HospitalInspections.org

Based on review of hospital documents, policy review, medical record review, and interview, the facility failed to ensure patient rights were protected and patients received care in a safe setting for 2 of 6 (Patient #10 and #44) sampled patients reviewed for falls.

The findings included:

1. Review of the undated "Targeted Toileting Scripting Examples," revealed " ...Your safety is a priority for us as we work together to help you heal during your stay. We will keep you safe from falling by always escorting you to and from the bathroom. We will provide you with as much privacy as possible while in the bathroom, but your safety is most important. So, we will remain within arm's reach or line of sight to keep you safe from falling ..."

Review of the "Let Us Help You Stay Safe Signage," revealed " ...Don't go to the bathroom alone. Let a nurse or caregiver help you get back to the bathroom, stay close by while you go, and help you back to bed. This is very important to make sure you don't fall ..."

2. Review of the policy titled "Falls Prevention Policy," dated February 2024, revealed " ...Fall ... A patient fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface ... ( ...a counter), on another person, or on an object ( ...a trash can). This includes all types of falls, whether they result from physiologic reasons ( ...fainting) or environmental reasons ( ...slippery floor) ...Medications with High Potential for Contributing to Patient Falls ...Consider medications with high potential for contributing to patient falls ...hypnotics and sedatives ...Fall Prevention Reference Chart ...HIGH FALL RISK Maintain low interventions, moderate interventions AND do the following ...Education family/patient every shift about high fall risk status and why they need to call for assistance, Closely monitor/protect/engage the patient, Remain with patient during toileting, Provide bedside toileting devices if needed, Assist with ambulation and transfers, Bed alarms/chair alarms where appropriate, Toileting schedule (individualized or per unit protocol), Provide yellow non-skid footwear, Laminated high fall risk sign, if feasible, Yellow high fall risk armband, For patients/families unable or unwilling to participate in the fall prevention program, consider a sitter ( ...virtual sitter or in-person sitter) ..."

3. The hospital failed to ensure care was provided in a safe setting for Patient #10 and Patient #44 out of 6 sampled patients.

Patient #10 was found on the floor at a friend's house on 4/15/2023 and was taken to an outside hospital where she was found to have a subdural hematoma (a pool of blood between the brain and its outermost covering) with a midline shift (a life-threatening condition that occurs when brain tissue is displaced across the brain's center line). Patient #10 was intubated at the outside hospital and transferred to Hospital #1 for a higher level of care.

Patient #10 was assessed as a high fall risk and was placed on fall precautions and remained a high fall risk until discharge.

On 4/25/2023 at approximately 11:53 AM, Patient #10's bed alarm sounded, and Registered Nurse (RN) #2 entered the room to find Patient #10 standing halfway to the bathroom while still connected to telemetry, pulse oximetry and the blood pressure monitor. RN #2 disconnected the monitors from Patient #10 and assisted her to the commode. After Patient #10 urinated, she stood up next to RN #2 and asked to wash her hands. Patient #10 then fell away from RN #2 and landed on her hip on the bathroom floor and hit her forehead on the floor. Immediately after the fall, Patient #10 was alert and oriented X4, and neurological checks were unchanged. RN #2 assisted Patient #10 back to bed, and Patient #10 was assessed to be hypertensive on subsequent vital sign checks. RN #2 administered 2 doses of intravenous hydralazine (blood pressure medication), and a stat computerized tomography (CT) was ordered. The CT scan revealed Patient #10 had a new right subdural hematoma. Upon arriving back on the floor following the CT, Patient #10 became more somnolent, had snoring respirations, and her pupils became dilated. Patient #10 was intubated and transferred to the operating room for an emergent craniotomy (removal of portion of the skull for brain surgery).

RN #2 failed to ensure Patient #10 safety by assisting Patient #10 to the bathroom alone and failed to use the bedside commode as recommended.

Patient #44 was admitted to the hospital on 3/28/2025, with diagnoses including Syncope and Idiopathic Intracranial Hypertension (increased pressure in fluid surrounding brain).

Patient #44 was assessed as a high fall risk and was placed on fall precautions.

Review of the "Medication Administration Record," revealed Patient #44 received Benadryl on 3/30/2025 at 11:00 PM. Benadryl (sedative) is considered a high-risk drug for falls.

Review of the "Significant Event Note," dated 3/31/2025 at 4:56 AM revealed Care Partner (CP #3) instructed Patient #44 to wait while she got help from the nurse in order to move her safely given her baseline weakness. When CP #3 left the room, Patient #44 fell out of the bed and landed on her shoulder on the floor.

CP #3 failed to ensure Patient #44's safety by leaving Patient #44 alone in her room to get the nurse.

Refer to A-144

Based on policy review, medical record review, My Health at (Named Hospital #1) review and interview, the facility failed to follow its policy for resolution of grievances related to time frames for patient termination for 1 of 3 (Patient #45) sampled patients.

