HospitalInspections.org

Based on document review and interview, the facility failed to maintain an effective Quality Assessment and Performance Improvement (QAPI) program, to ensure that data collected was analyzed to identify opportunities for improvement in health outcomes, patient safety, and quality of care.

Findings include:

Review of Quality Improvement Program for Psychiatric Emergency Services for the 2nd quarter of 2018 to the 1st quarter of 2019 revealed a substantial increase in the use of physical restraints in the 1st quarter of 2019.

2nd quarter 2018 - 22
3rd quarter 2018 - 40
4th quarter 2018 - 23
1st quarter 2019 - 53

There was no documented evidence that the data for each quarter was analyzed. The reason the number of restraints more than doubled in the 1st quarter of 2019 compared to the previous quarter was not documented.

Review of the Performance Improvement meeting minutes for Medical Emergency Services from May 2018 to January 2019 showed the department collected monthly data that includes the following:
1. Staff compliance with Hand Hygiene
2. Number of patients who left the Emergency Department (ED) before and after triage without medical evaluation
3. Number of falls in the ED
4. Number of ED Diversions

There was no documented evidence that the data collected for each indicator was analyzed and actions plans aimed at performance improvement was proposed and implemented.

During interview on 6/10/19 at 11:45 AM, Staff J, Medical Director for Psychiatric Services acknowledged findings and stated that data for falls is analyzed only when there is a spike in the number of falls.

During interview on 6/10/19 at 11: 50 AM, Staff D, Interim Director of the Medical Emergency room acknowledged findings.

Based on observation and interview, the facility did not maintain a sanitary environment in the Emergency Department (ED).

Findings include:

On June 06,2019, at 12:28 pm, during the tour of the Emergency Department, a sharp container on wheels was observed in the shower cabin in Room 1C-15.

The storage of a sharp container in a designated patient area poses a risk for safety and infection.

This finding was witnessed by Staff C, Interim ED Associate Director and Staff B, Chief Nursing Officer who acknowledged findings.

Based on medical record (MR) review, document review, and interview, in one (1) of 17 medical records, the facility failed to implement its policies and procedures to ensure safety of patients who are at risk for falls.

This failure may have placed the patient at risk for harm.

Findings include:

Review of the medical record for Patient #1 revealed that on 04/15/2019 at 1:26 pm, this 68-year-old nursing home resident was triaged in the Emergency Department for aggressive behavior. The patient had a history of falls and subdural hematoma (A condition due to bleeding under the membrane covering the brain). The fall risk assessment identified him as a high risk for falls due to cognitive impairment, sensory deficits, and impaired mobility. A document from the nursing home indicated the patient was non-ambulatory. After triage, the patient was placed on close observation that requires visual checks every 15 minutes.

On 04/15/19 at 4:40 pm, nurse documented the patient attempted to get up and ambulate ... patient fell to the floor face forward. CT scan of the head revealed a subdural hematoma measuring 1.8 cm, and a mm of right-to-left midline shift.

Review of facility policy titled "Fall Risk Assessment/Prevention (Reviewed on 03/2017) notes: "The MORSE Fall Risk Assessment Tool will be used to assess patient's risk for falls ...Based on the patient's risk factors, an individualized plan for prevention of falls will be incorporated in the nursing care plan. This plan will define the appropriate measures to be instituted for that particular patient."

There was no documented evidence that the MORSE Fall Risk Assessment was used to assess the patient and to determine his risk level for falls. In addition, there was no documented evidence that an individualized care plan was developed and implemented for the safety of the patient.

On 06/07/19, at 13:12 (pm), during an interview with Staff F (NP, Associate Psychiatric Emergency Service Director), she acknowledged findings.