HospitalInspections.org

Based on review of hospital policies and procedures, review of the Governing Board Bylaws and meeting minutes, review of internal hospital reports, review of clinical records and staff interviews, it was determined that the Governing Body failed to ensure that the hospital operations and hospital functions provide a safe environment for the patient population.

Cross Reference: A-0047 The hospital failed to ensure that the Governing Body implemented and monitored the effectiveness of the Medical Staff Bylaws in providing, monitoring, and addressing quality patient care issues such as the increased falls in the facility from 01/01/2023 through 02/25/2023.

Cross Reference: A-0049 The hospital failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to patients in the facility by addressing, monitoring, and reviewing the efficacy of the fall prevention techniques in the facility and fall data in preventing future patient related falls.

Cross Reference: A 0129 The hospital failed to ensure proper handling and access of patient belongings were implemented and or followed by the facility personnel, which could potentially lead to undetected misappropriation of the patient personal and private property by facility personnel.

Cross Reference: A 0144 The hospital failed to provide an environment protecting patients from falls, addressing patient falls, and evaluating fall prevention tools of its usability to prevent future patient falls.

Cross Reference: A 0171 The hospital failed to ensure that each patient order for seclusion follows the CMS limitations of 4 hours for adults 18 years of age or older and outlined in the facility's policies and procedures to ensure the unnecessary or unlawful use of seclusion by staff that could result in patient harm.

Cross Reference: A 0273 The hospital failed to ensure that a method to measure, analyze, monitor, and track quality indicators, such as patient falls, and an ongoing program is in place for evaluation to improve the health and safety of patients while in the facility.

Cross Reference: A0286 The hospital failed to ensure that a consistent and measurable improvement of patient falls were analyzed and track along with the active involvement of the governing body to address the increased number of patient falls in the facility from 01/01/2023 through 02/25/2023.

Cross Reference: A-0353 The hospital failed to ensure that the providers followed and implemented the authentication process approved by the governing body, which is to authenticate orders within 72 hours to ensure physician orders are correct, legible, and followed by hospital staff.

Cross Reference: A 0386 The hospital failed to assign a Director of Nursing Services to establish policies and procedures that are effective in providing quality patient care, to monitor nursing staffing requirements based on patient care needs, and to oversee the overall efficacy of the nursing operations in the facility.

Cross Reference: A0392 The hospital failed to ensure patient care units were staffed according to policy and patient acuity to ensure safe staffing is provided through an appropriate number and skill mix of personnel to ensure patient safety.

Cross Reference: A 0396 The hospital failed to ensure that nursing care plans are current, updated, and patient-specific to effectively provide quality care depending on patient condition and needs.

Cross Reference: A0454 The hospital failed to require that verbal or telephone orders given by a medical provider were authenticated, to include the medical provider's signature, the date and time signed, and performed within the required seventy-two (72) hours as stated in the Medical Staff Rules and Regulations after the verbal or telephone order was given to ensure patients receive accurate care and treatment.

Cross Reference: A 0468 The hospital failed to ensure that a discharge summary is available in each of the patient's medical records to describe the patient's prognosis, medical condition, medical services provided during patient admission to the facility, and follow-up services needed by a patient upon discharge are outlined to ensure the continuity of patient care is provided in the outpatient setting when necessary.

Based on review of facility documents, and interviews, it was determined that the hospital failed to ensure that the Governing Body implemented and monitored the effectiveness of the Medical Staff Bylaws in providing, monitoring, and addressing quality patient care issues such as the increased falls in the facility from 01/01/2023 through 02/25/2023.

Cross reference: A0043, A0049, A0338, A0353

Findings Include:

1. Hospital document titled "Medical Staff Bylaws" revealed: "...Medical Executive Committee ...8.2 FUNCTION When approval of procedural details related to credentialing, corrective action, or selection and duties of leadership are delegated to the MEC, it shall represent to the Board the organized Medical Staffs view on issues of patient safety and quality of care ...(a). Receiving and acting upon committee reports ...11.1 STAFF RULES AND REGULATIONS AND POLICIES. Subject to approval by the Board, Medical Staff shall adopt Rules and Regulations, and policies necessary to implement more specifically the general principles found within these Bylaws .... No one document will supersede another. Instead, they will work congruently ...."

Hospital document titled " Incident Report Log " revealed: "21 falls documented from 01/01/2023 through 02/25/2023."

A review of Governing Board Meeting Minutes Quarter 1, dated 04/25/2022, Quality/PI, did not reveal any discussion/s regarding patient falls. Responsible Party and Due date not completed. No Performance Improvement studies were documented for the 1st quarter 2022.

A review of Governing Board Meeting Minutes Quarter 2, dated 08/08/2022, revealed Falls:4.9 June. Responsible Party and Due date not completed. Opportunities for possible improvement not documented. No performance improvement studies were documented for the 2nd quarter 2022.

A review of Governing Board Meeting Minutes Quarter 3, dated 10/07/2022, revealed, Falls: July 13, August 11, and Sept. 9. Responsible Party and Due date not completed. Opportunities for possible improvement not documented.

A review of the Quality Council Meeting Minutes dated 10/27/2022 revealed: Quality/PI Falls: July 13, August 11, Sept. 9. Responsible Party and Due date not completed. No performance improvement studies were documented for the this quarter.

