HospitalInspections.org

Based on observation, record reviews, and interviews, the facility failed to provide care in a safe setting by failing to implement post fall intervention, including reporting, assessing, and documentation for 1(P(patient)1) out of 10 patients sampled. This failed practice is likely to lead to direct physiological harm, additional medical services, and risk of mortality.

The findings are:

A. Facility's "Fall Prevention" policy dated 02/21/2020 states:
1. If a patient does fall, and incident report and QA tool must be completed and sent to Risk Management within 72 hours.
2. If the patient falls and sustains an injury, report fall to Chief Nursing Officer and the Clinical Services Director. If the patient falls and sustains a serious bodily injury, contact the FAS Legal Department for further guidance.
3. A copy of both reports should be sent with the incident report and QA tool to Quality tool to Quality Management.
4. If a fall occurs, qualified staff evaluates patient/resident for injury form the fall and determines what may have caused or contributed to the fall and completes a fall Investigation Worksheet.
5. Any unwitnessed fall will have neurological checks (flow of blood occurring furthest away from the central body, registration of an incoming nerve impulse in the part of the brain that detects feeling, action of muscles upon the skeleton) completed per policy regardless of the resident's cognitive status at the time of the incident.
6. Reports of patient/resident falls are tracked and trended through the QAPI process within the facility, and that the QA. Quality of Care Meeting. Incident/Accidents are to be logged at least weekly.

B. On 09/08/2021 at 11:58 am video observation of facility's security camera from 07/04/2021 revealed:
1. On 07/04/2021 at 6:20 am P1 was standing in the day room (communal room for all patients in the unit) near a table when she fell onto the floor landing on the left side of her body.
2. S18 (Registered Nurse), S21 (Charge Nurse), S23(Mental Health Technician), and S24 (Mental Health Technician) approached P1 while she was lying on her left side on the floor.
3. S18 (Registered Nurse) placed non-skid socks on P1's feet.
4. S18 (Registered Nurse) picked P1 up by placing her arms under her and sitting her in a wheelchair that was in the room where P1 fell.
5. S18 (Registered Nurse) staff wheeled P1 to a table where she was left and staff exited the dayroom where P1 experienced fall.

C. Record review of facility's "Patient/Resident Incident/Accident Investigation Worksheet" dated 07/12/2021 for incident occurring on 07/04/2021 at 5:30 am, a separate reported fall event to that at 6:20 am revealed:

1. P1 "was found on the floor. Patient called for help while in her room and on getting there saw her struggling to get into wheelchair from the floor. Patient could not explain how and when she fall because she has been confused since she was admitted. She was seen sitting on the floor while trying to grab the wheelchair."
2. No reporting of P1's fall at 5:30 am.

D. Review of P1's medical chart dated 07/04/2021 following revealed:
1. No documentation of head to toe assessment (evaluation of the body from head to toe.)
2. No documentation of neurological check.
3. No documentation of provider notification
4. No documentation of notification of on call administration.
5. No documentation of notification to family.
6. No medical chart documentation of P1's reported fall at 5:30 am.

E. Review of facility's "5 Day Summery" (fall investigation form from fall 07/04/2021 at 6:20 am.) revealed:
1. P1 experienced a fall, while at [facility]. Facility Identifier is substantiating abuse due to the staff's failure to follow proper procedure after the fall. To include but not limited to; completing the head-to-toe assessment, initiate neuro checks, notifying the provider, administrator on-call, family, completing the incident report, and proper documentation in the medical record.
2. Two nurses and one mental health tech (MHT) were terminated, one agency nursing contract was terminated.
a. Record review of facility's "Termination Form" for S(staff)20 (Mental Health Technician) on 07/16/2021 revealed, termination based on "Violation of Patient Care Policies."
b. Record review of facility's "Termination Form" for S18 (Registered Nurse) on 07/16/2021 revealed, termination based on "Patient Neglect."
c. Record review of facility's "Termination Form" for S21 (Registered Nurse) on 07/16/2021 revealed, termination based on "Patient Neglect."
d. On 07/15/2021 at 3:12 pm email notification from [facility] to S19's (Registered Nurse)contract agency reveals "Termination for failure to report a fall."


F. On 9/13/2021 at 10:30 am interview with S2 (Director of Compliance) revealed, S19 submitted "Patient/Resident Incident/Accident investigation Worksheet" on 7/12/2021, "I was not able to get facts about the falls, we are treating this as the patient did have 2 falls at the facility." S2 confirmed there was no documentation of falls, or post fall interventions documented, in P1's medical record.

G On 9/01/2021 at 5:40 pm interview with family representative of P1 sated, "My mom was admitted July 1, 2021 to [facility], she fell on July fourth, she did not go to the hospital until the seventh of July, I was not notified until the 10th or 11th of July. I was called by provider from the hospital [facility] sent her to, she had a broken femur and hip." S2 (Directory of Compliance) said there is a video of the fall, and [facility] accepted full responsibility. S2 (Director of Compliance) told me 2 people got fired over the incident. My mom P1 doesn't remember falling, she is on hospice now."