HospitalInspections.org

Based on observation, interview, record review and policy review the facility failed to complete a comprehensive assessment upon admission or complete a patient reassessment after patient was found outside in below freezing temperatures for one (#4) of one patient observed. This had the potential to affect all patients in the facility for safety concerns. The facility census was 26.

Findings included:

1. Record review of the facility's policy titled, "INITIAL ASSESSMENT" revised 10/05, gave the following direction to staff:
- Every discipline assesses the patient if indicated;
- Nursing is the coordinator of the assessment process;
- A Registered Nurse [RN] completes all screens for all disciplines and the outcomes of these screens determine the need and timing of further assessment by other disciplines.
- An assessment identifies the patient's immediate and emerging needs, and considers those needs broadly - not only physiological status but psychosocial and social concerns too. This initial assessment helps staff determine what care the patient needs as well as any further assessments. The information collected at the first patient contact may indicate that the patient needs a broader or more detailed assessment.
- PROCEDURE: The admitting RN completes the patient admission assessment and screens that might generate a need for an assessment by another discipline and completes the pain and safety screens. The patient admission assessment will be completed with problems identified and prioritized within 24 hours of inpatient admission.
- Interdisciplinary Patient Care Team: Continually evaluate patients response to interventions and assess for changing needs.

Record review of the facility's policy titled, "Nursing Policy and Procedure Manual, Fall Prevention" dated 07/12, gave the following direction:
- POLICY: All patients admitted to the facility are assessed to determine their risk of experiencing a fall. The appropriate precautions will be initiated and maintained.
- ASSESSMENT: Initiate high fall risk precautions based on assessment and nursing judgment and document rationale.
- Complete the assessment tool: Upon admission and daily; whenever there are changes in patient's functional or cognitive status.

2. Record review of the Patient #4's medical record showed:
- Patient was admitted to facility on 12/14/12 for a non-healing sternal (over the breast bone) surgical wound;
- The Admit Interdisciplinary Education Record showed the patient had "Some understanding of basic information";
- Assessment of Education needed for Orientation to facility and patient room;
- Required education on fall prevention; pain management and nutrition.
- Activity/Mobility assessment showed the patient with impaired gait; impaired bed mobility; impaired ability to transfer and impaired balance or coordination.

The patient's medical record did not reflect initial assessment for cognition or fall risk.

3. Record review of the Nurses Progress Notes for Patient #4 dated 01/23/13 at 4:15 AM showed that the patient had exited the facility through an alarmed ambulance entrance without the ability to reenter the building through the same door as it is armed with code access only.

4. During a telephone interview on 01/29/13 at 8:30 PM, Staff M, RN, stated that she heard the alarm and found Patient # 4 outside waving at her through a window. The patient wore pajama bottoms, socks and a shirt. She stated the patient told her he was looking for his brother. She stated the patient's brother is deceased.

5. Record review of the National Weather Service data showed the outside temperature at 3:51 AM on 01/23/13 was 15.1 degrees Fahrenheit (F) and the wind speed was 6.9 miles per hour (mph). The temperature at 4:51 AM on 01/23/13 was 14.0 degrees F and the wind speed was 5.8 mph.

6. Record review of the facility's "Nurses Progress Notes" dated 01/23/13 at 4:15 AM stated, "The patient was confused when asked why he went out in the cold. He agreed it was cold. He said he was looking for his brother. Educated patient on dangers of being outside in the cold without proper clothes on. He apologized, I believe he understood".

7. During an interview on 01/29/13 at 10:20 AM, Patient #4 was oriented to person but not to place, time, day, date or year. He stated that he didn't remember going outside but he probably did and maybe just wanted to go for a walk. Patient #4 said he didn't know what door he exited from and didn't remember it being cold. He stated that he was in the facility for his head but couldn't verbalize what was wrong with his head. He said that the High Risk for Falls notice over his bed had been there the whole time but couldn't explain why.

8. Record review of the patient's daily nursing flow sheets from the patient's admission on 12/14/12 to 01/29/13 documented he had a cognitive deficit (lethargy, agitation, confusion, disorientation, poor judgment) 29 times, no deficit 12 times and no assessment of cognitive deficit eight times.

This would account for approximately 50 percent of his inpatient stay.

