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Based on hospital policy/procedure, medical record reviews, interviews, observations, and grievance/complaint documentation, the facility failed to completely investigate the cause of patient identifier (PI)# 10's fall on 10/24/2010. As a result, the facility administration did not know that Unit E staff are not consistently implementing the hospital's fall risk policy, and were not aware of a malfunction in Ethernet controlled patient call / bed exit alarm system prior to the survey.
On 11/11/2010 and 11/12/2010, observations of the patient call system revealed a malfunction in the centralized computer controlled patient call /bed exit alarm system.
The failure to investigate a fall affected PI# 10, one of 10 sampled patients. The failure to implement the facility fall risk policy affected four of ten sampled patients (PI# 4, #5, #6, #7). The failure of the computer controlled patient call / bed alarm system (identified on 11/11/2010) has the potential to affect the health and safety rights of all patients dependant on this system to communicate their needs, and resulted in an immediate jeopardy being identified by the surveyor on site 11/11/2010.
The surveyor (on 11/11/2010) and facility staff, accompanying the surveyor on tour, reported the identified computer and beeper malfunctions to hospital administration. The administration implemented actions to remove the immediate jeopardy by directing all staff to physically respond to patient calls and bed exit alarms; Until the call / bed exit alarms, and beeper concerns were identified, corrected, checked by engineering, and checked by technical staff to assure the call / bed exit alarm system was operating properly.
Findings Include:

1. The policy entitled "Patient's Bill of Rights and Responsibilities" (effective February 1994) and revised in May 2008 includes:
"...YOU HAVE THE RIGHT TO:
...2. Know that the effectiveness and safety of care, treatment and services for your health condition does not depend on your race, creed, religion, sex, gender, sexual orientation, ethnicity, country of origin, age, handicap, or source of payment.
...11. Have a surrogate ...exercise the patient's rights when the patient is incapable of doing so without coercion, discrimination or retaliation.
...21. Be told how and to whom you may voice a complaint or safety concern including the Hospital Administrative Representative ... "

2. The Policy and Procedure entitled "Fall Management" (effective July 1999) and revised April 2009 includes:
"...Purpose: The purpose of this policy is to identify patients who are at risk for falling and to implement strategies to minimize the risk for falls...
Procedure:
A. Adult Inpatient (including 23 hour admitted patients, Labor and Delivery and Post Partum) and ED Assessments.
1. All patients will be assessed for their fall risk utilizing the appropriate Patient Care Documentation Tool:
A. On admission to the facility/department...
B. Fall Prevention and Management Interventions/Protocol for Adult Patients...
2. Place a yellow armband on the patient and sign at the head of the bed...
6. Place call bell within reach, visible, and inform the patient of the location and use
7. Light cord within reach, visible and inform the patient of the location and use
10. Bed in lowest position with wheels locked and bed alarm turned on if appropriate..."

3. Patient Identifier (PI) # 10 was admitted to the hospital's geriatric psychiatric unit on 10/22/2010 at 12:35 PM (from a nursing home). Staff documented PI# 10 "becoming...very paranoid and delusional...refusing to eat...resistant to care..." The patient is documented to have accused staff of stealing and reported "...feeling that people walking past..." her (PI#10's) room were talking about her (PI# 10). Staff documented the patient was admitted with "...increase in generalized weakness..." and with a "...soft wrist immobilizer to rt [right] hand / wrist..." PI# 10 was unable to tell staff what happened and could not "...grasp or move..." the right hand. The admission notes indicate PI# 10's mobility decreased in the three weeks prior to her admission, she used a walker for transfer, but had reported "...Hx [history] of falls..."

The 10/22/2010 "FALLRISK" assessment includes:
"...History of Falling ...Medication / Sedation ...Gait / transferring ...overestimates or forgets limits ...Fall Risk Total 40 ...Placed on fall precautions ...on Adult Fall Prevention Protocol... "

On 10/24/2010 at 4:37 AM, the night nurse documented:
"...SAFETY Interventions: ...Utilized measures to maintain safe environment ...Free of injury ...Patient rested well no distress noted ... "

