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Based on observation, interview, and record review the facility failed to provide care in a safe setting when,
- three (3) patients were placed at risk for further falls, they were not assessed for falls and interventions were not put in place.( #4, #5, and #7)
- four (4) patients in the Emergency Department (ED) were placed at risk for neglect or injury, call lights were not accessible. (Room #s 25,22,18, and 21)
- eight (8) patient rooms on the Psych unit contained cracked missing laminate with exposed unclean able wood and sharp edges, and/or unclean able shower stalls, and or sticking dresser drawers.(Room #s 101, 102, 103, 108, 110, 111, 112, and 113)

Findings Included:

Record review of Emergency Room patients with an admission complaint of a fall or at risk of falling revealed three (3) out of six (6) patients were placed at risk for further falls.
- On 12/20/15, Patient # 4, a 63 year old female fell prior to arrival. A fall assessment was completed and she was scored a 0 fall risk. She did not have documented interventions put in place to prevent further falls.
- On 12/19/15, Patient #5, a 53 year old female fell with a head injury prior to arrival. There was no fall risk assessment completed. There were no documented interventions put in place to prevent further falls.
- On 12/17/15, Patient #7 a 60 year old male came in following a fall, he felt dizzy, fell forward and hit his head on the concrete. No fall risk assessment was completed. There were no documented interventions put in place to prevent further falls.

Subject: FALL RISK/ SAFETY PRECAUTIONS
POLICY:
The Fall Risk assessment tool should be completed at the time of admission to the Emergency Department to determine patient risk for falling. Patient care should be implemented using the appropriate fall prevention interventions.
PROCEDURE:
1. Morse Fall Scale Variable Descriptions and Scoring Hints
A. History of falling
i.) This is scored as 25 if the patent has fallen during the present hospital admission or if there was an immediate history of physiological falls prior to admission. If the patient has not fallen, this is scored 0.

Review of the Fall training reflected:
IN SUMMARY:
All Nurses and nursing staff will be responsible for reading this education and will be having all questions regarding the new tool answered prior to it going live on 8-11-14.
Each nursing staff member will be held accountable when it comes to appropriate fall assessment and post fall protocol.

Review of the training IF A PATIENT FALLS dated October 15, 2015 reflected:
- If the fall is not witnessed or the patient hits his/her head neuro checks are to be done
- Enter the event into ERS at the time of the event BEFORE the end of your shift
- Reasses the fall risk
- Update the Care Plan
- Perform possible preventative interventions as needed such as bed alarms, chair alarms, or non-slip socks etc.
- Pass information on during shift report

Observations of the psychiatric unit rooms on 12/30/15 at 12:20 p.m. revealed:
111- The door had a large unclean able area of missing laminate exposing wood and sharp edges. The large bottom dresser drawer was difficult to open. The shower curtain was observed to have a two inch dark brown stain across the lower edge. The inner corner of the shower stall had a ten inch vertical gap in the wall where the caulk had pulled away. The caulking around the base of the shower was blackened.
113- revealed two (2) large plastic bags filled with clothing sitting on the floor unattended, cracked unclean able missing laminate on the door exposing wood. The dresser drawers were difficult to open. The shower stall caulk had dark stains along the base.
112- The door had a large unclean able area of missing laminate exposing wood and sharp edges.
110- The caulking around the base of the shower was blackened. The dresser drawers were difficult to open.
108- The door had a large unclean able area of missing laminate exposing sharp edges. The dresser drawer was difficult to open. The caulking around the base of the shower was blackened.
103- The dresser drawer was difficult to open. The caulking around the base of the shower was blackened.
102- The door had a large unclean able area of missing laminate exposing wood and sharp edges. The dresser drawer was difficult to open. The caulking around the base of the shower was blackened.
101- The door had a large unclean able area of missing laminate exposing wood and sharp edges.

During an interview on 12/29/15 in the afternoon, in the conference room, Staff #1, RN ED Educator stated Patient #4 should have been rated at least a 25 and fall preventions put in place; and Patients #5 and #7 should have had fall assessments completed and fall preventions should have been put in place. Staff #1, RN ED educator confirmed (3) out of the (6) charts reviewed for fall assessments were either not completed or were completed inaccurately.

