HospitalInspections.org

Based on document review and staff interviews, the facility failed to promote the patient right to safety. The facility failed to provide care in a safe setting and take action to prevent further accident/injury (A144). The cumulative effect of this problem resulted in the hospitals inability to ensure the provision of quality healthcare in a safe environment.

Based on document review and staff interviews, the facility failed to ensure an RN supervised and evaluated patient care (A0395) and ensure adequate staffing was provided (0392). The cumulative effect of this problem resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.

Based on document review and staff interview, the facility failed to assure personal safety of patients for 1 (#7) of 5 patients.

Findings include:

1. Review of patient #7's medical record indicated the following:
(A) The patient was admitted to the behavioral health unit (BHU) under the care of M.D. #4 on 12/1/09 from a longterm care (LTC) facility due to aggression toward staff and verbal abuse.
(B) The patient was documented as a high risk for falls throughout his/her stay.
(C) The patient was documented as requiring assistance with eating, toileting, transfers, ambulation, bathing and dressing at the time of admission.
(D) The patient had a fall on 12/2/09 next to the nurse station. Nurse notes indicated he/she got up without assistance. Per a CAT scan on 12/2/09, the patient sustained nondisplaced fractures involving the left lateral and anterior maxillary sinus wall as well as nondisplaced fracture involving the left inferior orbital wall. The record lacked documentation that family was notified to sit with patient or that any additional fall prevention interventions were put into place to prevent future falls.
(E) Nurse notes indicated that the patient was found on the floor in his/her room at 1615 on 12/3/09. The record lacked documentation that family was notified to sit with patient or that any additional fall prevention interventions were put into place to prevent future falls.
(F) The patient had a fall on 12/5/09 at 5:15 a.m. and sustained a laceration to the left 3rd finger. He/she was sent to the emergency department (ED) for repair of the laceration. The record lacked documentation that family was notified to sit with patient or that any additional fall prevention interventions were put into place to prevent future falls.
(G) The patient had another fall at 9:40 a.m. on 12/5/09 in his/her bathroom and hit their head on the sink. The patient sustained a skin tear to his/her elbow from the fall. the nurse notes beginning at 2000 of same date indicated patient was constantly attempting to get up. The record lacked documentation that family was notified to sit with patient or that any additional fall prevention interventions were put into place to prevent future falls.

2. Facility policy titled "FALLS PREVENTION PROGRAM" last reviewed/revised 12/09 listed on page 2 for a level II fall risk interventions including, but not limited to, notifying family to request they sit with patient when possible; utilizing bed/chair alarms as indicated and placing increased risk sign at patients room door.

3. Staff member #3 verified the above medical record documentation at 1:45 p.m. on 1/27/10.

Based on document review, the facility failed to ensure adequate numbers of nursing assistants (CNAs) were provided on the medical surgical (med/surg) unit for 2 of 15 days and on the behavioral health unit (BHU) for 1 of 16 days.

Findings include:

1. Review of staffing for the med/surg unit for 10/17/09-10/24/09 and 10/3/09-10/9/09 indicated the unit was lacking one (1) CNA for a portion of dayshift on 10/17 and the unit had no CNA on dayshift on 10/4/09. According to staffing guidelines, the unit should have had one (1) CNA for each shift on each day.

2. Review of staffing for the BHU for 10/19/09-10/26/09 and 12/1/09-12/8/09 indicated the unit was lacking one (1) CNA on dayshift 12/8/09. According to staffing guidelines, the unit should have been staffed with four (4) CNAs for a census of 19 on this date.

Based on document review and staff interview, the facility failed to ensure a registered nurse evaluated the care provided to 5 (#1-3, #7-8) of 5 patients.

Findings include:

1. Review of patient #1's medical record indicated the following:
(A) The patient was admitted to the medical/surgical (med/surg) unit on 9/28/09 and discharged on 10/1/09.
(B) The record lacked documentation that the patient received a bath or had linen changes on 9/28/09, 9/29/09, or 9/30/09.

2. Review of patient #2's medical record indicated the following:
(A) The patient was admitted to the med/surg unit on 10/15/09 and discharged on 10/17/09.
(B) The record lacked documentation that the linens were changed on 10/15/09 or 10/16/09. The record lacked documentation that the patient received a bath during his/her stay.