A review of the Quality Council Meeting Minutes dated 02/15/2023 revealed that no discussions regarding the ongoing patient falls and how to further prevent this from happening for review.

Based on observation, record review, and interviews, the hospital failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to patients in the facility by addressing, monitoring, and reviewing the efficacy of the fall prevention techniques in the facility and fall data in preventing future patient related falls.

Cross reference: A0043, A0047, A0338, A0353

Findings Include:

Hospital document titled "Medical Staff Bylaws" revealed: "...9.3 (b) QUALITY COMMITTEE. The Medical Staff Quality Committee will pursue Hospital quality initiatives and select cases for Medical Staff Bylaws ...(d) Fulfilling the Medical Staffs' accountability to the Board of the quality of overall medical care rendered to the patients in the Hospital ...(f) Assuring regular reporting of QAPI and other staff issues to the Board as well as communicating findings, conclusion's, recommendations and actions to improve performance to the Board and appropriate Medical Staff members ...."

Hospital document titled "Incident Report Log" revealed: "21 falls documented from 01/01/2023, through 02/25/2023.

Hospital document titled "Incident Report" revealed: A Patient Fall Evaluation is to be completed with the incident report after a patient fall. Upon review of 17 patient incident reports after a fall., only 3 patient reports had the additional patient fall evaluation.

Hospital documents "Incident Reports": 13 out of the 21 incident reports reviewed did not contain documentation that the incident was reported to Risk Management or the Quality Director.

A review of Governing Board Meeting Minutes Quarter 1, dated 04/25/2022, Quality/PI, did not reveal any discussion regarding patient falls. Responsible Party and Due date not completed

A review of Governing Board Meeting Minutes Quarter 2, dated 08/08/2022, revealed Falls:4.9 June. Responsible Party and Due date not completed. Opportunities for possible improvement not documented

A review of Governing Board Meeting Minutes Quarter 3, dated 10/07/2022, revealed, Falls: July 13, August 11, and Sept. 9. Responsible Party and Due date not completed. Opportunities for possible improvement not documented

A review of the Quality Council Meeting Minutes dated 10/27/2022 revealed: Quality/PI Falls: July 13, August 11, Sept. 9. Responsible Party and Due date not completed. Opportunities for possible improvement are not documented.

A request for any performance improvement studies completed relating to patient falls, none was provided.

Based on the review of policies and procedures, facility documents, medical records, observation, and interview, it was determined that the hospital failed to ensure the rights of patients are protected by providing a safe environment conducive to the provision of quality care while patients are admitted in the facility.

Cross Reference: A-0129: The hospital failed to ensure proper handling and access of patient belongings were implemented and or followed by the facility personnel, which could potentially lead to undetected misappropriation of the patient personal and private property by facility personnel.

Cross Reference: A-0144: The hospital failed to provide an environment protecting patients from falls, addressing patient falls, and evaluating fall prevention tools of its usability to prevent future patient falls.

Cross Reference: A-0171: The hospital failed to ensure that each patient order for seclusion follows the CMS limitations of 4 hours for adults 18 years of age or older and outlined in the facility's policies and procedures to ensure the unnecessary or unlawful use of seclusion by staff that could result in patient harm.

Based on the policies and procedures, medical records, observations, and staff interviews, the hospital failed to ensure proper handling and access of patient belongings were implemented and or followed by the facility personnel, which could potentially lead to undetected misappropriation of the patient personal and private property by facility personnel.

Cross reference: A0043, A0115

Findings Include:

The policy titled "Management of Patients Belongings" revealed: " ...4. Upon admission, staff will inventory patient belongings and sign the Personal Belongings Inventory Form ... "

The policy titled "Patients Clothing Laundering" revealed, "Clothing will be washed in a washing machine on a normal cycle using a hospital-approved laundry detergent. 6. Clothing will be promptly removed from the dryer when the cycle is complete, folded, and put away in the patient ' s tote in the patient belonging area .... "

Patient # 1 ' s medical record review revealed that:

01/15/2023 a document titled "Patient Belonging Sheet" listed the following: Patient Clothing ...Men 's tan jeans ... Men ' s shirt plaid ...Columbia Boots ...

01/18/2023, a document titled "Patient Belonging Sheet" listed the following: Grey Sweat pants {sic}, 3 pairs of underwear, 2 black, 1 grey, tie-dyed green sweatshirt, 1 pair of shorts, brown slipper shoes, 3 pairs of socks, 1 teal long sleeve work out {sic} shirt, 1 long sleeve purple shirt, and 1 grey blanket ...

The facility was asked for the status of Patient #1's belongings as listed for the date of 01/15/2023, but none was provided.

Employee #5 confirmed during an interview conducted on 03/13/2023, that Patient #1 did not acknowledge receipt of listed belongings for the date 01/15/2023.

Based on a review of hospital policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined the hospital failed to provide an environment protecting patients from falls, addressing patient falls, and evaluating fall prevention tools of its usability to prevent future patient falls.

Cross reference: A0043, A0115

Findings Include:

Policy titled "Patient Care Management" revealed: " ...Safety ...Standard of Care II: Pertinent patient identification and medical information is communicated to ensure a safe delivery of care. 1. High-Risk factors are assessed at time of admission. 2. Side rails are kept up as needed, bed maintained in low position. 3. Floors are kept clean and dry ...."