On 10/24/2010, the night shift psychiatric technician / direct care staff member [Employee Number (EI) # 11], assigned to PI# 10 on 10/24/2010, documented 15 observations of PI# 10 from midnight (00:00 AM) until 05:00 AM. EI#) 11 coded the "Geriatric Observation Round Sheet" to indicate observations of PI# 10. These codes indicate PI# 10 was observed (by EI# 11) to be "sleeping" in the "Bed (Bed exit alarm activated)" at each 15 minute observation from midnight until 05:00 AM. From 05:00 until 05:45 AM, EI# 11 documented PI# 10 was in the bed, awake, and calm.
The nurse call operator (NCO) provided a copy of the patient call / bed exit report for Room C (PI# 10's room) from 10/23/2010 to 10/26/2010. This document indicates only one call came from this room, during the above time period. This one call was an automatic bed exit alarm activation on 10/24/2010 at 00:37. There is no patient name on this report. The word "vacant" appears in the section for patient name. This call was pending for 1 minute and 1 second. No page or communication with the NCO is noted and no other calls to the NCO from this room is entered for the above dates.
EI# 11 (interviewed 11/11/2010 at 12:15 PM) recalled finding PI# 10 on the floor on 10/24/2010, around 05:00 AM. EI# 11 states he went to get PI# 10 up for the day. PI# 10 was wet and he (EI# 11) left the room to get linens. Shortly after leaving the room, EI# 11 says he heard a "thump," and ran back to the room. He found PI# 10 lying beside the bed, on the floor. PI# 10 was lying on her side, with her back to the door. EI# 11 recalled one of the four bed rails was down when he returned to the room, the bed rail on the left side at the foot of the bed. He noticed a little blood on the floor and blood in PI# 10's hair. EI# 11 states he called out "fall," as he began getting PI# 10 back into the bed. The night shift RN (EI# 10) came to the room and helped get PI# 10 back into bed. The nurse cleaned the cut on PI# 10's head.
EI# 11 denies hearing the bed alarm, and states his beeper did not sound before, or after, he went to PI# 10's room. When asked if anyone asked about this incident before the survey, EI# 11 states yesterday (11/10/10) the nurse manager (EI# 8) said you (surveyor) would be calling me (EI# 11); Other than this, "Nobody said nothing to me about this until now."

On 10/24/2010 at 5:20 AM, the night nurse (EI# 10) documented:
"...patient found lying on the floor beside her bed by the tech. [psychiatric patient care technician]. Patient does not remember why she was trying to get up...vital signs are stable... demonstrated no change in mental status ...cut on the occipital area of... head...swollen...cleaned...Patient denies pain at present...Dr...notified of fall and...explained ...[PI# 10] has a cut...has a large knot...to continue with the neuro checks per protocol. House supervisor...notified of fall ...tried to contact...family... unsuccessful..."
This nurse (EI# 10 interviewed on 11/11/2010 at 1:40 PM) states she was in the day room, across the hall from the nurse's station on 10/24/2010. EI# 10 states she heard someone call out "fall" and ran to PI # 10's room. She found EI# 11 in the room with PI# 10 and observed the patient (PI# 10) lying on the floor, on her (PI# 10's) back, on the side of the bed that is next to the door. PI# 10 stated she was trying to get out of bed but the patient could not recall why she (PI# 10) did not call for help. The nurse recalled PI# 10 complained of a headache and the patient had a small cut on her (PI# 10's) scalp. According to EI# 10, she saw a little blood on the floor and the bed rails were up on PI# 10's bed when she (nurse/EI# 10) entered the room.
EI# 10, when asked if she heard a patient call light or the bed alarm sound prior to or after finding the patient on the floor, stated staff cannot hear the bed alarms or patient call lights from the desk.
When asked about fall prevention, EI# 10 explained the hospital fall prevention program includes using bed alarms, fall bracelets, putting signs above patient beds, and checking patients every 15 minutes. When asked if anyone talked with her about this incident before the survey. EI# 10 replied, "No, I reported the fall...I filled out an accident report and gave it to the house supervisor."

PI#10's medical record has three pictures with no identifying patient name. One picture is a picture of a scalp laceration. This picture has a hand written note on the edge of the picture that includes: "fall 10/24/2010 @ [at] 05:10". Two pictures are of an arm that has a circular dark purple area on the lateral aspect of the arm, near the elbow. These two pictures have no name, date, time, signature or initial.

On 10/25/2010 at 08:20 AM and 11:30 AM, the physician's progress notes include: "...received call from RN at 6:30 AM...pt [patient] fell sustaining laceration to occipital scalp. Using steri strip ...Pt seen on rounds ...quiet. Review Report from RN...x-rays negative for fractures or suturing of the scalp laceration..."

The Patient History dated 10/24/2010 at 3:33 PM, includes:
"...cc [chief complaint] Behavioral disturbance...Medical management ...HPI [history present illness] S/P [status post] fall last night with small head laceration ...Physical Exam ...limited ROM [range of motion] right shoulder ...Musc. Str [muscle strength]...weak diffusely, unable to test right UE [upper extremities] secondary to pain ...shoulder x-ray 10/11 show possible dislocation ...wrist, elbow without acute pathology...
Discussed With:...Family.
Assessment "...y/o [year old] ...with dementia. Admitted for stabilization of paranoid delusions. Also c/o [complaining of] falls and right arm pain...
Dementia, COPD, Falls, Head laceration, Shoulder pain... Plan ...repeat XRAY right shoulder in AM ... Orthopedic consult ... shoulder pain in AM ...PT [physical therapy] consult for gait evaluation and treatment...Continue current medical treatment plan..."

On 11/08/2010, hospital administration received a complaint from PI# 10's emergency contact alleging hospital staff failed to contact him/her after PI# 10 fell on 10/24/10. The letter of complainant indicated this family member visited PI#10, the day after the incident, and observed the patient injuries. The complainant writes that staff said PI# 10 fell but the patient said she was attacked "...by another patient." EI# 8 and EI# 9 stated (on 11/11/2010) the complainant did not respond to telephone calls from facility staff.
On 11/15/2010 at 11:37 AM, the administrative representative (EI# 16) responsible for maintaining complaint/grievance files stated PI# 10's fall and the complaint was investigated by EI# 8 and EI# 9.