The findings include:

1. Review of a facility policy titled, "Termination of Clinician-Patient Relationship: Patient Discharge Process" dated September, 2023 revealed, "...Circumstances that may justify ending the Clinician-Patient relationship include...Persistent patterns of not showing up to appointments and not following prescribed treatments or recommended care when non-adherence is a risk to the patient's health...Patient Notification...For Level 1 and Level 2 terminations, 30 days' notice from the date of the letter is the minimum notification period...The patient termination letter includes...Level 1 and Level 2 termination letters specify whether the patient has any appointment in the next 30 days, and, if so, the Clinician or a member of the Clinician's department will meet with the patient to discuss transition plans..."

2. Review of the closed medical record revealed Patient #45 was seen as an outpatient at Hospital #1 Dermatology Clinic multiple times beginning in July, 2022 through March 2024 for a diagnosis of melanoma and Basal Cell Carcinoma (BCC) lesions. There was a gap in treatment from Hospital #1 Dermatology Clinic from September, 2022 until November, 2023 with no documentation any treatment was done at any facility for the melanoma and the other BCC lesions identified in the medical record.

Review of the My Health at (Named Hospital #1) communication dated July, 2022 through August, 2022 revealed 6 communication entries from Patient #45 to different staff members at Hospital #1. There was documentation of 7 communication entries from multiple staff members to Patient #45 during the same time period regarding surgical appointments and the need for treatment for the melanoma and BCC lesions. A note from staff member #1 dated 8/12/2022 revealed, "...I have you scheduled Tuesday August 16, 2022@ 10 am with [Named Physician #1] for a consult and to answer any and all questions you have..." A note dated 8/19/2022 titled, "SURGERY SCHEDULED" revealed, "Would you be able to come in on 10/19 @9:00 for your surgery...Please let me know if the above date and time will work for you..." On 8/19/2022, Patient #45 responded, "...I need FT [Full Time] professional work with a living wage and medical benefits with an employer that recognizes my credentials. [Named Hospital #1] does not recognize my credentials...and neither do the other TN [Tennessee] employers. I'm told that in TN, jobs are secured by WHO you know, not WHAT you know. Therefore, I need to get work in a place that hires based on qualifications. For the record, I need Mohs, [A specialized surgical procedure used to remove skin cancer. This technique allows for precise removal of cancerous tissue while sparing healthy tissue, leading to a high cure rate and minimal scarring.] melanoma care...But because [Named Hospital #1] and other employers in TN will not hire me, I am unable to preserve and restore my health without an income."

There was a gap in treatment for Patient #45 from September, 2022 until November, 2023 with no communication documented in My Health at (Named Hospital #1).

Review of the My Health at (Named Hospital #1) communication from November, 2023 through March, 2024 revealed approximately 20 communication entries from Patient #45 to different staff members at Hospital #1.

Review of the My Health at (Named Hospital #1) communication from November, 2023 through March, 2024 revealed communication entries from multiple staff members to Patient #45 during the same period regarding the continued need for treatment for the melanoma and BCC lesions. There were multiple communication entries between physicians and other staff members regarding Patient #45's need for treatment and how that treatment and surgeries could be accomplished.

Review of the My Health at (Named Hospital #1) note from Physician #2 revealed, "12/05/23...Please reschedule pt [patient] for the procedures we planned on when we saw her last in 2022-she canceled the scheduled procedure an did not follow up. The melanoma is in [Named Physician #3's] territory And please confirm with [Named Physician #2] what else he wants us to schedule for tx [treatment] in Mohs [a specialized surgical procedure for removing skin cancer]."

Review of the My Health at (Named Hospital #1) note from Physician #3 revealed, "12/20/23...seen in July, 2022. I discussed options for management including wide excision and wide excision with sentinel node [the first lymph node that cancer cells from a primary tumor are likely to spread to] biopsy. The patient had multiple...social issues and was living in her car at that time. She was offered Social Work...but the patient declined those interventions. At the completion of our discussion, she elected to proceed with wide excision in clinic. Multiple attempts were made to schedule this but the patient failed to respond. She was counseled that melanoma is a malignancy with potential to spread and is therefore life threatening...PLAN: The patient has a history of melanoma of the right calf. I reviewed the diagnosis with the patient and clearly articulated again that this is a life threatening malignancy which requires treatment I discussed the options for surgical management again...I favored wide excision for local control. WE also discussed the recurrent skin lesion of the chest which is consistent with basal cell carcinoma. I recommended conservative excision for this local control. After considering the risks and benefits for surgery, the patient declined to schedule surgery. Her rational for this was illogical in inconsistent. She stated that her major concerns were the fact that she did not have a job or health insurance and felt that she was being discriminated against for several reasons. I explained that she was approved for care through OORA [Office of Outpatient Referral Assistance] and that I was happy to perform the procedure free of charge if she would simply schedule it. She declined to do so stating that she did not have money for gas to get to the procedure. When I asked her how she was able to come to the appointment today, she stated that a church gave her a gas card...When I offered to help her obtain a gas card through [Named Hospital #1's] Social Work, she declined this stating that the state of TN and [Named Hospital #1] were "trying to keep her on welfare". I again offered to provide care free of charge, but she declined stating that she was unwilling to do so until "her other needs were met" by obtaining a job and heath insurance. This circular discussion was repeated three times over a span of at least 15 minutes. the end of the discussion, I wished the patient well and told her that I would be happy to perform the surgical procedure if she reconsidered decision in the future. No additional Surgical Oncology follow up was scheduled, but I would be happy to see her again if she is willing to proceed with surgery..."

