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Based on observation, review of policies/procedures, documents, and staff interviews, the facility failed to have a system in place that ensured patient care in a safe setting for 2 of 2 sampled patients at risk for falls in the PCCU (Post Critical Care Unit). The facility reported an average daily census of 10 patients in the PCCU.

The facility failed to:

- Ensure nursing staff implemented and documented safety measures to protect patients from falls including use of bed alarms. (Refer to A-0144)

-Ensure staff assessed each patient's need for a third siderail prior to implementing use of a third siderail.

- Ensure nursing staff assessed and recognized the patients at risk for injury if the patient should fall and document appropriate interventions on the patient's plan of care. (Refer to A-144)

- Ensure nursing staff adequately communicated and documented all pertinent patient care information during notification of a patient related event to the on-call physicians. (Refer to A-144)

- Provide and document orientation, training, evaluation of performance, and competencies of all non-employee nursing personnel. (Refer to A-144)

The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to ensure the safe care and monitoring of patients at risk for falls that had the potential for life-threatening injury or death to the patient.

Based on review of policies and procedures, documents, and staff interviews, the facility failed to ensure nursing staff implemented and documented patient safety measures, including use of bed alarms, to help protect patients from falls for 2 of 2 sampled Post Critical Care Unit (PCCU) patients (Patients #1 and 2) who fell while patients in the facility and each sustained injury. The facility reported an average daily census of 10 patients in the PCCU. The facility identified a census of 69 inpatients at the start of the survey.

Failure to implement patient safety measures, including consistent use of bed alarms to alert staff of increased patient activity, potentially placed patients at higher risk for falls that can result in injury, serious impairment, or death of a patient.

Findings include:

1. Review of a document titled "Patient Handbook", last revised 11/11, revealed, in part,"Your Rights as an Alegent Health Patient...Safety and Comfort-You have the right:...To receive your healthcare in a safe and secure environment...."

Review of facility policy titled "Fall Prevention Program," dated 5/12, revealed, in part,"Once a patient has been identified as being at high risk for falls, (Morse Fall Risk 51 or above), they will remain on high-risk precautions throughout their current hospital stay...Once fall risk assessment is completed, initiate the fall interventions and any additional measures that pertain to the patient. If patient scores as a high risk for falls, document the risk for falls on the plan of care. . . .For patients who are confused, impulsive, or cannot teach back fall prevention instructions, implement the following: Bed and chair alarms ...."

Review of the VersaCare Bed User Manual flip chart, page 7 of 16, revealed, in part, "Activate...4. Press the Enable control. 5. Press the applicable Bed Exit mode control. When the system beeps one time and the indicator stays on solid, the system is armed. If the system does not arm, the system will beep rapidly for a few seconds and the selected mode indicator will flash. This means: the patient weighs less than 70 lb (31.8 kg [kilogram]) or more than 500 lb (227 kg); the patient is not in the correct position; or the system has malfunctioned...."

2. Review of 79-year-old Patient #1's medical record revealed Patient #1 presented to the Emergency Department on 6/28/12 at 8:22 PM. Registered Nurse (RN) DD documented, on the Emergency Department (ED) Mercy Hospital Primary form page 4, patient complained of, "Difficulty breathing and light headedness, both of which have been present for at least 1 week...bilateral [both] leg aches. Emergency Medical Services (EMS) reports oxygen saturation 85% of RA [room air] upon arriving at pt's [patient's] home....Fall Risk Assessment [score]: No History of Falling: Immediate or within three months (0), Ambulatory Aids: Crutches/Cane/Walker (15), IV/Saline Lock: Yes (20), Gait/Transferring: Weak (10), Mental Status: Oriented to own ability (0), Total 45."

At 8:52 PM, RN EE documented, on the Emergency Department (ED) Mercy Hospital Primary form pages 4-6, the medical history was obtained from the patient. The patient arrived from home via EMS with unsteady gate, appears generally ill, and is cooperative, alert, oriented to person, place and time. Mucous membranes are cracked with dried blood noted on patient's lips and mouth upon arrival. Lower extremity strength weak on the left and right. RN EE also documented Patient #1's current medications: Plavix once daily and baby aspirin once daily. (These are medications that can increase blood clotting time.)

At 8:41PM, Emergency Physician E examined Patient #1. Emergency Physician E documented, on the ED Mercy Hospital Primary form pages 1, 2, and 3 that Patient #1 complained of increased weakness for the past 2-weeks. With worsening shortness of breath and shortness of breath on exertion; Patient #1 reported being unable to walk more than a few steps without holding on to something. The respiratory exam included findings of mild respiratory distress, no wheezing but with crackling and snoring sounds present. Emergency Physician E ordered laboratory tests that showed increased blood clotting time, and a chest X-ray. Emergency Physician E diagnosed the patient with pneumonia, ordered antibiotics and admitted Patient #1 to the hospital.

Patient #1 arrived on the Post Critical Care Unit (PCCU) on 6/28/12 at approximately 10:50 PM with diagnoses of pneumonia, weakness, dehydration, and acute kidney injury. Patient #1 had cancer which had spread (metastasized) to the liver, was on the blood thinning medications, Plavix and baby aspirin, had an increased blood clotting time, and low platelet count with a downward trend from admission. (Platelet count: 6/28/12, 57; 6/29/12, 49; 6/30/12, 41; and 7/1/12, 46. Normal range is 140-440 thousands per cubic milliliter (k/ul). Low platelet count could result in prolonged bleeding).

On 6/29/12 at approximately 12:30 AM, Advanced Registered Nurse Practitioner (ARNP) F examined Patient #1. ARNP F documented the examination findings in the History and Physical note. "Chest X-ray does show an early pneumonia. [Patient #1] does have a known left lower lobe nodule currently unchanged from previous CT....Increased weakness....Mouth: Positive lip bleeding...Positive bruising, patient on Plavix and aspirin...positive easy bleeding, positive easy bruising...is edentulous [had no teeth] and has multiple ecchymosis to bilateral arms...Positive bilateral petechiae and hematoma to bilateral arms [Note: these findings could potentially indicate conditions in which fibrin (a protein that helps blood clot) is formed and then broken down, such as liver disease.] ...Alert, oriented X 3 [i.e., person, place and time], thinking clearly....Labs and X-rays: ...D-dimer 3.48 platelet count is 57,000 [a low platelet count could result in prolonged bleeding]...Urinalysis shows...large amount of blood....Condition stable."

(Review of Physician J's, Hematology/Oncology, dictated consultation note dated 7/1/12 revealed Patient #1 had undergone a CAT (computerized axial tomography) scan on 6/30/12. The results showed: "CAT scan of the abdomen and pelvis performed on June 30, 2012 shows interval development of multiple low attenuation lesions within the liver thought to represent metastatic disease.")

On 6/28/12 at 10:50 PM, PCCU RN GG documented an admission assessment on the Health Record Report Nursing Assessment that, Patient #1 was alert, oriented to person, place, time, event, and oriented to own ability. However, Patient #1 was unsteady walking or transferring, had a history of falls, and was a fall risk with a fall risk score of 70 (fall risk score greater than 51 requires interventions and documentation on the patient's care plan). RN GG documented bruises to Patient #1's right buttocks, right upper back, right flank, right inner calf, left elbow, and left foot. RN GG also documented the left and right top siderails on the bed were in the up position, cardiac monitor and non-invasive blood pressure cuff alarms were on and audible, hourly rounding and fall precautions in place. However, the medical record did not include documentation showing what, if any, fall precautions were in place. The medical record documentation also lacked evidence that a bed alarm was in use with Patient #1.

On 6/29/12 at 4:30 AM, PCCU RN GG documented on the Health Record Report Patient Shift/Transfer Report that Patient #1 had fallen in the past 3-months and had many bruises as documented on the 6/28/12 10:50 AM skin assessment. The patient is on Plavix at home due to heart valves, and the patient is alert. This documentation carried on, through the electronic medical record system, to assessments completed on 6/29/12 at 3:40 PM, 6/30/12 at 5:18 AM, 6/30/12 at 1:00 PM, and 6/30/12 at 6:49 PM. The documentation on 6/30/12 occurred just prior to PCCU RN GG assuming Patient #2's care and was readily available to PCCU RN GG.

From 6/28/12 through 6/30/12, nursing assessments showed the patient continued to be alert and oriented, but remained a high fall risk. The medical record lacked:

- Documentation showing staff initiated a bed alarm for the patient;
- Documentation to show when and who initiated the bed alarm for the patient;
- Nursing documentation of evidence of an assessment of the patient's risk for increased injury related to the patient's increased risk for bleeding (as evidenced in the ED medical record documentation from 6/28/12 and the History and Physical completed on 6/28/12 at 12:30 AM.); and
- Documentation of an evaluation showing that Patient #1's condition had changed to meet the criteria for implementing a bed or chair alarm as stated in the facility's Fall Prevention Program policy: "For patients who are confused, impulsive, or could not teach back fall prevention instructions, implement the following: Bed and Chair alarms...."

On 6/30/12 at 8:24 PM, RN L documented on the Health Record Report Nursing Assessment that Patient #1 was alert, oriented to person, place, time, and event. 3 siderails were up: the right and left top rails and the left bottom rail. The assessment lacked documentation that showed Patient #1 requested a third siderail or that the patient's status had changed so that a third siderail was necessary.

