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Based on observation, record review, and interview, the hospital failed to provide a safe environment for patients as evidenced by 288 patient falls occurred during the calendar year 2018 with no indication of resolution other than continuing education to staff.

On 01/09/19, at 10:11 am, surveyors observed the lobby of the crowded 22 bed geriatric-psychiatric (GP) unit with patients in geriatric reclining chairs (geri-chairs) and chairs along the wall by the nursing station facing the television. There were also patients attempting to walk around the patients in geri-chairs. The census was 24 patients. There was a strong smell of urine noted. Patients had been waiting to begin group therapy.

Staff A stated, the patients would be divided into groups to begin group therapy. According to the Geriatric Unit - Daily Schedule, Unit Orientation would run from 9:00 am to 9:15 am, Coping Skills from 9:15am to 9:45am, Process Group A from 9:45am to 10:15am, and Process Group B from 10:15am to 10:45am. When staff were asked why the patients had not been in any group therapy sessions by 10:15 am, staff stated, the "group tech should be here".

Documents showed a total of 288 reported falls in this 60 bed adult facility during calendar year 2018.

- Of the 288 reported falls, 196 (68%) were on the GP unit. A total of 74 patients sustained an injury during their fall; 35 were observed falls by staff, and 39 were unobserved. More than half of the patient falls resulted with patient injuries, the patients were not in line-of-sight.

- Of the 288 reported falls, 65 falls (23%) were on the adult unit. A total of 20 patients sustained an injury during their fall; 10 were observed falls by staff, and 10 were unobserved

- Of the 288 reported falls, 27 (9%) were on the ID unit. A total of 19 patients sustained an injury during their fall; 6 falls were unobserved by staff, and 13 were observed


The COO/Risk Manager stated (on 1/9/19 at 9:15 am) that "level 3" incident reports are not reviewed, falls are considered "level 3". There was no tracking or trending of data, only reported the number of falls quarterly to the quality committee. When asked how the committee made recommendations (including staffing, medications, etc.) related to the falls, he stated, the incidents were not investigated but could "see where we definitely need to review and evaluate cause of falls".


Staff K (an RN in the GP unit) stated (on 1/11/19 at 11:30 am) that adding more nurses on the floor with the technicians might help reduce falls but the hospital would have to pay the nursing staff time and a half overtime because nursing staff would not have time to complete paperwork and be on the floor more. Staff K stated, all patients on this unit are considered high risk for falls and "mainly move high risk fall patients to line of sight" and inform the technicians of any medication changes.


The Director of Nursing (DON) stated (on 1/11/19 at 11:00 am), falls are a big problem at the facility. The DON met with staff daily to discuss issues with patients including patients who had fallen the previous day; met monthly with staff and discussed patient care issues including falls. The DON stated, she kept a spreadsheet of the falls because she had not received copies of the incident reports.

Based on record review and interview, the hospital failed to ensure that patients' weights were documented in the patient's medical record, physician/licensed independent practitioner (LIP) were notified, and medical care provided for identified weight loss for four of six patients reviewed (#1, 2, 5, and 11) for weight loss.

This failed practice had the potential for increased risk to patient safety due to lack of accurately obtaining and documenting patient weights. This failed practice did not allow for medical and nursing decisions to be made by the health care team and had the potential for adverse health outcomes for all patients in the hospital.

Findings:

Hospital Policy #247, "Vital Signs, Weights", (06/2015) and stated that the patient's weight would be taken upon admission and weekly unless ordered more frequently. Nursing staff documented the vital signs and weights in the medical record on the Vital Signs Flowsheet, and documented actions taken in response to abnormal vital signs.


A review of medical records showed:

1. Patient #1, a 70 year old male admitted to the hospital for dementia and alcoholism, had an admission weight of 149 pounds on 11/26/18. Other weights documented were:

12/03/18: 150.2 pounds
12/10/18: 135.2 pounds
12/17/18: 139.4 pounds
01/07/19: 136.4 pounds

Patient #1 had a 12.6 pound weight loss from 11/13/18 to 01/07/19. There was no documentation in the medical record that a physician/Licensed Independent Practitioner (LIP) was notified of the patient's weight loss and no documentation of medical care provided related to the weight loss.