Review of the My Health at (Named Hospital #1) note from Nurse #2 to Physician #1 revealed, "1/19/24...She is scheduled for Mohs to treat BCC [Basal Cell Carcinoma] on chest on 2/8/24..."

Review of the My Health at (Named Hospital #1) note from Nurse #3, "1/23/24...Patient called...for lodging left a message. I have called back, we talked about hotels, missions. Per patient is living in her car and homeless..."

Review of the My Health at (Named Hospital #1) note from Licensed Social Worker #1 to Patient #45 revealed, "1/24/24...I wanted to encourage you to use the services at the Women's Shelter at the Rescue Mission. Their number is...and the address is...I hope you use their services. Their new facility sounds really nice."

Review of the My Health at (Named Hospital #1) response note from Patient #45 to Licensed Social Worker #1 revealed, "1/24/24...I've notified my medical team that you expressed unfamiliarity with my background and an inability to make recommendations for my situation...I would like to formally request the removal of any shelter recommendations from my...record, as these were not discussed or agreed upon during our conversation. I am in need of professional assistance that takes into account my unique background, education, skills, and needs to develop an individualized care plan...It is crucial for me to work with professionals who understand the importance of market-rate solutions rather than focusing solely on FPL [Federal Poverty Level] low-income programs. It is unacceptable to be directed towards Low-income programs..."

Review of the My Health at (Named Hospital #1) note from Patient #45 to Physician #1 revealed, "1/25/24...I received unsolicited advice that has nothing to do with my immediate needs. I asked that only my medical doctors and nurses have access to my chart. I kindly ask that you remove your notes from my chart. We did not discuss any of this, My file notes mention that social workers only offer FPL temporary, unsafe low-income solutions that do not match my market rate needs and don't acknowledge my advanced education and professional experience..."

Review of the My Health at (Named Hospital #1) note from Patient #45 to Physician #1 revealed, "2/05/24...I am very grateful for your time and kindness to help me with my very painful basal cell carcinoma...no one on my medical team is offering me help with my post-operative accommodation needs. I had to reach up higher to advocate for myself because I care about my health and desire to work..."

Review of the My Health at (Named Hospital #1) note from Patient #45 to Physician #1 revealed, "2/08/25 [date of scheduled surgery] Regarding my scheduled surgery for basal cell skin cancer at the Mohs clinic on Thursday, 2/8/24, I was unable to proceed as planned. [Named Director of Patient Services] informed me on 2/7/2024 that [Hospital #1] had no provisions for my outpatient post-operative care. He stated that there were no resources available to assist me during this critical period..."

Review of the My Health at (Named Hospital #1) note from staff member #1 revealed, "2/14/24...spoke with [Named Patient #45]...She was needing help with appts. [appointments]. I was able to call over to the MOHS clinic and get her 3/5/24 apt with [Named Physician #1] rescheduled to this Friday 2/16/24 at PM. She was aware of this appt and where to go, as well as her appt tomorrow 2/15/24 with [Named Physician #5] She is also aware after confirming with FC [Financial Counseling] that her FA [Financial Assistance] has been approved thru early July [2024]. She discussed multiple things with me voicing many frustrations she has had in the past with [Named Hospital #1] including patient relations as well. I told her I would try to look into some outside resources for her that could be beneficial to her."

Review of the My Health at (Named Hospital #1) note from Patient #45 to Physician #1 revealed, "2/25/24...The vulnerable deserve genuine support, not exploitation. I refuse to be treated as a commodity for the enrichment of nonprofits and state agencies. I will continue to share my experiences publicly, both within and outside Tennessee, in the hope of exposing the unethical and unjust circumstances I have faced as a competent, capable, and ethical woman..."

Review of an email sent from the Director of Patient Relations to Patient #45 on February 28, 2024 at 8:38 AM revealed, "... Dear [Named Patient #45], Thank you for responding to my messages. No, [Named Hospital #1] is unable to provide you with hotel accommodations after your procedure. While we are not at all unsympathetic to your plight, please accept this as I have communicated this with you on several occasions and it will not change. I believe our social workers have provided you with information regarding services in the community. Do you need me to resend that information? Additionally, I need to know by 9:00 am this Friday, March 1 if you plan to keep the appointment for this procedure on March 5. Another no-show is unfair to the other patients we ' re attempting to serve and will result in discontinuation of all services from [Named Hospital #1] Dermatology.

Review of an email sent from Patient #45 to the Director of Patient Relations and Tennessee Legislators on February 28, 2024 at 8:03 PM revealed, "I am deeply troubled by the unprofessional behavior I have experienced from...the Director of Patient Relations. On February 7, 2024, just one day before my scheduled medical procedure, [Named Director of Patient Relations] informed me that [named Hospital #1] had no postoperative solutions available to meet my needs. This lack of communication and last-minute notification left me with no time to find an alternative solution and ultimately led to the cancellation of my surgery...I request Named Hospital #1] to work with me to find an appropriate discharge planning option that addresses my needs and protects my health and safety..."


