HospitalInspections.org

Based on document review and interview, it could not be determined that nursing services had adequate numbers of licensed registered nurses (RN), licensed practical nurses (LPN), and other personnel to provide nursing care to all patients as needed for 1 (one) facility.

Findings include:

1. Review of the policy titled Nurse Staffing Plan - non-California, Review Date 1/22, indicated the following:
Policy: To define patient staffing for nursing that will be based on patient acuity and in accordance with state, federal, and accreditation regulations.
Procedure: The licensed nurse-to-patient ratios will be in accordance with the acuity of the patient.
Nurse Staffing Schedules: Nurse staffing requirements and assignments will be assessed and evaluated based on the following demonstrated patient needs (not all inclusive): Ability of patient to care for himself/herself. Patient's degree of illness/acuity. Requirements for special nursing activities.
Patient Staffing System: The daily staffing pattern for each unit is determined by the Nursing Supervisor based on patient status, unit geography, and special care needs of the hospital patients (sic) population, and census of patients.
The policy lacked evidence of an acuity and or census staffing scale, formula or grid.

2. Review of the One Week Staffing Pattern Worksheet for the week of 7/26/22 through 8/1/22 lacked documentation/evidence of patient acuity levels for assignments. Unable to determine appropriate staffing due to lack of an acuity scale and/or census grid.

3. On 8/30/22, beginning at approximately 2:00 PM, A5, Chief Nursing Officer (CNO), indicated nursing no longer uses a staffing grid for assigning number of nurses to patient care. A5 also indicated acuity of patients was not scored nor did the facility have documentation of levels of patient acuity assigned per nurse.

Based on document review and interview, the hospital failed to ensure nursing care was provided in accordance with their hospital policies for 4 of 10 patients (P1, P3, P4, and P10) related to fall risk assessment, fall prevention, post-fall assessment, physician notification, hourly rounding, completing an incident report and return of patient belongings.

Findings include:

1. a. Review of the policy titled Fall Prevention and Management Program, Review Date 1/22, indicated the following:
High Risk Fall Prevention Interventions (not all inclusive): These interventions are designed to be implement for patient with multiple fall risk factors and those who have fallen. Use for those who score High Risk on the Fall Risk Assessment (>45 on Modified Morse Fall Risk Assessment). Nursing staff: Bed and chair alarm. Seat belt alarm. Low bed. Alarms at exits. Nurse Call and communication systems.
Assessment of the patient post fall: Nursing Staff: Assess patient for level of injury. Assess airway, breathing and circulation (ABC). Obtain vital signs and neuro (neurological) checks when appropriate. Assess for range of motion. Alert physician. Assess and treat any injury. Assess and treat for pain. Consider safety devices to prevent further falls. Documentation and Communication (not all inclusive): Complete incident report. Notify supervisor.

b. Review of the policy titled Hourly Rounding, Review Date 1/22, indicated the following: Patient rounding will occur every hour.

c. Review of the policy titled Valuables and Patient Belongings, Review date 1/22, indicated the following: Notification to the patient and family for the valuable to be returned home should also be noted in the Admission Assessment. If the patient does not take their items at discharge, the business office or HIM (Health Information Manager) will attempt to contact the patient and/or family to retrieve their belongings.

2. Review of medical records (MR) indicated the following:
a. The MR of patient P1 indicated the following: The History and Physical (H&P) Assessment/Plan indicated the patient's current level of functioning required maximum assist with transfers, dressing, bathing, ambulation, impaired swallowing. Admission orders included Fall Precautions every shift daily. The Nursing Admission Assessment (NAA) documented belongings included cell phone and jewelry left at bedside. Interdisciplinary Note (IN) dated 7/27/22 initiated at 13:22 hours by Registered Nurse (RN), N2 and signed at 16:06 hours, indicated the following: Patient with episode of fall today. Patient was being assisted by 2 CNAs (Certified Nursing Assistant) for toileting. After he/she was done, patient helped him/herself up and fell onto his/her ankle. I was not around at the event and was attending other patients. No change in neurological condition. Left ankle swollen and cyanotic with decreased left pedal pulses. Report provided to paramedic. Patient transported to ED (Emergency Department) around 14:00 hours. Interdisciplinary Note dated 7/27/22 at 14:26 hours by FNP (Family Nurse Practitioner), NP1, indicated the following: Patient had fell (sic) in BR (bathroom) this afternoon and ankle now with ecchymosis and some deformity. Patient being sent out due to notable injury. Physical Therapy (PT) note dated 7/27/22 at 15:07 hours indicated the following: Patient was found in bed stating he/she attempted to transfer him/herself off of the commode and fell. Patient apparently was left up in bathroom alone. Patient reported felt/heard a pop in his/her ankle very painful to touch and swollen. Physician and nurse practitioner notified and patient to be sent out acutely for assessment of potential ankle injury and therapy placed on hold. Neurological Assessment/Post-fall assessment, signed on 7/27/22 at 16:02 hours by RN N2, lacked documentation of the nurse having performed a full assessment. The note indicated the patient's temperature and oxygen saturation were unable to be taken/obtained before leaving for ED.
The MR lacked documentation of belongings returned to patient or sent with patient and/or family. The MR lacked evidence of CNAs maintaining fall precautions during patient toileting, CNA notification to staff/personnel of patient fall, RN notification to physician and Administration of patient fall, and/or full assessment by a nurse of patient immediately post fall/prior to the patient being moved.

