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Based on observation, record review and interview the facility failed to have adequate numbers of licensed Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and other personnel, including Certified Nursing Assistants (CNAs), for 2 East unit to ensure the immediate availability of an RN, LPN or CNA for the bedside care of 1 of 3 sampled patients. This failure affected patient #1, who was not on telemetry monitoring for 40 minutes, was not accurately and appropriately assessed for fall risk, was found on the floor and was inadequately supervised by nursing and support staff.

The findings Include:

Review of the clinical record for patient #1 revealed the patient was admitted to the facility on 06/10/10 with multiple pertinent diagnoses to include the following: Aspiration Pneumonia, Renal Insufficiency, Diabetes, Seizures, Stroke and Hypertension. Nurses' notes dated 06/10/10 document the patient was admitted to the Medical/Surgical Telemetry unit at approximately 9:45 PM. The patient was placed on 2 liters Oxygen (O2) via nasal cannula and on telemetry monitoring.

Nursing Admission Assessment dated 06/11/10 at 7:20 AM, documents a fall risk assessment was performed on the patient by an RN. The RN assessed the patient as having no physical status risk and assigned an overall fall risk score of (3) to the patient, meaning that the patient was at low risk for falls (score of 10 or greater means the patient is at high risk for falls). As a result of the patient being assessed as being at low fall risk for falls, a plan of care with interventions for "Risk for Falls" was not developed for the patient and could not be found in the clinical record review. A neurological assessment performed on the patient at 10:17 AM by an RN, revealed the patient was confused and oriented only to person.

Review of the nurses' notes dated 06/11/10 revealed the patient was restless and agitated and was at high risk for falls as evidenced by the following: Nurses' notes dated 6/11/10 at 1:00 AM, an RN inserted a nasogastric tube (NGT) into the patient in order to start tube feeding as ordered by the physician. At 6:00 AM, the nurses' notes document the patient's NGT was found in bed, and that numerous times, the patient was found with his/her legs hanging out of the bed. The notes document that mittens were applied at the time.
Review of the patient charges by department confirmed the patient was charged for mittens. Based on the fact that the patient was restless and agitated, required placement of mittens to prevent removal of his/her NGT, the patient should have been assessed as being at risk for falls.

Respiratory Therapy Progress notes dated 06/11/10 at 6:03 PM, document the patient was found on the floor on his/her face by a Respiratory Therapist (RT). Cardiopulmonary Resuscitation (CPR) was started and a code alert was called. The patient was successfully resuscitated and intubated, and was later transported to the Intensive Care Unit (ICU) for specialized care.

A review of the staffing of the unit during the day shift on 06/11/10, the day patient #1 was found on the floor, was conducted. The unit's census was noted to be (9) patients. There were (4) patients on ventilators. These patients are considered high acuity patients meaning they have multiple medical issues and required extensive care for: Wounds, Foley Catheters, NGTs and Gastrostomy Tubes (GT), Central and Peripheral Intravenous Lines, Activities of Daily Living, Repositioning and Transfers. Staffing was noted to be 2 RNs and 1 CNA scheduled. Unit secretaries are not employed to assist with clerical work, therefore nursing staff is also responsible for answering the phones. Prior to patient#1 being found on the floor, the RN sent the CNA off the unit to obtain a battery for patient #1's telemetry box. For a questionable period of time, the relieving RN was the only licensed nursing staff on the unit, immediately available to assess, monitor, supervise, provide bedside care to the patients, admit patients, answer phone calls and respond to emergencies.

Review of the physician notes dated 06/21/10 revealed that the patient was not fully on the monitor prior to being found on the floor.

