HospitalInspections.org

Based on interview, clinical record review, and policy review the hospital failed to ensure Patients #5, #8, #10 and #13 received care in a safe setting.
On 10/15/10, Patient #8 who had been assessed as a fall risk, fell twice during his one day hospital stay.
On 11/12/10. Patient #5, who had been assessed as a fall risk, was found on the floor of his/her bedroom.
On 11/20/10, Patient #10, who had been assessed as a fall risk, was found on the floor in the hospital's day room.
All three elderly patients (#5, #8 and #10) were transferred to an emergency room at another hospital for suspected head injury.
Patient #13, who was also elderly, suffered a fall and was eventually discharged home.

Thirteen of thirteen patients from the psychiatric unit, whose records were reviewed had been assessed to be at risk for falls and did not have an individualized plan of care for the prevention of falls.
Four of the thirteen patients reviewed (#5, 8, 10 and 13) suffered falls while in the hospital.

The facility's tracking showed four patient falls in September 2010, ten patient falls in October 2010, and eight patient falls in November 2010, however review of the hospital's quality assurance performance improvement (QAPI) program minutes showed that fall precautions were discussed; but lacked evidence the facility had developed a plan, initiated interventions, or monitored the effectiveness of any fall prevention strategies.

Four of those patients reviewed (Patient #6, 7, 8 and 9), were closed records as the patients had been discharged prior to 11/14/10. Three patients ( Patient #1, 12 and 13) were discharged during the survey. This left six ( Patients #2, #3, #4, #9 and #10) currently at risk for immediate harm.

Based upon this investigation, the chief clinical officer was notified on 11/24/10 at 2:50 PM, of the existence of immediate jeopardy due to the hospital's failure to ensure all patients were safe from injury and failure to implement fall prevention strategies.

Findings include:

The clinical record review for Patient #8 was completed on 11/24/10. The clinical record revealed that Patient #8, a 85-year-old patient, was admitted to the facility on 10/15/10 at 4:39 P.M. with a diagnosis of dementia with behavioral problems. The admission nursing assessment, dated 10/15/10 at 4:39 P.M, revealed the patient fell hitting his/her head during the night of 10/13/10, while a patient in the nursing home.

The clinical record revealed a fall risk assessment, dated 10/15/10 at 8:15 P.M., documented the patient was at risk for falling and instructed staff to continue following the fall treatment plan. The clinical record lacked evidence of a fall treatment plan. An initial generic treatment plan, dated 10/15/10, directed the staff to monitor and document the patient's location every 15 minutes as part of a safety check.

The clinical record contained a nursing note, dated 10/15/10 at 11:15 P.M., which documented the patient was found in the television room lying on the floor at 6:00 P.M. and the physician was notified at 6:45 P.M. The nursing note documented the physician directed the staff to observe the patient but not to send the patient to the emergency room. The patient sustained a contusion and skin tear to his/her left forehead and became drowsy, combative, weak and confused. At 8:30 P.M., the physician ordered the patient to be taken to the emergency room for a CAT scan. The nursing note stated, "As mobile care (ambulance personnel) was approaching nurse looked into day room where patient was observed leaning forward falling onto floor forehead first. Patient unable to verbalize name at present time." The nursing note stated the patient was transferred to a local hospital with a C-collar in place (placed by ambulance personnel) at 9:30 P.M.

The clinical record review for Patient #5 was completed on 11/24/10. The clinical record revealed the patient was admitted to the facility on 11/10/10, with a diagnosis of dementia. The nursing admission assessment, dated 11/10/10, revealed the patient had fallen previously and hit his/her head on 10/07/10, while a patient at the extended care facility and sustained a left facial bruise, left posterior shoulder bruise and a left posterior/lateral chest bruise. The clinical record revealed a fall risk assessment form, dated 11/12/10, and documented in the 7:00 A.M. to 3:00 P.M., area of the form, Patient #5 had been assessed as at high risk for falls.

A nursing note dated 11/12/10 at 7:30 P.M. revealed the patient was found on the floor in his/her room at the side of his/her bed with a "large" amount of blood noted on left side of the patient's head and a large laceration near the patient's left brow. The nursing note stated the patient remained alert. A nursing note dated 11/12/10 at 8:15 P.M., documented the patient was transported to a local emergency room. The clinical record lacked evidence a plan of care had been created to address Patient #5's risk for falls.