On 11/11/2010 at 2:00 PM, the surveyor toured the facility, and randomly checked patient call / bed exit alarms with employee identifier (EI) # 8, and EI #9.
EI# 8 and EI# 9, touring with the surveyor, explained that all patient calls and bed exit alarms are answered by one nurse call operator (NCO). The NCO is stationed in an office on the first floor.
The surveyor talked with the nurse call operator (NCO) during the tour. The NCO explained the operation of this hospital's nurse call / bed exit system and states each unit is responsible for entering patient names and identifying each staff assignment on a daily basis. The NCO states patient information should be updated as the census changes, or the system does not recognize the patient room is occupied.
If no patient name is entered in the computer patient call / bed exit alarm system, and a patient call or bed exit alarm is activated, the NCO computer display indicates the room is "vacant."
Each activation of a patient call or bed exit alarm is entered into the computer automatically, and the NCO computer screen displays (1) the date and time of the call, (2) the call mode (i.e. automatic), (3) the call type (patient call, bed exit call, or bathroom emergency call), (4) the patient room number, and (5) the patient name or the word "vacant."
Once this information appears on the screen, the NCO telephones the room, asks what is needed, and types a note of the patient's request into the computer. The computer automatically beeps the staff member assigned to the room. The assigned staff member's beeper sounds an alert, displays the room, patient name, and the typed message from the NCO.
NCO can view and or print a list of patient calls and or bed exit alarms from any specified patient room. The list will include the date of the patient calls or bed exit alarm, when or if NCO responded to the call, when a staff beeper was activated, if a call message was sent. NCO has no way of knowing when or if the patient's call was acted upon; Unless a patient or family member calls back to report their call or request was not answered. The call system does not automatically indicate a malfunction in the system or identify problems with beeper communication.

During the tour (11/11/2010), the surveyor, EI# 8, and or EI #9 randomly tested patient call/bed exit alarms and observed:
1. Room A on Unit E: The call light was activated. A light located above the entrance door to the room came on and a low beep (not audible outside the room) sounded. No one called the room to answer the light. Staff on duty were questioned and no one received a beep or a message about the call or bed exit alarm activation.
2. Room B on Unit E: A staff member laid on the bed and the bed alarm was turned on. The staff member got up from the bed but no alarm or beep sounded at the bed. Then the light outside the door in the hall came on. However, the call light turned off within seconds of activation, without the staff touching the light and without anyone pressing the cancellation button above the patient bed.
3. Staff assigned to the patient rooms (on tour 11/11/2010) on unit E and F were randomly beeped to check beepers assigned to identified patient rooms. Staff contacted by the NCO reported their beepers did not sound or indicate a call from the NCO.
4. Unit E's the patient call / bed exit alarm did not always distinguish and or display the reason for the call light activation (i.e. a patient calling for assistance or a patient exiting the bed) at the nurse call station.
5. The nurse call operator could not communicate with the patient room (to question the reason for the call) due to the telephone line indicating the telephone in the room was busy (staff performing the tests initially in vacant rooms and reportedly were not using the telephone);
6. The call system (on unit E and F) randomly terminated a call without intervention or response from nurse call and;
7. The patient call system does not indicate, to the nurse call station operator, when, if the call system fails, or when there is a malfunction in the system.

On 11/11/2010 at 4:45 PM, EI# 4 explained the procedure for reporting problems with the patient call/bed alarm system. According to EI# 4, the call system was only down for a few moments (when identified by the surveyor and staff). EI# 4 states the problem reported only occurred on Unit E and all that was required to fix the problem was to "reboot" the system. EI# 4 states the vendor (EI# 17) had talked NCO how to reboot the system, and now the system is working properly.
The surveyor explained, and staff confirmed, observations of the staff beepers not responding to the NCO calls and the telephone system not allowing the NCO to communicate with patient rooms. EI# 13 (interviewed 11/12/2010 after EI# 4) stated the facility is not sure what happened to the system or why. The hospital vendor and technical services began working to identify and correct problems on 11/11/2010 and 11/12/2010.

On 11/11/2010 at 4:00 PM, facility administration implemented the following corrective actions:
All staff on duty signed the following statement:
" ...I understand that we have a current outage of our nurse call system. Pagers are not operating consistently and nurse call operators may be unable to answer patient calls. Please watch patient call lights diligently until you are notified that the system has been restored to working order. Overhead page reminders will be sounded periodically as a reminder. "

