HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure clinical staff personnel records contained documentation that demonstrated Patient Rights competencies had been successfully completed during orientation upon hire for 3 (S6CNA, S7CNA, and S8RT) of 7 (S6CNA, S7CNA, S8RT, S9LPN, S10LPN, S11RN, and S12RN) clinical staff reviewed for Orientation with Patient Rights education.
Findings:

Review of personnel files for S6CNA, S7CNA, and S8RT revealed no evidence indicating successful completion and competency regarding Patient Rights education.

During an interview on 08/27/2024 at 11:42 a.m., S1ADM, S2DON, and S13DOQ confirmed there was no evidence indicating successful completion and competency regarding Patient Rights education for S6CNA, S7CNA, and S8RT.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the care for each patient. This deficient practice is evidenced by failing to document a post fall assessment on 1 (#2) of 3 (#1-#3) patients reviewed.
Findings:

Review of hospital policy titled, "Assessment and Reassessment," last approved 05/2023, revealed in part: A. Nursing Documentation: 7. Reassessment of the Patient shall be performed at regular intervals in the course of care by medical and Nursing Staff. Reassessments shall take place when there is a significant change in a Patient's condition or a change in diagnosis.

Review of the hospital policy titled, "Incident Reporting," last approved 05/2023, revealed in part: Procedure: 5. If the occurrence involves a patient/resident injury or fall or potential injury, a Registered Nurse must perform a patient assessment and document the assessment in the medical record. 15. Other actions to be taken after completion of incident report: c. Document the event and follow up assessment and actions in the medical record.

Review of an Incident Report Form revealed, in part, that Patient #2 had an unwitnessed fall on 07/17/2024 at 5:40 p.m. Patient #2 was found on the floor on his knees and had a skin laceration to right knee.

Review of Patient #2's medical record revealed, in part, the patient was a 69 year old admitted to the hospital 07/09/2024. Patient #2 had an admit diagnosis of acute respiratory failure with hypoxia. Further review of Patient #2's medical record failed to reveal documentation regarding the incident of Patient #2 having a fall or documentation of a post fall assessment.

In an interview on 08/26/2024 at 12:31 p.m., S2DON confirmed Patient #2 did not have a post fall assessment completed after the fall on 07/17/2024 or any additional documentation regarding the fall. S2DON also confirmed a post fall assessment should have been completed by the nurse.

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflected the patient's goals and the nursing care expected to meet the patient's needs. This deficient practice was evidenced by failing to update a care plan after a fall for 1 (#2) of 3 (#1-#3) patients reviewed.
Findings:

Review of the hospital policy titled "Incident Reporting," last approved and effective date 05/2023, revealed in part: Procedure: 5. If the occurrence involves a patient/resident injury or fall or potential injury, a Registered Nurse must perform a patient assessment and document the assessment in the medical record. 15. Other actions to be taken after completion of incident report: d. Update the patient's care plan as necessary (i.e: after a fall, after an injury).

Review of Incident Report Form revealed, in part: Admit date 07/09/2024. Date of report 07/17/2024. Report Time: 6:52 p.m., Event Date: 07/17/2024, Time 5:40 p.m. Reporter's Name & Title. S12RN. No witness. Severity Level 3. Location: patient room. Nature of event: fall with injury. Review of Additional Information revealed, in part: Notification. The section for Family/Legal Representative "No" was checked. Overview of incident: CNA found patient on floor on knees, patient stated that he was trying to pull out dirty pad from beneath himself. Patient stated that he rolled off the side of the bed. Side rails x2 in place. Call light in reach. Fire department called to assist staff to get patient off the floor. Clinical supervisor and NP on call notified. Patient alert and oriented x4. Vital signs BP 91/49, HR 66, temperature 98.6, respiratory rate 18, O2 96% on 2L NC. Patient denies LOC or head trauma. Skin laceration to right knee.

Review of Patient #2's electronic medical record revealed no evidence that Patient #2's care plan was updated after a fall on 07/17/2024.

In an interview on 08/26/2024 at 11:44 a.m., Patient #2 stated that he had a fall out of the bed at the hospital trying to reach over. Patient #2 stated that he thinks his sister was notified of incident.

In an interview on 08/26/2024 at 12:42 p.m., S2DON confirmed Patient #2's care plan was not updated after the fall by the nurse, but should have been.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the care for each patient. This deficient practice is evidenced by failing to document a post fall assessment on 1 (#2) of 3 (#1-#3) patients reviewed.
Findings:

Review of the hospital policy titled, "Incident Reporting," last approved 05/2023, revealed in part: Procedure: 11. Notify the immediate supervisor, physician, and family/legal representative and document the name of person notified in each section including the date and time of notification.

Review of an Incident Report Form revealed, in part, that Patient #2 had an unwitnessed fall on 07/17/2024 at 5:40 p.m. Further review of this form revealed the section for family/legal representative notification was blank.

Review of Patient #2's medical record failed to reveal documentation that the family/legal representative was notified of Patient #2 having an incident involving a fall.

In an interview on 08/26/2024 at 12:36 p.m., S2DON confirmed there was no documented evidence that Patient #2's family/legal representative was notified of the fall in the medical record or on the incident report.

Based on record reviews and interviews, the hospital failed to ensure all patient records included a completed discharge summary within 30 days of discharge. This deficient practice was evidenced by failure of the hospital to ensure a delegated discharge summary was co-authenticated with a date to verify its contents for 3 (#1-#3) of 3 patients sampled.
Findings:

Review of Patient #1's medical record revealed an admit date of 06/26/2024 and a discharge date of 07/22/2024. Further review revealed the discharge summary was completed by S5NP and that it was not co-authenticated by a physician.

Review of Patient #2's medical record revealed an admit date of 07/09/2024 and a discharge date of 07/19/2024. Further review revealed the discharge summary was completed by S5NP and that it was not co-authenticated by a physician.

Review of Patient #3's medical record revealed an admit date of 07/10/2024 and a discharge date of 07/19/2024. Further review revealed the discharge summary was completed by S5NP and that it was not co-authenticated by a physician.

During an interview on 08/26/2024 at 3:05 p.m., S2DON confirmed that the above mentioned patients had discharge summaries completed and signed by the midlevel provider and that they were not co-authenticated by a physician.