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Based on observation interview and record review the facility failed to ensure that patient falls were consistently documented, and Incident and Accident reports were completed for four of four falls documented in the clinical record and for two of two additional falls reported by staff for one (#1) of two patients reviewed for falls out of a total sample of 10, resulting in the potential failure to treat detect and treat injuries in a timely manner, perform comprehensive root cause analyses, and accurately track and trend adverse events to determine the need for Quality Assessment and Performance Improvement measures. Findings include:

On 11/5/19 at approximately 1615 Patient #1 was observed and interviewed during a tour of the facility. Patient #1 was monitored closely by two resident care aides (RCAs). Patient #1 reported that two staff members, Staff E and Staff F broke her left leg in January of 2019. Patient #1 said that she had an operation in January to repair the hip and had screws and metal put in to fix it. Patient #1 complained that she did not like having sitters and said, "I don't need two people on me (two to one staff monitoring)."

On 11/5 19 at approximately 1620 Staff Nurse D was interviewed regarding Patient #1 and reported that Patient #1 had an open reduction internal fixation (ORIF) surgery to repair a fractured hip earlier in the year and had two or three additional surgeries on that hip afterwards. Staff D reported that Patient #1 needed to be continuously supervised by two sitters (two to one staff supervision) because she was a high fall risk and because she was dangerous to staff and other patients.

On 11/6/19 at approximately 0930 through 11/7/19 at 1500 Patient #1's clinical records, abuse investigations and Incident and Accident reports were reviewed and revealed the following information:

Patient #1 was a 39 year old female who was admitted into the facility on 10/19/16 with a probate court order for involuntary commitment. Diagnoses included Schizoaffective Disorder - Bipolar type, Borderline Personality Disorder, Social Maladjustment Disorder, History of closed Head Injury, Post Traumatic Stress Disorder, Parkinson's Syndrome, and At Risk for Injury Related to Falls. Freedom of Movement documentation dated 11/6/19 and 1/2/19 at 1215 noted that Patient #1 required enhanced supervision including bathroom supervision because of a danger/threat to self and others and a high risk for falls. A Psychiatrist assessment dated 10/16/19 at 0815 documented that Patient #1 broke her right leg in a fall in the facility in 2016. Radiology reports done during her hospitalization from 5/18/19 to 6/1/19 documented that she had osteopenia (poor bone density - a possible side effect of anti-psychotic medication).

Facility fall risk assessments dated 9/25/18 at 0857, 3/1/19 and 5/16/19 at 0132 documented that Patient #1 had a history of falls and was at risk for falling. Weekly physician Medical Progress Notes and Nursing Notes from 10/1/18 through 11/5/19 documented that Patient #1 was at high risk for falls with multiple falls in the facility in 2018. Nursing documentation noted that Patient #1 disliked having enhanced staff supervision and restricted access to the courtyard (outdoor access restricted for fall prevention safety).

Review of an abuse investigation dated 4/29/19 for Patient #1 revealed she broke her left (L) hip (proximal femur) in the facility and was sent out to hospital on 1/12/19 at 0030 and had surgery (ORIF) to repair the hip fracture. Patient #1 made an allegation to Staff V on 1/15/19 that Staff E and Staff X broke her leg on the night of 1/11/19. The 4/29/19 abuse investigation report noted that Staff V said when he reported the allegation on 1/15/19 that Patient #1 told him that she had fallen on the floor in her room on the night of 1/11/19 and was unable to get back up and Staff E and Staff X broke her leg by pulling on her to get her off the floor.

Additional staff interviews (Staff E, Staff I, Staff X , Staff Y and Staff Z ) included in the 4/29/19 abuse investigation report confirmed that Patient #1 was found on the floor of her room lying on her left side in a puddle of urine facing the restroom at approximately 2230 on 1/11/19. These staff interviews noted that Patient #1 was unable to move her leg or get up and was complaining of severe left leg pain. The investigation report noted that Staff I, Staff Y and Staff Z said during separate interviews that Patient #1 told them that she fell while she was trying to walk to the restroom. These staff interviews and interviews of two security officers included in the investigation report noted that two security officers were called to assist Patient #1 off the floor because nursing staff were unable to do so. The Patient was wrapped in a "burrito sling" and transferred to bed and then sent to the emergency department (ED) by ambulance.

There was no Incident and Accident Report created for this fall on 1/11/19 at 2230, and this fall was not included on the list of Patient #1's falls since 8/1/18 provided by the facility for their Quality Assessment and Performance Improvement (QAPI) tracking and trending of patient falls.

The 4/29/19 abuse investigation report documented that both Staff E and Staff X both separately said that Patient #1 also fell earlier in the day on 1/11/19. Staff E and Staff X both separately reported that they found Patient #1 on the floor in the restroom yelling in pain shortly after supper at approximately 1830. Patient #1 screamed at them to leave her alone. Staff X reported that he and Staff E assisted her to her feet and helped her to walk to the day room at approximately 1845. Video transcription included in the 4/29/19 investigation confirms this timeline of events.