On 11/12/2010 at 09:15 AM, the surveyor interviewed a hospital engineering staff member (EI# 13) and a technical staff member with the nurse call/bed exit system (EI# 17). These staff members, notified during the tour of the call system issues being identified, explained the call/bed alarm system failure.
According to EI# 13 and EI# 17, this hospital's patient call / bed exit alarm system is controlled by one designated nurse call operator (NCO). This hospital's patient call system is one of three hospitals (located in three counties) that are part of one common Ethernet network of patient call systems. Each hospital determines if they will use one or more nurse call operators to answer patient calls. The nurse call operator (NCO) answers the patient call and relays information to an assigned staff member's beeper.
One of the three hospitals on this network has call operators on each unit. This hospital designates one person as the nurse call operator (NCO). The NCO answers all patient calls and bed exit alarms. Once a patient call or the bed exit alarm is activated, the NCO contacts the patient by telephone, identifies the patient need, types the patient request or need into the computer, and the system sends the patient request/need to staff beepers. The message entered by the call operator appears on the assigned staff member's beeper. Staff assigned to the patient room receives a beep and a message on their beeper. The staff respond to the patient request.
According to the engineering and technical staff (EI# 13 and EI# 17), the link between this hospital and the network went down (failed). When the NCO notified EI# 13 and EI# 17 of the problems identified during the tour and testing of the call/bed exit alarm system (on 11/11/2010), the NCO was directed (by technical staff over the telephone) to reset the system.
EI# 13 and EI# 17 state the computer system reset but the radio page application failed to reset, so staff were not getting patient call or bed exit alarm information on their beepers. The vendor (EI# 17) had to access the system remotely and manually reset the radio controlled beeper system. When asked how long the system had been down before it was reset, EI# 17 said staff were busy getting the system back up and did not think to check to see how long it had been down before the reset (during the survey).
When asked if the bed exit call system works the same as patient call system, EI# 17 said, "Yes and no." According to EI# 13 and EI# 17, the bed exit alarm has to be set when a patient is put into the bed. Once set, if a patient gets out of bed, the bed exit alarm sounds, the system automatically calls the nurse call station, and automatically sends a page to whoever is assigned to the patient. If no one is assigned to the specific room, the system sends a team page to the unit.
EI# 13 and EI# 17 stated they are not sure what happened or why the patient call / bed exit alarm system developed the problems identified during the tour. They (EI# 13 and # 17) indicated their staff are working to identify and correct the cause of the identified problems.
When asked about who maintains and checks staff beepers, EI# 13 and EI# 17 indicated they are not sure who is supposed to make certain staff beepers are working properly.

On 11/12/2010 at 11:05 AM, the surveyor conducted the second test of the patient call/bed exit system (accompanied by nursing administrative, engineering and technical staff EI# 4, # 8, # 9, # 13, #17). A test from one semi-private room with two beds, but only one call light connected to the call systems wall inlet, revealed the bathroom emergency failed to send a call to the nurse call operator (NCO EI# 12), therefore, no message was send to the assigned staff beeper to indicate a bathroom emergency patient call was activated. A second test, in a different semi-private room with both call lights connected to the wall inlet, revealed the emergency bathroom patient call functioned properly when both call lights were connected to the inlet.
During the tour (11/12/2010), the hospital implemented staff training and began checking semi private room to assure patient call lights were in all wall inlets, even if the room was occupied by only one patient.

On 11/12/2010, the day of the survey exit, hospital staff continued to respond to patient calls when a call light activated outside the patient's doors. The hospital's engineering and contract technical staff began checking and or rechecking patient call/bed exit alarms. Hospital administration states only Unit E uses the patient call/bed exit system.

On 11/16/2010 at 15:04, the hospital submitted (by facsimile) the following:
"Nurse Call Trouble Shooting Guide / Back Up Plan for the Nursing Units
ISSUE
1. Light on Outside of room -no page received
ACTION
Check patient
Complete patient request
Check nurse call system
Press Nurse Call button on Check patient bed / telemike
Talk with Nurse Call Operator
Wait to receive page; if no page received have operator send test page
If no page received, operator will check patient assignments. If correct, a unit test page will be sent to check all pagers on the unit
If single pager issue, a new pager will be assigned to the nurse.
If entire unit issue. Engineering and the Nurse Call Vendor support will be called investigate the issue.
Nurses will be instructed by Nurse Manager / House Supervisor to observe patient lights until issue is resolved.

ISSUE
2. No Communication with the Nurse Call Operator
ACTION
Nurse will check room by calling the Nurse Call operator by phone (3335) while in room pressing bed nurse call button / telemike
If no communication is made, the nurse will contact Engineering and Nurse Call.
If only one room is affected, engineering will replace the room nurse call station.
If the entire floor is affected, the Nurse Call Vendor will be called by Engineering / Nurse Call.
Nurse Call will notify House Supervisor who will notify unit management
Nurses will be instructed by Nurse Manager / House Supervisor to observe patient lights until issue is resolved

ISSUE
3. House Wide Nurse Call System Issues
ACTION
Back Up Plan Initiated
Nurse on Units Instructed to watch call lights on halls until further notice
Verbal notification of nursing by House Supervisor and Nurse Managers of Nurse Call System issue
Overhead pages each shift the Nurse Call system is down until problem resolved
Verbal reminders will occur by House Supervisors to each unit during their shift rounds.

This citation is written as a result of the investigation of Complaint Number AL00023443.