Policy titled "Patient Treatment Plan" revealed: " ...Policy ...8. Treatment modalities/interventions for each goal are b. Focused on the identified problems ...."

Policy titled "Fall Prevention Program" revealed: " ...Policy: It is the policy of the Hospital to assess and appropriately identify patients who are at risk for possible falls while hospitalized ...PROCEDURE: RISK IDENTIFICATION/PRECAUTION/PREVENTION:1. All patients presenting for admission to the hospital will be assessed and identified for the level of fall risk during the nursing admission assessment ...4. Patients who score a moderate risk for falls (scoring 25-44 on the Morse Fall Scale) and high risk for falls scoring 45 and higher on the Morse Fall Scale) will receive red-colored non-skid socks, as well as any other potential interventions ...5. Fall precautions will be added to the Admission orders ...PROCEDURE: POST FALL EVALUATION. 1. Each time a patient falls, the patient will be assessed by the nurse directly after the fall and the nurse will notify the provider to obtain any necessary orders. 2. Interventions necessary to stabilize the patient will be completed in a timely manner. 3. If the patient is witnessed hitting their head, or is suspected of hitting their head, neurological checks are to be initiated. 4. The nurse must notify all applicable parties including but not limited to; the CEO, DON, Nursing Supervisor, Provider, POA/Guardian and/or patient family. 5. The incident report will be submitted through RL Datix. 6. Any Neuro checks conducted will be maintained in the patient's chart ...."

Hospital document titled "Incident Report Log" revealed: "21 falls documented from 01/01/2023, through 02/25/2023."

Hospital document titled "Incident Report" revealed: A Patient Fall Evaluation is to be completed with the incident report after a patient fall. However, upon review of 17 patient incident reports after a fall., only 3 patient reports had the additional patient fall evaluation.

Hospital document titled "Post Fall Huddle Form" revealed: " ...Page 2. NPH- Post Fall Instructions Checklist. Incident Report completed, Notify CON/CEO (as soon as possible after floor), Morse Fall Risk Assessment to be completed after fall, Post fall Huddle Form completed ( soon as possible after fall), Neurological Assessment Initiated, Skin Assessment Tracking form updated to document the presence of injuries or lack of, Fall Precautions initiated or maintained with presence of yellow armband, Fall Socks: verify patient is wearing correct color socks, Master treatment plan updated to include fall problem with goals and intervention. POA/Family notification, Nursing Documentation in the nursing note of fall occurrence ...."

Medical record review of the 21 patients have no Post Fall Huddle Form in each patient chart.

Medical record review for Patient #4, Patient #10, Patient #13, Patient # 16 and Patient # 18 revealed no documentation of fall precautions in the treatment plan.

During the tour of the facility on 03/16/2023, it was observed that the hallway floor in unit 100 was being mopped; but no "wet floor" signage was visible within the area to alert patients and staff of the wet floors.
Employee # 2 stated that the staff is educated in fall precautions during their initial facility orientation. Employee # 2 explained that a Post Fall Huddle Form are not available for review in the patient charts

Based on the review of hospital policies/procedures, medical records, and interviews, it was determined that the hospital failed to ensure that each patient order for seclusion follows the CMS limitations of 4 hours for adults 18 years of age or older and outlined in the facility's policies and procedures to ensure the unnecessary or unlawful use of seclusion by staff that could result in patient harm.

Cross reference: A0043, A0115

Findings Include:

Policy titled "Restraint or Seclusion Use" revealed: " ...DEFINITIONS: ...Seclusion-the confinement of a person alone in a room or an area where the person is physically prevented from leaving ...RESTRAINT/SECLUSION ORDERS ...Restraints/seclusion may only be utilized upon the written order of a Licensed Independent Practitioner, Nurse Practitioner or Physician's Assistant permitted by the hospital and state law to write orders or through emergency application ...Restraint orders include the following components:
Justification of restraint/seclusion ...Duration of seclusion ...Criteria for the release from restraint/seclusion ...restraint orders must be discontinued and renewed every 4 hours ...."

Patients medical record dated 02/26/2023, at 0000-0100 revealed: " ...Seclusion order given for 1 hr to calm patients anxiety, the patient went into seclusion, faced the wall then fell asleep. One-on-one staff monitoring patient while in seclusion ...

Patient # 9's medical record Physicians orders dated 02/27/2023 at 0205 revealed: " ...TORB.(Telephone Order Read Back) Seclusion For 1 hour then re-assess ...." Order without provider's signature.

Patient # 9's medical record Physician order dated 02/227/2023 at 0405 revealed: " ... TORB ( Telephone Order Read Back) Seclusion for 8 hours then reassess ...." Order with out provider's signature.

Employee # 6 confirmed in an interview that Orders for Seclusion can not be longer than 4 hours.

Based on clinical record reviews, facility documentation, and staff interviews, it was determined the hospital failed to develop, implement. and maintain an effective hospital-wide quality assessment and performance improvement program in preventing patient falls.

Cross Reference: A0273 The hospital failed to ensure that a method to measure, analyze, monitor, and track quality indicators, such as patient falls, and an ongoing program is in place for evaluation to improve the health and safety of patients while in the facility.

Cross Reference: A0283 The hospital failed to ensure that the data collected to track, monitor, and evaluate patient related falls was effective and sustainable in lowering the number of fall incidences in the facility.