During an interview on 12/30/15 at 1:15 p.m. in the psychiatric hospital conference room, Staff #16, Assistant Director of Environmental Services (EVS) stated, "We use a quaternary cleaner on the shower stalls. If the shower stall gets to the point of mold, furry, dark green, we call the facilities department to place a work order. My staff is not trained to determine if there is mold or remove mold." Staff #16 further stated there is a first line EVS supervisor that rounds daily; and that Staff #16 does not review the daily reports.

During an interview on 12/30/15 at 1:00 p.m., in the psychiatric hospital conference room, Staff #17, Director of Facilities stated, "If there is mold we have to have someone re-grout the shower stalls." Staff #17 stated that Facilities conducts environmental rounds twice a year. Staff #17 stated there were no current work orders for the psychiatric hospital shower stalls.

Based on observation and record review the facility's failed to provide oversight for the quality of patient care provided by the nursing service when:
- three (3) patients were placed at risk for further falls, they were not assessed for falls and interventions were not put in place.( #4, #5, and #7)
- four (4) patients in the Emergency Department (ED) were placed at risk for neglect or injury, call lights were not accessible. (Room #s 25,22,18, and 21)

Findings Included:

Record review of Emergency Room patients with an admission complaint of a fall or at risk of falling revealed three (3) out of six (6) patients were placed at risk for further falls.
- On 12/20/15, Patient # 4, a 63 year old female fell prior to arrival. A fall assessment was completed and she was scored a 0 fall risk. She did not have documented interventions put in place to prevent further falls.
- On 12/19/15, Patient #5, a 53 year old female fell with a head injury prior to arrival. There was no fall risk assessment completed. There were no documented interventions put in place to prevent further falls.
- On 12/17/15, Patient #7 a 60 year old male came in following a fall, he felt dizzy, fell forward and hit his head on the concrete. No fall risk assessment was completed. There were no documented interventions put in place to prevent further falls.

Subject: FALL RISK/ SAFETY PRECAUTIONS
POLICY:
The Fall Risk assessment tool should be completed at the time of admission to the Emergency Department to determine patient risk for falling. Patient care should be implemented using the appropriate fall prevention interventions.
PROCEDURE:
1. Morse Fall Scale Variable Descriptions and Scoring Hints
A. History of falling
i.) This is scored as 25 if the patent has fallen during the present hospital admission or if there was an immediate history of physiological falls prior to admission. If the patient has not fallen, this is scored 0.

Review of the Fall training reflected:
IN SUMMARY:
All Nurses and nursing staff will be responsible for reading this education and will be having all questions regarding the new tool answered prior to it going live on 8-11-14.
Each nursing staff member will be held accountable when it comes to appropriate fall assessment and post fall protocol.

Review of the training IF A PATIENT FALLS dated October 15, 2015 reflected:
- If the fall is not witnessed or the patient hits his/her head neuro checks are to be done
- Enter the event into ERS at the time of the event BEFORE the end of your shift
- Reasses the fall risk
- Update the Care Plan
- Perform possible preventative interventions as needed such as bed alarms, chair alarms, or non-slip socks etc.
- Pass information on during shift report

During an interview on 12/29/15 in the ED, Staff #2, the Safety Coordinator confirmed the findings. Staff #2 stated, "The call lights need to be within reach."

During an interview on 12/29/15 in the afternoon, in the conference room, Staff #1, RN ED Educator stated Patient #4 should have been rated at least a 25 and fall preventions put in place; and Patients #5 and #7 should have had fall assessment completed and fall preventions should have been put in place. Staff #1, RN ED educator confirmed (3) out of the (6) charts reviewed for fall assessments were either not completed or were completed inaccurately.

Based on record review and observation the facility failed to maintain accurately document evaluations and treatments when:
- three (3) patients were placed at risk for further falls, they were not assessed for falls and interventions were not put in place.( #4, #5, and #7)

Findings Included:

Record review of Emergency Room patients with an admission complaint of a fall or at risk of falling revealed three (3) out of six (6) patients were placed at risk for further falls.
- On 12/20/15, Patient # 4, a 63 year old female fell prior to arrival. A fall assessment was completed and she was scored a 0 fall risk. She did not have documented interventions put in place to prevent further falls.
- On 12/19/15, Patient #5, a 53 year old female fell with a head injury prior to arrival. There was no fall risk assessment completed. There were no documented interventions put in place to prevent further falls.
- On 12/17/15, Patient #7 a 60 year old male came in following a fall, he felt dizzy, fell forward and hit his head on the concrete. No fall risk assessment was completed. There were no documented interventions put in place to prevent further falls.