During an interview conducted with the Director of Quality Management on 08/05/10 at 3:00 PM to determine the circumstances surrounding the patient's fall, the director stated the fall investigation revealed the patient was not connected to telemetry monitoring for (40) minutes. The director stated the RN assigned to patient was on lunch, while the only other RN staff on the unit was supposed to be monitoring the patient. The investigation revealed that the monitor technician, who was physically located on another unit, at a central monitoring station, had called and notified the relieving RN that the patient was not connected to the telemetry monitor. The covering RN, who was busy at the time with a new admission to the unit, and was on the phone taking a call from the physician, confirmed that she had been notified by the technician, but did not glance at the "slave" monitors at the nursing station to check the patient's connection status. The director further stated the RN did not assess the patient at the time of the notification, instead, she sent the CNA to obtain a battery from the telemetry technician. Upon her return to the unit, the RN sent the CNA to change the battery on the patient's telemetry box. In addition, the nursing supervisor, covering the shift, was notified by the telemetry technician. The director reported the nursing supervisor was confronted with two patient care issues at the time and decided to prioritize the other patient and not patient #1. The director confirmed the technician monitors as many as 30 patients on telemetry during the shift.

During an interview on 08/05/10 at 2:20 PM with the RN who had been assigned to patient #1, the RN confirmed, there is only (1) monitor technician for the whole facility. The RN stated the technician is physically located on another unit and notifies the nurse by phone or overhead page if a patient is not connected to telemetry monitoring. The RN also stated the technician could also call the rapid response team. The RN was unable to confirm that, as a last resort, the technician, called the rapid response team. The RN was asked whether the patient was restless before she left the unit for lunch. The RN stated that when she assessed the patient, the patient was unable to move. The RN denied the patient was restless and that mittens had been placed on the patient due to restlessness and agitation.

During an interview conducted on 08/05/10 at 3:25 PM and 3:40 PM with 2 Respiratory Therapist (RTs #1 and #2), who worked with the patient, the RTs confirmed that the patient was restless and agitated during the shift. RT #1 stated that she observed the patient's legs over the bedside rail and obtained assistance in repositioning him/her in bed. The RT also stated that she observed the nurse to be busy with a phone in each of her ears, while making rounds on the unit and prior to the patient falling out of bed. RT #2 stated that he observed the patient to be restless and agitated and confirmed the patient had mittens on.

During an interview conducted with the nursing supervisor on 08/05/10 at 5:45 PM to determine how the facility determines their staffing needs, the supervisor stated that staffing is based on observation of the patients, census, workload and that the patient acuity tool is used as a guideline.

A review of 2 patients (#2 and #3) who fell on the same unit as patient #1 and around the same time, prior to shift change (at 6:15 PM) revealed the following:
When patient #2 fell on 05/27/10, the census was 10 patients, 3 of which were on ventilators. The staffing was 2 RNs and 1 CNA. When patient #3 fell on 06/28/10, the census was 12 patients, 3 of which were on ventilators. The staffing did not change regardless of the census.

During the a tour of 3 East Medical/Surgical Telemetry unit conducted on 08/05/10 beginning at 11:00 AM, it was noted that staffing remained unchanged, even though the unit was similar and provided similar patient care service. The census was 12 patients, 6 of which were on ventilators. There were 2 RNs and 1 CNA assigned to provide similar care for an increased number of high acuity patients.

Staffing on the unit did not allow for proper supervision of a restless and agitated patient while the assigned RN was at lunch. The relieving RN was not available and could not realistically supervise, monitor and meet the bedside needs of (9) patients, most of which required a higher level of care. The supervisor failed to use proper judgement in deciding to physically go to the unit and assess the issues of both staffing and patient #1 not being connected to telemetry monitoring.

Based on observation, record review and interview registered nurses (RNs) failed to supervise and evaluate the nursing care of 1 of 3 sampled patients. This failure affected patient #1 who was not adequately supervised and was not appropriately evaluated for nursing care related to risk for falls.

The findings Include:

Review of the Nursing Admission Assessment dated 06/11/10 at 7:20 AM, documents a fall risk assessment was performed on patient # 1 by a RN. The RN assessed the patient as having no physical status risk and assigned an overall fall risk score of (3) to the patient, meaning that the patient was at low risk for falls (score of 10 or greater means the patient is at high risk for falls). As a result of the patient being assessed as being at low fall risk for falls, a plan of care with interventions for "Risk for Falls" was not developed for the patient and could not be found in the clinical record review. A neurological assessment performed on the patient at 10:17 AM by an RN, revealed the patient was confused and oriented only to person.