Cross Reference: A0286 The hospital failed to ensure that a consistent and measurable improvement of patient falls were analyzed and track along with the active involvement of the governing body to address the increased number of patient falls and to implement fall prevention techniques to prevent future incidences of falls in the facility.

Based on the review of policies and procedures, documents, medical records, and interviews, the hospital failed to ensure that a method to measure, analyze, monitor, and track quality indicators, such as patient falls, and an ongoing program is in place for evaluation to improve the health and safety of patients while in the facility.

Cross reference: A0043, A0263, A0283, A0286

Findings Include:

Policy titled "Organizational Performance Improvement Plan" revealed: " ...Quality Improvement Measures will be conducted by the Director of Quality through the facility's Quality Council, and will be communicated by regular reports to the Medical Staff and Governing Body ...SCOPE OF PROGRAM. The scope of the program encompasses the patient population, visitors, staff, and providers. The program addresses maintenance and improvement in service provision in all departments. In all activities, there will be an emphasis on important patient care and organizational function, processes, and outcomes. Leadership identifies and sets performance improvement initiatives annually. This may be completed through the use of risk assessments, strategic planning, staff input, leadership, data analysis, safety huddles, etc ...REPORTING. Communicate the results of the monitoring, assessment, and evaluation process to relevant individuals, departments, and services, as well as the Quality Council via the Medical Executive Committee and the Governing Board ...DATA MANAGEMENT, DATA COLLECTION. Data Collection focuses upon: Processes, particularly those that are high-risk, high volume, problem, prone, and or may result in sentinel events ...INDICATORS. Objective indicators are used to evaluate performance related to processes of care, hospital services, and or operations. Metrics may include the following but are not limited to ...safety Related Parameters. Falls ...DATA ANALYSIS & EVALUATION ...What are opportunities and priorities for possible improvement of existing processes or implementation of new processes?
(Problems that are identified as the high-risk potential that directly affect patient care and outcomes will be addressed preferentially) ...PERFORMANCE IMPROVEMENT REPORTING ...The outcome of the reviews performed for all hospital functions in addition to results of PI projects will be submitted through the QA/PI report to the Medical Executive Committee for its analysis and recommendations and subsequently to the Governing Board ...."

Hospital document titled "Incident Report Log" revealed: "21 falls documented from 01/01/2023 through 02/25/2023.

Hospital document titled "Incident Report" revealed: A patient fall evaluation is to be completed with the incident report after a patient fall. Upon review of 17 patient incident reports after a fall., only 3 patient reports had the additional patient fall evaluation.

Hospital documents "Incident Reports": 13 out of the 21 incident reports reviewed did not contain documentation that the incident was reported to the Risk Management or the Quality Director.

Review of Governing Board Meeting Minutes Quarter 2, dated 08/08/2022, revealed Falls: 4. 9 June, but no discussions regarding patient falls on how to track, monitor, and evaluate to prevent future patient falls.

Review of Governing Board Meeting Minutes Quarter 3, dated 10/07/2022, revealed, Falls: July 13, August 11, and Sept. 9; but no discussions regarding patient falls on how to track, monitor, and evaluate to prevent future patient falls.

Quality Council Meeting Minutes dated 10/27/2022 revealed: Quality/PI Falls: July 13, August 11, Sept. 9, but no discussions regarding patient falls on how to track, monitor, and evaluate to prevent future patient falls.

A request for any performance improvement studies related to patient falls, none was provided.

Medical record review of the 21 patients that were reported to have fallen from 01/01/2023 through 02/25/2023. revealed the lack of a post-fall huddle form attached to each patient chart.

Employee # 2 stated during an interview that the post-fall huddle forms should be placed in each patient's chart after a fall.

Employee # 1 stated during an interview on 03/13/2023, that [he] conducts a risk cause analysis after every patient fall. Upon request of the risk cause analysis documentation, none was provided.

Based on the review of policies and procedures, documents, and interview, the hospital failed to ensure that the data collected to track, monitor, and evaluate patient related falls was effective and sustainable in lowering the number of fall incidences in the facility.

Cross reference: A0043, A0263, A0273, A0283

Findings Include:

Policy titled "Organizational Performance Improvement Plan" revealed: " ...Quality Improvement Measures will be conducted by the Director of Quality through the facility's Quality Council, and will be communicated by regular reports to the Medical Staff and Governing Body ...SCOPE OF PROGRAM. The scope of the program encompasses the patient population, visitors, staff, and providers. The program addresses maintenance and improvement in service provision in all departments. In all activities, there will be an emphasis on important patient care and organizational function, processes, and outcomes. Leadership identifies and sets performance improvement initiatives annually. This may be completed through the use of risk assessments, strategic planning, staff input, leadership, data analysis, safety huddles, etc ...REPORTING. Communicate the results of the monitoring, assessment, and evaluation process to relevant individuals, departments, and services, as well as the Quality Council via the Medical Executive Committee and the Governing Board ...DATA MANAGEMENT, DATA COLLECTION. Data Collection focuses upon: Processes, particularly those that are high-risk, high volume, problem, prone, and or may result in sentinel events ...INDICATORS. Objective indicators are used to evaluate performance related to processes of care, hospital services, and or operations. Metrics may include the following but are not limited to ...safety Related Parameters. Falls ...DATA ANALYSIS & EVALUATION ...What are opportunities and priorities for possible improvement of existing processes or implementation of new processes?
(Problems that are identified as the high-risk potential that directly affect patient care and outcomes will be addressed preferentially) ...PERFORMANCE IMPROVEMENT REPORTING ...The outcome of the reviews performed for all hospital functions in addition to results of PI projects will be submitted through the QA/PI report to the Medical Executive Committee for its analysis and recommendations and subsequently to the Governing Board ...."

