HospitalInspections.org

Based on review of medical records and interview with staff. This requirement is not met as follows:

Findings:

In review of 6 medical records reviewed of patient who fell while on the rehabilitation unit, it was observed that 4 out of 6 (66%) medical records reviewed ( MR # 1,2,3 and MR #4) showed falls that were not documented in the medical record appropriately and did not show details of assessments conducted. The nursing care plan did not reflect any changes needed because of the falls or near falls. The nursing care plans were not kept current.

In review of 6 medical records reviewed of patient who fell while on the rehabilitation unit, it was observed that 4 out of 6 medical records reviewed ( MR # 1,2,3 and MR #4) showed falls that were not documented in the medical record appropriately and did not show details of assessments conducted. The nursing care plan did not reflect any changes needed because of the falls or near falls. The nursing care plans were not kept current.


Refer toTag A396 and Tag A397.

Based on Interview and Observation of Complaint and Grievance Policy the this requirement was not met as follows:

Findings:

A. Reviewed Patient Complaint/Grievance policy revised on 11/30/09, it states under grievances that when there are multiple minor complaints for a single complaint, when taken together, would rise to the level of a grievance and trigger the Grievance process set forth in the policy. In this process, it includes logging the grievance into a Grievance log and generating a letter to the complainant that the facility is aware and will look further into the grievance, this is usually sent to the complainant within 5 days of the grievance.

The husband of the patient (Pt #1) complained several times during his wife stay in the facility about concerns for his wife and lack of communication with nursing and physical therapy staff on transferring the patient. He feared that she would fall and further injure herself. This was his main concern along with the other issues like air mattress and air cushions not being provided for the patients wheelchair. It appeared that nursing staff and physical therapy staff tried to address his concerns. In review, the question is left open about following of the facility's grievance policy since in addition the patient had his wife transfer out of the facility because of their dissatisfaction with the nursing staff.


B. In interview with interviewee #5, patient #1 husband, at 10:30am on November 19, 2013, via telephone , he did acknowledge that he did not address with the hospital administration and Quality/Risk management because of his frustration with both nursing services and physician response. But both the nursing staff and physician were fully aware of his and the patients dissatisfaction and concerns. The grievance of the patient #1 and husband was not entered into a Grievance log or letter generated in response to the their grievance in accordance to the Complaint/Grievance policy.


C. In interview with staff #2, Director of Quality, at 9:40am on November 19, 2013, in the Director of Quality's office confirmed that the patient husband multiple complaints were not at a minimum placed in a Grievance log and a letter was not generated to patient #1 and her husband . The patient and her husband decided to transfer the patient from the hospital because of dissatisfaction of care while at the facility. Staff #2 assumed that this was not needed since the nursing staff were addressing their concerns.


D. In review of the patient's medical record, througout the medical records it is documented several concerns of the patient's husband in regards to the patient. These many complaints would be classified as a Grievance according to the hospital's policy and the facility Grievance policy should have been followed.

Based on review of medical records and interview with staff. This requirement is not met as follows:

Findings:

a. In review of 6 medical records reviewed of patient who fell while on the rehabilitation unit, it was observed that 4 out of 6 (66%) medical records reviewed ( MR # 1,2,3 and MR #4) showed falls that were not documented in the medical record appropriately and did not show details of assessments conducted. The nursing care plan did not reflect any changes needed because of the falls or near falls. The nursing care plans were not kept current.


Medical Record #1, 64 y/o female fell on March 16, 2013 0930, nurse and certified nursing assistant (CNA) went into Pt's room because light was going off. "When arrived in room the patient was found on floor with another aid. Aid stated she lowered the patient to the floor. Called Nurse Manager to assist in lifting pt off floor. Pt did not get hurt. Will monitor."

The patient required a 2 person assist as per physician order and the CNA tried to assist in transferring the patient to the bathroom alone resulting in the fall incident. The day before on March 15, 2013, there was a mishap where the patient became unstable while the staff was lifting her from the toilet. The patient leaned on the wall for support according to the staff and they were quickly able to balance her. The patient told staff said she was ok. The patient told her husband (who was not in the room or area) that she hit her head on the tile wall when she became unstable while staff were assisting her. There was no documentation of this found in the nursing notes, it was found through interview with staff #11, House supervisor, and documented in the House Supervisor notes. This was also confirmed in an interview with staff #12, CNA who assisted with a license vocational nurse (LVN) in transferring patient to bathroom on March 15, 2013. There was no documentation in the patient's medical record.

Staff #11 did assess patient and spoke to patient's husband about what happen to clear his concerns about the patient allegation that she was injured as a result of hitting her head on the tile wall while being assisted from the toilet. The patient's nursing care plan did not reflect event and also was not kept current on both the exception on March 15, 2013, and the actual fall incident on March 16, 2013.