On 7/1/12 at 3:28 AM, Contracted Staff Services A (CSSA) RN L documented on the Health Record Report Nursing Assessment that Patient #1 climbed over the siderail and fell out of bed striking his/her head on the floor on 7/1/12 at 3:00 AM.

Interviews regarding the bed alarm include the following:

- Interview with CSSA RN L on 7/9/12 at 1:45 PM revealed staff had placed Patient #1 on a bed alarm sometime after admission to the PCCU on 6/28/12. RN L reported working the 7PM to 7AM shift on 6/30/12 and that she cared for Patient #1 during that shift. According to RN L, Patient #1 needed assistance to ambulate and the patient did use the call light to call her. RN L reported the bed alarm was functional and she had responded to the alarm a couple of times between 1:00 AM and 3:00 AM because the alarm sounded when the patient moved in the bed. RN L reported before she left the patient's room, after responding to the bed alarm sounding, at approximately 2:15 AM, the bed alarm was on but she did not hold the bed alarm button long enough for it to activate. RN L explained when the bed alarm goes off you have to press a key and a button to turn the alarm off. When you turn the alarm back on, you have to push the key and hold it in for about 3-seconds. When it beeps, you know it is engaged. The bed alarm is only activated when you hold the button long enough to hear the beep. The alarm had to be on and activated to sound.

- During an interview on 7/10/12 at 7:10 AM, Staff HH explained when a bed alarm sounds; they have to shut the alarm off. To reset the alarm they must press the green button and push the middle button. When the bed alarm is on, it beeps and illuminates a light.

- During an interview on 7/17/12 at 3:35 PM, PCCU RN BB, stated she was the charge nurse the 7 PM - 7 AM shift on 6/30/12 - 7/1/12. RN BB reported hearing Patient #1's bed alarm sounded a couple of times during the shift. RN BB was in the nurse's station with CSSA RN L around 3:00 AM when they heard an unfamiliar noise. They went to Patient #1's room, found the patient had climbed over the raised side rails, and fallen out of bed. There was a "goose-egg" on the patient's forehead above the left eyebrow. RN BB said, Patient #1's bed alarm did not sound.

- During an interview on 7/18/12 at 4:40 PM, Staff A, Operations Director PCCU, acknowledged Patient #1's medical record failed to include documentation of the bed alarm being engaged prior to the patient's fall on 7/1/12.

On 7/1/12 at 3:00 AM, CSSA RN L documented on Patient #1's medical record in the Physician Orders/Progress Notes: "Dr. Notified of Patient fall" and a telephone order from Physician A, a hospitalist, at 3:00AM, "CT [Computed Tomography] of head w/o [without] contrast."

Results of Patient #1's CT scan, completed on 7/1/12 at 3:43 AM, showed bleeding in the brain: "subdural hematomas, most prominent in the right frontal distribution extending superiorly. 2. Multifocal subarachnoid hemorrhage."

On 7/1/12 at 4:15 AM CSSA, RN L documented on Patient #1's medical record in the Physician Orders/Progress Notes: "Dr [Physician A, a hospitalist] notified of CT results," and a telephone order at 4:15 AM from Physician A, a hospitalist, to, "Transfer to ICU [Intensive care Unit] Consult Neurosurgery Now. (Done)"

The patient was transferred to the Intensive Care Unit on 7/1/12 at 5:45 AM.

Patient #1's medical record lacked evidence of a physician coming to the patient's room to assess the patient until Physician D, a hospitalist, saw the patient on 7/1/12 at 8:10 AM, approximately 5-hours after Patient #1 climbed over the raised siderails and fell to the floor sustaining a head injury.

The medical record showed CSSA RN L documented the physician order to consult Neurosurgery but lacked documentation that showed what time staff contacted the neurosurgeon regarding the consult.

Neurosurgeon B, who was consulted "Now," did not see Patient #1 until 7/1/12 at 10:56 AM; approximately 8-hours after Patient #1 climbed over the raised siderails and fell to the floor sustaining a head injury and approximately 7-hours after Physician A ordered the consult.

At 12:07 PM, Neurosurgeon B ordered fresh frozen plasma (a blood product to help slow bleeding) and type and crossmatch packed red blood cells STAT (immediately). At 1:49 PM, Neurosurgeon B ordered Platelets STAT (also a blood product to help slow bleeding).

A second CT ordered by Physician D, a hospitalist, completed on 7/1/12 at 3:00 PM, approximately12 hours after the patient's fall showed worsening of the bleeding in the patient's brain.

The patient died on 7/3/12 at 9:25 PM.


3. Regarding communication that the patient had been on Plavix and baby Aspirin, and at higher risk for bleeding, interviews revealed the following:

- During an interview on 7/12/12 at 8:20 AM, Physician A, a hospitalist, stated when CSSA RN L called him, he was not informed Patient #1 may have been at a higher risk for bleeding with injury because the patient was taking Plavix and Aspirin (medications that help prevent blood from clotting) and had blood tests that showed increased blood clotting time during the patient's hospital stay.

- During an interview on 7/16/12 at 2:55 PM, Neurosurgeon B, stated when CSSA RN L called him, he was not informed Patient #1 may have been at a higher risk for bleeding with injury because the patient was taking Plavix and Aspirin (medications that help prevent blood from clotting) and had blood tests that showed increased blood clotting time during the patient's hospital stay.

- During an interview on 7/12/12 at 9:50 AM, CSSA RN L stated she did not inform Physician A or Physician B that Patient #1 received Plavix and Aspirin and had blood tests that showed increased blood clotting time during his/her hospital stay. RN L stated she had not gone through the patient's home medications and did not remember the patient had been on Plavix at home. RN L stated she did see the patient was on Aspirin because she looked to see if the patient was on any blood thinner after the patient the patient fell, but did not inform Physicians A or B that the patient was on Aspirin.


4. During an interview on 7/12/12 at 9:35 AM, with Staff V, Contracted Staff Services A Director Staff AA, Contract Staff Manager, and RN U, Chief Nurse Executive. Staff V stated training for Contract Staff nursing personnel Staff L did not include training on bed/bed alarm function. (See A-398 for additional information.)

5. Review of 76-year-old Patient #2's medical record revealed the patient was admitted to the PCCU on 12/11/11 at approximately 3:40 PM from the ED, where the patient complained of worsening pain in the buttocks area and felt weak. On 12/11/11 Physician I, a hospitalist, dictated a History and Physical stating Patient #2's admitting diagnosis was: 1. Perirectal abscess (a pocket of pus adjacent to the anus) that requires surgery, orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down.), and chronic back pain.

On 12/11/11 at 4:30 PM, PCCU RN II assessed Patient #2 and documented the assessment findings on the Health Records Report Nursing Assessment. The patient was alert and calm, lethargic, with generalized weakness, and was on oxygen at 2 liters per minute. The patient had three siderails up, a call light in reach, was on fall prevention, hourly and PRN (as needed) rounding, fall precautions with a fall risk score of 60, and the head of the bed elevated. The assessment lacked documentation that showed Patient #2 requested a third siderail or that the patient's status required a third siderail was necessary.

(Review of a document provided by the facility of the actual fall event revealed the nursing staff failed to follow the fall prevention plan for Patient #2 when staff failed to post a no fall sign or place an arm band on the patient.)

On 12/11/11 at 5:48 PM, PCCU RN II documented on the Health Records Report Nursing Assessment that Patient #2 was confused at times.

On 12/11/11 at 8:57 PM, PCCU Staff JJ documented on the Health Records Report Nursing Assessment that Patient #2 was alert but confused and had decreased awareness, the patient was on hourly and PRN rounding, and fall precautions. However, staff failed to implement Patient #2's fall prevention plan, as stated above.

On 12/12/11 at 2:52 PM, PCCU RN KK, documented on the Health Records Report Nursing Assessment Shift/Transfer Report that Patient #2 was confused at times and a bed alarm was on.

On 12/12/11 at 8:05 PM, unsigned nursing documentation on the Health Records Report Nursing Assessment showed Patient #2's bed alarm was on and audible.

On 12/13/11 at 4:00 AM, unsigned nursing documentation on the Health Records Report Nursing Assessment showed Patient #2's bed alarm was on and audible and the bed had 3-siderails up.

On 12/13/11 at 4:07 AM, unsigned nursing documentation on the Health Records Report Nursing Assessment revealed, "Pt [patient] had gotten out of bed and was walking to the bathroom when he fell. [He/she] hit [his/her] head on the wall, and had 2 skin tears to left arm and a skin tear to left knee Pt was assisted by staff to BSC [bed-side commode], and then assisted back in bed. VS [vital signs] taken ...HMS [Hospitalist Medical Service] notified and seen patient, orders received." The documentation did not include whether the alarm had sounded prior to the patient's fall.

Additionally, staff had failed to implement Patient #2's fall prevention plan, as stated above.

On 12/13/11 at 4:00 AM, ARNP G documented on the Physician Progress Notes/Consultation, "Called to bedside found [patient] sitting on floor. Contusion left eyebrow. Pt confused [oriented] to self only...." On 12/13/11 at 4:00AM, ARNP G ordered staff to place a alarm the bed and do neurological checks every hour until Physician J sees the patient.

