HospitalInspections.org

Based on record review, interview, policy review, and root cause analysis event form review, it was determined that the provider failed to:
*Identify and implement a fall strategy to protect and promote the safety for one of ten sampled patients (8) who had an unwitnessed fall with a major injury that resulted in a sentinel event [unanticipated event resulting in a serious injury or death].
*Investigate and submit a mandatory online incident report to the South Dakota Department of Health [SD DOH] after a fall resulting in a major injury and sentinel event for one of one sampled patient (8) who was assessed and identified as a high fall risk.
*Have a preventative maintenance program in place for checking bed and chair alarms prior to their use as a fall prevention.
Findings include:

1. Observation and interview on 1/5/21 at 3:05 p.m. with registered nurse (RN) G regarding the day room revealed:
*On the south side of the nurses' station there was a large room.
*The room:
-Was approximately 15 feet away from the nurses' station and had two separate entrance doors to the room.
-Had multiple large windows that allowed the staff to easily view patients in the room.
-Had several tables with chairs, a television, sitting area, and kitchenette area.
-Was currently empty with no patients, staff, and visitors inside of it.
*RN G stated:
-"The day room is used for patients that need assistance or monitoring with their meals and eating or assisted dining."
-"Someone is always with them."
-"No patient is left alone in that room."

Interview on 1/5/21 at 3:20 p.m. with RN D regarding the day room revealed:
*She had confirmed and further supported the interview above with RN G regarding the day room.
*She stated:
-"They might be left alone after meals when staff are taking patients back to their rooms or therapy."
-"But not for very long."
-"So no, can't guarantee they would never be left alone."

Interview and medical record review with RN H and quality risk director B regarding patient 8 revealed:
*He was ninety-five years old and was admitted to the facility on 12/4/20 and discharged to a higher level of care on 12/20/20.
*His diagnoses included: stroke with expressive aphasia and altered mental status, confusion, dysarthria [slurred speech], high blood pressure, an irregular heartbeat, insomnia, and anxiety.
*He had required the staff to assist him with activities of daily living [ADL].
-Those activities included bed mobility, transfers, toileting, eating, personal hygiene, and walking.
*A Morse Fall Risk Scale assessment was completed and a score of 75 indicated he was at high risk for falls.
*He was alert and oriented to self only.
*He had impulsive behaviors with no judgement and safety awareness.
-During those episodes he would attempt to transfer himself without assistance from the staff.
-Those behaviors along with his poor memory recall, decreased strength, and fluctuation of mental awareness had placed him at a high risk for falls.
-He would repeatedly attempt to stand-up and move on his own causing the chair alarm to go off.
-Close observation from the staff was required during those episodes of increased anxiety.
*He:
-Was dependent on the staff to implement fall precautions to ensure his safety.
-Had two unwitnessed falls during his stay on 12/17/20 and 12/20/20.
*On 12/20/20 he was transferred out to a higher level of care due to the severity of the injuries he received from that fall.
-There was no final incident report with an investigation submitted to the SD DOH for patient 8 on this fall to support abuse and neglect had not occurred.
*The quality risk director B stated:
-"We did not know we were supposed to report this to the state."
-"The state rules are vague and don't really support us having to do that."
-"I am currently in the middle of doing a root cause analysis on this fall for our corporate office. But it is not complete and does not have to be done and turned in until 2/15/21."
-"He was not one to one for observation."
-"In order to be a one to one for observation a doctor's order is required."
-"And he never had an order for that."

Continued medical record review and interview with RN H for patient 8 revealed:
*He was working with:
-Physical and occupational therapy five days per week for strengthening and increased independence with ADL.
-Speech therapy due to his memory impairment and communication deficit.
*His goal was to return home with the capability to assist with his ADL and improve verbal communication to ensure all needs were met.
-The severity of his mental awareness, fluctuation on level of alertness, and decreased communication had interfered with the progression of his goals.
*RN H confirmed both medical record reviews above and stated:
-"He was not a one to one for staff to watch."
-"We would need an order for that."
-"He had fall precautions in place so no, he didn't require one to one from the staff."
-"He had a chair alarm and a bed alarm, plus a wristband for fall awareness, nonskid socks."
*No documentation the bed and chair alarm had been routinely checked by the staff, maintenance, and the bio-medical department to support they were operational at the time of use.