2. Patient #2, a 53 year old male admitted for depressive disorder with unstable moods. The patient's admission weight was documented at 191 pounds on 12/24/18. Other weights documented:

01/01/19: 178.4 pounds
01/07/19: 178.4 pounds

Patient #2's medical record showed a 12.6 pound weight loss from 12/24/18 to 01/07/19. There was no documentation in the medical record that a physician/ LIP was notified of the patient's weight loss and no documentation of medical care provided related to the weight loss.


3. Patient #5, a 26 year old female admitted for schizoaffective disorder, had an admission weight documented at 214 pounds. Other weights documented:

12/26/18: 206.5 pounds
12/31/18: 207 pounds
01/07/19: 204.5 pounds
01/10/19: 374 pounds

Patient #5's medical record showed a 9.5 pound weight loss from 12/20/18 to 01/07/19 and a 169.5 pound weight gain from 01/07/19 to 01/10/19. There was no documentation in the medical record that a physician/LIP was notified of the patient's weight loss and no documentation of medical care provided related to the weight loss. There was no additional documentation in the medical record related to the 169.5 weight gain.


4. Patient #11, a 61 year old male was admitted for agitation and aggression. The patient's History and Physical dated 07/26/18 documented patients weight was 155 pounds. Other weights documented:

07/30/18: 136.0 pounds
08/13/18: 169.4 pounds
08/20/18: 135 pounds
09/03/18: 134.8 pounds
09/10/18: 132.6 pounds
09/17/18: 130.2 pounds
09/24/18: 131.4 pounds
09/28/18: 130.2 pounds
10/08/18: 127.2 pounds

Patient #11's medical record showed a 27.8 pound weight loss from 07/25/18 to 10/08/18. There was no documentation in the medical record that a physician/ LIP was notified of the patient's weight loss and no documentation of medical care provided related to the weight loss.


The Admissions Director (01/14/19 @ 11:36 am), stated, the hospital received admission weights from the sending facility. If the patient's initial weight, from the sending facility was radically different from Rolling Hills' admission weight, staff followed the patient's weights for differences. The admitting counselors took vital signs and weighed patients.


The DON (01/14/19 @ 2:30 pm), stated, patient weights were documented on flow sheets but they were not documented correctly in the charts. The scales allowed wheel chairs to be weighed and the scales were not always accurate.

Based on observation, record review, and interview the hospital failed to:

A. Designate, in writing, a qualified individual (through education, training, experience or certification) as the infection control officer (See A-0748)


B. Develop an infection control program and implement infection control measures ensuring maintenance of a sanitary hospital environment by:

i. Allowing sterile wrapped supplies to be stored next to and on the sink in the medication room with no protection from splashes to prevent contamination.

ii. Allowing patient medications to be mixed and dispensed in an environment that included dust, employee drinking cups, and an uncleaned, cluttered counter and floor.

iii. Allowing patient food refrigerator to not be cleaned, storing electrical cords and office supplies containing dust and debris on top of the refrigerator, unclean floors and a metal 5-drawer filing cabinet with paper and debris stored next to the refrigerator (See A-0749)


C. Ensure the hospital-wide QAPI program implemented successful corrective action plans for problems identified through the infection control program (See A-756)

Based on record review and interview, the hospital failed to designate, in writing, the responsibility of the infection control program to a qualified (through ongoing education, training, experience or certification) individual to oversee the infection control program.

This failed practice of an untrained Infection Control Preventionist (ICP) had the potential to cause harm to all patients by causing an increased risk of developing infections and communicable diseases due to the ICP's lack of knowledge regarding the infection control program.

Findings:

The previous ICP left abruptly in October 2018, and currently the responsibilities have been informally delegated to the Director of Nursing.