A Nursing documentation by Staff I dated 1/12/19 at 0550 confirmed that Patient #1 was found on the floor in pain on 1/11/19 at approximately 1830. Staff I documented that Patient #1 later crawled from the day room to her bedroom. Transcription of video footage from 1/11/19 included in the 4/29/19 abuse investigation confirmed that Patient #1 was seen crawling on the floor in the dayroom.

There was no Incident and Accident Report created for this fall on 1/11/19 at 1830, and this fall was not included on the list of Patient #1's falls since 8/1/18 provided by the facility for their Quality Assessment and Performance Improvement (QAPI) tracking and trending of patient falls.

Staff Nurse I stated during the 4/29/19 abuse investigation interview that he was told during shift report that Patient #1 threw herself on the floor during a behavior outburst on 1/9/19 (one day before Patient #1 was observed limping on video monitoring review). Transcripts of video footage from 1/10/19 and 1/11/19 revealed Patient #1 was limping slightly on 1/10/19 and on 1/11/19. There was no Accident and Incident report for this alleged fall on 1/9/19 and no other Nursing documentation of this reported fall.

On 11/6/19 at approximately 1500 RCA Staff F was interviewed about Patient #1. Staff F reported that Patient #1 disliked her since an incident in the autumn of 2018 when Patient #1 physically assaulted her and fell during the attack. The facility was unable to provide any Incident and Accident report for this reported fall or the reported assault on Staff F.

On 11/6/19 at approximately 0930 an Office of Recipient Rights (ORR) investigation dated 5/18/19 was reviewed. The ORR investigation documented an allegation that Patient #1 fell on 5/14/19 and was not sent out to the hospital until 5/18/19. Patient #1's clinical record and the ORR investigation summary was reviewed at this time with Staff J who was also interviewed at this time. A

The only documentation of Patient #1's fall on 5/14/19 was a Nursing Note dated 5/14/19 at 1401 which was labeled " RN (Registered Nurse) Post Fall Assessment." This documented that Patient #1 had a witnessed fall in the day room on 5/14/19 at 1339 when she fell when she got up from a chair. Four days later, on 5/18/19 Patient #1 was sent to the hospital for evaluation of "unbearable left leg pain." Radiology studies taken during her acute care medical hospital admission from 5/18/19 to 6/1/19 revealed there was some shifting of the left leg ORIF hardware.

There was no Incident and Accident Report created for this witnessed fall on 5/14/19 at 1339, and this fall was not included on the list of Patient #1's falls since 8/1/18 provided by the facility for their Quality Assessment and Performance Improvement (QAPI) tracking and trending of patient falls.

On 1/6/19 at approximately 1200 Patient #1's clinical record was reviewed with Staff J and a second "RN Post Fall Assessment" with no documented Incident and Accident Report was revealed. The RN Post Fall Assessment dated 12/15/18 at 1248 documented that Patient #1 had a witnessed fall in the dayroom on 12/14/19 at 2104. The RN documented that Patient #1 was agitated and tried to hit a chair and lost her balance and fell.

There was no Incident and Accident Report created for this witnessed fall on 12/15/18 at 1248. although this fall was included on the list of Patient #1's falls since 8/1/18 provided by the facility for their Quality Assessment and Performance Improvement (QAPI) tracking and trending of patient falls.

A Physician's Progress Note for Patient #1 dated 7/8/19 at 1536 noted that Patient #1 had courtyard access. The physician documented that she felt that this was not a good plan due to the patient's high fall risk and refusal to use a walker. A Physician's order dated 7/24/19 removed Patient #1's courtyard restrictions and mandated walker use because her orthopedic physician documented that he will assume the risk for any falls.

A Nursing documentation for Patient #1 dated 10/4/19 at 0308 documented that Patient #1 told the nurse that her hip "snapped" and asked the nurse "not to report it so they don't take away her courtyard access." Patient #1 was sent out to the ED on 10/4/19 for severe pain and had a second ORIF on the left hip to repair fractured (broken) pins/screws in the ORIF hardware. There was no Incident Report for this event and no documentation that any investigation or staff interviews were done to find out if Patient #1 fell in the courtyard or on the unit.

On 1/7/19 at 1300 the facility Director Staff A was interviewed regarding documentation of falls and the facility's falls tracking and trending. Staff A stated that the facility's rate of patient falls was low and had decreased since 2015. Staff A stated that Nursing staff were expected to complete an "OAS MNI" nursing note for any unusual event, an administrative report for the Director, and also fill out an Incident and Accident Report.