Review of patient 8's physician progress notes from 12/6/21 through 12/20/21 revealed:
*The assessment notes had not varied much from day to day.
*The notes confirmed:
-He had memory recall deficits with occasional variations in comprehension.
-He slept poorly at night and had increased behaviors during that time of day. An antipsychotic had been ordered to be given as needed to help with this.
--That medication had interfered with his level of alertness in the morning and capability to participate in therapies.
--During those episodes he became dependent upon the staff to complete his ADL for him.
*With further medication changes to help improve his level of alertness he still continued to:
-Require safety measures to prevent falling.
-Require verbal cues for walking, eating, grooming, and dressing.
-Have poor judgement, safety awareness, and memory recall.
*On 12/19/20 he was assessed by the nurses' station.
-He had been sitting in his wheelchair at the nurses' station for close monitoring to prevent him from falling.

Review of patient 8's 12/17/20 fall event form revealed:
*At 3:45 p.m. he was found on the floor in his bathroom.
-The fall was unwitnessed and had resulted in minor injuries.
*The potential contributing factors had been:
-Confused/disoriented/agitated.
-Lost/impaired balance.
*Safety precautions in place were:
-Bed and chair alarms.
-Call light within reach.
-Bed to be placed in the low position.
-Nonskid socks.
-Both side rails up.
*There was no documentation to support:
-He required one on one supervision by the staff to ensure safety from falls had occurred.
-What new precautions were put in place to promote his safety and prevent further falls.
*For resolutions and outcomes of the event they had talked with patient/family.
-There was no documentation:
--That an investigation was conducted to rule out abuse and neglect.
--A review and change of the fall interventions he currently had in place.

Review of patient 8's 12/20/20 fall event form revealed:
*At 1:30 p.m. he had been found on the floor in the dayroom.
-The fall was unwitnessed and had resulted in major injuries.
*Brief Factual Description: "Pt [patient] was in the dayroom during lunch. Other pt's were being brought back to their rooms and pt was found after RNT [Rehab nurse tech] [name of RNT] walked back into dayroom and pt was lying on the ground. Charge nurse and staff responded and pt was assessed, vitals were taken, and cared for. [Certified nurse practitioner] [CNP name] present and assessed, ordered to transfer pt at this time."
*"Potential Contributing Factors: "Confused/Disoriented/Agitated."
*Nature of Injury:
-"Abrasion/Bruise/Contusion.
-Bleeding/Hemorrhage.
-Pain, skin tear, and swelling/inflammation."
*"Equipment malfunction contributed to this event: Unknown."
*His mental state was altered and they were unsure if he had lost consciousness.
*He had a history of falls and required safety precautions for the prevention of them.
*Preventative measures the staff had put in place for his safety from falls were:
-"Armband/charm/fall alert.
-Bed alarm and in low position.
-Call light and personal items within reach.
-Chair alarm, non skid socks, and a sitter."
*Final outcome: Transferred to a higher level of care due to an intracranial injury.