On 11/23/10 at 4:00 P.M., during an interview, Staff B confirmed there wasn't a plan of care created to address Patient #5's risk for falls. Staff B said there should have been a plan of care and falling should have been identified as a problem.

The clinical record review for Patient #10 was completed on 11/23/10. This patient was admitted to this hospital on 11/18/10 at 4:25 P.M. with a diagnosis of Alzheimer's with psychosis. The patient was determined to be at high risk for falls due to a history of falling. On 11/19/10, a generic non-individualized treatment plan was dated 11/19/10, however, the treatment plan lacked interventions to prevent the patient from falling.

A nursing note, dated 11/20/10 at 2:15 A.M., documented Patient #10 fell and hit the floor and called out to the staff. The patient complained of head pain and a bump was noted on the back of the patient's head. The patient's physician was notified and the patient was transported by a medical transport service to a local acute care hospital for an X-ray of the head. The patient returned to this hospital approximately 12 hours later after the X-ray findings were determined to be negative for a fracture.

The nurse, upon return of the patient to this hospital assessed the patient to remain at risk for falls. The clinical record lacked evidence of the hospital's plan for an intervention to prevent further falls.

Patient #13's clinical record review was completed on 11/24/10. The patient was admitted to this hospital with a history of falls which required placement in a nursing home for rehabilitation. The patient was referred to this psychiatric hospital due to exit seeking behaviors, wandering, and agitation. The patient was admitted to this hospital on 11/13/10, with a diagnosis of Dementia, Alzheimer's type. The admitting physician placed Patient #13 on elopement, falls and safety precautions.
Nursing assessed the patient's risk for falls at 17 points with a score of 4 or more requiring the initiation of the hospital's falls precautions. No care plan addressing falls was found in the clinical record.
A nursing note, dated 11/19/10, documented a bed alarm was used while the patient was in bed at 11:20 AM. No other interventions were documented to determine how the hospital ensured the safety of Patient #13 when the patient was up in the wheelchair. Review of an incident/accident report on 11/24/10, and according to a nursing progress note dated 11/22/10 at 1:00 PM, Patient #13 was found on the floor in the day room. No injury was noted and no complaints of pain were offered by the patient. One of the other patients on the psychiatric unit saw Patient #13 on the floor and reported the information to a staff member. The fall itself was not witnessed and the facility's intervention after the fall was not documented. A nurses note written on 11/22/10 at 1:00 PM stated, " Physician notified of incident. New order received for Merry Walker for safety. " No further nursing notes describe Patient #13's response to the device.
Staff G stated on 11/24/10 at 2:45 PM, he/she saw the patient in the Merry Walker on 11/22/10 and knew the patient was able to lift the seat on the walker device and used the walker for a short time only. Patient #13 was discharged on 11/23/10 at 1:00 PM to the care of a family member.
All the above findings were confirmed during an interview with Staff B on 11/23/10 at 3:00 P.M.

A review of the safety meeting minutes of August 2010, September 2010, and October 2010 was completed on 11/18/10. The review revealed in the August 2010 and September 2010 meeting minutes bed alarms, floor pads, and wheelchair alarms were discussed as fall precaution items to be used at the hospital. The review of the October 2010, meeting minutes lacked discussion of fall prevention items despite patient falls occurring in October, 2010.

A review of the facility's fall tracking matrices for August 2010, September 2010, and October 2010, revealed the facility had four minor falls in August, one major and three minor falls in September and four major and six minor falls in October, 2010.

On 11/23/10 at 1:40 P.M. during an interview, Staff A said they had the fall prevention alarms mentioned in the safety meetings since May 2010. He/She was unable to say why they weren't used in the past with Patient #5 and #8, nor why they were not currently in use for Patient #10.

Please refer to 42 CFR 482.13; Tag A144 for more detailed information.

Based on observation and staff interview it was determined the hospital failed to provide the Ohio Department of Health complaint hotline number to all patients serviced by the hospital. The patient census at the time of the survey was 19 including 11 patients from the 20 bed detox unit and 8 patients from the 22 bed psychiatric unit.