Review of the My Health at (Named Hospital #1) note from Physician #1 to staff member #4 revealed, "2/29/24...Send patient our notes on post op wound care. If she wants to speak with me, make her an appointment but tell her I will not get involved in her political agenda..."

Review of the My Health at (Named Hospital #1) note from Patient #45 to Physician #1 revealed, "2/29/24...I very much need the surgery...[Named Social Worker #1] entered unauthorized notes into my chart stating she discussed discharge planning with me which wasn't true...As a middle aged woman, [Named Hospital #1] and most of all TN employers self-fund their medical insurance plans and refuse to hire me at [age] so I can have both an income and insurance. The state wants people unemployed & dependent on govt [government] programs & nonprofit social services to general Federal aid for its funding budgets. I need to be working. I need discharge planning accommodations. [Named Social Worker #1] wrote notes in my chart unrelated to my discharge needs. No one at [Named Hospital #1] will discuss that with me. Can you call me so I can discuss my discharge planning needs with you before the 3/5/24 surgery..."

Review of an email sent from the Director of Patient Relations to Patient #45 on March 1, 2024 at 12:01 PM revealed, "Good Afternoon...We sincerely regret the need to cancel your appointment next week with [Named Physician #1]. You will receive a letter from the department in the mail. Thank you..."

Review of a termination letter dated 3/01/2024 from the Chair of Named Hospital #1 Dermatology to Patient #45 revealed, "I write to inform you that [Named Physician #1] and the clinicians of Vanderbilt Dermatology are unable to continue as your health care providers. Your appointment with [Named Physician #1] on March 5, 2024 has been canceled and no future appointments or procedures will be scheduled unless you have an urgent need for care in the next thirty days...Please note [Named Physician #2's] discussion with you on February 27, 2024 in which he emphasized the importance of seeing surgical oncology for definitive surgical treatment of the malignant melanoma on your right calf. Failing to treat this malignancy is against
our best medical advice...Also note the untreated basal cell skin cancers that were biopsied in the summer of 2022 on the left forearm, right shoulder, and left neck, and discussed with [Named Physician #1] on Dec 2023. At that time you declined to schedule further follow-up for these cancers except for the chest lesion. We would recommend that you have these lesions evaluated..."

The facility did not follow the "Termination of Clinician-Patient Relationship: Patient Discharge Process" which stated a 30 day notice from the date of the termination letter is the minimum notification period. Patient #45's scheduled surgery for 3/5/24 was canceled by the facility 5 days after the date of the termination letter dated 3/1/24 and was within the 30 day minimum notification period.

Review of the My Health at (Named Hospital #1) note from Patient #45 to Physician #1 revealed, "3/02/24...On 2/8/24 I was denied Mohs surgery that was scheduled. It was rescheduled for 3/1/24, but I was denied once again by [Named Physician #1] (as per [Named Director of Patient Relations] due to a lack of discharge planning support..."

Review of the My Health at (Named Hospital #1) note from Patient #45 to Physician #2 revealed, "3/04/24...My Mohs surgery was scheduled on 3/5/24 and [Named Director of Patient Relations] called 3/1/24 to cancel it. Despite these challenges, my primary concern lies with the dismissal of my requests for suitable and private discharge planning accommodations that can facilitate my medical care..."

Review of the My Health at (Named Hospital #1) note from Physician #2 to Patient #45 revealed, "3/05/24...Unfortunately, [Named Physician #1] has decided to remove you from the [Named Hospital #1] Dermatology clinic. I think a letter has been sent to you that should detail the reasons for this decision...I strongly recommend that you get ALL of these treated as soon as you can. I am sorry things have gone this way..."

Review of the My Health at (Named Hospital #1) note from Patient #45 to Physician #2 revealed, "3/05/24...[Named Hospital #1] approved my surgery under charity care and then rescinded it simply because I requested assistance with discharge planning,.."