Based on hospital policy/procedures, medical record reviews, observations, interviews, and grievance/complaint documentation, the facility failed to do a thorough investigation of the 10/24/2010 fall involving patient identifier (PI) #10. As a result, hospital administration was not aware that the fall prevention policy was not being implemented on Unit E (for patients at risk for falls (PI# 4, #5, #6, #7 observed on tour 11/11/2010 and on 11/12/2010 with no fall risk bracelets on), and facility staff failed to identify malfunctions in the Ethernet controlled patient call / bed exit alarm system; prior to the surveyor's test on 11/11/2010 and the system retest on 11/12/2010.
On 11/11/2010 and 11/12/2010, observations and testing of the patient call / bed exit alarm system revealed previously unidentified malfunction in the Ethernet controlled central computer and employee beeper system. This system failure has the potential to effect the health and safety rights of all patients dependant on this system to communicate their needs; And resulted in an immediate jeopardy being identified by the surveyor on site 11/11/2010.
Following the tours (on 11/11/2010 and 11/12/2010), the facility staff accompanying the surveyor on tour (employee identifier [EI] #8, #9, #4, #13, and # 17 joining and leaving the surveyor at different times during the tour) reported the identified computer and beeper malfunctions to hospital administration.
Hospital Administration responded by directing all staff to physically respond to all patient calls and bed exit alarms; Until the problems identified with the patient call / bed exit alarms, and employee beepers are corrected, checked by engineering, and checked by technical staff to assure the system is operating properly. These measures removed the immediate jeopardy, while hospital staff continued to identify and correct the patient call / bed exit alarm system.
Finding Include:

Hospital policy/procedure: "Patient's Bill of Rights and Responsibilities,"
(effective February 1994) and revised in May 2008, includes:
"...YOU HAVE THE RIGHT TO:
...2. Know that the effectiveness and safety of care, treatment and services for your health condition does not depend on your race, creed, religion, sex, gender, sexual orientation, ethnicity, country of origin, age, handicap, or source of payment.
...11. Have a surrogate ...exercise the patient ' s rights when the patient is incapable of doing so without coercion, discrimination or retaliation.
...21. Be told how and to whom you may voice a complaint or safety concern including the Hospital Administrative Representative ... "

Hospital policy/procedure: "Fall Management" (effective July 1999, revised in April 2009) approved May 2009 includes:
"...Purpose: The purpose of this policy is to identify patients who are at risk for falling and to implement strategies to minimize the risk for falls...
Procedure:
A. Adult Inpatient (including 23 hour admitted patients, Labor and Delivery and Post Partum) and ED Assessments.
1. All patients will be assessed for their fall risk utilizing the appropriate Patient Care
Documentation Tool:
A. On admission to the facility/department...
B. Fall Prevention and Management Interventions/Protocol for Adult Patients...
2. Place a yellow armband on the patient and sign at the head of the bed...
6. Place call bell within reach, visible and inform the patient of the location and use
7. Light cord within reach, visible and inform the patient of the location and use
10. Bed in lowest position with wheels locked and bed alarm turned on if appropriate..."

On 10/22/2010 at 12:35 PM, Patient Identifier (PI) #10 was admitted to the geriatric psychiatric unit (Unit E) from a nursing home. The admission notes document that PI# 10 was becoming "...very paranoid and delusional...refusing to eat...resistant to care..." accusing staff at the nursing home of stealing, and verbalized feeling that people walking past her (PI#10's) room were talking about her.
Staff documented PI# 10 was having delusional thoughts, paranoia, and noted an "increase in generalized weakness." PI# 10 arrived at the hospital with soft wrist immobilizer in place on the right hand / wrist. Staff noted PI# 10 was "unable to state what happened" to her arm, and was unable to move or grasp with her right hand. PI# 10's mobility is documented to have decreased in the three weeks prior to this hospital admission.

The 10/22/2010 "FALLRISK" assessment notes indicate PI# 10 had no history of falling, however the patient's medications, gait, transferring issues were identified fall risk factors noted by staff. Staff documented that PI# 10 "...overestimates or forgets limits...Fall Risk Total 40...Placed on fall precautions...Adult Fall Prevention Protocol..."

On 10/24/2010 at 4:37 AM, the night nurse, employee identifier (EI# 10) documented: "...SAFETY Interventions:...Utilized measures to maintain safe environment...Free of injury...Patient rested well no distress noted..."