Review of patient 8's 12/21/20 root cause analysis event form revealed:
*General information about the sentinel event: "The patient was in the day room with around 5 other patients to participate in assisted dining. After dining group was over and all patients were done eating, staff began to bring patients back to their rooms. All patients were taken back to their rooms with the exception of this patient, who was the last one. RN was in the day room with this patient talking with him. The phone rang at the nurses stations, so RNwent to answer it. The nurses station is directly outside of the day room. The day room has windows across the wall that look out to nurses station. The day room also has 2 doors, both of which were open when this event occurred. RNT came back too the day room after a few minutes, after bringing another patient back to their room, to find patient lying face down on the floor in a pool of blood. Patient had fallen out of his wheelchair onto the floor. Nurses were called into the dayroom to assist. Nurse practitioner was onsite when event happened and responded as well. Patient was sat back up into his wheelchair and was conscious at this time. He was assessed and an ambulance was called immediately due to the extent of his injuries. Patient was transported to an acute care hospital to receive treatment and was admitted for an intracranial bleed."
-Prior to the fall he had been participating in the assisted dining program.
*Did equipment performance contribute to the outcome?
-Explain: "When interviewing staff, it was noted that the patient's chair alarm was not going off when the patient was found on the floor. The RN who took the phone call at the nurses station when this event occurred also stated that she never heard the chair alarm. The day after the event, RN and DQR [director of quality risk] went to patient's room to inspect the chair alarm on his wheelchair. It was noted to be on. The chair alarm was tested at this time and noted to be working properly. Staff interviewed all stated that they believe the alarm was on when the event occurred, as nobody turned it off. Per maintenance, chair alarms are currently not tested on a regular basis. Also, the batteries are not charged on a regular basis. The Alarm Management policy states that devices will be evaluated for default settings by biomedical before equipment is installed. The chair alarms do not have a biomed sticker on them, indicating they have not been inspected. The chair alarm instruction manual states that when the batteries get low, the low battery LED will blink red, and the batteries need to be replaced. When the batteries get critically low, an audible cue will say "low battery" every 15 seconds. When the chair alarm becomes activated with weight, it verbally announces, "Sensors activated."
-There was no determination if there was a failure in equipment.

Continued review of patient 8's 12/21/20 root cause analysis event form revealed:
*"Was staff properly qualified and currently competent for their responsibilities at the time of this event: Staff stated they believe more training is needed for RNs and RNTs on how to utilize and maintain the chair alarms."
-RNTs had 90 days to complete their training and competencies from the date of hire.

Interview on 1/5/21 at 11:40 a.m. with quality risk director B revealed:
*South Dakota reporting information had not been included in the Mandatory Abuse Reporting Requirements policy.
*She was not:
-Sure where to report falls in the state's electronic reporting system.
-Aware that falls should have been reported under abuse and neglect.

Interview on 1/5/21 at 3:05 p.m. with RNT E and F revealed:
*RNT E felt the facility did not have enough staff to perform one to one supervision.
*They try to prevent falls.
*They prioritize rooms closest to the nurses' station for patients with the worst cognitive function.
*Patient 8:
-Needed to be supervised.
-Fell in the dayroom.
-His chair alarm had not alarmed or sounded when he fell.
-Was the last patient left in the day room after the meal.
*They had:
-Planned to take him to the nurses' station for observation.
-Not received any education after the initial review of the fall occurred.

Interview on 1/5/21 at 3:35 p.m. with nurse supervisor D regarding patient 8 revealed:
*She had performed the fall risk assessment when he was admitted.
*He was:
-Lethargic on admission.
-A poor historian and was alert to self only.
*The wife was headed to work at the time of his admission, so she had documented that she would get history from his wife later.
*No orders for one to one supervision had been received.
*He was oriented times two the next morning.
*He would:
-Get restless at night around 3:00 a.m. so the physician ordered Seroquel [anti-psychotic].
-Be tired in the morning and was more alert later in the day.
-Get restless around 5:00 p.m. with Sundowners so they kept someone around him at all times.
-Eat his meals in the day room so the staff could keep an eye on him.
*He:
-Liked to stand up.
-Was fine if someone was present to redirect him.
-Was inconsistent with unpredictable behaviors.
*She stated:
-"If they take any more patients with his level of acuity, they will need one to one supervision."
-"We don't' have the staff for that."
*One to one supervision would have required a physician's order.
*He had two falls while he was at the facility.
*On the day of the second fall:
-He was in the day room eating with five other patients.
-Staff were taking patients back to their rooms.
-There were times in this process that no staff were in the day room.
-He was the last patient they were going to take out of the day room.
-The staff had planned on taking him to the nurses' station so he could be supervised.
*She had:
-Been notified around 1:30 p.m. that he had fallen.
-Gone to the day room and performed a neurological assessment.
*He was:
-Able to give his name and birthdate.
-Transferred to another facility via ambulance.
*She:
-Had not received any education after review of the fall and there should have been.
-Agreed due to his impulsive behaviors and poor safety awareness he had to be within sight of the staff to ensure he did not fall.