Review of the nurses' notes dated 06/11/10 revealed the patient was restless and agitated and was at high risk for falls as evidenced by the following: Nurse's notes dated 6/11/10 at 1:00 AM, an RN inserted a nasogastric tube (NGT) in order to start tube feeding as ordered by the physician. At 6:00 AM, the nurse's notes document the patient's NGT was found in the bed, and numerous times, the patient was found with his/her legs hanging out of the bed. The notes document that mittens were applied at the time.

Respiratory Therapy Progress notes dated 06/11/10 at 6:03 PM, document the patient was found on the floor on his/her face by a Respiratory Therapist (RT). Cardiopulmonary Resuscitation (CPR) was started and a code alert was called. The patient was successfully resuscitated and intubated, and was later transported to the Intensive Care Unit (ICU) for specialized care.

A review of the staffing of the unit during the day shift on 06/11/10, the day patient #1 was found on the floor, was conducted. The unit's census was noted to be (9) patients. There were (4) patients on ventilators. These patients are considered high acuity patients meaning they have multiple medical issues and required extensive care for: Wounds, Foley Catheters, NGTs and Gastrostomy Tubes (GT), Central and Peripheral Intravenous Lines, Activities of Daily Living, Repositioning and Transfers.

Review of staffing revealed that 2 RNs and 1 CNA were scheduled on 06/11/10. Unit secretaries are not employed to assist with clerical work, therefore nursing staff is also responsible for answering the phones. Prior to patient#1 being found on the floor fall, the RN sent the CNA off the unit to obtain a battery for patient #1's telemetry box. The relieving RN was the only licensed nursing staff on the unit, immediately available to assess, monitor, supervise, provide bedside care to the patients, admit patients, answer phone calls and respond to emergencies.

Physician notes dated 06/21/10 document the patient was not fully on the monitor prior to being found on the floor.

During an interview conducted with the Director of Quality Management on 08/05/10 at 3:00 PM to determine the circumstances surrounding the patient's fall, the director stated the fall investigation revealed the patient was not connected to telemetry monitoring for (40) minutes. The director stated the RN assigned to patient was on lunch, while the only other RN staff on the unit was supposed to be monitoring the patient. The investigation revealed that the monitor technician, who was physically located on another unit, at a central monitoring station, had called and notified the relieving RN that the patient was not connected to the telemetry monitor. The covering RN, who was busy at the time with a new admission to the unit, and was on the phone taking a call from the physician, confirmed that she had been notified by the technician, but did not glance at the "slave" monitors at the nursing station to check the patient's connection status. The director further stated the RN did not assess the patient at the time of the notification, instead, she sent the CNA to obtain a battery from the telemetry technician. Upon her return to the unit, the RN sent the CNA to change the battery on the patient's telemetry box. In addition, the nursing supervisor, covering the shift, was notified by the telemetry technician. The director reported the nursing supervisor was confronted with two patient care issues at the time and decided to prioritize the other patient's nursing care and not the care of patient #1.

During an interview on 08/05/10 at 2:20 PM with the RN assigned to patient #1, the RN confirmed there is only (1) monitor technician for the whole facility. The RN stated the technician is physically located on another and notifies the nurse by phone or overhead page if a patient is not connected to telemetry monitoring. The RN stated the technician could also call the rapid response team. The RN was unable to confirm that, as a last resort, the technician, called the rapid response team. The RN was asked whether the patient was restless before she left the unit for lunch. The RN stated that when she assessed the patient, the patient was unable to move. The RN denied the patient was restless and that mittens had been placed on the patient due to restlessness and agitation.

