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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to ensure nursing staff assigned appropriate risk score values, based on the patient's current status when completing a fall risk assessment, as demonstrated by 2 of 10 patient records reviewed (Patient #1001 and Patient #1002), and failed to provide nursing oversight for the assessment, evaluation and treatment of patient care needs for 1 of 1 patients reviewed (Patient #503).

Failure to provide appropriate patient safety assessments and failure to provide nursing oversight for the assessment, treatment, and evaluation of patient care needs can lead to inappropriate interventions, resulting in injury or death.

Findings included:

1. Document review of the hospital's policy titled, "Fall Prevention Program Guidelines," reviewed 01/19, showed that nursing staff will assess patients at risk for fall on admission to the hospital and place them on appropriate precautions. The hospital utilizes the Morse Fall Scale for adults and the Humpty Dumpty Scale for children. Patients are to be continuously assessed for fall risk with changes in their condition or treatment and after each fall. The hospital's risk assessment tool contains 4 variables:

-History: including a history of previous falls (total score is 2);

-Physical status: includes fatigue/weakness (2 pts), dizziness/balance problems, impaired mobility, sensory impairment, seizure disorder, & alteration in elimination (total score up to 7);

-Mental status: includes confusion, impaired memory, disorientation, lack of familiarity with immediate surroundings, and inability to understand/follow instructions (total score up to 8);

-Medication: includes diuretic drugs, hypotensive drugs, drugs that increase gastrointestinal mobility, polypharmacy, and drugs from different classifications (total score up to 4).

A score of 5 or greater places patients on fall precautions which includes signage to alert staff, non-skid socks (or shoes), placing the patient close to the nurse's station, assisting with transfers and daily care, and patient/family environmental safety.

2. On 06/03/19 at 10:30 AM, Surveyor #10 reviewed the medical record for Patient #1001 who was admitted on 05/05/19 for the treatment of altered mental status, paranoid thoughts, and substance abuse disorder. A Designated Crisis Responder (DCR) had assessed the patient as a danger to self-prior to admission. The patients recorded history showed ADHD, bipolar disorder, and polysubstance abuse. The record showed that the patient's initial fall risk assessment resulted in a total score of 3 (not a fall risk) and no fall prevention interventions were initiated.

Patient #1001's admission record showed that she has a seizure disorder, taking multiple prescribed medications including a hypotensive medication. When these factors were included into the Morse Assessment, the patient's actual fall risk score was 5. A score of 5 or above indicates the patient was at risk for falls and staff should have placed the patient on fall precautions. The record showed that the patient sustained a fall 18 days after her admission.

3. On 06/04/19 at 3:00 PM, Surveyor #10 reviewed the medical record for Patient #1002 who had been admitted to the hospital on 03/18/19 for treatment of suicidal ideation, increased depression, and substance abuse disorder (alcohol). The admission history showed the patient was taking two different blood pressure medications (diuretic & hypotensive drugs) for the treatment of hypertension, two medications with sedative effects (drugs that alter the thought process), and two different antidepressants (polypharmacy). Review of the initial admission fall risk assessment showed a score total 0 (not a fall risk) and no fall prevention interventions were initiated. Based on the patient's admission status, the actual fall risk score totaled 6. A score of 5 or above indicates a patient is at risk for falls and fall precautions should be initiated.

4. On 06/05/19 at 11:00 AM, the Chief Nursing Officer (Staff #1001) confirmed the inappropriately scored risk assessments and confirmed the tool the staff were utilizing was not the tool approved in the hospital's policy titled, "Fall Prevention Program Guidelines."


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Item #2 Nursing Oversight: Assessment, Treatment and Evaluation of Patient Care Needs

1. Document review of the hospitals document titled, New Employee Orientation," no date, showed that nursing staff received medication management, and medication administration education on Orientation Day #5.

Document review of the hospitals document titled, "Nursing Pharmacology Training," no date, showed that nursing staff receive education on anti-psychotic and antipolitical drugs, and their side effects. Staff also received education related to Neuroleptic Malignant Syndrome (NMS) (a potentially life threatening response to anti-psychotic medications), Extrapyramidal Symptoms (EPS) and the Abnormal Involuntary Movement Scale (AIMS) an assessment scale used to assess for EPS.

2. On 06/04/19 at 11:00 AM, Surveyor #5 and the Nurse Educator (Staff #504) reviewed the medical record for Patient #503, who was admitted on 05/21/19 for the treatment of schizoaffective disorder, paranoid persecutory delusions, medication non-compliance, and suicidal ideation.

a. Document review of physician orders and the medication administration record showed PRN medications including:

-Trazadone 100 mg by mouth at bedtime as needed for sleep;

-Cogentin 1 mg by mouth every 4 hours as needed for Extrapyramidal Symptoms (EPS);

-Ativan 2 mg by mouth twice daily as needed for anxiety;

-Benadryl 50 mg by mouth twice daily for anxiety;

-Zyprexa 5 mg every 4 hours as needed for psychosis.

b. On 05/29/19 at 8:22 PM, a nurse (Staff #503) administered PRN medications including: Cogentin 1 mg, Trazadone 100 mg, Ativan 2 mg and Benadryl 50 mg.

c. Surveyor #5 observed that nursing staff were medicating the patient concurrently with PRN medication for anxiety, EPS, and sleep on 05/27/19, 05/28/19, 05/30/19, 05/31/19, 06/01/19, 06/02/19, and 06/03/19. Surveyor #5 found no evidence the patient was assessed prior to or reassessed after medications for symptoms and symptom resolution.

d. Surveyor #5 found similar concurrent PRN medication administration for anxiety, EPS, and sleep for patient #502.

3. At this time, Surveyor #5 asked the Nurse Educator (Staff #504) how the staff identified which symptoms were which and how the staff identified which medication was effective for which symptom. Staff #504 stated that it was difficult for nurses with less experience in psychiatric care to identify symptoms of anxiety and symptoms of EPS. She identified that for the approach observed in the medication administration record it would be difficult to identify which medications was effective for treating which specific symptom.

4. On 06/06/19 at 10:30 AM, during interview with Surveyor #5, a Provider (Staff #512) stated that although the order did not specifically state this, the PRN medications were given to prevent symptoms of EPS, and that staff needed more education and experience related to the assessment for and treatment of anxiety versus EPS symptoms.

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