On 10/24/2010 from 12 midnight until 05:45 AM, Employee Identifier number (EI#) 11, the night shift psychiatric technician and direct care staff member assigned to PI# 10, documented observations of PI# 10 every 15 minutes.
EI# 11 documented these observations by checking codes on the "Geriatric Observation Round Sheet." The codes (entered by EI# 11) indicate PI# 10 was observed in "Bed (Bed exit alarm activated)" and "sleeping" when checked every 15 minutes until 05:00 AM.
At 05:00 AM, EI# 11 documented that PI# 10 was awake, calm, and in bed at each 15 minute check from 05:00 AM until 05:45 AM (when it is documented that the patient was out of bed and in the hall).
EI# 11 (interviewed 11/11/2010 at 12:15 PM) recalled finding PI# 10 on the floor, on 10/24/2010 at approximately 5:00 AM. According to EI# 11, he went to get PI# 10 out of bed (at approximately 5:00 AM) and found PI# 10 was wet. He (PI# 11) states he left the room to get linens. EI# 11 says one of the four bed rails (the left rail at the foot of the bed) was down when he (EI#11) left PI# 10's room.
Shortly after leaving the room, EI# 11 says he heard a "thump" and ran back to PI# 10's room. EI# 11 states he found PI# 10 lying on the floor, beside the bed. PI# 10 was lying on her side with her back toward the door. EI# 11 recalled seeing a little blood on the floor and noticed blood in PI# 10's hair. EI# 11 states he called out "fall" and began getting PI# 10 back into the bed. The night shift registered nurse ( RN / EI# 10) came to the room. EI# 11 states the nurse (EI# 10) helped him (EI# 11) get PI# 10 back into bed. The nurse cleaned the cut on PI# 10's head.
EI# 11 denies hearing the bed alarm, and states his beeper did not sound before, or after, he went back to PI# 10's room.
When asked if anyone asked (EI# 11) about this incident before the survey; EI# 11 replied, yesterday (11/10/10) the nurse manager (EI# 8) said you (surveyor) would be calling me (EI# 11). Other than this "Nobody said nothing to me about this until now."

On 10/24/2010 at 5:20 AM, EI# 10, the night shift nurse documented: "...Psych [psychiatric]...Note...patient found lying on the floor beside her bed by the tech. [psychiatric patient care technician]. Patient does not remember why she was trying to get up...vital signs are stable... demonstrated no change in mental status...cut on the occipital area... head...swollen...cleaned...denies pain at present...Dr ...notified of fall and...explained...cut that was steri stripped and...a large knot...to continue with the neuro checks per protocol. House supervisor ...notified of fall... tried to contact...family...unsuccessful..."
EI# 10 (interviewed on 11/11/2010 at 1:40 PM) recalled being in the day room, across the hall from the nurse's station, when she heard someone call out "fall." EI# 10 states she ran to PI# 10's room and observed the patient (PI# 10) lying on the floor and EI# 11 in the room. The nurse (EI# 10) states PI# 10 was awake and said (to nurse EI# 10) that she (PI# 10) was trying to get out of bed. EI# 10 states the patient did not recall why she did not call for help.
EI# 10 recalled PI# 10 complaining of a headache, seeing a small cut on PI# 10's scalp, and seeing a small amount of blood on the floor. According to EI# 10, the bed rails were up when she entered PI# 10's room. When asked if the patient call/bed alarm was sounding, EI# 10 states staff cannot hear the bed alarms or the nurse calls at the desk. EI# 10 explained that the nurse call operator (NCO) answers all patient calls and bed alarms. The NCO sends beeper message to the assigned staff person's beeper.
When asked about the fall prevention policy, EI# 10 states the fall prevention program includes using bed alarms, fall bracelets, putting signs above at risk patient's bed, and checking the patients every 15 minutes. When asked if anyone asked about the patient's fall before this survey, EI# 10 responded, "No, I reported the fall...I filled out an accident report and gave it to the house supervisor."

PI#10's medical record contains three pictures that have no identifying name. One picture is a picture of a scalp laceration with the following hand written note (on the edge of the picture): "fall 10/24/2010 @ 05:10."
Two pictures show an arm that has a dark purple, circular, discolored area near the lateral aspect of the elbow. These pictures have no name or date to indicate who is in the picture, when, or why the pictures were taken.

On 10/25/2010 at 08:20 AM, the physician's progress notes document that PI#10's x-rays are negative for fractures, and no suturing of the scalp laceration was necessary. The physician documented receiving a "...call from RN at 6:30 AM ...pt [patient] fell sustaining laceration to occipital scalp...seen on rounds ..."

On 10/24/2010 at 3:33 PM, staff documented that PI# 10 "...S/P [status post] fall last night with small head laceration...limited ROM [range of motion] right shoulder...weak diffusely, unable to test right UE [upper extremities] secondary to pain...wrist, elbow without acute pathology...head: no bleed ...Discussed With...Family...Continue current medical treatment plan..."

On 11/08/2010, hospital administration documented a complaint from the family of PI# 10, relating to the patient's fall on 10/24/2010.
On 11/10/10 at 3:00 PM, Employee identifier (EI) # 8 and EI# 9 stated that they had the complaint but they had not made contact with the complainant (prior to the date of the survey 11/10-12/2010).
The administrative representative (EI# 16) responsible for maintaining complaint/grievance files (interviewed by telephone 11/15/2010 at 11:37 AM) states the complaint from PI# 10's family was investigated by EI# 8 and EI# 9.