b. The MR of patient P2, indicated the patient was admitted 7/27/22 and discharged 8/15/22. The H&P indicated the patient was admitted to the rehab hospital due to aphasia and impaired mobility. On 7/28/22, Precaution Orders were placed for Fall Precautions every shift. Nursing Shift Assessment dated 7/30/22, indicated the patients FRA score was 35 (moderate risk). Nursing note by RN, N5, indicated the following: Radioed patient on floor at 19:38 hours. Patient found on floor, sitting next to bed. Complained of back upper and lower pain and right leg pain. Abrasion on upper back and lower with some bleeding. Called NP1 and was advised to send out for evaluation. Patient Rounding notes lacked documentation of patient rounding on 7/30/22 from 1904 hours through 7/31/22 at 0300 hours and lacked documentation of Safety Activity/fall precautions implemented.

c. The MR of patient P4, admitted 7/27/22 and transferred/discharged 8/1/22 indicated patient belongings included glasses, kept at bedside. The MR lacked documentation of patient belongings sent with or returned to patient.

d. The MR of patient P10 Nursing Admission Assessment indicated the patient's FRA score was 65 (high risk) and safety measures/fall precautions were to be implemented. Nursing note dated 7/12/22 at 20:43 hours indicated the following: CNA called out for nurse assistance, entered room and patient was standing with cane being assisted to bed, CNA stated he/she was at doorway in the hallway and patient stated he/she had fallen. Stated he/she was trying to get to bathroom, patient previously sitting in chair at bedside. Instructed patient on call light use and needing assistance for toileting. The MR lacked documentation of chair alarm on or sounding prior to fall. Patient Rounding notes by CNA N1, dated 7/13/22, lacked documentation of Safety Activity/fall precautions in place after the fall. The Discharge Summary indicated the following: Discharge Diagnosis: Mental status changes. Evening of admission, patient experienced unwitnessed fall. In the morning, admission day two, mental status changes. Physician recommended sending patient to acute hospital for evaluation. The MR lacked documentation of high risk fall precautions implemented, lacked documentation of an adequate post-fall assessment, and lacked documentation of nursing having notified the physician and/or administration of the fall.

3. Review of Root Cause Analysis of the fall incident for patient P1 indicated the following: RCA and Action Plan indicated the following for "Take Action": Findings: Clinical staff re-education on post fall response and management. Findings: Communication and investigation of the event were not adequate. Delay in treatment due to delay in notification. Action Plan: #1: Staff education of EMR (electronic medical record) driven falls assessment tool including use of clinical judgement, and re-education of all clinical staff on the required and suggested interventions. #2: Clinical staff re-education of post fall response and management. #3: Unusual Occurrence Team initiate meetings 8/5/22. #4: Rapid Response Team procedure implement post fall.

4. Review of re-education documentation indicated only Registered Nurse(s) (RN) N2 and N5, and Certified Nursing Assistant(s) N3 and N4, had re-education. The facility lacked evidence of post fall response and management and/or notification to physician re-education for all clinical staff.

5. On 8/30/22, beginning at approximately 12:00 PM, A3, Health Information Manager, verified the MR of P1 lacked documentation of disposition of patient belongings upon/after transfer/discharge. A3 verified the MR of P1 lacked evidence of CNAs maintaining fall precautions during patient toileting, CNA notification to staff/personnel of patient fall, RN notification to physician and administration of patient fall, and/or full assessment of patient immediately post fall/prior to the patient being moved. A3 also verified lack of documentation of disposition of patient belongings upon/after transfer/discharge for P4 and MR findings for P2 and P10.