During an interview on 12/13/12 at 4:50 PM, Staff A, Operations Director PCCU, reported they had investigated Patient #2's fall and found that the night nurse thought she had activated the bed alarm but did not and the patient fell.


6. On 8/3/12 at 10:30 PM, a request, via a phone call, to the Chief Executive Officer of the hospital for additional information related to the facility's expectation regarding a physician's response time to a consult "now" order resulted in the following written explanation from the facility's Campus Chief Quality Officer, received on 8/3/12 at 1:47 PM:

"Regarding timeliness of physician response I reference the following:

"ORGANIZATION AND FUNCTIONS MANUAL
"ALEGENT HEALTH-MERCY HOSPITAL
"MEDICAL STAFF
"COUNCIL BLUFFS, IOWA

"ARTICLE VI - RULES AND REGULATIONS

"SECTION A. ADMISSION AND DISCHARGE OF PATIENTS...

"9. Each practitioner must assure timely, adequate professional care for his patients in the hospital by being available or having available through his office an eligible alternate practitioner with whom prior arrangements have been made. Failure of an attending practitioner to meet these requirements should result in loss of clinical privileges.

"Our interpretation and practice of the above paragraph is that it is the professional judgment of the physician that determines the timeliness of care and treatment based on the individual patient's needs. Many different types of patients are admitted to the hospital and to the Critical Care Unit, which makes it impossible to generalize a specific time frame for what is appropriate in any given case. The Mercy Medical Staff holds each provider accountable to provide timely care that is appropriate for the standard in the community. If it is found that a provider fails to provide timely care, the case is referred to our Physician Excellence Committee, our peer review committee, where other physicians use their expertise and experience to determine whether or not a provider has met the standard of care."

Based on document review and staff interview, the facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) program when the hospital failed to:

- Implement a system to track and analyze the actual factors the caused patients to fall. See A-287.

- Develop an independent system to collect and analyze data specific to the hospital to determine the causative factors involved in patient falls at Alegent Health Mercy Hospital.

- See the deficiency at A-287.

The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to ensure an effective QAPI program assuring an increase of safety for all patients at risk for falling.

I. Based on staff interview and document review, the facility failed to ensure their quality program included a system to track all relevant data needed to analyze the cause of patient falls in the hospital. The facility staff identified an average of 7 patient falls per month.Failure to determine the individual causative factors involved in a patient's fall prevented the hospital Quality Improvement (QI) staff members from determining trends in patients that fell in the hospital, and prevented the hospital from implementing specific interventions targeted at identifying causes of patient falls in order to prevent or minimize the potential for another patient experiencing a fall which may be avoidable.
Findings include:
1. The facility Quality Improvement (QI) staff members monitored the falls that occurred in the hospital for trends by tracking the number of patients that fell. Review found QI staff members performed analysis of the patients that fell by determining the most common age of a person who fell, the most common time of day a patient fell, and how long after admission a patient commonly fell. However, the hospital QI staff members did not analyze the data from the falls to determine the causative factors, such as if the bed alarm failed to activate, if the patient tripped over equipment, if the patient fell when trying to reach the toilet, etc. When the facility failed to analyze the data for common causative factors, the facility lacked the ability to develop an effective plan to minimize the potential of patients falling.
2. Review of the "Mercy Campus Patient Safety and Quality Committee Report", presented on 3/22/12 for data from 7/11 to 3/12, found it did not include any data on patients that fell at Mercy Hospital. However, review of incident reports showed 31 patients fell in the same time frame. The report did not include any evidence Mercy Hospital's QI staff analyzed the causative events surrounding the patient falls at Mercy Hospital, such as the bed alarm failing to be activated or sound if a patient at risk for falls tried to leave the bed, if the patient tripped over equipment, etc.

2. During an interview on 7/18/12 at 9:30 AM, QI Specialist Z stated the Patient Safety and Quality Committee reviewed patient falls in the hospital and looked at the falls to determine trends in the falls. However, QI Specialist Z did not keep formal documentation of trends with patients that fell. Instead, QI Specialist Z relied on their memory to determine if a fall involved a common causative factor with prior patient falls. QI Specialist Z could not state the frequency patients fell due to common causative factors such as if the patient tripped over equipment.3. During an interview on 7/18/12 at 8:30 AM, Advanced Registered Nurse Practitioner (ARNP) X stated they only tracked the number of patients that fell in the hospital each month. ARNP X provided a report to a national organization every 3 months with the number of patients that fell in the hospital. This allowed the hospital to compare their data with similar hospitals across the nation. ARNP X state the Operations Performance Improvement Council (OPIC) members had the responsibility to analyze the data of patient falls to determine common trends in the causes of the falls and report the number of falls to the OPIC monthly.Review of the meeting minutes for the OPIC, from 6/22/11 to 5/23/12, revealed the committee members identified 68 patients who fell during the time frame. The meeting minutes revealed the committee members examined patients that fell for factors such as the patient's age, sex, length of stay, body mass index (BMI), time of day the fall occurred, and day of week the fall occurred. However, the meeting minutes lacked evidence the committee members analyzed each fall to determine the individual causative factors involved in why the patient fell.
During an interview and review of meeting minutes on 7/18/12 at 4:00 PM, CNU E acknowledged the OPIC meeting minutes lacked evidence the committee members analyzed the individual falls for causative factors to determine why patients fell at the hospital.

4. During an interview on 7/18/12 at 2:00 PM, QI Specialist Z stated they reviewed all the incident reports for information about a patient that fell (such as the time the patient fell, if the patient received medication prior to falling, and the location where the patient fell). QI Specialist Z stated they did not analyze the incident reports to determine the individual causative factors involved why each patient fell in the facility.5. Review of an undated document titled "Executive Summary - Alegent Health Quality Plan [Fiscal Year] 2012", revealed the Quality Plan lacked a requirement for QI staff members to analyze the data they collected to determine the underlying causative factors to determine their role in understanding why patients fell in the hospital.6. During an interview and review of meeting minutes on 7/18/12 at 4:00 PM, Chief Nurse Executive (CNE) U stated the facility lacked a systemic process to analyze the individual causative factors involved in each patient's fall to determine why the patient fell. CNE U acknowledged the OPIC meeting minutes lacked an analysis of the individual causative factors involved in why patients fell at the hospital. CNE U stated they could not state the frequency patients fell due to common causative factors, such as staff members failed to ensure a patient's bed alarm was on and working, or if the patient tripped over equipment, because the QI system did not analyze the individual falls to determine the causative factors.
II. Based on document review and staff interview, the facility failed to ensure their quality improvement program included a system to analyze the data on patient falls in the hospital that was specific to the facility. Facility staff members identified an average of 7 patients that fell per month.Failure to analyze data specific to the facility could potentially result in the QI staff members failing to identify facility-specific problems, and then analyzing the information to identify facility-specific interventions to fix the problem.Findings include:1. During an interview on 7/18/12 at 9:30 AM, Chief Nursing Executive (CNE) U stated:

- On 5/11, the hospital started the Mercy Hospital Falls Committee to analyze the causative factors involved in determining why patients fell at the hospital. The Mercy Hospital Falls Committee met twice, on 5/31/11 and 8/8/11. However, after 6 months, the hospital stopped performing an independent investigation of the falls that occurred at the hospital. CNE U acknowledged the 2 meetings, over 6 months, did not give the committee members sufficient data to perform an analysis of the causative factors involved in the patient falls at the hospital.
- After 11/11, the hospital joined in the Alegent Health System (AHS) of hospitals to participate in a joint investigation of all the patients that fell at all 5 AHS hospitals located near Council Bluffs. This allowed the hospitals to help identify trends of patients that fell by allowing committee members to examine a wider variety of patients that fell in the 5-hospital system. The committee members could then identify trends that may only happen rarely at a smaller hospital, such as Alegent Health Mercy Hospital.
- CNE U acknowledged that the Alegent System did not isolate falls specific to Alegent Health Mercy Hospital. The data they reviewed was purely aggregate data for all 5-hospitals which did not identify fall data unique to Alegent Health Mercy Hospital. Being part of the system may not be useful to them because what may be a problem in the larger hospitals may not be applicable to smaller hospitals like Alegent Health Mercy Hospital.
- The AHS Board of Directors approved a single Quality Plan for all 5 hospitals and expected each hospital to follow the system-wide Quality Plan. Alegent Health Mercy Hospital followed the Quality Plan the Board of Directors approved for all hospitals that belonged to the Alegent Health System
2. Review of the undated document titled "Executive Summary - Alegent Health Quality Plan [Fiscal Year] 2012" revealed the Alegent Health system-wide "Quality Management Services provides support in campus and system oversight and support for Board [of Directors] approved system initiatives." The Quality Plan instructed QI staff members to monitor nationally-recognized standards for quality. However, the Quality Plan did not include anything specific to any of the 5 individual hospitals comprising the Alegent Health System.
3. Review of the undated document titled "Key Initiatives System - Metro Hospitals" for all 5 member hospitals in Alegent Health Systems revealed the AHS QI staff members only monitored the number of patients that fell for all 5 Alegent Health System hospitals and did not track the number of patients that fell at Mercy Hospital or analyze the events surrounding the patient falls at Mercy Hospital, such as the bed alarm failing to activate or if the patient tripped over equipment.
4. Review of the Mercy Hospital Falls Committee meeting minutes from 5/31/11 and 8/8/11 revealed the committee members tracked the total number of falls and the number of patients that sustained injuries as a result of their fall. However, Falls Committee members did not analyze the data from the individual falls to determine the causative factors involved in the falls.
5. During an additional interview and review of meeting minutes on 7/18/12 at 4:00 PM, CNE U acknowledged the meeting minutes from the Mercy Hospital Falls Committee and the AHS "Fall Mobility 100 Day Steering Meeting" lacked evidence the committees had investigated or analyzed the individual causative factors involved in determining why patients fell at Mercy hospital.6. Review of the Alegent Health System "Fall Mobility 100 Day Steering Meeting", from 1/9/12 to 5/2/12, revealed the committee members tracked the total number of falls on each unit at each hospital. The meeting minutes lacked evidence the committee members examined the data from individual hospitals to analyze the causative factors involved in the patient's fall. Additionally, the committee meeting minutes lacked evidence the committee members analyzed the information to determine specific interventions for each independent hospital. Instead, the meeting minutes focused on system-wide strategies and did not focus on any specific strategies for each of the individual facilities to reduce the incidence of falls at each individual hospital.