Medical Record #2, 85y/o female, fell on March 2, 2013. The patient tried to get up without assistance. Incident report states she was assisted to floor. Patient denied pain. Vital signs were stable and patient was afebrile. Nurse practitioner and family were aware.

In review of the medical record there was no documentation of this patient's fall in the nursing notes. It was referred to in the physical therapy notes as a fall that had happen . This should have been captured in the nursing notes with full explanation of the follow-up assessment provided. This was the second fall for the patient in the month of March 2013, the 1st fall happen on March 1, 2013.


Medical Record #3, 60 y/o male, fell on March 26, 2013. Incident report said the patient was found lying prone on the floor. States he was getting up to go to the bathroom. No injuries/abrasions noted. The patient able to more right lower extremity (RLE) with equal strength prior to fall. Vital signs stable, MD notified.

In review of nursing documentation in the medical record on the date of the fall March 26, 2013. There was no documentation of this fall demonstrating fall, assessment and follow-up of fall.


Medical Record #4, 85 y/o female, fell on March 21, 2013. Incident report said the patient fell out of bed, bed alarmed, 2 staff went to room, found patient on floor right side of bed. Vital signs stable, alert and oriented times 3, Oxygen saturation at 96% on 2: oxygen through nasal cannula, small bump on right side of head-ice applied. Physician and family notified.

In review of the patient ' s medical record the fall is documented but there is no documentation of the follow-up assessment of the patient ' s injury. In the physical therapy notes it documents about the patient hitting her head and having a " bump " on her head from a fall. There was no evidence of any follow up treatment i.e. radiological exams, etc.


Two of the patient medical record of Falls for March 2013 had fell twice during the month:

Patient #5, fell on March 27, 2013 (found sitting on floor in bathroom) and March 28, 2013 (found on bathroom floor)

Patient #6, fell on March 7, 2013 (found on floor) and fell on March 29, 2013 (found on bathroom floor)

In all events it was documented on the incident reports but the patient nursing care plans in the medical record did not reflect any changes of care as a result of the falls. They were not kept current.



b. On November 20, 2013, at 1:20pm, in the administration boardroom interviewed staff #4 RN, Director of Nursing and reviewed medical records with staff #4 pointing out discrepancies in records. She explained the current fall protocol and incident reporting from the nursing perspective. Spoke to Staff #4, DON about areas that could use improvement especially in nursing documentation.

Interviewed Staff #4, Director of Nursing again at 2:20pm on 11.20/13, in the administration office who reviewed some of the other patient medical records of patients who fell in March 2013. Medical records (MR #2-4). Staff #4 recognized the inappropriateness of nursing documentation of falls. Many of the nursing notes lacked details of assessment and follow- up of the falls. It was not well documented in physician notes either of actions taken because of falls. Most notes said physician was notified but no other actions taken. Staff #4 agreed that documentation was inappropriate the nursing care plans were not kept current and she could not show were the medical records with discrepancies met this requirement.

Based on review of medical records and interview with staff. This requirement is not met as follows:

Findings:

a. In review of 6 medical records reviewed of patient who fell while on the rehabilitation unit, it was observed that 4 out of 6 medical records reviewed ( MR # 1,2,3 and MR #4) showed falls that were not documented in the medical record appropriately and did not show details of assessments conducted. The nursing care plan did not reflect any changes needed because of the falls or near falls. The nursing care plans were not kept current.


Medical Record #1, 64 y/o female fell on March 16, 2013 0930, nurse and certified nursing assistant (CNA) went into Pt ' s room because light was going off. "When arrived in room the patient was found on floor with another aid. Aid stated she lowered the patient to the floor. Called Nurse Manager to assist in lifting pt off floor. Pt did not get hurt. Will monitor."

The patient required a 2 person assist as per physician order and the CNA tried to assist in transferring the patient to the bathroom alone resulting in the fall incident. The day before on March 15, 2013, there was an mishap where the patient became unstable while the staff was lifting her from the toilet. The patient leaned on the wall for support according to the staff and they were quickly able to balance her. The patient told staff she was ok. The patient told her husband (who was not in the room or area) that she hit her head on the tile wall when she became unstable while staff were assisting her. There was no documentation of this found in the nursing notes , it was found through interview with staff #11, House supervisor, and documented in the House Supervisor notes. It was also confirmed in an interview with staff #12, CNA who assisted alone with a license vocational nurse (LVN) in transferring patient to bathroom on March 15, 2013. There was no documentation in the patient's medical record. Staff #11 did assess patient and spoke to patient's husband about what happen to clear his concerns about the patient allegation that she was injured as a result of hitting her head on the tile wall while being assisted from the toilet. The patient's nursing care plan did not reflect event and also was not kept current on both the exception on March 15, 2013 and the actual fall incident on March 16, 2013.