3. Review of patient #3's medical record indicated the following:
(A) The patient was admitted to the med/surg unit on 10/20/09 and discharged on 10/25/09.
(B) The record lacked documentation that the linens were changed on 10/20/09, 10/21/09 or 10/22/09.

4. Review of patient #7's medical record indicated the following:
(A) The patient was admitted to the behavioral health unit (BHU) under the care of M.D. #4 on 12/1/09 from a longterm care (LTC) facility due to aggression toward staff and verbal abuse.
(B) The patient was documented as a high risk for falls throughout his/her stay.
(C) The patient was documented as requiring assistance with eating, toileting, transfers, ambulation, bathing and dressing at the time of admission.
(D) The patient had a fall on 12/2/09 next to the nurse station. Nurse notes indicated he/she got up without assistance. Per a CAT scan on 12/2/09, the patient sustained nondisplaced fractures involving the left lateral and anterior maxillary sinus wall as well as nondisplaced fracture involving the left inferior orbital wall. The record lacked documentation that family was notified to sit with patient or that any additional fall prevention interventions were put into place to prevent future falls.
(E) Nurse notes indicated that the patient was found on the floor in his/her room at 1615 on 12/3/09. The record lacked documentation that family was notified to sit with patient or that any additional fall prevention interventions were put into place to prevent future falls.
(F) The patient had a fall on 12/5/09 at 5:15 a.m. and sustained a laceration to the left 3rd finger. He/she was sent to the emergency department (ED) for repair of the laceration. The record lacked documentation that family was notified to sit with patient or that any additional fall prevention interventions were put into place to prevent future falls.
(G) The patient had another fall at 9:40 a.m. on 12/5/09 in his/her bathroom and hit their head on the sink. The patient sustained a skin tear to his/her elbow from the fall. the nurse notes beginning at 2000 of same date indicated patient was constantly attempting to get up. The record lacked documentation that family was notified to sit with patient or that any additional fall prevention interventions were put into place to prevent future falls.

5. Review of patient #8's medical record indicated the following:
(A) The patient was admitted to med/surg unit on 1/1/10. He/she was discharged on 1/5/10.
(B) The record lacked documentation that the patient received a bath on 1/1/10, 1/3/10 or that linens were changed on 1/3/10.

6. Facility policy titled "Bed Bath" last reviewed/revised 12/08 stated under policy on page 1: "It is the policy of (facility #1) that every person is to receive a daily bath (unless otherwise ordered) in order to promote a feeling of well being, stimulate circulation and remove secretions, perspiration and microorganisms." Page 3 states "Linen is usually changed after bath." and under documentation on page 3, the policy states: "date and time, type of bath given, patient's response to the procedure..................."

7. Facility policy titled "FALLS PREVENTION PROGRAM" last reviewed/revised 12/09 listed on page 2 for a level II fall risk interventions including, but not limited to, notifying family to request they sit with patient when possible; utilizing bed/chair alarms as indicated and placing increased risk sign at patients room door.

8. Staff member #3 indicated the following in interview at 3:30 p.m. on 1/26/10 and 1:45 p.m. on 1/27/10:
(A) He/she verified the medical record documentation as indicated above.
(B) The facility's practice is to change bed linens on a daily basis.

9. Staff member #7 indicated the following in interview at 11:15 on 1/27/10:
(A) Daily routine with patients includes vitals, daily bath and linen change.

Based on document review and staff interview, the facility failed to ensure transfer paperwork was sent to receiving facility for 2 (#7-8) of 5 patients discharged.

Findings include:

1. Review of patient #7's medical record indicated the following:
(A) The patient was admitted 12/1/09 and discharged to a longterm care (LTC) facility on 12/10/09.
(B) The record lacked documentation of a transfer form.

2. Review of patient #8's medical record indicated the following:
(A) The patient was admitted on 12/20/09 and was discharged to a LTC facility on 1/5/10.
(B) The record lacked evidence of transfer paperwork.

3. Facility policy titled "PATIENT TRANSFER TO ANOTHER FACILITY" last reviewed/revised 12/09 stated on page 2: "6. ...A transfer form must be completed and sent with the patient to the receiving facility." and "8. Transfer forms will be checked for completion and signed by two nurses."

4. Staff member #3 verified the above medical record documentation at 1:45 p.m. on 1/27/10: