North Dakota State Hospital

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 42397 Based on record review, facility policy review, professional literature review, and staff interview, the Hospital failed to ensure nursing supervision and appropriate assessment occurred for 5 of 6 patient records (#4, #5, #19, #24 and #31) who had falls with head injury. Failure of staff to appropriately assess the neurological status of patients after a fall with head injury may delay identification and possible treatment of signs/symptoms or worsening of injury. Findings include: Review of the facility policy titled “Neurological Assessment” occurred on 01/09/24. This policy, revised June 2021, stated, “. . . nursing will assess neurological function for clients who have had a change in neurological function or have had a known or assumed head injury (i.e. [example] due to a fall) . . . PROCEDURES: Every 15 minutes x [times] 4 . . . Every 30 minutes x 2 . . . Every 60 minutes x 2 . . . Every 2 hours x 2 . . . Every 8 hours x 3 . . . Monitoring should be at a minimum of 72 hours (or until the client is asymptomatic for 24 hours) . . .” Bell, Lee, Zeeman, Kearney, Macko, & Cartwright’s, “Neurological Assessment of the Adult Hospitalized Patient” aann.org. Published 2021. Accessed January 23, 2024. https://aann.org/uploads/about/AANN21_Neuro_White_Paper_V9.pdf, stated, “. . . Timely and accurate assessment of a patient’s neurological status is an important aspect of nursing care . . . Nurses are instrumental in preventing irreversible damage by identifying in patients subtle changes from baseline that could signal deterioration . . . gait impairment could suggest an underlying neurological deficit. . . .” Lerner, Shepherd, & Batra, “Hyponatremia in the Neurologically Ill Patient: A Review” Neurohospitalist. Published July 10, 2020. Accessed January 25, 2024. https://doi.org/, stated, “. . . Hyponatremia is associated with up to a 60% increase in mortality when present following acute brain injury . . . Hyponatremia is defined as serum sodium concentration of <135 mEq/L [less than 135 milliequivalents per liter]. . . . Syndrome of inappropriate antidiuretic hormone [SIADH] is a disorder of inability to suppress the secretion of ADH resulting in impaired water excretion. . . . There are multiple causes of abnormal ADH release and these can be grouped into several categories: central nervous system (CNS) disturbance . . . Central nervous system disturbances including . . . trauma . . . can enhance ADH release due to direct hypothalamic and pituitary dysfunction. . . . Hyponatremic encephalopathy is the term broadly used to define neurological dysfunction during hyponatremia. . . . The early findings of hyponatremic encephalopathy include impairment in gait and attention. Other . . . early symptoms include headache, nausea, lethargy, confusion, and even agitation. . . .” - Review of Patient #4’s medical record occurred on 01/08/24. Diagnoses included vascular dementia and schizophrenia. A post fall assessment note, dated 11/12/23 at 7:30 p.m., stated, “. . . fell forward and hit head on floor . . . [approximately] 1” [inch] laceration (R) [right] forehead. . . . pt. [patient] to ER [emergency room] for eval. [evaluation]. . . .” Patient #4’s medical record showed the patient transferred to the emergency room at 8:14 p.m. A clinical staff note on 11/13/23 at 2:01 a.m., stated “. . . patient returned . . .” The medical record showed facility staff performed neurological assessments at 7:35 p.m., 7:50 p.m., 8:05 p.m., and 11:40 p.m. The record lacked documentation of neurological assessments completed per facility policy or provider’s orders for specific neurological assessments. - Review of Patient #5’s medical record occurred on 01/08/24. Diagnoses included schizoaffective disorder, bipolar type, and cervical disc disease. A post fall assessment note, dated 12/05/23 at 6:50 p.m., stated, “Loud bang heard from client’s room. . . . found trying to get into her wheelchair. On the back right side of her head is a laceration, approximately one inch in length. . . . Bruising around the laceration started immediately. While checking her pupils, it was noted that there was a difference between the right and the left. The left pupil was approximately 8 mm [millimeters], not reactive to light, and the right pupil was approximately 4 mm, reactive to light. There was a slight abnormal shape to the left pupil. Dr. . . . notified and it was determined that . . . will go to the ER for evaluation. . . . left with [staff names] to [emergency room name] @ [at] 1942 [7:42 p.m.] . . .” Patient #5’s medical record showed the patient returned to the facility at 11:25 p.m. and facility staff performed neurological assessments on 12/05/23 at 7:00 p.m., 7:15 p.m., 7:30 p.m., 11:35 p.m., and on 12/06/23 at 12:35 a.m., 2:35 a.m., and 4:30 a.m. The record lacked documentation of neurological assessments completed per facility policy or provider’s orders for specific neurological assessments. - Review of Patient #19’s medical record occurred on 01/08/24. Diagnoses included dementia with behaviors. A post fall assessment, dated 08/05/23 at 4:39 p.m., identified the patient fell and hit the top of his head with bleeding noted. A medical provider’s order stated staff to complete neurological checks for one hour, and if no abnormal indications, discontinue. Staff performed one neurological assessment at 4:53 p.m. The record lacked