Hospital document titled "Incident Report Log" revealed: "21 falls documented from 01/01/2023, through 02/25/2023.

Hospital document titled "Incident Report" revealed: A Patient Fall Evaluation is to be completed with the incident report after a patient fall. Upon review of 17 patient incident reports after a fall., 3 patient reports had the additional patient fall evaluation.

Hospital documents "Incident Reports": 13 out of the 21 incident reports reviewed did not contain documentation that the incident was reported to Risk Management or the Quality Director.

Review of Governing Board Meeting Minutes Quarter 1, dated 04/25/2022, Quality/PI, did not reveal any discussion regarding patient falls. Responsible Party and Due date not completed

Review of Governing Board Meeting Minutes Quarter 2, dated 08/08/2022, revealed Falls:4.9 June. Responsible Party and Due date not completed. Opportunities for possible improvement not documented

Review of Governing Board Meeting Minutes Quarter 3, dated 10/07/2023, revealed, Falls: July 13, August 11, and Sept.9. Responsible Party and Due date not completed. Opportunities for possible improvement not documented

Quality Council Meeting Minutes dated 10/27/2022 revealed: Quality/PI Falls: July 13, August 11, Sept.9. Responsible Party and Due date not completed. Opportunities for possible improvement not documented.

A review of the Governing Board Meeting Minutes dated 02/15/2023 revealed the lack of discussions of the increased fall incidents from 01/01/2023 through 02/14/2023 in the facility.

A request for any performance improvement studies completed relating to patient falls, none was provided.

Employee # 1 stated during an interview on 03/13/2023, that [he] conducts a risk cause analysis after every patient fall. Upon request of the risk cause analysis documentation, none was provided.

Based on the policies and procedures, record review, and interview, the hospital failed to ensure that a consistent and measurable improvement of patient falls were analyzed and track along with the active involvement of the governing body to address the increased number of patient falls in the facility from 01/01/2023 through 02/25/2023.

Cross reference: A0043, A0263, A0273, A0283

Findings Include:

Policy titled "Safety Plan" revealed: " ...PERFORMANCE IMPROVEMENT ACTIVITIES. The Safety Management program will implememt a process in order to identfiy, analyze and correct problems and monitor and evaluate the effectiveness of corrective action specific for performance improvement activities...The Safety Committee will monitor the folwoing stndards and the Saety Officer will report all activity to the Sagety Comittee:...5. Incident Reports/Risk Managmenent...EFFECTIVENESS. The Safety Committee per establsied policy and procedure will review, update, and appprive the Life Safety Manaement Plan as freuently as necessay,but at least once per year. The evaluation will include the objectives, scope, performance and effectiveness of utilty systems management plan. The results will be evaluated by the Safety COmmittee and sumbitted to the MEC and Governing Board...."

Policy titled "Organizational Performance Improvement Plan" revealed: " ...Quality Improvement Measures will be conducted by the Director of Quality through the facility's Quality Council, and will be communicated by regular reports to the Medical Staff and Governing Body ...SCOPE OF PROGRAM. The scope of the program encompasses the patient population, visitors, staff, and providers...DATA MANAGEMENT, DATA COLLECTION. Data Collection focuses upon: Processes, particularly those that are high-risk, high volume, problem, prone, and or may result in sentinel events ...INDICATORS. Objective indicators are used to evaluate performance related to processes of care, hospital services, and or operations. Metrics may include the following but are not limited to ...safety Related Parameters. Falls ...DATA ANALYSIS & EVALUATION ...What are opportunities and priorities for possible improvement of existing processes or implementation of new processes?
(Problems that are identified as the high-risk potential that directly affect patient care and outcomes will be addressed preferentially) ...PERFORMANCE IMPROVEMENT REPORTING ...The outcome of the reviews performed for all hospital functions in addition to results of PI projects will be submitted through the QA/PI report to the Medical Executive Committee for its analysis and recommendations and subsequently to the Governing Board ...."

Hospital document titled "Incident Report Log" revealed: "21 falls documented from 01/01/2023, through 02/25/2023.

Hospital document titled "Incident Report" revealed: A Patient Fall Evaluation is to be completed with the incident report after a patient fall. Upon review of 17 patient incident reports after a fall., 3 patient reports had the additional patient fall evaluation.

Hospital documents "Incident Reports": 13 out of the 21 incident reports reviewed did not contain documentation that the incident was reported to Risk Management or the Quality Director.

A review of the Quality Council Meeting Minutes dated 10/27/2022 revealed: Quality/PI Falls: July 13, August 11, Sept.9. Responsible Party and Due date not completed. Opportunities for possible improvement are not documented.

A request for documentation of the quality council meeting regarding discussions to monitor the increasing fall incidents of patients in the facility for review from 01/01/2023, through 02/14/2023, none was provided.

A request for a safety plan for the increased number of patient falls from 01/01/2023, through 02/25/2023, but none was provided.