During a telephone interview on 4/22/25 beginning at 1:30 PM, Patient #45 stated, "... I'm speaking up for myself because I have to so the only solution for me to get out of my situation is market rate living wage income...I know how to solve my problem I know how to solve homelessness but nobody will allow me to work in those positions and exercise my knowledge including experiential because they don't want to solve the the homeless problem.
I was pushed into poverty. I didn't come to Tennessee like this I was pushed down into it and denied health care so they engineered poverty in this state by doing exactly what they've done to me, and the reason why I'm being silenced is because if anybody speaks to me whether it's the media or anybody and they see a lucid sober sane non drug addicted non mentally ill person with a masters degree from private schools homeless, then that means the system does not work.
when I was scheduled to have my surgery [Director of Patient Relations] created interference so that I couldn't communicate with my medical team...I'm in my car, I couldn't have surgery and then go back to my car...I wrote [Named Previous Board Member at Hospital #1] a letter and I said, "I did volunteer work at your upscale [Named Senior Living facility] and I said, would you help me get into a Marriott a Hyatt or Hilton Hotel for one to two months so I can recover from my surgeries and heal and get back in the workforce. That's all I want. You know that costs them [Hospital #1] nothing. Corporate hotel rates...that's not going to break them or bankrupt them I said, but could you put me up in a respectful hotel because I can't be in a shelter with people that have mental health problems, their own trauma and addictions. That's not suitable for me because that's not my background"... why am I being treated this way. It's inhumane, it makes no sense to me. I'm in a very unusual situation, probably something you've never come across. I'm actually a [named age] year old woman who's never married and child free and not from here originally, and I'm denied employment because of my pre-existing health issues that are not disabling so nobody will hire me with these conditions to work and earn the money to pay for the medical care not even [Named Hospital #1] would hire me...I said why don't you do an MRI [Magnetic Resonance Imaging is a technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in the body] or PET scan [Positron Emission Tomography diagnostic imaging test that uses radioactive tracers to show how the body's tissues and organs are functioning] or you know some sort of standing evaluation before you cut open my leg, can we do that. There is a step before that wide open excision that you can do, you can either take my blood or you know do a PET scan, CT scan [Computed Tomography imaging test that detects diseases and injuries] or MRI, one of those things on my leg and they didn't want to do that because that doesn't generate enough money, so I said, how about this my body my choice. I spoke their liberal language, my body my choice and I said I want to get back to work so why don't we focus on the MOHS surgeries first, it's cheaper and on my face and my neck and my left temple, because I have another basal cell my left temple they have biopsied...And I said let's do that so that I can get back to work put me in a hotel for a month or two so I can recover, because I'm a professional and I've histoplasmosis [a lung infection]. I can't be around other immunocompromised homeless speaking intelligently and using my education, so I said I don't authorize that because I deserve better. I do, so they retaliated against me because I challenged their malignant Melanoma diagnosis, they did...Then I would go to the emergency room with my untreated medical conditions, they trained their medical team to threaten me with death; you know if you don't get your wide open excision to have [Named Physician #3] look at your lymph node to see if it's cancer you could die. I said really you don't think I know anything about this, you're not asking me what I know that I think and what I need, because...you're talking at me. I said remember we are in Nashville and this is liberal my body my choice. I'm speaking your language here, I want my Mohs skin cancer done so that I can be presentable to go back in the workforce and then I can contribute to the cost of my medical care. I come from the conservative background and that's what we do and and then I can worry about my malignant Melanoma diagnosis later. My body my choice, it's a bipartisan issue so they don't get it and I'm really not that impressed with [Named Hospital #1]..."

During a TEAMS (virtual audio and/or video conferencing to communicate and have conversations) interview on 4/24/2024 beginning at 1:45 PM, the Associate Director of Patient Relations stated, "...I understand [Director of Patient Relations] had communication with [Named Patient #45] for several years and has done a lot to try to help help her unique situation and leading up to the case in dermatology he was able to help encourage her to reach out to our financial assistance department and work together with them to get her some financial assistance with some of the needs that she had. [Named Director of Patient Relations] did a lot of work to help help...the dermatology situation. [Named Patient #45] was asking for help with things outside of our scope so she was asking for discharge planning care which included a hotel stay for her recovery, gas cards, employment so that she could eventually pay for all of these things, and on several occasions [Named Director of Patient Relations] was able to say that's something that's beyond our scope and aren't able to help with that, but here are some resources that you can tap into to help...Her messages started to escalate and got continual and persistent and there was nothing that was clinical in nature, it was all always about how she was being kept down and how she needed to have a hotel stay and gas cards and employment in order to have her clinical needs met...I do know that between January 20th and March 2nd she sent us 19 different lengthy e-mail messages all asking for the same thing. I know of at least 5 responses that were documented from [Named Director of Patient Relations] reiterating each time that we could not accommodate her requests for hotel stays and gas cards...so [Named Patient #45] didn't show up for her MOHS procedure on February 8th after several conversations letting letting her know that we couldn't accommodate the recovery process that she wanted. She did not show up for the MOHS procedure... They did reschedule that for the next month and there was condition that she not ask continually or vent continually about her situation and her unique needs that [Named Hospital #1] wasn't providing. It was from that point on that the emails started being lengthier...repetitive and persistent and it got to the point where that just degraded the relationship between the physician and the patient and at that point the physician no longer felt comfortable offering care and asked to move forward with the dismissal...we felt it was appropriate to pursue a dismissal from the clinic...

