of facility falls log for month of March, April, and May 2024 revealed Patient #5 had 5 falls since admission (03/25/2024, 04/07/2024, 04/21/2024, 04/23/2024, and 05/01/2024).

A review of the "Incident Report" for Patient #5 revealed "Incident Date: 04/21/2024 Incident Time: 4:15 AM Report Date: 04/21/2024" revealed, "Pt was brought to the toilet by CNA, Pt did not call for assistance and tried to wipe herself. Pt. lost balance and fell off toilet. Pt. denies hitting head, pain, or injury..."

A review of Patient #5's medical record was completed. There was no documentation of the post fall review for Patient #5's fall on 04/21/2024.

A review of the "Incident Report" for Patient #5 revealed "Incident Date: 04/23/2024 Incident Time: 1:00 AM Report Date: 04/24/2024" revealed, "On 04/24/2024 day shift, the patient reported to therapy that she had a fall the night before. DQM followed up with the patient and she reported a girl came in to take her to the bathroom. The girl placed the wheelchair in front of the patient, and not at the side as they usually do. Additionally, the patient stated the girl did not use a gait belt. The patient reports the girl was trying to transfer patient and the patient slid to the floor and landed on her buttocks. The patient denies any injury or pain. The patient reports "[RN V] came in to help the girl." They put the patient into bed."

A review of Patient #5's medical record was completed. There was no documentation of the post fall review for Patient #5's fall on 04/23/2024.

During an interview on 05/06/2024 at 2:00 PM the medical record review findings were discussed with and confirmed by DQM C who stated, "When a patient has a fall the staff are expected to document the post fall assessment in the medical record."

Based on record review and interview the facility staff failed to evaluate and revise the care plan with appropriate interventions and goals to reflect patient care needs in 4 of 10 medical records reviewed (Patient #5, 6, 9, 11) and staff failed to ensure established fall interventions were utilized correctly by staff for 2 of 10 Patients (Patient #1, 5) in a total sample of 10 patient records reviewed.

Findings include:

A review of form titled, "Post Fall Huddle Form" dated 09/23/2023 revealed, "Patient Falls Checklist: ...Update Care Plan".

A review of policy titled, "Patient Falls" dated 09/05/2023 revealed, "To identify patients at risk of falling so that appropriate interventions can be implemented... The medical record should also reflect documentation of interventions deployed to prevent falls."

Examples of care plans not being updated:

A review of Patient #5's medical record revealed an admission date of 03/20/2024 following a CVA (Cerebral Vascular Accident). Patient #5 remains a current patient at the facility.

A review of facility falls log for month of March, April, and May 2024 revealed Patient #5 had 5 falls since admission (03/25/2024, 04/07/2024, 04/21/2024, 04/23/2024, and 05/01/2024).

A review of the "Incident Report" for Patient #5 revealed "Incident Date: 04/21/2024 Incident Time: 4:15 AM Report Date: 04/21/2024" revealed, "Pt was brought to the toilet by CNA, Pt did not call for assistance and tried to wipe herself. Pt. lost balance and fell off toilet. Pt. denies hitting head, pain, or injury..."

A review of Patient #5's medical record was completed. There was no documentation of Patient #5's care plan being updated after the 04/21/2024 fall. No new fall interventions were added to the care plan.

A review of the "Incident Report" for Patient #5 revealed "Incident Date: 04/23/2024 Incident Time: 1:00 AM Report Date: 04/24/2024" revealed, "On 04/24/2024 day shift, the patient reported to therapy that she had a fall the night before. DQM followed up with the patient and she reported a girl came in to take her to the bathroom. The girl placed the wheelchair in front of the patient, and not at the side as they usually do. Additionally, the patient stated the girl did not use a gait belt. The patient reports the girl was trying to transfer patient and the patient slid to the floor and landed on her buttocks. The patient denies any injury or pain. The patient reports "[RN V] came in to help the girl." They put the patient into bed."

A review of Patient #5's medical record was completed. There was no documentation of Patient #5's care plan being updated after the 04/23/3034 fall. No new fall interventions were added to the care plan. Patient #5 had another fall on 05/01/2024.

A review of Patient #6's medical record revealed an admission date of 04/19/2024 following weakness. Patient #6 remains a current patient at the facility.

A review of the facility falls log for month of March, April, and May 2024 revealed Patient #6 had 2 falls since admission (05/02/2024 and 05/04/2024).

A review of the "Incident Report" for Patient #6 revealed "Incident Date: 05/04/2024 Incident Time: 7:00 AM Report Date: 05/04/2024" revealed, "Pt was trying to self-transfer out of recliner and slid out instead onto her bottom."

A review of Patient #6's medical record was completed. There was no documentation of Patient #6's care plan being updated after the 05/04/2024 fall. No new fall interventions were added to the care plan.

A review of Patient #9's medical record revealed an admission date of 03/07/2024 following a CVA. Patient #9 was discharged from the facility on 04/06/2024.

A review of the facility falls log for month of March, April, and May 2024 revealed Patient #9 had 2 falls since admission (03/09/2024 and 04/05/2024).

A review of the "Incident Report" for Patient #9 revealed "Incident Date: 04/05/2024 Incident Time: 3:15 PM Report Date: 04/05/2024" revealed, "Patient's chair alarm sounded- CNA (Certified Nursing Assistant), CNO (Chief Nursing Officer), & nursing supervisor entered pt's room to find pt. kneeling on floor in front of wheelchair; pt reported needing to have a bowel movement- had not utilized call light."