On 11/11/2010 (beginning at 2:00 PM) and on 11/12/2010, the surveyor and employee identifier (EI) # 8 and EI # 9 conducted a tour of the facilty, testing to the patient call / bed exit alarm system (administrative and technical employees joining the tour and testing at different times include EI# 13, EI# 17, EI# 4).
During the tour (on 11/11/2010 and 11/12/2010) the surveyor observed four sampled patients, identified at risk for falls on Unit E (PI# 4, #5, #6, #7), who were not wearing fall risk bracelets. EI# 8 and EI# 9 stated (on 11/12/2010 at 12:30 PM) that all patients on Unit E are at risk for falls.
EI# 8 and EI# 9 and engineering staff EI# 13 explained that Unit E's patient call and bed exit alarm are part of the same computer controlled call system. Staff explained that all patient calls and bed exit alarms are answered by one central nurse call operator (NCO). The NCO (EI# 12) is in an office on the first floor of the building.
The surveyor and employee identifier (EI) # 8 went to the nurse call operator (NCO) station on the first floor. The NCO, EI# 12, explained that each unit is responsible for entering patient names into the patient call system computer on a daily basis. Also staff assignments are entered into the computer system each shift. The computer system should be updated as the census and staff assignments change. If no patient name is in the system and a patient call or bed exit alarm is activated, the word "vacant" is displayed on the NCO computer screen.
Each time a patient call or bed exit alarm is activated, the NCO's computer screen displays (1) the date and time of the call, (2) the call mode (i.e. automatic), (3) the call type (patient call, bed exit call, or bathroom emergency call), (4) the patient room number, and (5) the patient name or the word "vacant" if no patient name is in the system.
When a patient call /bed exit alarm is activated and the NCO information appears on the screen, EI# 12 (the designated NCO at the time of the survey) states she (NCO) contacts the patient room by telephone, talks to the patient or the individual making the call, asks what is needed, and enters the patient's request/need into the computer call system. The NCO enters the patient request into the computer system, the computer automatically beeps the staff member assigned to the room. EI# 12 states each patient care assigned staff member has a beeper. The computer calls the beeper and the beeper sounds an alert and displays the room, patient name, and the typed message from the NCO. According to EI# 12, the NCO can view and or print a list of any patient call, or bed exit alarm activation. However, the NCO has no way of knowing when or if the patient's call was acted upon; Unless a patient or family member calls the NCO back to report their call or request was not answered.
The NCO (EI# 12) states the computer does not automatically indicate to the NCO if there are malfunctions in the computer, the computer's communication with the staff beepers, or when the computer is automatically terminating a patient call.

During the 11/11/2010 test of the nurse call/bed exit alarm system (beginning at 2:00 PM) the surveyor and facility staff observed the following:
(a) Staff failed to enter all in-patient names into the computer system, so the nurse call operator answered calls from the "vacant" room and staff receiving NCO's typed message on their beeper had no patient name.
(b) Staff assigned to the patient rooms (on unit E and F) were randomly beeped, by the NCO and sent a message to check identified occupied and unoccupied patient rooms. Staff contacted, after the beeper was activated, reported their beepers did not sound or display the call.
(c) On unit E the call system did not always distinguish and display the reason for the call light activation (i.e. a patient calling for assistance or a patient exiting the bed) at the NCO's station;
(d) The NCO could not always communicate with the patient room (to question the reason for the call) due to the telephone line indicating the telephone in the room was busy (staff performing the tests initially in vacant rooms and were not using the telephone);
(e) The call system terminated the call without intervention or response from nurse call and;
(f) The computerized patient call/bed exit alarm system does not indicate, to the NCO, when or if the call system fails or when there is a malfunction in the system.
These system failure has the potential to affect the health and safety rights of all patients dependant on this system to communicate their needs; And resulted in immediate jeopardy being identified by the surveyor on site 11/11/2010.

The surveyor (on 11/11/2010), and facility staff with the surveyor on tour, reported the computer and beeper malfunctions identified during the tour to hospital administration. According to hospital administrative staff EI# 4 (following the 11/11/2010 tour), the patient bed exit alarm does not sound, unless a patient moves off the mattress for more than 30 seconds. This staff member states the patient call / bed exit system was off only a few moments and the bed exit alarm automatically calls the beeper of the staff assigned to the room.