During a TEAMS interview on 4/28/25 beginning at 9:00 AM, Physician #2 stated, "...So I met her first in clinic. I do general dermatology as well as dermatopathology so I saw her in the general dermatology clinic...she had several skin cancers biopsied at that visit some with basal cell carcinomas and then she had a a melanoma biopsy from her leg. We referred her both to the MOHS [a specialized surgical procedure for removing skin cancer] micrographic surgery team for the basal cell carcinomas and then the for the melanoma we sent her to surgical oncology. I followed her from a chart perspective just to make sure I have the melanoma was taken care of. She was sent to [Named Physician #3] oncology. She refused therapy to have it excised...she was lost to follow up... [Patient #45] came back and again not have them treated. At that point, so we tried to impress upon her the danger of letting the melanoma just kind of hang around to her general health and then she had some biopsies of some basal cell carcinomas we encouraged her to go back to surgical oncology...she was so anti treatment for whatever reason...the next thing I heard was that she was being dismissed from our clinic...I didn't know why that was happening...so then I had to tell her you need to get all this treated, unfortunately you're going to have to seek treatment outside of [Named Hospital]. These are serious conditions though. You need to find another clinic to do it. At that point I didn't know everyone has tried to get her insurance coverage or get someone to help with this. I didn't know where she stood when she left [Named Hospital] in terms of treatment so it's kind of on her to try to find that other provider to to help because I feel like we had done quite a bit at [Named Hospital]. I know I had my nurse and I had talked to her...like war and peace level emails, and didn't seem like we'd gotten anywhere...it's an unfortunate case..."

Based on review of hospital documents, policy review, medical record review, and interview, the facility failed to ensure patient rights were protected and patients received care in a safe setting for 2 of 6 (Patient #10 and #44) sampled patients reviewed for falls.

The findings included:

1. Review of the undated "Targeted Toileting Scripting Examples," revealed " ...Your safety is a priority for us as we work together to help you heal during your stay. We will keep you safe from falling by always escorting you to and from the bathroom. We will provide you with as much privacy as possible while in the bathroom, but your safety is most important. So, we will remain within arm's reach or line of sight to keep you safe from falling ..."

Review of the "Let Us Help You Stay Safe Signage," revealed " ...Don't go to the bathroom alone. Let a nurse or caregiver help you get back to the bathroom, stay close by while you go, and help you back to bed. This is very important to make sure you don't fall ..."

2. Review of the policy titled "Falls Prevention Policy," dated February 2024, revealed " ...Fall ... A patient fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface ... ( ...a counter), on another person, or on an object ( ...a trash can). This includes all types of falls, whether they result from physiologic reasons ( ...fainting) or environmental reasons ( ...slippery floor) ...Medications with High Potential for Contributing to Patient Falls ...Consider medications with high potential for contributing to patient falls ...hypnotics and sedatives ...Fall Prevention Reference Chart ...HIGH FALL RISK Maintain low interventions, moderate interventions AND do the following ...Education family/patient every shift about high fall risk status and why they need to call for assistance, Closely monitor/protect/engage the patient, Remain with patient during toileting, Provide bedside toileting devices if needed, Assist with ambulation and transfers, Bed alarms/chair alarms where appropriate, Toileting schedule (individualized or per unit protocol), Provide yellow non-skid footwear, Laminated high fall risk sign, if feasible, Yellow high fall risk armband, For patients/families unable or unwilling to participate in the fall prevention program, consider a sitter ( ...virtual sitter or in-person sitter) ..."

3. Review of the closed medical record revealed Patient #10 was admitted to the facility on 4/15/2023 with diagnoses including Ischemic Stroke, Subdural Hematoma and Brain Herniation.

Review of the "Flowsheet," dated 4/15/2023, revealed, " ...Per reports, the Patient #10 was found down while at friend's house earlier this afternoon ...She [Patient #10] was taken to [named] OSH [Outside Hospital] where she was found to have a 2 cm [centimeter] left convexity SDH [Subdural Hematoma] with 1 cm midline shift. The patient was intubated and transferred to our institution for higher level of care ..."

Review of the "Clinical Note," dated 4/16/2023, revealed, " ...CTH [Computed Tomography of Head] confirmed acute left lateral convexity SDH with 10 mm [millimeters] MLS [Midline Shift] and left uncal herniation. Patient was taken to the OR [Operating Room] emergently by Neurosurgical team for left decompressive craniotomy and subdural hemorrhage evacuation. She was brought to the ICU [Intensive Care Unit] from the OR still intubated. She has been admitted to the NCU [Neuro-intensive Care Unit] for close post-operative hemodynamic and neurological monitoring and ventilator weaning and management ..."

Review of the "Flowsheet," dated 4/15/2023, Patient #10 was considered a high fall risk and was placed on fall precautions and remained a high fall risk until discharge.

Review of the "Flowsheet," dated 4/24/2023, revealed, " ...Patient #10 is at a heightened risk of falls ...impaired cognition with delayed processing, unclear if Patient #10 understands education provided ...recommended use of bedside commode ...2-person level of assistance ..."

Review of the "Clinical Note", dated 4/25/2023 at 11:53 AM, revealed " ...Responded to bed alarm at approximately 0800 [8:00 AM] to find patient [Patient #10] standing out of bed, all four side rails raised, halfway to the bathroom with telemetry, pulse oximetry, and blood pressure monitors still tethered to patient. Monitors were detached to prevent further entanglement and patient was assisted into restroom and down onto toilet. Patient urinated and then stood up with RN #2 next to patient the entire time. Patient then asked to wash hands and abruptly fell away from RN #2 back into the bathroom, I [RN #2] was unable to break patients fall. She [Patient #10] landed on her hip and then hit her forehead on the floor ...Patient was alert and oriented X [times] 4 and neuro [neurological] checks were unchanged. Patient insisted on trying to stand repeatedly saying, "I need to go home". At this time, I [RN #2] stabilized the patient and got her to get back into the bed safely. I immediately notified my charge nurse and NP [Nurse Practitioner] on the primary care team. Patient was found to be hypertensive on subsequent vitals checks and I administered 2 doses of 10mg [10 milligrams] IV [intravenous] hydralazine [used to treat high blood pressure]. STAT [immediately] CT [computed tomography] was ordered and department was contacted .... transported patient to CT on monitor. Upon transport back to room patient became more somnolent, had snoring respirations, and patient's pupils became equal but dilated ...RRT [Rapid Response Team] was initiated, patient was intubated and transferred to OR [Operating Room] 1 for further surgical intervention ..."

