HospitalInspections.org

Based on document review and staff interviews, the Acute Rehabilitation Hospital failed to document hourly rounding after that change was made in the nursing plan of care in response to a fall for 1 of 1 patients reviewed (Patient #1). Failure to document hourly rounding may have contributed to Patient #1 falling a second time which required transfer to the Emergency Department (ED) for a potential injury. The Acute Rehabilitation Hospital identified an average daily census of 40.

Findings include:

1. Review of Patient #1 medical record revealed:

On 12/01/22, Patient #1 was admitted to the Acute Rehabilitation Hospital for further care after having a stroke, left sided hemiparesis (paralysis of half of the body) with sensory loss. Past medical history included atrial fibrillation (irregular heartbeat, the heart beats faster than normal), hypertension (high blood pressure), and chronic back pain

On 12/4/22 at 6:30 AM, Patient #1 fell out of bed. RN A documented that Patient #1 had been found face down as if they had rolled out of their bed onto their left side. Patient #1 did not sustain any injuries from the fall.

On 12/5/22 at 3:53 AM, RN A updated the care plan to increase the frequency of rounding from every two hours to every one hour (done to ensure patients are safe and their needs are met) from every two hours to hourly.

On 12/10/22 at 12:00 PM, Nursing Assistant (NA) B rounded on Patient #1.

On 12/10/22 RN G documented that Patient #1 had fallen from their bed at 1:34 PM. (This is 1 hour and 34 minutes after previous rounding.) Patient #1 stated that they hit their head.

On 12/10/22 at 2:15 PM, Patient #1 was transferred to Hospital A's ED for further evaluation.

On 12/10/22 at 4:42 PM, MD C documented that Patient #1 had been found on the floor after attempting to get out of bed without calling for help. Patient #1 had hit their head during the fall and had been sent immediately for a Head CT (diagnostic imaging that uses x-ray to take pictures of the inside of the body). Patient #1 had then been sent to Hospital A's ED for further evaluation by a neurosurgeon.

Medical record lacked documentation of hourly rounding between 12/5/22 at 3:53 AM (when the care plan change was documented) until 12/10/22 at 12:00 PM (approximately an hour and a half before Patient #1 fell a second time and was sent to the ED).

2. During an interview on 1/23/23 at 1:35 PM, RN D recalled caring for Patient #1 after their fall on 12/4/22. RN D did not recall if they were the RN that had changed the care plan, but confirmed that the NA's do the rounding, and if the care plan required hourly rounding then that should be documented in the medical record.

3. During an interview on 1/23/23 at 11:30 AM, RN A recalled caring for Patient #1 after their fall on 12/4/22. RN A explained that changes in the care plan would be communicated during report from nurse to nurse and NA to NA. If the care plan required hourly rounding then that should be documented in the medical record.

4. During an interview on 1/23/23 at 10:30 AM, NA E recalled doing hourly rounding on Patient #1 after their fall. NA E remembered that a nurse had told them to keep an eye on Patient #1 because of their fall, and NA E also felt like Patient #1 needed to be watched more frequently. NA E stated that documentation of their hourly rounding should be in the medical record.

5. During an interview on 1/19/23 at 12:50 PM, NA F remembered caring for Patient #1 bit not recall if Patient #1 had had a fall. NA F explained that they learn about their patients during their daily report and discuss all patients who are high risk for falls. Generally, NA F would round every hour on these patients but they would only document their rounding every two hours.

6. During an interview on 1/23/23 at 1:20 PM, NA B confirmed they cared for Patient #1 just prior to their second fall, and recalled Patient #1 had then been sent to the ED. NA B explained they typically do their rounding every two hours, Patient #1 had had an earlier fall so NA B would have been notified of hourly rounding. NA B confirmed that they would be required to document hourly rounding.

7. During an interview on 1/23/23 at 3:45 PM, the Chief Nursing Officer and the Director of Quality Management confirmed that the care plan had been updated to include hourly rounding after Patient #1's first fall on 12/4/22. They also confirmed that the medical record lacked documentation that hourly rounding had been done, and Patient #1 had fallen a second time requiring transfer to the ED for evaluation and treatment.