A request for any performance improvement studies completed relating to patient falls, but none was provided.

Employee # 1 stated during an interview on 03/13/2023, that [he] conducts a risk cause analysis after every patient fall. Upon request of the risk cause analysis documentation from Employee #1, none was provided.

Based on clinical record reviews, facility documentation, and staff interviews, it was determined that the hospital failed to have an organized medical staff that operates under Medical Staff Bylaws approved by the governing body to ensure quality care is provided to patients.

Cross Reference: A-0047 The hospital failed to ensure that the Governing Body implemented and monitored the effectiveness of the Medical Staff Bylaws in providing, monitoring, and addressing quality patient care issues.

Cross Reference: A 0049: The hospital failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to patients in the facility by addressing, monitoring, and reviewing the efficacy of the fall prevention techniques in the facility and fall data in preventing future patient related falls.

Cross Reference: A-0353 The hospital failed to ensure that the providers followed and implemented the authentication process approved by the governing body, which is to authenticate physician orders within 72 hours to ensure orders are correct, legible, and followed by the hospital staff.

Based on review of facility documents, and interviews, it was determined that the hospital failed to ensure that the providers followed and implemented the authentication process approved by the governing body, which is to authenticate physician orders within 72 hours to ensure orders are correct, legible, and followed correctly by the hospital staff.

Cross reference: A0043, A0047, A0049, A0338

Findings Include:

Hospital document titled "Medical Staff Bylaws" revealed: "...Medical Executive Committee ...8.2 FUNCTION When approval of procedural details related to credentialing, corrective action, or selection and duties of leadership are delegated to the MEC, it shall represent to the Board the organized Medical Staffs view on issues of patient safety and quality of care ...(a). Receiving and acting upon committee reports ...11.1 STAFF RULES AND REGULATIONS AND POLICIES. Subject to approval by the Board, Medical Staff shall adopt Rules and Regulations, and policies necessary to implement more specifically the general principles found within these Bylaws .... No one document will supersede another. Instead, they will work congruently ...."

Hospital document titled "Medical Staff Rules and Regulations" revealed: " ...I. MEDICAL RECORDS. All medical record entries must be legible, complete, accurate, dated, timed, and authenticated promptly ...f. Orders. All diagnostic and therapeutic orders, including telephone orders, standing orders, order sets, and protocols must be appropriately authenticated by the responsible practitioner. Standing orders, order sets, and protocols for patient orders must be ...ensured that such orders and protocols were dated, timed, and authenticated within 72 hours in the patient medical record by the ordering practitioner responsible for the care of the patient ...."

Medical record review conducted on 03/15/2023 revealed that 18 out of 20 physician orders reviewed were not signed within the 72-hour required time frame required according to the Physician Rules and Regulations:

The review of Patient #9's medical record that a hospital document titled, "Provider Orders" revealed as follows:
1.) Thorazine 50 mg po q 6 prn dated 02/26 at 1830 without the provider's signature
2.) One-on-one for physical aggression, and inappropriate behavior with staff for safety/supervision dated 02/27/23 at 0006 without the provider's signature
3.) Thorazine Injection 50mg/2ml IM stat physical aggression dated 02/27/2023 at 0035 without the provider's signature
4.) Seclusion for 1 hrs then re-assess dated 02/27/2023 at 0205 without the provider's signature

Based on facility Policy and Procedure, Medical Records and Staff Interviews that the hospital failed to appoint a Director of Nursing who can oversee the nursing services provided to patients, monitor sufficient personnel are available to address patient needs, and proper documentation of patient services are implemented and followed in the patient charts.

Cross Reference: A0386 The hospital failed to assign a Director of Nursing Services to establish, monitor, follow up, and implement continuous improvement processes of patient care needs and assignments as well as any required administrative functions.

Cross Reference: A0392 The hospital failed to ensure patient care units were staffed according to policy and patient acuity to ensure safe staffing.

Cross Reference: A0396 the hospital failed to ensure that Nursing Care Plans were completed and updated per hospital policy.

Based on a review of hospital policies/procedures, documents, and staff interviews, the Hospital failed to assign a Director of Nursing Services to establish policies and procedures that are effective in providing quality patient care, to monitor nursing staffing requirements based on patient care needs, and to oversee the overall efficacy of the nursing operations in the facility.

Cross reference: A0043, A0385

Findings Include:

Policy titled "Staffing Plan" revealed: " ...Policy ...The DON maintains 24-hour accountability for adequate staffing for each shift ...."

Hospital document titled "Director of Nursing Job Description " revealed: "...Position Summary. Functions under the direction of the CEO of the Hospital. Given broad guidance and direction is expected to function with initiative and independent judgment ...Ensures patient care needs are met. Responsible for appropriate staffing levels throughout areas of responsibility including staffing patient care units when appropriate or needed ...Responsible for the policy and procedures that reflect the standard of professional care in accordance with the standard of care/practice ...Responsible for patient safety, efficiency, and suitability of the environment of care ...Ensures incident reports, chart audits, all other assigned quality indicators are monitored, and nursing peer review are accomplished ...."

A review of the facility organizational chart on 03/14//2023 revealed that the Director of Nursing position for the hospital is vacant. Further, Employee #1 is currently the assigned temporary Director of Nursing at the same time the Director of Quality and Risk Management for the facility.