7. See the deficiency at A-0144 regarding the fall of Patient #1 who fell over bed side rails to the floor and the bed alarm failed to sound.

Based on review of policies/procedures, documents, and staff interviews, the facility failed to implement a system that nursing staff updated the patient's written plan of care to include the patient's risk for a potential fall and include fall risk interventions. This was found during review of 8 of 11 patient care plans reviewed. (Patients #1, 2, 3, 4, 5, 6, 7, and 8). The facility identified a census of 69 inpatients at the start of the survey.

The written care plan provides direction for the individualized care of each patient based on that patient's needs and is used to communicate directions and any updates to nursing, physicians, and other health care professionals to ensure continuity of care. Lack of a complete, accurate, and up-to-date written nursing plan of care inhibits the nursing staff's ability to provide cares specific to each patient's needs, including ensuring patient safety and/or protection from injury during their hospital stay.

Findings include:

1. Review of facility policy/procedure titled "Plan of Care and Discharge Planning", dated 11/11, showed it stated in part, "Patient's plan of care goals are based on the nursing assessment which is realistic, measurable, and consistent with therapy prescribed. . . Actual and potential health problems identified as having the potential to be resolved through actions or interventions of the healthcare team will be identified on the patient's Interdisciplinary Plan of Care. . . Documentation in the patient's medical record will reflect the actual or potential problems identified on the plan of care. . . Documentation will reflect the expected outcome, interventions, and the patient's and/or significant other's response to the intervention. . . ."

2. Review of facility policy/procedure titled "Fall Prevention Program", dated 5/12, showed it stated in part, "Once fall risk assessment is completed, initiate the fall interventions and any additional measures that pertain to the patient. If patient scores as a high risk for falls, document the risk for falls on the plan of care. . . ."

3. Review of Patient #1's medical record revealed the patient was admitted to the facility with diagnoses of pneumonia, weakness, dehydration, and acute kidney injury on 6/28/12. Patient #1 had metastasis to the liver, was on the blood thinning medications (Plavix and baby aspirin), had an increased blood clotting time, and low platelet count with a downward trend from admission (platelet count: 6/28/12, 57; 6/29/12, 49; 6/30/12, 41; and 7/1/12, 46. Normal range is 140-440 thousands per cubic milliliter (k/ul). Low platelet count could result in prolonged bleeding). Patient #1 was weak and needed some assistance to ambulate, but was alert, oriented, and able to teach back use of the call light.

Nursing assessments identified the patient as a high fall risk with a fall risk score of 70 on 6/28/12 at 10:30 PM, 85 on 6/29/12 at 4:00 PM, and 80 on 6/30/12 at 8:25 PM. The medical record documentation also showed Patient #1's bed alarm failed to sound when the patient climbed over the siderails (3of 4 side rails were in the up position) and fell. However, the medical record lacked documentation that Patient #1 met the criteria for a bed alarm or third siderail or when staff initiated the bed alarm.

Patient #1's written Plan of Care showed initiation of the goal "Absence of Falls with Injury" on 6/29/12 at 1:58 AM, but lacked any documentation of the interventions implemented. The Care Plan lacked evidence staff initiated a Plan of Care related to the Patient's increased risk for bleeding, increased risk for injury with a fall associated with the patient's increased risk for bleeding, the patient's need for a bed alarm, or a third siderail.

4. Review of Patient #2's medical record revealed the patient was admitted to the facility with complaint of worsening pain in buttocks area and weakness on 12/11/11. Nursing assessments identified the patient as a high fall risk of 60 on 12/11/11 at 4:00 PM, 95 on 12/13/11 at 4:47 AM, and 75 on 12/13/11 at 8:00 AM. However, review of Patient #2's Plan of Care showed initiation of the goal "Absence of Falls with Injury" on 12/12/11 at 1:32 PM, but lacked documentation of any interventions implemented.

5. Review of Patient #3's medical record revealed the patient was admitted to the facility with complaint of worsening of pain and swelling in the right elbow on 7/8/12. Nursing assessments identified the patient's fall risk as a high fall risk of 60 on 7/9/12 at 7:30 PM and 60 on 7/10/12 at 10:04 AM. However, Patient #3's written Plan of Care lacked documentation showing the patient was at risk for falls.

6. Review of Patient #4's medical record revealed the patient was admitted to the facility with diagnosis of seizure activity on 7/9/12. Nursing assessments identified the patient as a high fall risk of 60 on 7/9/12 at 1:27 PM, 70 on 7/10/12 at 8:00 AM, and 60 on 7/11/12 at 8:10 AM. While Patient #4's written Plan of Care showed initiation of the goal "Absence of Falls with Injury" on 7/9/12 at 8:23 PM, it lacked any documentation of any interventions implemented.

7. Review of Patient #5's medical record revealed the patient was admitted to the facility with diagnosis of a ruptured tendon right knee area on 7/10/12. Nursing assessments identified the patient as a high fall risk of 70 on 7/10/12 at 2:35 PM, 60 on 7/10/12 at 10:00 PM, 60 on 7/11/12 at 8:35 AM, 75 on 7/11/12 at 7:45 PM, 60 on 7/12/12 at 8:11 AM, 75 on 7/12/12 at 8:00 PM, and 70 on 7/13/12 at 8:17 AM. However, review revealed Patient #5's written Plan of Care lacked evidence showing the patient was at risk for falls after the patient was identified as a high risk of falls on 7/10/12 at 2:35 PM. Patient #5's Plan of Care documentation showed initiation of the goal "Absence of Falls with Injury" on 7/11/12 at 10:48 AM, but lacked documentation of any interventions implemented.

8. Review of Patient #6's medical record revealed the patient was admitted to the facility with diagnosis of a left ankle fracture on 7/6/12. Nursing assessments identified the patient as a high fall risk of 60 on 7/6/12 at 12:47 PM, 60 on 7/6/12 at 1:19 PM, 60 on 7/7/12 at 7:40 AM, 60 on 7/7/12 at 7:41 AM, 60 on 7/7/12 at 8:00 PM, 60 on 7/8/12 at 9:10 AM, 70 on 7/9/12 at 8:30 AM, 60 on 7/9/12 at 7:40 PM, 60 on 7/10/12 at 9:20 AM, and 60 on 7/11/12 at 8:58 AM. While Patient #6's written Plan of Care showed initiation the goal "Absence of Falls with Injury" on 7/6/12 at 7:01 PM, it lacked documentation of any interventions implemented.

9. Review of Patient #7's medical record revealed the patient was admitted to the facility with diagnosis of left ankle and right foot fracture on 7/9/12. Nursing assessments identified the patient as a high fall risk of 60 on 7/10/12 at 12:00 PM, 60 on 7/11/12 at 1:00 AM, and 65 on 7/11/12 at 8:28 AM. However, Patient #7's Plan of Care documentation showed initiation of the goal "Absence of Falls with Injury" on 7/10/12 at 10:28 AM, but it lacked documentation of any interventions implemented.

10. Review of Patient #8's medical record revealed the patient was admitted to the facility
with diagnosis of right-sided weakness on 7/8/12. Nursing assessments identified the patient as a high fall risk of 70 on 7/8/12 at 5:03 PM, 70 on 7/9/12 at 8:00 AM, 75 on 7/10/12 at 8:00 AM, 55 on 7/11/12 at 8:00 AM, 55 on 7/11/12 at 8:00 PM, 50 on 7/12/12 at 8:00 AM, 70 on 7/12/12 at 4:00 PM, 85 on 7/12/12 at 8:00 PM, and 75 on 7/13/12 at 8:00 AM. Nevertheless, although Patient #8's Plan of Care documentation showed initiation of the goal "Absence of Falls with Injury" on 7/8/12 at 9:38 PM, it lacked documentation of any interventions implemented.

11. During an interview on 7/18/12 at 4:40 PM, Staff A, Operations Director, Post Critical Care Unit, acknowledged Patients #1, 2, 4, 5, 6, 7, and 8's Plans of Care lacked documentation of interventions implemented related to the patient's risk for falls. Staff A acknowledged Patient #3's Plan of Care lacked documentation the patient was at risk for falls although the patient was assessed to be at high risk of falls.