Subject: FALL RISK/ SAFETY PRECAUTIONS
POLICY:
The Fall Risk assessment tool should be completed at the time of admission to the Emergency Department to determine patient risk for falling. Patient care should be implemented using the appropriate fall prevention interventions.
PROCEDURE:
1. Morse Fall Scale Variable Descriptions and Scoring Hints
A. History of falling
i.) This is scored as 25 if the patent has fallen during the present hospital admission or if there was an immediate history of physiological falls prior to admission. If the patient has not fallen, this is scored 0.

Review of the Fall training reflected:
IN SUMMARY:
All Nurses and nursing staff will be responsible for reading this education and will be having all questions regarding the new tool answered prior to it going live on 8-11-14.
Each nursing staff member will be held accountable when it comes to appropriate fall assessment and post fall protocol.

Review of the training IF A PATIENT FALLS dated October 15, 2015 reflected:
- If the fall is not witnessed or the patient hits his/her head neuro checks are to be done
- Enter the event into ERS at the time of the event BEFORE the end of your shift
- Reasses the fall risk
- Update the Care Plan
- Perform possible preventative interventions as needed such as bed alarms, chair alarms, or non-slip socks etc.
- Pass information on during shift report

During an interview on 12/29/15 in the ED, Staff #2, the Safety Coordinator confirmed the findings. Staff #2 stated, "The call lights need to be within reach."

During an interview on 12/29/15 in the afternoon, in the conference room, Staff #1, RN ED Educator stated, "Patient #4 should have been rated at least a 25 and fall preventions put in place; and Patients #5 and #7 should have had fall assessment completed and fall preventions should have been put in place." Staff #1, RN ED educator confirmed (3) out of the (6) charts reviewed for fall assessments were either not completed or were completed inaccurately.

Based on observation, interview and record review the facility failed to maintain a sanitary hospital environment when it Based on observation, interview, and record review the facility failed to provide care in a safe setting when,

- eight (8) patient rooms on the Psychiatric unit contained cracked missing laminate with exposed unclean able wood and sharp edges, and/or unclean able shower stalls.(Room #s 101, 102, 103, 108, 110, 111, 112, and 113)

Findings Included:

Observations of the psychiatric unit rooms on 12/30/15 at 12:20 p.m. revealed:
111- The door had a large unclean able area of missing laminate exposing wood and sharp edges. The shower curtain was observed to have a two inch dark brown stain across the lower edge. The inner corner of the shower stall had a ten inch vertical gap in the wall where the caulk had pulled away. The caulking around the base of the shower was blackened.
113- revealed cracked unclean able missing laminate on the door exposing wood. The shower stall caulk had dark stains along the base.
112- The door had a large unclean able area of missing laminate exposing wood and sharp edges.
110- The caulking around the base of the shower was blackened.
108- The door had a large unclean able area of missing laminate exposing sharp edges. The caulking around the base of the shower was blackened.
103- The caulking around the base of the shower was blackened.
102- The door had a large unclean able area of missing laminate exposing wood and sharp edges. The caulking around the base of the shower was blackened.
101- The door had a large unclean able area of missing laminate exposing wood and sharp edges.

The surveyor requested policies for cleaning the shower stalls and cleaning schedules for the patient bathrooms, the requested documents were not provided prior to exiting.

Review of the facility provided INFECTION CONTROL PLAN 2015 (revised 7/15) reflected: GOALS:
The goals of the program are to identify the risks associated with healthcare associated infections, develop strategies to prevent and/or reduce them from occurring...

The Infection Control Plan 2015 did not reflect environment exposures and controls.

During an interview on 12/30/15 at 1:15 p.m. in the psychiatric hospital conference room, Staff #16, Assistant Director of Environmental Services (EVS) stated, "We use a quaternary cleaner on the shower stalls. If the shower stall gets to the point of mold, furry, dark green, we call the facilities department to place a work order. My staff is not trained to determine if there is mold or remove mold." Staff #16 further stated there is a first line EVS supervisor that rounds daily; and that Staff #16 does not review the daily reports.

During an interview on 12/30/15 at 1:00 p.m., in the psychiatric hospital conference room, Staff #17, Director of Facilities stated, "If there is mold we have to have someone re-grout the shower stalls." Staff #17 stated that Facilities conducts environmental rounds twice a year. Staff #17 stated there were no current work orders for the psychiatric hospital shower stalls.