The hospital document titled "Facility Organizational Chart" revealed that the Department of NURSING included: Nurse manager, BHA Lead/Scheduler, and RN 's/LPNS, BHA, and CNA.

Employee #2 confirmed during an interview conducted on 03/14/2023 that the facility has been without a Director of Nursing since 12/2022 to oversee the provision of nursing services at the facility. Further observations and confirmed during the interview with Employee #2 that that nursing services are overseen by Employee #1 who is assigned as the Director of Quality and Risk Management for the facility and the interim Director of Nursing Services since 01/01/2023.

Based on review of hospital policies and procedures, documents, and staff interviews, the hospital failed to ensure patient care units were staffed according to policy and patient acuity to ensure safe staffing is provided through an appropriate number and skill mix of personnel to ensure patient safety.

Cross reference: A0043, A0385

Findings include:

Policy titled, "Staffing Plan", revealed: "...The hospital will take reasonable steps to ensure that there are sufficient numbers of qualified and competent staff members available to meet the precaution level and needs of the patients...Scheduled core staffing for a predetermined average daily census shall establish a minimum number of nursing staff to ensure nursing care needs of each patient...Under no circumstances shall there be less than one registered nurse on each unit, if the unit has more than one patient...."

Policy titled, "Nurse Staffing, Assignments, and Patient Acuity", revealed: "...A minimum staffing level system is used at the hospital to appropriately staff in compliance with federal, state and regulatory requirements ...Nursing will use an assessment tool based on patient medical conditions, behaviors and needs of the medical/psychiatric patient to assign an acuity score which will be used to make nursing assignments and adjust staffing as needed ...Staffing will be based on a mix of the Core Staffing matrix and augmented using the Patient Acuity tool ...Core Staffing Matrix per unit: Inpatient Programs for Days (7am-7pm)-Includes weekend and holidays. 1-12 patients: 1 Registered Nurse and 1 Aide/Tech; 13-24 Patients: 1 Registered Nurse plus 1 Nurse and 2 Aide/Tech ...Inpatient Programs for Nights (7pm-7am)-Includes weekends and holidays. 1-12 patients: 1 Registered Nurse and 1 Aide/Tech; 13-24 Patients: 1 Registered Nurse plus 1 Nurse and 2 Aide/Techs ...The hospital acuity tool will be completed on each twelve (12) hour shift ...The registered nurse will assign an acuity number, 1 (lowest acuity) to 4 (highest acuity), for each patient ...The Registered Nurse will complete the Acuity Tool and assign staff (nurse, aide/tech) to the patients based on the needs/acuity. For example: if there are two (2) nurses for 16 patients on day shift, and two (2) of the patients are considered a level 4 acuity, those two patients will be split between the nurses ... The level three (3) acuity patients will then be split between the staff, then the level two (2) patients will be divided among the staff, and lastly the level one (1) patients will be divided among the staff ....For level-4 patients requiring continuous 1:1 monitoring a staff member will be assigned to that duty exclusively ...Another aide/tech or nurse depending on the total census and patient acuity will be assigned to make rounds, supervision, and safety checks for other patients ...."

Staffing schedules from January 1, 2023 through February 25, 2023 were reviewed which revealed the following dates and shifts with insufficient staffing:
· 01/30/2023 Day shift (7am-7pm) Unit 400: One (1) registered nurse (RN) with zero (0) aide/tech assigned for a census of 6 patients.
A request was made for the staffing assignment sheet for 01/30/2023 Unit 400 Day shift and the facility was unable to provide.

· 01/31/2023 Day shift (7am-7pm) Unit 100: Two (2) registered nurses (RNs) with zero (0) aide/tech assigned for a census of 19 patients, total acuity of 51. One (1) RN had two (2) patients with an acuity of four (4) and one (1) patient with an acuity of three (3) and nine (9) patients with an acuity of two (2) for a total of nine (9) patients with a total of 23 acuity points. One (1) RN had two (2) patients with an acuity of four (4), four (4) patients with an acuity of three (3), and four (4) patients with an acuity of two (2) for a total of ten (10) patients with a total of 28 acuity points.
· 01/31/2023 Day shift (7am-7pm) Unit 200: One (1) registered nurse (RN), one (1) RN Orientee and 3 aide/tech for a census of 18 patients, total acuity 44. Further review of the assignment sheet revealed the RN Orientee was counted in the nursing staffing ratio. One (1) RN had five (5) patients with an acuity of three (3) and three (3) patients with an acuity of two (2) for a total of eight (8) patients with a total of 21 acuity points. One (1) RN Orientee had four (4) patients with an acuity of three (3) and six (6) patients with an acuity of two (2) for a total of ten (10) patients with a total of 22 acuity points.

Further review of the staffing assignments revealed staff assignments were not documented for aide/techs with no indicators for 1:1 observations or other specific assignments for the aide/tech.

Further review of the staffing assignments revealed staff assignments were made based on room location with the first twelve (12) rooms assigned to one nurse and the other twelve (12) rooms were assigned to the other nurse.

Employee #4 confirmed on 03/16/2023 that staffing assignments were not based on acuity. Employee #4 confirmed that orientees are counted in the staffing ratio. Employee #4 confirmed orientees should not be counted in the staffing ratio. Employee #4 confirmed that patient assignments are made by dividing the unit in half and each nurse is assigned a half regardless of the patient acuity.