Findings include:

Review of the patient admission packet was completed on 11/22/10. It was noted a part of the packet included a form entitled, "Patients Rights Advocacy Process". The form failed to include the Ohio Department of Health (ODH) complaint hotline number. This finding was confirmed with Staff B on 11/22/10 at 11:17 AM.

Tour of the hospital on 11/22/10 and 11/23/10, conducted by two surveyors revealed ODH hotline number was not observed posted anywhere within the hospital. This finding was confirmed with Staff B on 11/23/10 at 3:00 PM.

Based on interview, clinical record review, policy review and observation the hospital failed to ensure Patients #5, #8, #10 and #13 received services to prevent falls. The hospital failed to ensure that 13 of 13 patients reviewed (Patients # 1-13) had an individualized plan of care for prevention of falls.

The total patient census at the time of the survey was 19 including eleven patients from the detox unit and the eight patients from the psychiatric unit.

Findings include:

The clinical record review for Patient #8 was completed on 11/24/10. The clinical record revealed Patient #8, a 85-year-old patient, was admitted to the facility on 10/15/10 at 4:39 P.M. with a diagnosis of dementia. A nursing assessment form dated 10/15/10 at 4:39 P.M. revealed the patient had fallen, hitting his/her head during the night of 10/13/10, while in the nursing home. This injury to the head had resulted in the decline of the patient's alertness.

The clinical record revealed a fall risk assessment form dated 10/15/10 at 8:15 P.M. , which documented the patient was at risk for falling and instructed staff to continue following the fall treatment plan. The clinical record lacked evidence of a fall treatment plan. The clinical record included an initial generic treatment plan dated 10/15/10, that directed the staff to monitor and document the patient's location every 15 minutes as part of a safety check.

The review of the 15-minute safety check flow sheet revealed, on 10/15/10, the patient was in the day room at 5:30 PM and 5:45 PM; then at the hospital from 6:00 PM to 8:45 PM; then in the day room at 9:PM and 9:15 PM; and then at the hospital from 9:30 PM until midnight.

The clinical record review revealed a nursing note dated 10/15/10 at 11:15 P.M., that documented the patient was found in the television room, lying on the floor at 6:00 P.M. and the physician was notified at 6:45 P.M. (This is inconsistent with the documentation that the patient was in the hospital during the time from 6:00 PM to 8:45 PM on 10/15/10, as stated on the 15 minute safety check flow sheet.)

The physician directed staff to observe the patient, but not to send the patient to the emergency room. The patient sustained a contusion and skin tear to his/her left forehead and became drowsy, combative, weak and confused. At 8:30 P.M. the physician ordered the patient to be taken to the emergency room for a CAT scan. The nursing note stated, "As (ambulance personnel) was approaching nurse looked into day room where patient was observed leaning forward falling onto floor forehead first. Patient unable to verbalize name at present time." The ambulance personnel applied the C-collar to the patient. The note stated the patient was transferred to second hospital with a C-collar in place at 9:30 P.M.

The clinical record review for Patient #5 was completed on 11/24/10. The clinical record revealed the patient was admitted to the facility on 11/10/10, with a diagnosis of dementia. A review of the nursing admission assessment dated 11/10/10, documented patient had beaten his/her spouse and hit staff at the extended care facility. The patient had fallen and hit his/her head on 10/07/10, at the extended care facility sustaining a left facial bruise, left posterior shoulder bruise and a left posterior/lateral chest bruise. The clinical record revealed that a fall assessment form dated 11/12/10. in the 7:00 A.M. to 3:00 P.M. area, Patient #5 was assessed at high risk for falls.

A nursing note dated 11/12/10 at 7:30 P.M. revealed that the patient was found on the floor in his/her room at the side of his/her bed with a "large" amount of blood noted on left side of the head and a large laceration near the left brow and that the patient remained alert. A nursing note dated 11/12/10 at 8:15 P.M. revealed documentation the patient was transported to a local emergency room. The clinical record revealed that a plan of care had not been created to address Patient #5's risk for falls.

On 11/23/10 at 4:00 P.M. in an interview, Staff B confirmed there wasn't a plan of care created to address Patient #5's risk for falls. Staff B said there should have been a plan of care and falling should have been identified as a problem.