Medical Record #2, 85y/o female, fell on March 2, 2013. The patient tried to get up without assistance. Incident report states she was assisted to floor. Patient denied pain. Vital signs were stable and patient was afebrile. Nurse practitioner and family were aware.

In review of the medical record there was no documentation of this patient's fall in the nursing notes. It was referred to in the physical therapy notes as a fall that had happen . This should have been captured in the nursing notes with full explanation of the follow-up assessment provided. This was the second fall for the patient in the month of March 2013, the 2nd fall happen on March 1, 2013.


Medical Record #3, 60 y/o male, fell on March 26, 2013. Incident report said the patient was found lying prone on the floor. States he was getting up to go to the bathroom. No injuries/abrasions noted. The patient able to more right lower extremity (RLE) with equal strength prior to fall. Vital signs stable, MD notified.

In review of nursing documentation in the medical record on the date of the fall March 26, 2013. There was no documentation of this fall demonstrating fall, assessment and follow-up of fall.


Medical Record #4, 85 y/o female, fell on March 21, 2013. Incident report said the patient fell out of bed, bed alarmed, 2 staff went to room, found patient on floor right side of bed. Vital signs stable, alert and oriented times 3, Oxygen saturation at 96% on 2: oxygen through nasal cannula, small bump on right side of head-ice applied. Dr. Montenegro and family notified.

In review of the patient ' s medical record the fall is documented but there is no documentation of the follow-up assessment of the patient ' s injury. In the physical therapy notes it documents about the patient hitting her head and having a " bump " on her head from a fall. There was no evidence of any follow up treatment i.e. radiological exams, etc.

Two of the patient medical record of Falls for March 2013 had fell twice during the month :

Patient #5, fell on March 27, 2013 (found sitting on floor in bathroom) and March 28, 2013 (found on bathroom floor)

Patient #6, fell on March 7, 2013 (found on floor) and fell on March 29, 2013 (found on bathroom floor)

In all events it was documented on the incident reports but the patient nursing care plans in the medical record did not reflect any changes of care as a result of the falls. They were not kept current.



b. On November 20, 2013, at 1:20pm, in the administration boardroom interviewed staff #4 RN, Director of Nursing and reviewed medical records with staff #4 pointing out discrepancies in records. She explained the current fall protocol and incident reporting from the nursing perspective. Spoke to Staff #4, DON about areas that could use improvement. Especially nursing documentation.

Interviewed Staff #4, Director of Nursing, again at 2:20pm on 11/20/13, in the administration office who reviewed some of the other patient medical records of patients who fell in March 2013. Medical records (MR #2-4). Staff #4 had reviewed some of the files earlier in the day and recognized the inappropriateness of nursing documentation of falls. Many of the nursing notes lacked details of assessment and follow- up of the falls. It was not well documented in physician notes either of actions taken because of falls. Most notes said physician was notified but no other actions taken. Staff #4 agreed that documentation was inappropriate the nursing care plans were not kept current and she could not show were the medical records with discrepancies met this requirement.



c. In review of the medical record there was no evidence provided that demonstrated the patient received physician order document on On March 17, 2013 at 0850 (8:50am) when a verbal order was received "Air mattress for bed" and "pressure relief pad for wheelchair." There was no documented evidence in the medical record that the patient received the air mattress for her bed or the pressure relief pad for her wheelchair.

There was a Physical Therapy Daily Treatment Note on 3/17/13 at 10:30 - 12:00 stated, "Pt & SP concerned about sheet for air mattress ...W/C issues: switch foam cushion out for air cushion per MD orders." It was not clear "if or when" the patient received this ordered and staff interviewed could not verify when asked.



d. In review of the Texas Nurse Practice Act ?217.11. Standards of Nursing Practice, it states, in part:

"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...

(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered; ...
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status"



e. Interviewed staff # 11, House Supervisor, at 8:30pm on December 3, 2013, via telephone. Staff #11, explained what happen around change of day to night shift on March 15, 2013. When the two staff members tried to assist the patient #1, 64 year old female to the bathroom. She explained how the two staff members were assisting in elevating the patient from the toilet and she lost her balance and had to leaning on the wall on her left side for support. The staff members were able to re-stabilize her and aid her off the toilet and back to the bed. The patient told her husband that when she leaned over she hit her head on the wall. The staff said that she did not fall and asked her if she was okay and she said she was fine. Staff 11 documented it in the House supervisor notes but it was not documented in the nursing notes.

Staff #11 said she reviewed the patient record and saw also that there was no nursing notes on the what happen in the bathroom on March 15, 2013. She said she thinks it had to do with the fact that this happen during the change of shift. But she (staff #11)did document this in her House supervisor ' s notes. She said the patient never fell but while 2 staff members were assisting her she did get off balance and kind of lean on the side against a wall for additional support but the staff sturdy her and balanced her off of the toilet. She said the physician was informed of what happened in the bathroom. There was no appropriate documentation in the patient's medical record.