Employee #5 confirmed on 03/16/2023 that staffing assignments are not based on acuity. Employee #5 confirmed that only charge nurses are aware of how to assign acuity. Employee #5 confirmed that nursing patient assignments are made by assigning one half of the unit to each nurse.

Employee #1 confirmed on 03/16/2023 that there should always be one (1) registered nurse (RN) and one (1) other staff member on each patient occupied unit.

Based on review of hospital policies/procedures, documents, and medical record reviews, the hospital failed to ensure that nursing care plans are current, updated, and patient-specific to effectively provide quality care depending on patient condition and needs.

Cross reference: A0043, A0385

Findings Include:

Policy titled "Patient Treatment Plan" revealed: " ...POLICY: Each patient shall have a written, comprehensive, individualized treatment plan that is based on an assessment of his/her medical. Clinical and nursing needs. Individualized treatment planning shall be based on patient needs ...8. Treatment modalities/interventions for each goal that are b. Focused on the identified problems ...J. The treatment plan is reviewed regularly and revised in a manner designed to promote more effective treatment and less restrictive treatment conditions ...."

Hospital document titled "Incident Report Log" revealed: "21 falls documented from 01/01/2023, through 02/25/2023."

The review of the medical records for the following patients revealed no documentation of an updated nursing care to address the falls and on how to prevent future patient related falls in the future: Patient #4, Patient #10, Patient #13, Patient # 16, and Patient #18.

Employee #2 confirmed that nursing care plan updates for the 5 out of the 21 patients who experienced the falls from 01/01/2023, through 02/25/2023 were not performed by nursing personnel.

Based on Hospital Policy and Procedure, Medical Records and Staff Interviews the Hospital failed to ensure that a
medical record must be maintained for every individual evaluated or treated in the hospital.

Cross Reference: A0454 The Hospital failed to require that verbal or telephone orders given by a medical provider were authenticated, to include the medical provider's signature, date, and time, within the required seventy-two (72) hours as stated in the Medical Staff Rules and Regulations , after the verbal or telephone order was given.

Cross Reference: A0486B The hospital failed to ensure that a discharge summary is available in each of the patient's medical records to describe the patient's prognosis, medical condition, medical services provided during patient admission to the facility, and follow-up services needed by a patient upon discharge are outlined to ensure the continuity of patient care is provided in the outpatient setting when necessary.

Based on review of hospital policy and procedure, medical records, and interview, it was determined that the hospital failed to require that verbal or telephone orders given by a medical provider were authenticated, to include the medical provider's signature, the date and time signed, and performed within the required seventy-two (72) hours as stated in the Medical Staff Rules and Regulations after the verbal or telephone order was given to ensure patients receive accurate care and treatment.

Cross reference: A0043, A0431


Findings Include:

Policy titled "Verbal-Written Orders-General Practices" revealed: " ...3. Verbal/Telephone orders. A. Verbal orders are prohibited ...c. Telephone orders shall be used only when necessary to provide patient care when the Provider is not readily on set. D. Telephone orders must be verified through the Nationally accepted practice of "read-back verification" (RBVO) ...i. Notation documenting that the verbal order was read back to the prescriber after it was first rendered to writing. E.g. T.O Dr___/Nurse__/RB&V .... "

Hospital document titled "Medical Staff Rules and Regulations" revealed: "...f. Orders ...All diagnostic and therapeutic orders, including telephone orders, standing orders, order sets, and protocols must be appropriately authenticated by the responsible practitioner. Standing Orders, order sets, and protocols for patient orders must be ...ensured that such orders and protocols were dated, timed, and authenticated within 72 hours in the patient's medical record by the ordering practitioner responsible for the care of the patient ...."

A review of the medical records conducted on 03/15/2023 revealed that 14 out of 20 physician orders reviewed were not signed within the 72-hour as outlined in the facility's the hospital document titled "Medical Staff Rules and Regulations" and for the following sample patients:Patient # 8 received 3 telephone orders on 02/12/23, with no medical provider signature.
Patient # 9 received 1 telephone order on 02/26/2023, 3 telephone orders on 02/27/2023, with no medical provider signature.
Patient # 11 received 1 telephone order dated 02/24/2023, 2 telephone order dated 03/04/2023, 3 telephone orders dated 03/07/2023. with no medical provider signature.
Patient #24 received 1 telephone order on dated 01/23/2023, but no medical provider signature.

Based on policies and procedures, facility documentation, and interviews, the hospital failed to ensure that a discharge summary is available in each of the patient's medical records to describe the patient's prognosis, medical condition, medical services provided during patient admission to the facility, and follow-up services needed by a patient upon discharge are outlined to ensure the continuity of patient care is provided in the outpatient setting when necessary.

Cross reference: A0043, A0431

Findings Include:

A discharge policy and procedure for review was requested but none was provided.

The medical records review revealed that 8 out of the 21 patient medical records were missing Discharge Summaries for the following patients:
Patient # 3, Patient # 4, Patient # 7, Patient # 8, Patient # 12, Patient # 15, Patient # 16, Patient #25

A Patient Facility Discharge Packet was requested none was provided.

Employee # 2 confirmed in an interview dated 03/16/2023 that the facility utilizes a discharge packet when the patient is ready to leave the facility.