assessments for the ordered one hour. - Review of Patient #24’s medical record occurred on 01/08/24. Diagnoses included bipolar disorder and diabetes mellitus. A post fall assessment note, dated 12/08/23, identified an unwitnessed fall occurred on 12/04/23 at approximately 2:58 p.m. The note indicated the patient was a poor historian and required steri-strips to the head area. Staff completed neurological assessments at 2:58 p.m., 3:50 p.m., 4:29 p.m., 4:45 p.m., 5:15 p.m., 5:40 p.m., 6:45 p.m., and 7:44 p.m. The record lacked documentation of neurological assessments completed per facility policy or provider’s orders for specific neurological assessments. - Review of Patient #31’s closed record occurred on all days of survey. The facility admitted Patient #31 on 06/09/23 with diagnoses of vascular dementia with behavioral disturbances, schizophrenia spectrum and other psychotic disorders, and major depressive disorder. A post fall assessment note, dated 11/06/23 at 2:11 p.m., stated, “. . . Time of event: 12:00 p.m. . . . was walking backwards wrapped in blanket, client tripped over an unoccupied wheelchair . . . hit head on floor, neurochecks initiated. LIP [licensed independent provider] notified . . .” The medical record identified Patient #31 had additional falls on 11/06/23 at 8:54 p.m., 11/08/23 at 12:50 p.m., 11/09/23 at 4:10 p.m., and 11/11/23 at 8:40 p.m. Patient #31’s clinical staff notes stated the following: * 11/06/23 at 8:54 p.m., “. . . noted on floor in room after roommate came and got staff that client was on floor . . . client refused [sic] hitting head. LIP notified. Client verbalized that she was feeling tired . . . already on neurochecks for prior fall. Checks completed and WNL [within normal limits] . . .” * 11/06/23 at 9:58 p.m., “. . . sat on floor in room next to bed. Saying she doesn’t know whats [sic] going on with her . . . brought to the nurses station for closer monitoring.” * 11/11/23 at 8:41 p.m., “. . . was tripped by other client via stretching out her leg. Fall was reported by client and other client who witnessed incident. Head to toe assessment completed. No injuries noted. client also refused [sic]and pain at this time. LIP notified . . .” * 11/12/23 at 7:41 a.m., “. . . Roommate alerted staff to patient on the floor and that she threw up. patient denied falling. . . Very vague concerns. . . LP [licensed provider] notified . . . “ 11/12/23 at 9:42 a.m., “. . Pt noted to be very unsteady this AM and needed to use a walker with staff assist to ambulate safely - VS [vital signs] WNL - pt denies any specific complaints and only says, ‘Im [sic] nervous’ but cant [sic] specify as to why. Posture noted to be quite rigid as well with tremors noted to hands. Dr. . . up to assess - pt placed on 1:1 [one to one] for safety . . .” * 11/12/23 at 1:15 p.m., “. . . At lunchtime, it was noted that the client was not able to walk to the lunch room, could not lift her spoon to eat, and was not responding appropriately to questions. She tried to drink and dropped her cup. The client also had left side weakness in her arm and hand and a slight droop to her left side of mouth. Dr. . . . was notified at 1215 [12:15 p.m.] of these changes and assessed the client in the dining room at 1227 [12:27 p.m.] . . . Dr. [name] called 911 and ambulance arrived at 1255 [12:55 p.m.]. Client left facility via EMS [emergency medical services] at 1307 [1:07 p.m.] . . .” * 11/12/23 at 3:29 p.m., “. . . Based on these changes we called [critical access hospital] to have her evaluated on an emergency basis. Received a call around 2:50 p.m. from [provider name] at [critical access hospital] that [Patient #31] was found to have hyponatremia [low blood sodium level] . . . also was assessed to have a skull fracture and contusion [bruise] on the back of her head. He informed this writer that [Patient #31] was being transferred to [acute care hospital] via ambulance . . .” Patient #31’s medical record showed facility staff performed neurological assessments on 11/06/23 at 12:00 p.m., 12:15 p.m., 12:30 p.m., 12:45 p.m., 1:15 p.m., 1:45 p.m., 2:15 p.m., 2:45 p.m., 3:45 p.m., 4:45 p.m., 6:45 p.m., and 8:45 p.m. The record lacked documentation of neurological assessments completed per facility policy or provider’s orders for specific neurological assessments. The facility discharged Patient #31 on 11/13/23 to an acute care hospital. Review of Patient #31’s Discharge Summary from [acute care hospital] dated 11/22/23 at 1:35 p.m., stated, “. . . Discharge Diagnoses . . . Severe hyponatremia . . . Acute encepahlopathy . . . found to have bilateral subdural hematoma [pool of blood between the brain and its outermost covering] as well as occipital fracture [fracture at base of skull]. Sodium levels were also noted to be significantly low at 113. . . MRI [magnetic resonance imaging] brain with and without contrast showed . . . right frontal lobe hemorrhagic contusion . . . subdural hygromas . . . hyponatremia felt to be secondary to SIADH . . .” During an interview on 01/09/24 at 1:40 p.m., administrative nurse (#1) stated she expected nursing staff to complete neurological assessments for at least 24 hours on patients who had a fall with head injury unless specific provider’s orders directed otherwise. The facility nursing staff failed to appropriately assess the neurological status of patients who had falls with head injuries and may have delayed the treatment of Patient #31’s significant head injury. 32641”