Interview on 1/5/21 at 5:23 p.m. with chief executive officer A, quality risk director B, chief nursing officer C, and regional chief nursing officer I revealed:
*The:
-Physician would have needed to order one to one supervision.
-Provider did not have a policy for one to one supervision for the staff to follow.
*The determination for the need of one to one supervision would have been:
-Physician driven.
-Based on the individual patient need.
*The staff could have chosen to stay with the patient or taken other steps to prevent a fall prior to a physician order.
*They had:
-Been waiting for the results and completion of patient 8's fall investigation to determine if the fall would have been reported to the state.
-Not started staff education after ongoing review of the fall.
*They agreed:
-Patient 8 required one on one supervision to ensure no falls had occurred due to his memory deficits and poor safety awareness.
-A nurse had the knowledge and capability to determine if a patient required one on one supervision without a physicians' order.
-The investigation and education for the staff should have been completed as soon as possible after the fall had occurred on 12/20/20.
*The root cause analysis and investigation from the patient's fall on 12/20/20 was not required to be completed until 2/15/21.




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2. Review of the provider's 3/17/20 Allegation of Abuse/ Neglect Policy revealed:
*Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.
*Hospital staff would have taken necessary steps to ensure patients have been kept safe from neglect.
*All abuse/neglect would have been investigated promptly, thoroughly, and reported to the proper authorities as necessary.
*"Any incident or event where there is reasonable cause to suspect abuse or neglect of any patient by any person shall be reported within 24 hours of becoming informed of the alleged incident or event. The facility shall report each incident or event orally or in writing to the states attorney of the county in which the facility is located, to the Department of Social Services, or to a law enforcement officer. The facility shall report each incident or event to the department within 24 hours, and conduct a subsequent internal investigation and provide a written report of the results to the department within five working days after the event. (See ARSD 44:75:01:07)."

Review of the provider's 3/17/20 Recognition and Reporting of Suspected Abuse or Neglect policy revealed:
*The policy was a corporate policy for the provider.
*The attached Mandatory Abuse Reporting Requirements policy would provide state specific information on proper agency and method of reporting.

Review of the provider's 3/17/20 Mandatory Abuse Reporting Requirements policy revealed:
*The policy described:
-Definition of abuse/neglect for each state.
-What specifically must be reported to each state.
-Who must report to each state.
-When and how to report to each state.
*South Dakota information had not been included in this document.

Review of the provider's 11/13/20 Fall Prevention Program policy revealed:
*Patients should have been assessed for fall risks:
-Initially.
-Following a change of status.
-Following a fall.
-Weekly at a minimum.
*The Morse Fall Risk Scale was to be used by the provider.
*The Morse Fall Risk Scale assigned numerical values in the following areas:
-A history of two or more falls in past years was 25 points.
-Secondary diagnosis was worth 15 points.
-The use of furniture for an ambulatory aid was worth 30 points.
-The use of a crutch, cane, or a walker was worth 15 points.
-A patient with an Intravenous or heparin lock would have 20 points added.
-An impaired gait or transfer would have added 20 points.
-A weak gait or transfer would have added 10 points.
-Mental Status to include forgets limitations would have added 15 points.
*A patient scoring higher than 45 points would have been considered a risk for falls.
*Intervention strategies should have been based on level of risk identified through assessment, evaluation, and individual needs of the patient.
*Basic level interventions include:
-Bed alarms.
-Chair alarms.
-Self releasing seatbelts.
-Wheelchair positioning aids.
-Toilet before leaving room alone.
*Further fall interventions could have been:
-Toilet patient before giving high risk fall medication.
-Diversion activities.
*High risk for fall interventions may have included:
-Supervision at all times.
-One to one handoff.