I. Based on review of policies/procedures, documents, and staff interviews, the facility failed to ensure the Registered Nurse (RN) (referred to as CSSA RN L), employed by Contracted Staff Service A (CSSA), caring for Patient #1 on 7/1/12, communicated all relevant patient information to physicians caring for Patient #1, and documented physician notification of a consult ordered for Patient #1 on Post Critical Care Unit (PCCU) on 7/1/12 in accordance with the facility's policy/procedure. The facility identified 11 patients on the PCCU at the time of Patient #1's fall.

Failure to notify the physician of pertinent patient information when reporting test results and patient's condition compromised the physician's ability to make medical decisions based on the patient's most current health status and potentially compromised the patient's medical condition.

Findings include:

1. Review of policy/procedure titled "Utilization of Agency Personnel", dated 4/11, revealed in part, "All agency personnel will be required to comply with the established Alegent Health policies and procedures. . . ."

2. Review of policy/procedure titled "Physician Notification", dated 8/10, revealed in part, "Purpose: To establish guidelines for physician notification. . . Physician Consultation: a. The consulting physician must be notified immediately: Once the order is written, regardless if the order states, 'may see patient in the a.m.,' or, 'notify the physician in the a.m.'; b. Of the patient's information and condition. Document the notification of the consult in the progress notes or appropriate designated location to include the: a. Time and date. b. Physician or office staff notified. c. Staff Signature. . . ."

Review of Patient #1's medical record showed the patient was admitted on 6/28/12 with pneumonia, weakness, dehydration and kidney injury. Patient #1 received Plavix and Aspirin (medications that help prevent blood from clotting) during his hospital stay, had blood tests that showed increased blood clotting time, and a new diagnosis of cancer of the liver. Patient #1 fell out of bed striking his/her head on the floor on 7/1/12 at 3:00 AM. A Computed Tomography (CT) Scan ordered by Physician A, Hospitalist, after the fall showed bleeding in the brain. CSSA RN L documented notification Physician A of the patient's CT results on 7/1/12 at 4:15 AM in the progress notes. On 7/1/12 at 4:15 AM, Physician A ordered "Transfer to ICU. Consult Neurosurgery now."

However, Patient #1's medical record lacked the time and date, name of neurosurgeon notified, and staff signature of the physician notification for the order "Consult Neurosurgery now".

3. Review of personnel file for CSSA RN L showed CSSA RN L was oriented to the Post Critical Care Unit on 3/11/11 and that unit orientation included, in part, "Reference Materials: Policy and Procedure Manual. . . ."

4. During an interview on 7/12/12 at 8:20 AM, Physician A stated when CSSA RN L called him, he was not informed Patient #1 received Plavix and Aspirin (medications that help prevent blood from clotting) and had blood tests that showed increased blood clotting time during the patient's hospital stay .

5. During an interview on 7/16/12 at 2:55 PM, Neurosurgeon B stated he was not sure what time he received the call for a consult with Patient #1. When CSSA RN called him, he was not informed Patient #1 received Plavix and Aspirin and had blood tests that showed increased blood clotting time during the patient's hospital stay. CSSA RN told Neurosurgeon B the patient had a small bleed and wanted him to come see the patient. He did order a repeat CT for the next morning for follow-up. Neurosurgeon B further stated that because of Patient #1's liver function was decreasing, platelets were 41 thousand, INR was 1.5, and the patient was on Plavix - an anti-platelet medication, the Patient was at major risk for an intracranial bleed (bleeding within the head) whether the patient fell or not.

6. During an interview on 7/12/12 at 9:50 AM, CSSA RN L stated she did not inform Physician A or Physician B that Patient #1 received Plavix and Aspirin and had blood tests that showed increased blood clotting time during his/her hospital stay. CSSA RN L stated she had not gone through the patient's home medications and did not remember the patient had been on Plavix at home. RN L did see the patient was on Aspirin because she looked to see if the patient was on any blood thinner after the patient patient fell. Neurosurgeon B was on call for the Neurology group and called RN L. RN L said Neurosurgeon B did ask her if the patient was on blood thinners and she said no.

7. During an interview on 7/17/12 at 7:30 AM, Staff Y, RN, acknowledged she oriented CSSA RN L to the PCCU during CSSA RN L's first scheduled shift on that unit. Staff Y stated when she orients staff to PCCU, part of that orientation, as stated on the PCCU orientation checklist, was to show new staff the computer and where to find the policies/procedures.

8. During an interview on 7/19/12 at 8:05, Staff A, Operations Director PCCU, confirmed CSSA RN failed to document the time/date, name of physician notified and staff signature for the Neurosurgery consult ordered for Patient #1 in the patient's medical record.


II. Based on review of policies/procedures, documents, and staff interviews, the facility failed to implement a system that ensured all CSSA nursing personnel employed by the agency received orientation to the bed/bed alarm function and/or unit orientation prior to caring for patients at the facility. This was found for 9 of 9 records reviewed for CSSA staff (CSSA RN, M, N, O, P, Q, R, S, T). The facility identified 27 Registered Nurses and 20 Nursing Assistants, employed by Contracted Services A, worked at the facility in the past 3 months.

Failure to provide all contracted nursing personnel with orientation to bed/bed alarm function and unit orientation prior to caring for patients at the facility could compromise the effectiveness of contracted staff in safely caring for patients at the facility.

Findings include:

1. Review of policy/procedure titled "Orientation, Education, and Training", dated 1/12, revealed in part, "This policy applies to all full-time, part-time, and PRN [as needed] Alegent Health employees; nonemployees who provide care, treatment, or services in the organization will also comply with the intent of this policy, as appropriate. . . Orientation - All leaders will ensure that their new employee(s) attend and receive orientation for the overall Alegent Health System, department, and job-specific responsibilities prior to providing care, treatment, or services; each leader is to have their employees' department checklist(s) completed and available for review. . . ."

2. Review of policy/procedure titled "Utilization of Agency Personnel", dated 4/11, revealed in part, "All agency personnel must complete an Alegent Health orientation. . . An Agency Personnel Unit Orientation Checklist will be completed for each agency person that is new to Alegent Health. . . All agency personnel will be required to comply with the established Alegent Health policies and procedures. . . ."

3. Review of the contract for Contracted Staff Services A (non-employee nursing personnel), dated 5/2012, revealed in part, "Responsibilities - Alegent. . . Alegent will provide Unit specific orientation for Pool Members. . . ."

4. Review of 9 CSSA nursing personnel files revealed the following:

a. CSSA RN, L
- Hired 1/10/11
- Contracted Staff Services A orientation 1/19/11
- Post Critical Care Unit (PCCU) unit orientation 3/11/11 - included statement "Patient Rooms: b. Bed and function"
- Critical Care Unit (CCU) unit orientation 2/19/11 - included statement "Patient Rooms: b. Bed and function"
- Performance Reports (an evaluation of the individual's performance during a specified shift) revealed CSSA RN L worked on PCCU on 1/27/12, 5/18/12, 5/20/12, and 6/30/12
- Performance Reports revealed CSSA RN L worked on CCU on 2/26/12

b. Staff M, RN
- Hired 8/25/11
- CSSA orientation 9/1/11
- PCCU unit orientation 9/12/11 - included statement "Patient Rooms: b. Bed and function"
- CCU unit orientation 9/15/11 - included statement "Patient Rooms: b. Bed and function"
- Performance Reports revealed Staff M worked on PCCU on 9/17/11, 9/19/11, 10/11/11, 10/15/11, and 6/24/12
- Performance Reports revealed Staff M worked on CCU on 5/1/12

c. Staff N, RN
- Hired 10/15/07
- CSSA orientation 9/1/11
- PCCU unit orientation - none
- CCU unit orientation 3/15/07 - included statement "Patient Rooms: b. Bed and function"
- Performance Reports revealed Staff N worked on PCCU on 3/16/11, 4/19/11, 10/27/11, and 5/30/12
- Performance Reports revealed Staff N worked on CCU on 3/10/11 and 6/14/12

Review of performance reports revealed Staff N worked on PCCU on these dates and lacked documentation of orientation to that unit.

d. Staff O, RN
- Hired 6/28/06
- CSSA orientation 6/28/06
- PCCU unit orientation - none
- CCU unit orientation - none
- Performance Reports revealed Staff O worked on PCCU on 3/18/11 without documentation of orientation to the unit
- Performance Reports revealed Staff O worked on CCU on 2/17/11, 5/16/11, 2/10/11, 5/11/12, and 6/19/12 without documentation of orientation to the unit

Review of performance reports revealed Staff N worked on PCCU and CCU on these dates and lacked documentation of PCCU or CCU orientation.

e. Staff P, RN
- Hired 11/17/08
- CSSA orientation 11/17/08
- PCCU unit orientation 5/8/07 and 1/3/09 - included statement "Patient Rooms: b. Bed and function"
- CCU unit orientation 11/23/08 - included statement "Patient Rooms: b. Bed and function"
- Performance Reports revealed Staff N worked on PCCU - none
- Performance Reports revealed Staff N worked on CCU - none

The facility identified this staff member worked at the facility during the past 3 months but the staff member lacked any performance reports during the past 3 months.