RN #2 failed to ensure Patient #10's safety by assisting Patient #10 to the bathroom alone and failed to use the bedside commode as recommended.

Review of the "Clinical Communication," dated 4/25/2023, revealed " ...Got paged by RN that patient had gotten out of bed and fell in the bathroom hitting her head. At the time of the fall patient had no changes in mental status, a non-contrast head CT was ordered and patient assessed. Patient became more and more sleepy and hypertensive ...notified patient attending...Patient given Hydralazine 10mg [10 milligrams] IV [intravenous] x [times] 2 prior to going to CT scan. Went with patient to scan and reviewed the CT immediately after it was completed and notified [Named Medical Doctor #1] about new right subdural hematoma. Patient went back to the neuro [Neurology] stepdown and at this time stopped following commands, a rapid response was called since no open neuro ICU [Intensive Care Unit] bed. Patient intubated by anesthesia then we brought [Name Patient #10] down to OR [Operating Room] 1 for emergent craniotomy [removal of portion of the skull for brain surgery]. [Named APRN #2] ...Clinical Communication Name ... Received a call from [Named Doctor #1] regarding patient fall. Requesting trauma to review traumatic mechanism, which happened on 4/25/2023 morning. Reviewed chart. Repeat HCT [Head Computed Topography] was ordered appropriately and plan of care was implemented ..."

Review of the "Operative Report," dated 4/25/2023, revealed " ...Pre-operative Diagnoses ...Traumatic subdural hemorrhage ...with loss of consciousness ...Procedure performed ...Craniotomy, with evacuation of hematoma ...Location ...Subdural On the right side ...reportedly fell to right side and hit head, witnessed by patient's RN. Was responsive after however our team evaluated and got CT [computed tomography] head showing new R [right] SDH [subdural hemorrhage] with MLS [midline shift], she also was progressively declining mental status and was intubated in ICU. She was taken emergently for right craniotomy for subdural evacuation ..."

Review of the "Physical Medicine & Rehabilitation Consultation" dated 5/2/2023, revealed, " ...Per the daughter at bedside Patient #10 was living by herself ...she [Patient #10] had 8 steps to get in her building...She was independent in all of her ADLs [Activities of Daily Living] ...Patient #10 has been more sleepy and sedated since her second surgery...over the last couple days she has been responding more to external stimuli ...now fairly consistently following commands and nodding her head yes and no to questions ...has not started to respond with words consistently yet ...There was concern for seizure activity yesterday and she is currently on a continuous EEG [Electroencephalogram, records brain activity] ..."

Review of the "Social Worker Notes" dated 5/25/2023, revealed, " ...SW [Social Worker] discussed the extensive efforts that CM [Case Management] /SW have made to identify IPRs [Inpatient Rehabs] that may offer a charity bed and/or self- pay options, but there was no facility able to take Patient #10 under charity and family declined self-pay options...Family inquired about a 24hr home health aide and SW provided education and informed Patient #10 and family this would be self-pay ...Ongoing concerns were expressed by Patient #10s family ...discussed with Patient #10 and family that Patient #10 could receive PT/OT [Physical Therapy/Occupational Therapy] if they applied for [Named] Indigent Program and the steps needed to take to pursue this..."

Review of the medical record reveal Patient #10 was discharged home with family on 5/25/2023.

RN #2 was a contract employee amd unavailable for surveyor to conduct an interview.

4. Review of the closed medical record revealed Patient #44 was admitted to the hospital on 3/28/2025, with diagnoses including Syncope and Idiopathic Intracranial Hypertension (increased pressure in fluid surrounding brain).

Review of the "Emergency Department Care Timeline," dated 3/28/2025, revealed Patient #44 was considered a high fall risk and was placed on fall precautions.

Review of the "Medication Administration Record," revealed Patient #44 received Benadryl on 3/30/2025 at 11:00 PM. Benadryl (sedative) is considered a high-risk drug for falls.

Review of the "Significant Event Note," dated 3/31/2025 at 4:56 AM revealed " ...APRN [advanced practice Registered Nurse] #1 ...Patient [Patient #44] sustained a fall out of bed tonight ...Care Partner [CP #3] instructed patient to wait while she [CP #3] got help from RN [Registered Nurse] in order to move her [Patient #44] safely given her baseline weakness. Care Partner was out of the room for less than 3 minutes and when she returned with RN ...Patient [Patient #44] reports that she fell out of bed onto her left shoulder while reaching for the bucket. Patient states she did not hit her head upon fall. Xray [Radiographic Imaging] of left shoulder order and fall precautions in place ..."