A review of Patient #9's medical record was completed. There was no documentation of Patient #9's care plan being updated after the 04/05/2024 fall. No new fall interventions were added to the care plan.

A review of Patient #11's medical record revealed an admission date of 04/26/2024 following a CVA. Patient #11 is a current patient at the facility.

A review of the facility falls log for month of March, April, and May 2024 revealed Patient #11 had 1 fall since admission (05/05/2024).

A review of the "Incident Report" for Patient #11 revealed "Incident Date: 05/05/2024 Incident Time: 10:20 AM Report Date: 05/05/2024" revealed, "Pt was sliding out of chair. CNA assisted safely to ground."

A review of Patient #11's medical record was completed. There was no documentation of Patient #11's care plan being updated after the 05/05/2024 fall. No new fall interventions were added to the care plan.

During an interview on 05/06/2024 at 2:31 PM the medical record review findings were discussed with and confirmed by DQM (Director of Quality Management) C who stated, "When a patient has a fall the staff are expected to update the plan of care after each fall."

Examples of fall interventions not being followed:

A review of Patient #1's medical record revealed an admission date of 03/01/2024 with a diagnosis of CVA with hemiplegia (paralysis of weakness on one side of the body including arms, legs, and sometimes face).

A review of Patient #1's "RN Nursing Shift Assessment" dated 03/06/2024 at 1:04 PM written by RN X revealed, "Fall Precautions... bed alarms and Chair alarms."

A review of the incident report involving Patient #1's fall on 03/07/2024 at 7:23 AM revealed, "Patient found on the floor in room, pt reported he was attempting to take himself to the other side of his bed in his wheelchair when he fell out of his chair, chair alarm was on the chair but hadn't been turned on per CNA (education provided)..."

A review of Patient #5's medical record revealed an admission date of 03/20/2024 with a diagnosis of CVA with hemiplegia.

A review of Patient #5's care plan dated 03/20/2024 revealed, "Problem: Risk for falls related to cardiovascular abnormalities... Hx (history) of falls with the past 30 days as evidenced by weakness to left side, recent fall... Interventions: ... 5. Assist with all mobility and toileting."

A review of the incident report involving Patient #5's fall on 04/21/2024 at 4:15 AM revealed, "Pt was brought to toilet by CNA, Pt did not ask for assistance and tried to wipe herself. Pt. lost balance and fell off toilet. Pt. denies hitting head, pain or injury." Documentation by DQM C on 04/21/2024 at 3:29 PM revealed, "Follow up/Resolution: Per incident report, the patient's whiteboard reflected not to leave the patient unattended in the bathroom as she has a history of falls. CNA left patient unattended in the bathroom, and patient sustained a fall."

During an interview with DON D on 05/08/2024 at 8:25 AM, DON D stated, "The staff are expected to put new interventions in place following every patient fall. It is also the expectations that staff make sure all the fall prevention interventions are being utilized and followed."

Based on record review and interview, the facility staff failed to ensure agency staff are educated and demonstrate knowledge of safe patient handling and movement for 2 of 2 Agency CNA (Certified Nursing Assistant) (Agency CNA R and CNA S) in a total universe of 10 personnel files reviewed.

Findings include:

A review of policy titled, "Safe Patient Handling and Movement" dated 02/20/2023 revealed, "Staff will be educated in the techniques of safe patient handling and movements and the risk of injury. Devices will be provided by the hospital to decrease the risk to employees, and patients: Hoyer lift, slider boards, gait belts, and others ... Procedure: A. Staff Responsibilities 1. Unit/Nurse Manager and Supervisors are responsible for: a. Ensuring that all staff affected by the policy complete initial and annual training on patient-handling equipment, ambulatory aids, and safe patient handling ... 3. Unlicensed caregivers are responsible for: a. Being knowledgeable of the procedures to follow when transferring patients. b. Using proper techniques, patients handling equipment and ambulatory aids during performance of high-risk patient handling tasks."

A review of form titled, "Job Description" for Agency CNAs dated and signed by CNA R on 09/07/2023 and CNA S on 07/14/2022 revealed, "Job Title: Agency Certified Nursing Assistant, Position Summary: Assists professional nursing personnel in providing patient care in assigned area. Assist patient with activities of daily living, provides for personal care, emotional support and performs more complex clinical skills under the direction of professional nursing personnel."

A review of form titled, "Agency Competency Assessment- CNA" for CNA R revealed a list of "Departmental-Mandated Competencies", the form did not include any competencies related to the use of patient handling equipment or transfer aids.

A review of an "Incident Report" for Patient #1 on 03/06/2024 at 12:25 PM revealed, "[R] the CNA was in the room with the patient [#1], his/her daughter and [spouse]. S/he called for help and [K] RN and [X] RN responded. The patient was on the sara stedy and his/her leg had moved. We moved the sara stedy to the bed and put the patient in a sitting position on the bed. We repositioned his/her legs and got him/her back on the sara stedy and in the shower chair in the bathroom. When seated in the bathroom chair the patient vomited a small amount. [X] RN noticed patients left arm had a skin tear..."

During an interview with Director of Nursing D on 05/08/2024 at 8:25 AM, Director of Nursing D stated hospital staff are trained upon hire and then annually on safe patient handling including use of equipment and transfer aids. Director of Nursing D stated that Agency staff complete a competency the first day they work at the hospital, but use of equipment and transfer aids are not included in the competency. Director of Nursing D stated, "As far as agency staff, I would hope they are more experienced and know how to use equipment safely."