f. Staff Q, Nursing Assistant
- Hired 10/21/09
- CSSA orientation 10/21/09
- 3rd Medical/Surgical unit orientation 12/3/09 - included statement "Patient Rooms: b. Bed and function"
- PCCU, CCU, 4th unit orientation - none
- Performance Reports revealed Staff Q worked on PCCU on 11/17/11
- Performance Reports revealed Staff Q worked on CCU on 10/24/11
- Performance Reports revealed Staff Q worked on 4th unit 12/30/10, 3/2/11, 8/3/11, and 5/18/11
- Performance Reports revealed Staff Q worked on 3rd Medical/Surgical unit on 8/26/10, 10/20/10, 6/23/11, 8/26/11, and 3/28/12

Review of performance reports revealed Staff Q worked on PCCU, CCU, and 4th but lacked documentation of PCCU, CCU, or 4th orientation.

g. Staff R, Nursing Assistant
- Hired 11/1/99
- CSSA orientation - none
- 3rd Medical/Surgical unit orientation 12/09 - included statement "Patient Rooms: b. Bed and function"
- PCCU, CCU, 4th unit orientation - none
- Performance Reports revealed Staff R worked on PCCU on 7/12/11, and 8/10/11
- Performance Reports revealed Staff R worked on CCU on 1/28/12
- Performance Reports revealed Staff R worked on 4th unit 4/20/11, 10/27/11, and 6/22/12
- Performance Reports revealed Staff R worked on 3rd Medical/Surgical unit on 4/20/10, 8/21/10, 6/17/11, 8/14/11, 10/6/11, and 2/26/12

Review of performance reports revealed Staff R worked on PCCU, CCU, and 4th and lacked documentation of PCCU, CCU, or 4th orientation.

h. Staff S, Nursing Assistant
- Hired 5/22/95
- CSSA orientation - none
- McDermott unit orientation 4/4/03 - included statement "Patient Rooms: b. Bed and function"
- PCCU, 4th unit orientation - none
- Performance Reports revealed Staff S worked on PCCU on 12/19/11, 2/24/11, 2/25/11, and 6/24/12
- Performance Reports revealed Staff S worked on 4th unit 2/25/12 and 4/29/12
- Performance Reports revealed Staff S worked on McDermott 11/19/11

Review of performance reports revealed Staff S worked on PCCU and 4th unit and lacked documentation of PCCU or 4th orientation.

i. Staff T, RN
- Hired 4/12/11
- CSSA orientation 4/12/11
- PCCU unit orientation 5/11/11 - included statement "Patient Rooms: b. Bed and function"
- CCU unit orientation 5/11/11 - included statement "Patient Rooms: b. Bed and function"
- Performance Reports revealed Staff T worked on PCCU on 5/14/12
- Performance Reports revealed Staff T worked on CCU on 6/12/12 and 6/19/12


5. During an interview on 7/12/12 at 9:35 AM, Staff V, CSSA Director, Staff AA, Contract Staff Service A's Manager, and Staff U, Chief Nurse Executive, Staff V stated training for CSSA's nursing personnel (CSSA RN, M, N, O, P, Q, R, S, and T) did not include training on bed/bed alarm function. Staff V and AA acknowledged the lack of documentation that Staff N, O, Q, R, and S received unit orientation prior to caring for patients at the facility.

6. During an interview on 7/17/12 at 3:35 PM, Staff BB, Registered Nurse - PCCU, stated she has, at times, been responsible for unit orientation of CSSA nursing personnel. However, Staff BB stated she does not usually review bed functions or bed alarms because the CSSA nursing personnel generally are familiar with those.


III. Based on review of policies/procedures, documents, and staff interviews, the hospital nursing staff received information during required training. However, the facility failed to implement a system that ensured 9 of 9 CSSA (non-employee) nursing staff received this same information from the required hospital staff training to ensure competency related to bed/bed alarm functions in accordance with hospital policy (CSSA RN, M, N, O, P, Q, R, S, T). The facility identified 27 Contracted Staff Services A Registered Nurses and 20 Contracted Staff Services A Nursing Assistants that worked at the facility in the past 3 months.

Failure to complete required hospital training courses for all nursing personnel could prevent CSSA staff from having knowledge needed to provide safe, effective, and proficient care to hospitalized patients.

Findings include:

1. Review of policy/procedure titled "Orientation, Education, and Training", dated 1/12, revealed in part, "This policy applies to all full-time, part-time, and PRN [as needed] Alegent Health employees; nonemployees who provide care, treatment, or services in the organization will also comply with the intent of this policy. . . Employees participate in ongoing education and training: To maintain or increase competency. . . Alegent Health Organization Mandated - Education an employee must complete, as determined by the organization to aide in meeting organizational objectives. . . ."

2. Review of policy/procedure titled "Utilization of Agency Personnel", dated 4/11, revealed in part, "All agency personnel will be required to comply with the established Alegent Health policies and procedures. . . ."

3. Review of the contract for CSSA (non-employee nursing personnel), dated 5/2012, revealed in part, "Responsibilities - Alegent. . . Alegent will provide access to education it offers to its clinical staff to nursing Pool Members including, but not limited to, [basic life support and advanced and advanced critical life support]. . . ."

4. Review of documentation for Mercy Hospital Falls Team Skills Day, dated September 29/30, 2011, revealed the program goal was to identify patients who were at risk of falling, prevention of falling, implement fall-intervention measures, and protection of injury and examples of fall risk/safety interventions - evaluate need for bed/chair alarm.

However, review of attendance records, dated September 29/30, 2011, revealed no CSSA nursing personnel attended the mandatory education and competency evaluation related to "Patient Falls: Protecting and Preventing Injury" which included return demonstration on bed alarms. The facility's beds had bed alarms built into the bed and staff was responsible to engage/activate the alarms according to the specific needs of each patient.

During an interview on 7/11/12 at 9:20 AM, Staff X, Advanced Registered Nurse Practitioer (ARNP), stated she presented the "Patient Falls: Protecting and Preventing Injury" session of the skills day on September 29/30, 2011. Staff X stated the attendance at the skills day presentation was required for all staff that touched the patients and beds including Registered Nurses and Nursing Assistants. Staff X stated the education session included review of the bed alarms, how to activate and turn off the alarm with return demonstration of how to activate the bed alarm. Staff X stated she did not review the audio/visual signals of the activation of the bed alarms during the educational sessions. Staff X stated if CSSA nursing personnel attended the educational sessions, their names would have been listed on the attendance record of the sessions.

5. Review of Contracted Staff Services A nursing personnel files revealed CSSA RN, M, N, O, P, Q, R, S, and T lacked documentation of competencies related to bed/bed alarm function and safety as required for mandatory education, presented by the facility on September 29/30, 2011 for all Registered Nurses and Nursing Assistants.

6. During an interview on 7/12/12 at 9:35 AM, Staff V, Contracted Staff Services A Director; Staff AA, Contract Staff Service A's Manager; and Staff U, Chief Nurse Executive; Staff V stated competencies, specifically attendance at the "Patient Falls: Protecting and Preventing Injury" session of the skills day on September 29/30, 2011 (that included review of the bed alarms, how to activate and turn off with return demonstration of how to activate the bed alarm) was not required for CSSAs's nursing personnel (CSSA RN's L, M, N, O, P, Q, R, S, T). While the facility's policy required CSSA staff to attend the mandatory education, they only attended if they were onsite during the education. The facility had no system in place to assure CSSA staff received the mandatory education and competency testing.

7. During an interview on 7/17/12 at 3:35 PM, Staff BB, Registered Nurse - PCCU, stated she had been responsible for unit orientation of CSSA nursing personnel at times. Staff BB stated she does not usually review bed functions or bed alarms because the CSSA nursing personnel generally are familiar with those.

8. During an interview on 7/18/12 at 2:45 PM, CSSA RN stated she works at other facilities besides Alegent Mercy Hospital for CSSA and the beds at all the facilities at are not the same.


IV. Based on review of policies/procedures, documents, and staff interviews, the facility failed to provide adequate evaluation of the clinical activities of 9 of 9 CSSA (non-employee) nursing personnel. (CSSA RN, M, N, O, P, Q, R, S, T) The facility identified 27 CSSA Registered Nurses and 20 CSSA Nursing Assistants that worked at the facility in the last 3 months.

Failure to adequately evaluate the clinical activities of non-employee nursing personnel could compromise safe patient care.

Findings include:

1. Review of contract for CSSA, dated 5/2012, revealed in part, "Performance Evaluations: To comply with the standards of all regulating bodies, all Agency Employees must be periodically evaluated by the Facility's designated representative using a performance-based evaluation. . . Responsibilities - Alegent: Alegent will retain full responsibility for patient care and related duties while Pool Members are providing care in the Facility. . . ."

2. During an interview on 7/12/12 at 9:35 AM, Staff V, CSSA Director, Staff AA, CSSA's Manager, and Staff U, Chief Nurse Executive, Staff V verified annual performance evaluations were not completed on CSSA nursing personnel by the facility. Staff V stated the CSSA receives on-going feed back regarding the performance of CSSA's nursing personnel via phone calls from the facility and/or completion of a "Performance Report" form by the unit charge nurse at the end of a shift for CSSA's employees.

However, although the facility identified that Staff P and Q worked at the hospital during the past 3 months, no shift performance reports were available from the past 3 months.