During an interview conducted with 2 respiratory therapist (RTs #1 and #2), who worked with the patient on 08/05/10 at 3:25 PM and 3:40 PM respectively, the RTs confirmed that the patient was restless and agitated during the shift. RT #1 stated that she observed the patient's legs over the bedside rail and obtained assistance in repositioning him/her in bed. The RT also stated that she observed the nurse to be busy with a phone in each of her ears, while making rounds on the unit and prior to the patient falling. RT #2 stated that he observed the patient to be restless and agitated and confirmed the patient had mittens on.

The patient was restless and agitated and mittens were placed on the patient to prevent removal of his/her NGT. The patient should have been assessed by the assigned nurse as being at high risk for falls and nursing interventions should have been developed and implemented to decrease the patient's risk for falls.

Staffing on the unit was inadequate and did not allow for proper supervision of a restless and agitated patient while the assigned RN was at lunch. The assigned RN did not accurately assess the patient's risk for fall and did not communicate the importance of monitoring and supervision of the patient to the relieving RN when leaving for lunch. The relieving RN was not immediately available and could not realistically supervise, monitor and meet the bedside needs of (9) patients, most of which required a higher level of care. The relieving RN failed to assess and supervise a restless and agitated patient who was off the telemetry monitor.

Based on record review and interview the facility failed to develop and keep current a nursing fall risk plan of care for 1 of 3 sampled patients (#1), who was not appropriately and accurately assessed for fall risk on admission, and after falling and experiencing a change in condition, was not re-evaluated for fall risk.

The findings Include:

Review of the clinical record for patient #1 revealed the patient has a history of Seizures, Stroke and Hypertension. These diagnoses place the patient at a high risk for falls.

Nursing Admission Assessment dated 06/11/10 at 7:20 AM, document a fall risk assessment was performed on the patient by a registered nurse (RN). The RN assessed the patient as having no physical status risk and assigned an overall fall risk score of (3) to the patient, meaning that the patient was at low risk for falls (score of 10 or greater means the patient is at high risk for falls). A neurological assessment performed on the patient at 10:17 AM, by an RN, revealed the patient was confused and oriented only to person.

Review of the nurses' notes dated 06/11/10 revealed the patient was restless and agitated and was at high risk for falls as evidenced by the following: Nurse's notes dated 6/11/10 at 1:00 AM, document an RN inserted a nasogastric tube (NGT) in order to start tube feeding, as ordered by the physician. At 6:00 AM, the nurse's notes document the patient's NGT was found in the bed, and numerous times, the patient was found with his/her legs hanging out of the bed. The notes document that mittens were applied at the time.

Respiratory Therapy Progress notes dated 06/11/10 at 6:03 PM, document the patient was found on the floor on his/her face by a Respiratory Therapist (RT). Cardiopulmonary Resuscitation (CPR) was started and a code alert was called. The patient was successfully resuscitated and intubated, and was later transported to the Intensive Care Unit (ICU) for specialized care.

During an interview on 08/05/10 at 2:20 PM with the RN assigned to patient #1, the RN was asked whether the patient was restless before she left the unit for lunch. The RN stated that when she assessed the patient, the patient was unable to move. The RN denied the patient was restless and that mittens had been placed on the patient due to restlessness and agitation. The assigned RN failed to accurately assess the patient's fall risk, develop an individualized fall risk plan of care and implement interventions to reduce the patient's risk for falls.

Review of the the facility Policy: "Fall Prevention," revealed that patients will be subsequently reassessed for falls after changes in condition, and that all patients at risk for falls will have an interdisciplinary care plan initiated by an RN titled, "Potential for Self Injury Related to Risk for Falls."

The clinical record review revealed that after the patient fell and was transferred to the Intensive Care Unit (ICU), the patient's risk for falls was not re-evaluated as specified in the facility's Fall Prevention Policy.

During an interview conducted with the Director of Quality Management on 08/05/10 at 3:00 PM, the director agreed the facility's Fall Risk Screening Tool was not properly utilized by nursing staff, therefore, the assigned fall risk score assessment was inaccurate. The director agreed that an individualized plan of care for high fall risk was not developed for the patient and that a fall risk re-evaluation was not performed on the patient.