On 11/7/19 at 1340 the Director of Nursing was interviewed and stated that she was unable to provide any additional documentation.

On 1/7/19 at 1400 review of the facility policy entitled "Patient Fall Reduction" revised 11/9/17 was reviewed and revealed the following statements,

"A fall is a descent from a higher elevation to a lower elevation."

"Staff will complete OAS/ MNI and Incident Report to describe the incident"

"The RN will complete and document the Nursing Post Fall Assessment including: subjective and objective assessment for injury, environmental factors such as cluttered hallways wet floors, poor lighting etc that may have contributed to the fall, patient factors such as clothing footwear, poor safety skills, etc that may have contributed to the fall"

"An Administrative Report Form will be completed by staff as required to document environmental or other contributing factors that require administrative follow up'

"The RNM (unit managers) will review all OAS/MNIs to identify falls and assure completion of required documentation"

"The treatment team will complete documentation on multidisciplinary progress note within five business days"

"The RNM will provide a copy of the OAS/ MNI, RN Post Fall Assessment, Incident Report, Multidisciplinary Progress Note to the Nurse Executive.

Based on observation, interview and record review the facility failed to ensure that comprehensive Nursing care plans with targeted interventions for post surgical care were developed for one (#1) of one patients reviewed for surgical procedures out of a total sample of 10, resulting in missed opportunities for coordination of care and the potential for less than optimal outcomes. Findings include:

On 11/5/19 at 1615 during a tour of cottage 27 Patient #1 was seen walking around the unit with a decided limp. Patient #1 was not using any walker or cane. Patient #1 was interviewed at that time and said that she would use it to kill someone with it" if they tried to make her use one. Patient #1 said that she had an operation to repair the hip and had screws and metal put in to fix it in January of 2019.

On 11/5 19 at approximately 1620 Staff Nurse D was interviewed regarding Patient #1 and reported that Patient #1 had an open reduction internal fixation (ORIF) surgery to repair a fractured hip earlier in the year and had two or three additional surgeries on that hip afterwards.

On 11/6/19 at approximately 0930 through 11/7/19 at 1500 Patient #1's clinical records were reviewed and revealed the following information:

Patient #1 was a 39 year old female who was admitted into the facility on 10/19/16 with a probate court order for involuntary commitment. Diagnoses included Schizoaffective Disorder - Bipolar type, Borderline Personality Disorder, Social Maladjustment Disorder, History of closed Head Injury, Neoplasm of the Pituitary Gland, Post Traumatic Stress Disorder, Parkinson's Syndrome, and At Risk for Injury Related to Falls

Patient #1 was transferred to a medical hospital to repair a left femur neck fracture on 1/12/19 and returned to the facility on 1/15/19 after an Open Reduction Internal Fixation (ORIF) surgery to repair the fracture.

There were no wound care orders for the surgical incision. There was no documentation of wound care or dressing changes.

A Physician's Progress note dated 1/19/19 at 1619 documented that he was called to assess Patient #1's surgical incision site because her dressing was saturated with blood. He documented in his progress note that his plan for Patient #1 was zinc ointment to the surgical wound and abdominal dressing secured with nylon tape. The Physician failed to write this as an order and there was no documentation to indicate that this was implemented.

A Temporary Nursing Care Plan for skin integrity dated 1/15/19 at 1400 contained no targeted interventions for dressing changes or wound care.

Patient #1 was transferred to a medical hospital from 5/18/19 to 6/1/19 for severe pain in the left (ORIF surgery) leg and underwent a guided joint aspiration procedure on the left hip.

Patient #1 was transferred to a medical hospital from 10/4/19 to 10/14/19 for surgery (ORIF) to replace the left hip hardware installed in January 2019.

There were no wound care orders for the surgical incision. There was no documentation of wound care or dressing changes.

A Temporary Nursing Care Plan for skin integrity dated 10/15/19 contained no targeted interventions for dressing changes or wound care.

There was no Nursing Careplan for Patient #1's left hip fracture that contained comprehensive problems, goals and interventions to allow Nursing to coordinate post operative rehabilitation, and allow Nurses to see a timeline of all of Patient #1's hip surgeries, problems and care.

On 11/7/19 at 1145 the Unit Manager Staff R was interviewed about Patient #1's Nursing Care Plans and stated that she was unable to find any additional information or documentation of wound care. Staff R stated that there was no long term care plan for surgical healing or alteration in skin integrity because her healing was expected to be temperorary.

On 11/7/19 at 1220 the Director of Nursing was interviewed and stated that Nursing is responsible for ensuring that there are treatment orders and should contact the physician if there are no orders. The Director of Nursing stated, "There is clearly a need for orders."

On 11/12/19 at 0900 review of the facility policy entitled, "Dressings, Dry" , revised 4/2012 included the following instructions to nurses, "Verify treatment orders".