3. Review of Patient #1's medical record revealed CSSA RN L documented the patient fell out of bed striking his head on the floor on 7/1/12 at 3:00 AM.

Review of Post Fall Huddle form completed by CSSA RN L on 7/1/12 revealed that Patient #1 climbed over raised side rail. Post Fall Huddle form documentation stated bed alarm was not on/activated, RN turned it on but it was not on - RN may not have held in alarm button long enough for it to engage (and activate the alarm).

4. Review of the Bed Exit Alarm System documentation attached to the beds revealed the bed exit alarm system is built into the beds with controls on the head end of the patient's siderails. It will alarm if the patient attempts to leave the bed if staff (a) press the enable control button and (2) press and hold any bed exit mode control button until the system beeps one time and (3) the indicator light stays on solid. Then the system is engaged (alarm is activated).

5. Review of CSSA RN L's nursing personnel file revealed a Performance Report form dated 6/30/12 7 PM - 7 AM for completed by Staff BB, Registered Nurse, and faxed to CSSA on 7/1/12 at 6:28 AM. Performance Report documentation showed, "Observes safety measures" as Satisfactory.

During an interview on 7/9/12 at 3:30 PM, CSSA RN L acknowledged she cared for Patient #1 on 6/30/12 from 7 PM - 7 AM. CSSA RN L stated she was in the patient's room at approximately 2:15 AM when the patient's bed alarm was sounding. CSSA RN L stated the patient had moved in bed to reach for the urinal and the bed alarm sounded. CSSA RN L stated the patient had been alert but was weak so she had turned the bed alarm to the medium setting earlier in her shift. CSSA RN L stated at approximately 2:15 AM, when she went to leave the patient's room, she did not hold the bed alarm button to engage it so when the patient fell out of the bed while climbing over the siderails at 3:00 AM, the bed alarm did not sound.

6. During an interview on 7/17/12 at 3:35 PM, Staff BB, RN PCCU, stated she was the charge nurse the 7 PM - 7 AM shift on 6/30/12 - 7/1/12. Staff BB stated she had heard the bed exit alarm sound for Patient #1 a couple of times during the shift. Staff BB stated she was in the nurse's station with CSSA RN L when they heard an unfamiliar noise at approximately 3:00 AM. Staff BB and L went to Patient #1's room and found the patient had climbed over the raised side rails, fell out of bed, and hit his/her head. Staff BB stated Patient #1's bed alarm did not sound prior to hearing the patient's fall.

Staff BB acknowledged she completed an evaluation of the performance of CSSA RN L at the completion of the 7 PM - 7 AM shift on 6/30/12 - 7/1/12. Staff BB acknowledged she completed the Performance Report documentation of "Observes safety measures" as "Satisfactory" even though CSSA RN L failed to ensure the Patient's bed alarm was on and Patient #1 had climbed over the raised side rails, fell out of bed, and hit his/her head while being cared for by CSSA RN L.

Based on document review and staff interview, the facility failed to implement a system that ensured the medical record for each patient in the ICU was complete and maintained according to facility policy.

Patients admitted to the ICU at any time during hospitalization received care directly from a bedside nurse, but the facility had a system of monitoring the patients by electronic Intensive Care Unit (eICU) nurses who were remotely located in Omaha, Nebraska. Using an audio-visual equipment system, the eICU nurses could see and speak with the patient and bedside nurse in each patient's room.

The eICU nurses visually monitored the ICU patients using the eICU equipment, observed patients continually, reviewed patient written information that include medical history, procedures, medications, labs, and results of diagnostic testing. Using this patient information, the eICU nurses would suggest interventions for the patient to the bedside nurse.

The eICU nurses kept a temporary parallel eICU electronic medical record, which the bedside nurse could not access or review. Once the patient transferred out of the ICU, died in the ICU, or was discharged from the ICU, the eICU record was permanently purged from the eICU system and never added to the facility's permanent medical record for the patient. (Refer to A-467)

The cumulative effect of the systemic failure to capture the eICU nurse's role in the patient's care while in the ICU resulted in an incomplete medical record for each patient in the facility's ICU.

Based on document review, the facility failed to ensure all Post Critical Care Unit (PCCU) nurses authenticated their entries in the medical record for 1 (of 1) sampled closed PCCU patient reviewed (Patient #2).

Findings include:

Review of Patient #2's medical record nursing documentation from 12/11/11 through 12/15/11, revealed nursing staff failed to authenticate their entries in the following examples.

- On 12/12/11 at 8:05 PM, unsigned nursing documentation on the Health Records Report Nursing Assessment showed Patient #2's bed alarm was on and audible.
- On 12/12/11 at 10:00PM, unsigned nursing documentation on the Health Records Report Nursing Assessment; assessing the patient's pain
- On 12/12/11 at 10:37 PM, unsigned nursing documentation on the Health Records Report Nursing Assessment documenting the patient's intake.
- On 12/13/11 at 12:01 AM, unsigned nursing documentation on the Health Records Report Nursing Assessment documenting the patient's nursing assessment.
- On 12/13/11 at 2:00AM, unsigned nursing documentation on the Health Records Report Nursing Assessment documenting the patient's pain assessment.
- On 12/13/11 at 4:00AM, unsigned nursing documentation on the Health Records Report Nursing Assessment documenting the patient's nursing assessment and the patient's bed alarm was on and audible and had 3-siderails up.
- On 12/13/11 at 4:07 AM, unsigned nursing documentation on the Health Records Report Nursing Assessment revealed, "Pt [patient] had gotten out of bed and was walking to the bathroom when [he/she] fell. [He/she] hit [his/her] head on the wall, and had 2 skin tears to left arm and a skin tear to left knee Pt was assisted by staff to BSC [bed-side commode], and then assisted back in bed. VS [vital signs] taken ...HMS notified and seen patient, orders received." The documentation did not include whether the alarm had sounded prior to the patient's fall.
- On 12/13/11 at 4:44AM, unsigned nursing documentation on the Health Records Report Nursing Assessment documenting the patient's discharge instructions.
- On 12/13/11 at 4:45AM, unsigned nursing documentation on the Health Records Report Nursing Assessment documenting the patient's fall risk.
- On 12/13/11 at 5:00AM, unsigned nursing documentation on the Health Records Report Nursing Assessment documenting the physical and neurological assessment of the patient.
- On 12/13/11 at 6:00AM, unsigned nursing documentation on the Health Records Report Nursing Assessment documenting the patient's shift/transfer report, pain assessment, physical and neurological assessment.
- On 12/14/11 at 4:00PM, unsigned nursing documentation on the Health Records Report Nursing Assessment documenting the patient''s nursing assessment.
- On 12/13/11 at 4:55AM, unsigned nursing documentation on the Health Records Report Care Plan documenting the patient's fall this shift.
- A second entry on 12/13/11 at 4:55AM revealed unsigned nursing documentation on the Health Records Report Care Plan documenting the patient's pain: controlled with pain medication.

Based on staff interview and document review, the facility failed to implement a system to ensure electronic Intensive Care Unit (eICU) nurses documented their assessments and interventions in the patient's permanent medical record. The eICU nurses monitored all ICU patients on a continuous basis. This was found in 3 of 3 sampled ICU patients receiving eICU monitoring (Patient #10, 11, and 12). There were 6 current patients in the 16 bed ICU on 7/17/12. Facility staff identified an average daily census of 6 patients in the ICU.Failure to ensure the eICU nurse's documentation of assessments and medical interventions of patients in ICU was included and maintained in each patient's permanent medical record resulted in an incomplete medical record for the patients. This potentially compromises patient care for ICU patients after transfer or discharge from the ICU due to the lack of available patient information to record the patient's response to medical treatment.Findings include:
1. Review of the hospital policy "General Charting Guidelines", effective 9/10, revealed in part, "Charting will reflect evidence of care done and assessment of the patient throughout the hospitalization and their response to care and treatment."
2. The facility used eICU nurses to remotely monitor patients in the Alegent Mercy ICU.

When the bedside nurses admitted a patient into the ICU, the eICU nurse reviewed the patient's medical history and laboratory data from the patient's permanent medical record. The eICU nurse entered the information into their eICU software, which created a temporary eICU medical record. However, the temporary eICU medical record was purged after the patient left the ICU and never became part of the patient's permanent medical record.

The eICU nurse also examined the patient through a two-way audio-visual communication system and made their initial assessment, which was also entered into the temporary eICU medical record. During the patient's stay in the ICU, the eICU nurse monitored the patient's vital signs and laboratory data. If the eICU nurse noticed a change in the trend of the vital signs or laboratory data, the eICU nurse contacted the bedside nurse, and suggested an intervention, such as placing the patient on oxygen, then documented the assessment and intervention suggestion in the temporary eICU medical record.