On 11/12/2010 at 09:15 AM, the surveyor interviewed a hospital engineering staff member (EI# 13) and a technical staff member with the nurse call/bed exit system (EI# 17). These staff members, notified during the tour of the call system issues being identified, explained the call/bed alarm system failure. According to the vendor technician, this hospital's patient call/bed exit alarm system is controlled by a nurse call operator. This patient call system is one of three hospitals (located in three counties) that are part of one common Ethernet network of patient call systems. Each hospital determines if they will use one or more nurse call operators to answer patient calls. The nurse call operator (NCO) answers the patient call and relays information to an assigned staff member's beeper.
One of the three hospitals on this network has call operators on each unit. This hospital uses one call operator to answer all patient calls/bed exit alarms. When a patient activates the patient call or the bed exit alarm is activated, the NCO contacts the patient by telephone, identifies the patient need, types the patient request or need into the computer, and the system sends the patient request/need to staff beepers. The message entered by the call operator appears on the assigned staff member's beeper. Staff assigned to the patient room receives a beep and a message on their beeper. The staff respond to the patient request.
According to the engineering and technical staff (EI# 13 and EI# 17), the link between this hospital and the network went down (failed). When the NCO notified the vendor technician of the problems identified during the tour, and testing of the call/bed exit alarm system. The vendor technician directed the nurse call operator to reset the system. The system reset but the radio page application failed to reset, so staff were not getting information on the beepers. The vendor technician had to access the system remotely and manually reset the radio controlled beeper system. When asked how long the system had been down before it was reset, the vendor technician indicated they were busy getting the system back up and did not think to check to see how long it had been down before the reset (during the survey).
When asked if the bed exit call system works the same as patient call system, EI# 13 and EI# 17 responded, "Yes and no." The bed exit alarm has to be set when staff put a patient in the bed. Once set, if a patient gets out of bed, the bed exit alarm sounds, the system automatically calls the nurse call station, and automatically sends a page to whoever is assigned to the patient. If no one is assigned to the specific room, the system sends a team page to the unit.
EI# 13 and EI# 17 stated they are not sure what happened or why the call/bed alarm system developed the problems identified during the tour. They (EI# 13 and # 17) indicated their staff are working to identify and correct the cause of the identified problems. When asked about who maintains and checks staff beepers, EI# 13 and EI# 17 indicated they are not sure who supposed to make certain staff beepers are working properly.

On 11/11/2010, Hospital Administration (EI# 1, # 2, #3) responded to system failure by directing all on duty staff to physically respond to patient calls and bed exit alarms; Until the call / bed exit alarms, and beeper concerns were identified, corrected, checked by engineering, and checked by technical staff to assure the call / bed exit alarm system was operating properly.
The following measure (implemented on 11/11/2010 at 4:00 PM) removed the immediate jeopardy, while hospital staff continued to identify and correct the their patient call / bed exit alarm system. An overhead announcement to all staff directed staff physically respond to patient calls and bed exit alarms. Administrative staff sent training and administrative staff to each unit and staff on duty signed the following statement:
" ...I understand that we have a current outage of our nurse call system. Pagers are not operating consistently and nurse call operators may be unable to answer patient calls. Please watch patient call lights diligently until you are notified that the system has been restored to working order. Overhead page reminders will be sounded periodically as a reminder. "

On 11/12/2010 at 11:05 AM, the surveyor conducted the second test of the patient call/bed exit system (accompanied by nursing administrative, engineering and technical staff EI# 4, # 8, # 9, # 13, #17). A test from one semi-private room with two beds, but only one call light connected to the call systems wall inlet, revealed the bathroom emergency failed to send a call to the nurse call operator (NCO EI# 12), therefore, no message was send to the assigned staff beeper to indicate a bathroom emergency patient call was activated. A second test, in a different semi-private room with both call lights connected to the wall inlet, revealed the emergency bathroom patient call functioned properly when both call lights were connected to the inlet.
During the tour (11/12/2010), the hospital implemented staff training and began checking semi private room to assure patient call lights were in all wall inlets, even if the room was occupied by only one patient.

On 11/12/2010 (day of the survey exit), hospital Administration reported that staff are continuing to respond to patient calls and bed exit alarms when the light activated outside the patient doors are on. The hospital's engineering and technical staff will continue to check and will recheck the patient call / bed exit alarm system post the survey until issues are resolved. Hospital administration states only Unit E uses the patient call/bed exit system and the fall risk policy implementation on Unit E is being addressed.

On 11/16/2010 at 15:04, the hospital submitted (by facsimile) the following:
"Nurse Call Trouble Shooting Guide / Back Up Plan for the Nursing Units
ISSUE
1. Light on Outside of room -no page received
ACTION
Check patient
Complete patient request
Check nurse call system
Press Nurse Call button on Check patient bed / telemike
Talk with Nurse Call Operator
Wait to receive page; if no page received have operator send test page
If no page received, operator will check patient assignments. If correct, a unit test page will be sent to check all pagers on the unit
If single pager issue, a new pager will be assigned to the nurse.
If entire unit issue. Engineering and the Nurse Call Vendor support will be called investigate the issue
Nurses will be instructed by Nurse Manager / House Supervisor to observe patient lights until issue is resolved.

ISSUE
2. No Communication with the Nurse Call Operator
ACTION
Nurse will check room by call the Nurse Call operator by phone (3335) while in room pressing bed nurse call button/telemike
If no communication is made, the nurse will contact Engineering and Nurse Call.
If only one room is affected, engineering will replace the room nurse call station.
If the entire floor is affected, the Nurse Call Vendor will be called by Engineering / Nurse Call.
Nurse Call will notify House Supervisor who will notify unit management
Nurses will be instructed by Nurse Manager / House Supervisor to observe patient lights until issue is resolved

ISSUE
3. House Wide Nurse Call System Issues
ACTION
Back Up Plan Initiated
Nurse on Units Instructed to watch call lights on halls until further notice
Verbal notification of nursing by House Supervisor and Nurse Managers of Nurse Call System issue
Overhead pages each shift the Nurse Call system is down until problem resolved
Verbal reminders will occur by House Supervisors to each unit during their shift rounds.

This citation is written as a result of the investigation of Complaint Number AL00023443.