Review of the "Nursing Flow Sheet," dated 3/31/2025 at 4:43 AM revealed " ...Pt [Patient #44] had alleged fall from bed, unwitnessed by staff ..."

CP #3 failed to ensure Patient #44's safety by leaving Patient #44 alone in her room to get the nurse.

5. Review of the Competency Training for hospital employees revealed there was no documentation RN #1, RN #2, RN #3 and CP #3 received Fall Risk Assessment or Fall Prevention training in 2024.

Review of the "Fall Prevention Committee" meeting minutes revealed there were a total of 207 patient falls in the hospital from 1/1/2025-3/31/2025.

6. During a telephone interview on 4/21/2025 at 7:35 PM, Family Member #1 stated, " ...I received a telephone call informing me my mother had a fall ...she had to be rushed into surgery...The nurse [RN #2] stated he helped her to bathroom ...while she was washing her hands ...she fell and hit her head on toilet ...He [RN #2] said he was not required to stand by her to make sure she didn't fall..."

During an interview on 4/22/2025 at 11:20 AM, Care Partner (CP) #4 was asked if high fall risk patients were left alone while toileting. CP #4 stated " ...If a patient is a high fall risk, patients are assisted to the bedside commode. Once they are on the bedside commode you are not to leave the room ...a nurse must be within arm's reach ..."

During a Zoom interview on 4/29/2025 at 11:30 AM, the Director of Adult Management and Improvement Team was asked about high fall risk patient precautions. The Director of Adult Management and Improvement Team stated, " ...nurses are reminded they should be remaining with all high-risk patients in the bathroom ...however we know that there are patients that refuse for that to happen ...the best practice is staying in the bathroom with the patient ..." When asked what should happen after a fall is reported, the Director of Adult Management and Improvement Team stated, " ...We do a daily fall email if an event has been reported...that goes into a fall report...I will review them, then reach out to Patient Quality and Safety Advisor and the unit manager. Level of review is based with unit...Some may review them at a staff meeting, sometimes it's a one on one ...May be at weekly huddles like a reminder to staff at shift change ... The Director of Adult Management and Improvement Team was asked if there was a fall with harm, how does the hospital follow up. She stated, " ...It's up to the unit level ...units have different meetings so they don't all have one standard meeting ...some of them may review those at a staff meeting ..."

During a Zoom interview on 4/30/2025 at 7:45 AM, CP #3 was asked to tell me about the incident. CP #3 stated, " ...I heard a bed alarm going off, so I went to her [Patient #44] room. She [Patient #44] was trying to get out of bed, stating she had to use the bathroom. I told her [Patient #44] to stay in the bed until I came back with help ..." CP #3 was asked should she have left Patient #44's bedside. CP #3 stated, " ...I should have just stayed ..." CP #3 was asked if she was aware of the hospital policy regarding high fall risk patients. CP #3 stated, " ...Yes, I'm aware ...I have been with the hospital [Hospital #1] for 2 years and have had fall prevention training..." When asked about fall prevention meetings, CP #3 stated, " ...we have daily unit meetings regarding updates on patients that are a fall risk and patients that get turned every 2 hours. CP #3 stated she did not receive any additional training following the incident.

During a Zoom interview on 4/30/2025 at 8:00 AM, RN #1 stated, " ...I was charting at the nurse's station ...heard a bed alarm going off ...then I didn't hear it anymore ....moments later [CP #1] told me a patient needed help going to bathroom...[CP #1] turned off the bed alarm ...told the patient [Patient #44] to please stay until she came back with help ...We [RN #1 and CP #1] got back into the patient's [Patient #44] room and she [Patient #44] was on the floor ... I assessed her vital signs and we helped her back to bed ...then I notified attending [physician] to come and assess her ..."

During a Zoom interview on 5/1/2025 at 2:20 PM, Registered Nurse (RN) #3 was asked if high fall risk patients were left alone while toileting. RN #3 stated, " ...you would not just leave them if their a high fall risk ...always stay within arm's reach ..."

During an interview on 5/6/2025 at 11:30 AM, the Senior Director Accreditation and Standards stated, " ...there was no Fall Competency Training in 2024 for existing staff, only new staff received training during orientation..." When asked about annual competency training, the Senior Director Accreditation and Standards stated, " ...there are certain units that have falls as an issue ... if a unit is meeting their goals and falls are not an issue then we're going to focus on something where there is an issue ...a competency package is built for each unit based upon their quality scores and data ...each unit has specified competency training depending on what unit they're on and what the units quality goals are..." When asked if nurses floated to different areas in the hospital even if they had received competency training for that specific unit, the Senior Director Accreditation and Standards stated, "yes" ..."

The facility failed to ensure its vulnerable patient population received care in an environment that a reasonable person would consider safe. The facility failed to provide physical safety to Patient #10 and Patient #44 by failing to monitor, provide protection, and ensure patient rights to physical safety by ensuring the staff members followed hospital policies related to fall preventions and failed to appropriately implement fall precautions.