Further review of the medical record showed that staff did not reassess the patient after the incident for a change in condition or implement new safety interventions. These failures leave the potential for the incident to reoccur and further threaten the safety of the patient.

9. During an interview on 01/29/13 at 12:18 PM, Staff B, RN, Director of Nursing, stated that she was aware of the incident with Patient #4 on 01/23/13 and that she had began her investigation on 01/29/13 and it would be completed by 02/12/13. She had no explanation as to why the Patient had not been reassessed or why no further assessments for safety had been put into place.



27727

Based on observation, interview and record review the facility failed to develop a comprehensive and individualized Plan of Care as directed by facility policy for one (Patient #4) of one patient observed that addressed cognition, falls, or safety. Staff also failed to revise the Plan of Care after the patient was found outside in below freezing temperatures. The facility census was 26.

Findings included:

1. Record review of the facility's policy titled, "INTERDISCIPLINARY PATIENT CARE PLANNING" #TX.1200 revised 09/09, showed the following direction:
-Purpose: To provide a comprehensive, goal-directed plan of care for patients utilizing a collaborative, interdisciplinary approach to assure coordination of care and planning to meet patient care goals and achieve optimal outcomes.
- Directive: Each patient shall have a comprehensive plan of care, which ensures that the patient's care needs are met or referred.
- The care plan will be initiated by the registered nurse [RN] and areas of primary concern will be identified. Initiating, updating and changing to the plan of care will be addressed as warranted by the appropriate discipline. The mix of disciplines involved and the intensity of the collaboration will vary as appropriate to each patient.
- Process: Upon admission, the RN shall initiate the appropriate Care Plans according to the assessment/evaluation of each body system. The care plan will include a problem, intervention and an expected goal.
- The care plan is reviewed and updated (if indicated) every shift by the RN/LPN (licensed practical nurse). The signature of the nurse on the care plan will indicate that the care plan was reviewed.
- Each entry will require date/time, problem (focus), interventions, goal for this admission, and signature of discipline completing this documentation.

2. Record review of the Nurses Progress Notes dated 01/22/13 showed Patient #4 to be "intermittently confused". Review of the Notes on 01/23/13 at 4:15 AM by Staff M, RN, documented the following, "I went to obtain ice for all my patients, another RN was at the nurses' station; when I came back no one was at the nurses' station. I proceeded towards the med [medication] room when I heard an alarm. Went to investigate and found the noise coming from the back door. Further investigation found Patient #4 outside, peering into the window. The patient was confused; when asked why he went out in the cold, he agreed it was cold. He said he was looking for his brother."

3. Record review of the Patient's daily nursing flow sheets from the patient's admission on 12/14/12 to 01/29/13 documented he had a cognitive deficit (lethargy, agitation, confusion, disorientation, poor judgment) 29 times, no deficit 12 times and no assessment of cognitive deficit eight times.

This would account for approximately 50 percent of his inpatient stay.

Further review of the medical record showed that staff did not reassess the patient after the incident for a change in condition or implement new problems, safety interventions or goals. These failures leave the potential for the incident to reoccur and further threaten the safety of the patient.

4. Record review of Patient #4's Plan of Care in the medical record showed the plan of care was initiated on 12/14/12 - the day of the patient's admission. The care plan assessed the following areas:
- Interdisciplinary Patient Education - initialed daily and shows no barriers to learning and only one instance of safety education on 01/23/13;
- Discharge Planning - initialed daily but without a problem, intervention or patient goal;
- Gastrointestinal - initialed daily and does include problems, interventions and patient goals;
- Activity/Mobility - initialed daily and includes problems, interventions and patient goals;
- Cardiovascular - initialed daily and includes problems, interventions and patient goals.

The Plan of Care did not include the patient's cognition even though the nurses documentation in the nursing flow sheets stated the patient was confused 50 percent of the time. The Plan of Care did not include patient safety even after the date of 01/23/13 (date of the incident), no new interventions, and no new goals regarding safety.

5. During an interview on 01/29/13 at 12:18 PM, Staff B, RN, Director of Nursing, stated that she was aware of the incident with Patient #4 on 01/23/13 and that she had not identified the incident as a safety concern. She had no comment as to why the patient's care plan did not reflect cognition and safety problems, interventions, or goals.




27727