The clinical record review for Patient #10 was completed on 11/23/10. This patient was admitted to this hospital on 11/18/10 at 4:25 P.M., with a diagnosis of Alzheimer's with psychosis. On 11/19/10, a treatment plan was put in place as the patient was determined to be at high risk for falls due to a previous history of falling. A fall risk assessment form completed by the nursing staff revealed a score of 8 which did not include an assignment of a point for previous falls as documented on the admission assessment.

Documentation by the nurse dated 11/20/10 at 2:15 A.M. revealed the patient fell hitting the floor and called out to the staff. The patient complained of head pain and a bump was noted on the back of the patient's head. The patient's physician was notified and the patient was transported by medical transport to a local acute care hospital for an X-ray of the head. The patient returned to this hospital approximately 12 hours later after the X-ray findings were determined negative for a fracture.

The nurse assessed the patient upon return to this hospital and determined the patient to have a score of 8 on the fall risk assessment. This score of 8 did not include a point for the patient's history of previous falls. The first time a point was added to the fall risk assessment score for the patient's history of fall was on 11/22/10 at 6:30 P.M. during the survey.

During tour on 11/23/10 at 12:00 P.M. with Staff C, it was observed that none of the hospital's prevention measures had been put in place for Patient #10.

All the above findings were confirmed in interview with Staff B on 11/23/10 at 3:00 P.M.

Patient #13's medical record review completed on 11/24/10, revealed the patient was admitted on 11/13/10, with a history of a fall which had required the patient's placement in a nursing facility. The patient's diagnosis was dementia Alzheimer's type. The admitting physician ordered the Patient #13 to be placed on elopement, falls and safety precautions.
Nursing assessed the patient's risk for falls at 17 points with a score of 4 or more requiring the initiation of the hospital's falls precautions. No care plan addressing falls was found in the clinical record.
A nursing note written on 11/19/10, revealed a bed alarm was used while the patient was in bed at 11:20 AM. No other interventions were documented to determine how the facility ensured the safety of Patient #13 when the patient was up in the wheelchair. Per review of an incident/accident report on 11/24/10 and a nursing progress note on 11/22/10 at 1:00 PM, Patient #13 was found on the floor in the day room. No injury was noted and no complaints of pain were offered by the patient. One of the other patients on the psychiatric unit saw Patient #13 on the floor and reported the information to a staff member. The fall was not witnessed and the facility's intervention after the fall was not documented. A nurses note dated 11/22/10 at 1:00 PM, stated, " Physician notified of incident. New order received for Merry Walker for safety. " No further nursing notes described Patient #13's response to the device.
Staff G stated on 11/24/10 at 2:45 PM, he/she saw the patient in the Merry Walker on 11/22/10 and knew the patient was able to lift the seat on the walker device and used the walker for a short time only. Patient #13 was discharged on 11/23/10 at 1:00 PM to the care of a family member.
Review of 13 of 13 clinical records revealed that an individualized plan of care had not been developed nor implemented to provide a safe environment free from falls for patients.

The hospital's policy for falls, 12.007 - Falls Policy, was reviewed on 11/23/10. Fall prevention measures listed on the Falls Policy included placing a wristband on the patient at high risk for falls, placing a falls identification form above the patient's bed and identifying the patient's fall risk on the patient board at the nurse's station.


A review of the safety meeting minutes of August 2010, September 2010, and October 2010 was completed on 11/18/10. The review revealed in the August 2010 and September 2010 meeting minutes bed alarms, floor pads, and wheelchair alarms were discussed as fall precaution items to be used at the hospital. Review of the October 2010, meeting minutes lacked evidence of discussion of fall prevention items despite evidence of patient falls during October, 2010.

A review of the facility's fall tracking matrices for August 2010, September 2010, and October 2010 revealed the facility had four minor falls in August, one major and three minor falls in September, and four major and six minor falls in October.

On 11/23/10 at 1:40 P.M. in an interview, Staff A said they had the fall prevention alarms mentioned in the safety meetings since May of this year. She was unable to say why they weren't used in the past with Patient #5 and #8, nor why they are not currently in use for Patient #10.