A review of the DON's employee file showed no training, experience, or education in the infection control field.

The DON (1/10/19 at 8:30 am) stated, she had no education, training or experience in infection control; she took over the responsibilities after the previous ICP left suddenly.

Based on observation, record review, and interview the hospital failed to:

A. Maintain a sanitary environment,

B. Provide active surveillance,

C. Provide evaluation and revision of the program


Findings:

1. On 01/09/19, at 11:00 am, a patient food refrigerator was observed in room labeled "Storage Room". The patient refrigerator was not clean; a cleaning schedule was not available. The top of the refrigerator contained electrical cords and equipment that contained dust and debris. A metal 5-drawer filing cabinet with additional equipment and supplies containing dust and debris on the top was butted next to the refrigerator. The floor of the storage room contained dust and did not appear to have been mopped recently.

2. On 01/09/19, at 10:45 am, in the medication room on the GP unit, sterile supplies were observed on the edge of the left side of the sink's rim blocking the hot water handle and on the right side of the sink within inches of the edge of the sink.

3. On 1/10/19, at 10:00 am, surveyors observed medications being prepared for patients in the "Charting Room" on the GP unit. The counter had not been sanitized and was littered with paper, dirt, and dust, and had a cracked and chipped top. Employees' drinking cups were observed on the counter mixed with open patient medications. Office supplies and equipment were on the counter mixed with the open patient medications; balls of dust were flying from the fan blowing onto the counter top and the floor was littered with paper and dust.


A review of the monthly Quality Council minutes from 06/26/18 through 09/20/18 documented infection control reporting of Exposures, OK State Reportable diseases, hand hygiene, MDRO (multi-drug resistant organisms) and infections with no actions or follow up indicated to address the reported issues. The 10/31/18 minutes documented there was no data to report from September 2018. There were no additional minutes provided.


The DON stated (1/14/19 at 3:15 pm), the only surveillance and reporting currently observed were the antibiotic reports and TB testing on employees; no other surveillance or reporting has occurred since the previous ICP left suddenly. When asked about the Infection Control Plan, the DON replied that the plan had not been updated or reviewed in quite some time; there was not a current IC Plan.

Based on document review and interview, the Chief Executive Officer, Medical Staff, and DON failed to ensure the infection control program addressed corrective actions plans for identified issues.

This failed practice created an ineffective infection control program and increased the infection control risk to the hospital's inpatients.


Findings:

The monthly Quality Council is attended by the CEO, COO/Risk Manager and DON. A review of the Quality Council minutes dated 06/26/18 through 10/31/18 showed the following Infection Control reporting:

1. The number of exposures, OK State reportable diseases, hand hygiene, MDRO and infections; there was no discussion documented. The Action plan is "Monthly monitoring, trending and reporting to continue".

2. The 06/26/18 minutes indicated an increase in HAI (healthcare associated infections) to 11. There was no discussion or follow up documented related to this increase in HAIs. There was no leadership involvement to identify the problem and take corrective actions.

3. The 07/23/18 minutes indicated an increase to 13 HAIs with no discussion or follow up documented related to this increase. There was no leadership involvement to identify the problem and take corrective actions.

4. The 08/17/18 and 09/20/18 minutes documented there was no discussion and the Action plan was "Monthly monitoring, trending and reporting to continue".

5. The 10/31/18 minutes document "There was no date to report for September 2018"; there was no discussion and the Action plan is "Monthly monitoring, trending and reporting to continue".

6. There were no additional minutes for the remainder of the year provided.


The DON stated (01/14/19 at 3:15 pm), the only surveillance and reporting submitted were the antibiotic reports and TB testing on employees; no other surveillance or reporting has occurred since the previous ICP left suddenly. There were no infection control problems reported. When asked about the Infection Control Plan, the DON replied that the plan had not been updated or reviewed in quite some time; there was not a current IC Plan. There was no leadership involvement to identify problems and take corrective actions.