The eICU nurses participated in the daily Interdisciplinary Care Team (ICT) meetings for the patient. The eICU nurses documented the ICT meetings in the patient's permanent medical record. However, the eICU nurse did not document their assessment or interventions in the patient's permanent medical record.
3. On 7/16/12 at 1:00 PM during an interview over the two-way audio-visual communication system used for monitoring the eICU patients, eICU Director C stated the facility had utilized eICU nurses to remotely monitor the vital signs and laboratory data for all the patients in the ICU for the prior 6 years. The eICU nurses remotely monitored the patients in the ICU from an office located in Omaha, Nebraska, approximately 25 miles away from the hospital, and were not physically present at the hospital. The eICU nurses provided monitoring for ICU patients in the facility and 6 other separate facilities in the geographic region.The eICU Director stated the eICU nurse used two-way audio-visual monitoring in the patient's ICU room to perform a visual assessment on each patient at the time the bedside nurse admitted the patient to the ICU. The eICU nurse could see the patient in the ICU room, see and talk with the bedside nurse in the ICU, and the bedside nurse in the ICU could see and speak directly to the eICU nurse in real time.The eICU nurse had access to the patient's permanent electronic medical record and the ability to communicate with the bedside nurse as needed. When the eICU nurse noticed a change in the patient or medical record information they monitored, the eICU nurse notified the bedside nurse caring for the patient in the ICU and suggested possible interventions for the bedside nurse to perform, such as starting to administer oxygen to the patient.During an interview on 7/17/12 at 1:00 PM, eICU Director C stated the eICU nurses could have documented the assessment and interventions they provided in the patient's permanent medical record. However, the eICU nurses acted as a back-up observer of the patient and considered the bedside nurse to have the responsibility to document the care provided to the patient. The eICU nurses did not document the visual assessment, assessment of information from the patient's permanent medical record or interventions they suggested to the bedside nurse in the permanent medical record.

The eICU Director acknowledged the eICU nurses' only documented the Interdisciplinary Care Team (ICT) meetings in the patient's permanent medical record because they could document the meetings in a more timely manner than the bedside nurses. The eICU nurse documented the interventions they communicated to the ICU nurse either in the patient's temporary eICU medical record or informed the next eICU nurse about care provided to the patient in a verbal report. The eICU Director also acknowledged the eICU nurse documented neither the assessment of the patient in ICU nor interventions they communicated, such as notifying the bedside nurse, in the ICU patient's permanent medical record. The bedside ICU nurse did not have access to any of the documentation the eICU nurse generated.The eICU Director stated the eICU software kept the patient's medical information for as long as the patient stayed in the ICU. After hospital staff transferred the patient out of the ICU, or the patient died in the ICU, the eICU software only kept the medical records of patients for a few days before purging it from the eICU software. Approximately 1 week after a patient's discharge from the ICU, the software permanently purged the eICU information from the patient's medical record, making it impossible to retrieve the data. The eICU Director acknowledged if the eICU software purged the patient's information, the patient's permanent medical record would not contain a complete record of all the care provided to the patient during their hospitalization.4. During an interview on 7/17/12 at 10:10 AM, ICU Team Leader FF stated each day, Monday through Friday, an Interdisciplinary Care Team (ICT) consisting of the patient's bedside ICU nurse, the eICU nurse, a respiratory therapist, a pharmacist, and a social worker discussed the patient's progress and plan of care for the rest of the patient's stay in the facility. The team discussed any problems the patient experienced, anything the patient might need during the hospitalization, and challenges facing the patient after discharge. The eICU nurse documented the ICT meetings in each ICU patient's permanent medical record.5. Review on 7/17/12 of Patient #11's temporary eICU medical record revealed:

Review of the "eICU Nurse - Admission Note" from the temporary eICU medical record revealed eICU Nurse E admitted the patient to the eICU and performed an initial assessment on 7/2/12 at 7:56 PM. The assessment contained information the eICU nurse obtained from the patient's permanent medical record, vital signs obtained by bedside staff members caring for the patient, and the eICU nurse's visual assessment of the patient through the two-way audio-visual equipment. Further review of the document revealed it included in part, "Do Not Print. Use for [eICU] only."Review of the "Nurse - Brief Progress Note" from the temporary eICU medical record revealed eICU Nurse B documented Patient #11 was not acting appropriately and the patient's pulse oximetry reading had decreased on 7/14/12 at 10:34 AM. The eICU nurse contacted the bedside nurse caring for the patient and instructed the bedside nurse to administer oxygen to the patient.
6. Review of Patient #11's open permanent medical record on 7/16/12 at 12:45 PM revealed the following information:
Review of the patient's permanent medical record revealed ICU staff members admitted Patient #11 to the ICU with diagnosis of "S/P [status post] Exploratory Laparotomy GI [gastrointestinal] Obstruction/ Ileus]. The permanent medical record lacked documentation showing the eICU nurse had performed an assessment of the patient and contacted the bedside nurse caring for the patient with instructions to start administering oxygen to the patient on 7/14/12.Review of the nursing Clinical Notes in the permanent medical record on 7/17/12 revealed the following documentation for Patient #11, demonstrating the eICU nurse's ability to document on the patient's permanent medical record:- On 7/3/12 at 11:46, eICU Nurse I documented discussing Patient #11's Plan of Care with the Interdisciplinary Care Team (ICT). At 11:50 PM, eICU Nurse F documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. - On 7/5/12 at 4:00 AM, eICU Nurse F documented discussing the patient's Plan of Care with the bedside nurse caring for Patient #11. At 11:37 AM, eICU Nurse G documented discussing the patient's Plan of Care with the ICT. - On 7/6/12 at 3:11 AM, eICU Nurse K documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. At 11:42 AM, eICU Nurse I documented discussed the patient's Plan of Care with the ICT. - On 7/7/12 at 3:11 AM, eICU Nurse H documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. - On 7/8/12 at 3:39 AM, eICU Nurse H documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. - On 7/9/12 at 4:19 AM, eICU Nurse H documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. At 9:59 PM, eICU Nurse J documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. - On 7/10/12 at 12:07 PM, eICU Nurse D documented discussing the patient's Plan of Care with the ICT. At 9:46 PM, eICU Nurse J documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. - On 7/12/12 at 4:01 AM, eICU Nurse H documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. - On 7/13/12 at 11:50 AM, eICU Nurse G documented discussing the patient's Plan of Care with the ICT. At 11:04 PM, eICU Nurse F documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. - On 7/16/12 at 11:57 AM, eICU Nurse F documented discussing the patient's Plan of Care with the ICT. At 11:03 PM, eICU Nurse E documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. - On 7/17/12 at 12:22 PM, eICU Nurse D documented discussing the patient's Plan of Care with the ICT. Further review of the documentation in the patient's permanent medical record revealed during the ICT the eICU nurses discussed the care provided to the patient, and provided suggestions to direct the care Patient #11 received. The documentation did not include the assessment the eICU nurse performed or the interventions the eICU nurse suggested.7. Review on 7/17/12 of Patient #10's temporary eICU medical record revealed the following information.Review of the "Nurse - Admission Note" from the temporary eICU medical record revealed eICU nurse I admitted Patient #10 to the eICU and performed an initial assessment on 7/14/12 at 11:55 AM. The assessment contained information the eICU nurse obtained from Patient #11's permanent medical record, vital signs obtained by bedside staff members caring for the patient, and the eICU nurse's visual assessment of the patient through the two-way audio-visual equipment. Further review of the document revealed it included in part, "E-ICU notes. Please do not print."Review of the "Nurse - Brief Progress Note" from the temporary eICU medical record revealed eICU nurse B documented on 7/14/12 at 1:19 PM the patient became agitated, removed the wrist restraints, and pulled out the feeding tube. The eICU nurse called the bedside nurse caring for the patient and instructed them to assess the patient and secure the patient's wrist restraints.8. Review on 7/16/12 at 12:45 PM of Patient #10's open permanent medical records revealed ICU staff members admitted Patient #10 to the ICU on 7/14/12 with Signs and Symptoms of Sepsis (SIRS). The open permanent medical record lacked documentation showing the eICU nurse performed an assessment of Patient #10, contacted the bedside nurse caring for Patient #10 on 7/14/12, instructed them to assess Patient #10, and secure the patient's wrist restraints.9. Review on 7/17/12 of the "eICU Nurse - Admission Note" from the temporary eICU medical record revealed eICU Nurse I admitted Patient #12 to the eICU and performed an initial assessment on 7/15/12 at 7:53 PM. The assessment contained information the eICU nurse obtained from the patient's permanent medical record, vital signs obtained by bedside staff member caring for the patient, and the eICU nurse's visual assessment of the patient through the two-way audio-visual equipment. Further review of the document revealed it included in part, "Do not print. Use for [eICU] only."
Patient #12's permanent medical record showed admission to the ICU with diagnosis of "Pneumonia Pleural Effusion" (fluid in the lungs). 10. Review of the nursing Clinical Notes in the permanent medical record on 7/17/12 revealed the following documentation for Patient #12, demonstrating the eICU nurse's ability to document on the patient's permanent medical record:
On 7/16/12 at 12:00 PM, eICU Nurse F documented discussing the Patient #12's Plan of Care with the members of the ICT. At 11:02 PM on 7/16/12, eICU Nurse E documented discussing the patient's Plan of Care with the bedside nurse providing care to the patient. On 7/17/12 at 12:23 PM, eICU nurse D documented discussing the patient's Plan of Care with the members of the ICT.

11. During an interview on 7/17/12 at 1:00 PM, eICU Director C stated the eICU nurses did not document the assessment and interventions they provided to patients in the ICU in the patients' permanent medical records. Instead, the eICU nurses documented their assessment and interventions in a temporary eICU medical record the software purged shortly after a patient left the ICU.