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Based on record review and staff interview it has been determined that the hospital failed to ensure nursing staff develops and keeps current a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs for 2 of 2 patient's reviewed who were assessed by Occupational Therapy, Patient ID #'s 1 and 2.

Findings are as follows:

The Hospital's policy titled, "Interdisciplinary Treatment Plans" effective 3/9/2021 states in part,

" ...III. Policy. It is the policy of Butler Hospital to ensure that an interdisciplinary care plan is developed for each patient and that each discipline involved in the care of the patient must participate in patient assessment, and propose a joint approach toward achieving the goals and interventions set for the patient ..."

1. Record review revealed that Patient ID #1 presented to the hospital in July of 2023 due to increased auditory hallucinations. Patient ID #1's diagnoses include, but are not limited to, right foot amputation, rheumatoid arthritis, chronic pain, developmental delays, and schizoaffective disorder (a mental health disorder characterized by hallucinations or delusions and disruptions in mood).

Record review of an "Occupational Therapy Progress note" dated 7/20/2023 entered by Employee A, Occupational Therapist, revealed that Patient ID #1 had a below the knee amputation and uses a prosthesis. The note states that upon assessment, Patient ID #1 attempted to stand "multiple times" eventually requiring the assistance of 1 to 2 staff members to remain standing after feeling dizzy. According to Employee A, Patient ID #1 revealed during the assessment that she/he uses a rollator walker at home, a bedside commode for toileting at night, a commode over his/her toilet seat, as well as grab bars and a shower chair in the bathroom. Additionally, Patient ID #1 revealed that she/he had a recent fall in July prior to admission when s/he was ambulating outside without assistance.

Record review of progress notes dated 7/20/2023 through 7/24/2023 revealed that Patient ID #1 was unsteady while ambulating which required a staff member to walk with him/her at times, was at risk for falls due to having a prosthetic, and experienced two falls while admitted to the hospital.

Further review of these notes revealed that after the second fall, Patient ID #1 sustained a small superficial abrasion to the left side of his/her forehead and was subsequently placed under constant observation.

The record failed to reveal evidence that Patient ID #1's interdisciplinary treatment plan was updated or modified to include a plan that addressed goals and interventions relative to Patient ID #1's risk for falls, use of assistive devices, mobility status, or presence of a prosthetic device relative to a right below the knee amputation.

During a surveyor interview with on 7/28/2023 at 12:02 PM with Employee B, Nursing Assistant/Mental Health Worker, he revealed that he was Patient ID #1's constant observer on 7/24/2023 at 3:30 PM for an hour and again at 9:30 PM for an hour. Employee B indicated that he did not know how well Patient ID #1 transferred from the bed onto the wheelchair when she/he requested to use the bathroom, but he assisted the patient anyway. Employee B revealed that the patient was able to transfer himself/herself onto the wheelchair and then onto the toilet.

During a surveyor interview on 7/31/2023 at 1:26 PM with the Director of Nursing Education, she indicated that Nursing Assistants and Mental Health Workers can review interdisciplinary treatment plans.

During a surveyor interview on 7/31/2023 at 2:54 PM with the Director of Occupational Therapy, she acknowledged that Employee A did not modify Patient ID #1's interdisciplinary treatment plan to reflect the patient's risk for falls status nor the goals and interventions specific to the patient's mobility status and use of assistive devices. Additionally, she indicated that the nurse could also modify the patient's treatment plan to reflect the patient's risk for falls.

2. Record review revealed that Patient ID #2 presented to the hospital in July of 2023 due to worsening aggression and elopement from his/her group home. Patient ID #2's diagnoses include, but are not limited to, borderline personality disorder, mild cognitive impairment, and mood disorder.

Record review of an "Occupational Therapy Progress note" dated 7/24/2023 entered by Employee A, revealed that Patient ID #2 was assessed by the Occupational Therapist as requiring moderate to maximum assistance with transferring from sitting to standing, and minimum assistance with dressing his/her lower body. Additionally, the note indicates that Patient ID #2 completed her toileting and dressing task with a Certified Occupational Therapy Assistant.

The record failed to reveal evidence that Patient ID #2's interdisciplinary treatment plan was updated or modified to include a plan that addressed goals and interventions relative to Patient ID #2's transferring and dressing assistance.

During a surveyor interview with the Director of Risk Management on 7/31/2023, she was unable to provide evidence that Patient ID #2's treatment plan included goals and interventions relative to Patient ID #2's transferring and dressing assistance.

Based on recorded surveillance video and staff interview, it has been determined that the hospital failed to ensure nursing personnel follow hospital policies relative to a patient who was placed on constant observation status due to their risk for falls for 1 of 1 patient reviewed who sustained a fall while hospitalized.

Findings are as follows:

The hospital's policy titled, "Categories of Observation" effective 8/10/2021 states in part,

" ...1) Constant Observation shall be ordered for any patient who needs to have a staff member with him/her at all times ...

a. An assigned staff member must be with the patient at all times, including in the bathroom.

b. The staff member must be able to visually observe the patient at all times and be able to quickly intercede should it become necessary ..."

Record review revealed that Patient ID #1 presented to the hospital in July of 2023 due to increased auditory hallucinations. Patient ID #1's diagnoses include, but are not limited to, right foot amputation, rheumatoid arthritis, chronic pain, developmental delays, and schizoaffective disorder (a mental health disorder characterized by hallucinations or delusions and disruptions in mood).

Record review of an "Occupational Therapy Progress note" dated 7/20/2023 entered by Employee A, Occupational Therapist, revealed that Patient ID #1 had a below the knee amputation and uses a prosthesis. The note states that upon assessment, Patient ID #1 attempted to stand "multiple times" eventually requiring the assistance of 1 to 2 staff members to remain standing after feeling dizzy.

According to Employee A, Patient ID #1 revealed during the assessment that she/he uses a rollator walker at home, a bedside commode for toileting at night, a commode over his/her toilet seat, as well as grab bars and a shower chair in the bathroom. Additionally, Patient ID #1 revealed that she/he had a recent fall in July prior to admission when she/he was ambulating outside without assistance.

Record review of progress notes dated 7/20/2023 through 7/24/2023 revealed that Patient ID #1 was unsteady while ambulating which required a staff member to walk with him/her at times, was at risk for falls due to having a prosthetic, and experienced two falls while admitted to the hospital.

Further review of these notes revealed that after the second fall, which occurred on 7/23/2023, Patient ID #1 sustained a small superficial abrasion to the left side of his/her forehead and was subsequently placed under constant observation.

Review of recorded surveillance video footage from 7/24/2023 in Riverview 3 revealed that Employee B, Nursing Assistant/Mental Health Worker, was assigned as Patient ID #1's constant observer on 7/24/2023. Employee B was observed walking out of the patient's room into the hall twice leaving the patient unattended while was using the bathroom.

During a surveyor interview on 7/31/2023 at approximately 8:50 AM with the Charge Nurse on Riverview 3, she indicated that it is the expectation that if a patient is on constant observation, the staff performing the duties of a constant observer is within arm's length of the patient and the staff cannot walk away from the patient due to safety concerns.

During a surveyor interview with the Director of Risk Management on 7/27/2023, she acknowledged that Employee B was not constantly observing Patient ID #1, who was at risk for falls, at all times per hospital policy.