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Based on observation, interview and record review the facility failed provide the appropriate supervision of staff, to monitor patients according to orders and hospital policies and failed to ensure that the nursing staff develops and keeps current nursing care plans, resulting in the potential for harm to all patients served by the facility requiring special safety/fall precautions.

See Tags
0392 - Staffing and Delivery of Care
0395 - RN Supervision of Nursing Care
0396 - Nursing Care Plan

Based on observation, interview, and record review, the facility failed to ensure nursing staff provided a safe environment for patients. The facility failed to take actions specified in policies and procedures to reduce the risk of harm for 4 (P-1, P-4, P-5, P-6) of 4 patients reviewed for safety precautions, resulting in the likelihood of negative outcomes for all patients. Findings include:

Observational tours of current nursing practice on the 2nd floor medical/surgical units revealed:

On 3/17/25 at 1030, P-4 was observed in room 258 B. Signage posted outside room indicated patient was on fall precautions, an AvaSys (video surveillance system) was observed to be in use, the bed alarm was checked for activation with the assistance of Staff N, the bed alarm was not on. Staff N confirmed the finding at time of observation and stated that bed alarms are part of fall precautions, and it should have been turned on.

On 3/17/25 at 1035, P-5 in room 258 A, was observed in a bed that was elevated to a high position in the air. (P-5 was unattended by staff). Staff N confirmed the observation at time of finding, lowered the bed to the lowest level, and stated beds should be at the lowest level for safety.

On 3/18/25 at approximately 1000, P-6 was observed in room 262. Signage outside room indicated patient was on fall precautions, an AvaSys (video surveillance system) was observed to be in use, the bed alarm was checked for activation with the assistance of Staff N, the bed alarm was not on. Staff N confirmed the finding at time of observation.

On 3/17/25 at 1300 record review for P-1 revealed provider notes of 2/14/25 at 0813 revealed, P-1 was assessed as confused and "Per staff she was found wandering the halls last night" and that nursing is requesting video surveillance system (AvaSys) to be placed into room".

On 3/18/25 at approximately 1000, record review of risk report for P-1 revealed P-1 was admitted to the facility on 2/10/25 at 1336 with a diagnosis of acute cystitis (extended-spectrum beta-lactamase Escherichia Coli - ESBL E. Coli) and altered mental status. On 2/15/24, at approximately 1600, P-1 wandered off unit, to front entrance and sat on a bench just outside the front doors. P-1 was returned to 2nd floor staff by Security at 1807. Investigation determined the bed alarm was not activated; and the AvaSys (video surveillance system) observers failed to alert the nursing staff that P-1 was out of bed/room.

Review of facility policy #22412 titled, "Patient Safety Precautions", dated 7/21/24 revealed, Standard safety equipment/in room interventions are put into place for all patients ...Standard in room interventions include ...bed wheels locked ...bed in low position...Call light in reach ... Every adult inpatient ...receives universal fall prevention interventions ...hourly rounding ...nonskid footwear ...*consider individual precautions based on patient risk factors ...fall risk wristband and door sign ...bed alarm if confused/orientated x 2 or less OR impulsive ..."

Based on interview and record review, registered nurses failed to supervise care, assess patient safety needs, and document findings according to hospital policy to ensure implementation of appropriate safety interventions for 1 (P-1) of 1 patients reviewed for wandering; resulting in P-1 wandering off unit with near miss from harm, and the potential for harm to all patients at the facility who have a high risk for wandering. Findings include:

Interview with Assistant Manager RN Staff M on 3/17/24 at 1100, revealed the use of video surveillance as a safety precaution is implemented first, if patients are redirectable, sitters would be implemented if video monitoring fails.

On 3/17/25, record review of P-1's medical record revealed nursing staff failed to document: a wandering event involving P-1 being out of her room in the hallway on 2/13/25 near elevators. (providers note of 2/14/25 at 0813 revealed nursing reported that P-1 was found wandering in the hallway by the elevator last night and requested video surveillance); no order for video surveillance system (AvaSys) was found in P-1's record; no documentation was found in the record for P-1 showing that the patient/family was educated on the monitoring system; ongoing documentation of video monitoring not found by nursing in the medical record notes or flowsheets, no documentation found that nursing performed a focused assessment every four hours.

Findings regarding nursing staff documentation in above paragraph confirmed during record review with Nurse Manager N on 3/18/24 at approximately 1030. Nurse Manager N stated an order should have been placed in the record, and an order for AvaSys is a practice that can be nurse driven.


Review of policy titled, "Video Monitoring for Patient Safety", dated 7/21/24 "revealed under definitions that "Visual Surveillance: The intentional act of observing an individual or individual(s) within the healthcare environment as means to mitigate safety risks; this can be achieved by either video monitoring or visual observation of the patient ' s secured environment for a defined period of time ...: Policy 1. Initiation of video monitoring to observe a patient is a nursing intervention based on nursing assessment and recommendation; it can be used to ensure patient safety and is an additional tool in the patient ' s plan of care ... The RN will follow the video monitoring initiation workflow (Appendix A) ...RN enters order for Visual Surveillance along with reason ... Prior to placing a video monitor in the room discuss with the patient/family that video monitor will be implemented to promote patient safety and there is no video recording that takes place. Document in the Electronic Health Record (EHR) the implementation of video monitoring in alignment with the Nursing Documentation Policy. On going documentation of video monitoring will occur in alignment with the Assessment Standards for Nursing: Adult Inpatient ... The RN will assess the patient every 4 hours, as a part of the focused assessment, to determine if video monitoring is still an appropriate intervention ...Re-evaluate if video monitoring is an appropriate intervention based on the following criteria: a. Numerous re-directions in a short period of time that interferes with the safe monitoring of other patients. b. Activation of an Emergency Response more than 3 times in 30 minutes. c. Ineffective re-direction (patient continues to pull at medical devices, puts leg off side of bed, or gets out of bed) ...".

Based on interview and record review, the facility failed to ensure nursing staff updated the care plan to include wandering/elopement precautions for 1 (P-1) of 1 patient reviewed for wandering, resulting in a near miss of harm to P-1, and the potential for harm to all patients at the facility who have a high safety risk (wandering). Findings include:

Review of provider notes dated 2/14/25 at 0813 revealed, staff reported P-1 was "found wandering the halls last night and requested an AvaSys video monitoring system to be placed into room".

Review of provider notes dated 2/15/25 at 0747 revealed per RN notification, "P-1 was found wandering by main entrance of hospital despite AvaSys monitoring system in room."

The Care Plan for P-1 was not updated to include wandering interventions, nor were interventions updated in fall/safety care plan to include the use of the video surveillance system. All care plan interventions, including fall/safety, were evaluated as progressing during the patients stay. No updated goals or assessments of "backward" progress were noted after the initial wandering event of 2/14/25. (P-1 was discharged after the 2nd wandering event per daughter's request)

Review of policy titled, "Patient Plan of Care", dated 7/21/24 revealed, "Each patient will have a plan of care that is appropriate to their unique needs ... The patient plan of care is individualized/revised based on ongoing assessment findings, the patient's response to treatment/interventions and evaluation of progress toward goals/outcomes ... Documentation of patient progress and an outcome/summary statement is recommended on change in patient condition and minimally twice per day for hospitalized patients ...The outcome summary statement addresses key milestones, events, or challenges to forward progress... For patients with backward progress during their stay, goals will be updated, and newly applicable goals added..."