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Based on record review and interview the facility failed to ensure (QAPI) program implemented effective measures for the health and safety of the patients based on quality indicators measured, tracked and analyzed for falls (A273) and failed to ensure the (QAPI) program was monitored by the governing body (A309). This finding has the potential to affect all patients admitted to the inpatient psychiatric units. The facility active census was 31.

Based on record review and staff interview it was determined the facility failed to ensure quality performance improvement activities were implemented based on the data collected to ensure patient safety within the facility.This finding has the potential to affect all patient admitted into the inpatient psychiatric facility. The facility census was 31.

Findings include:

Review of the Performance Improvement Plan Policy # PI.1 states the primary goal of performance improvement is to continually and systematically plan, design, measure, assess and improve the performance of key hospital-wide patient care processes and activities for optimal and safe patient outcomes. The Quality Assurance Performance Committee quarterly report will minimally include effectiveness of fall reduction activities.


1. Review of the unusual occurrence summary report from 11/01/18 through 01/08/19 revealed the facility identified thirteen falls on the geriatric psychiatric unit, one fall in an unspecified area, and another fall on the adult psychiatric unit for a total of fifteen falls that reportedly resulted in only minor injuries. Three of the fifteen patients were identified as repeat falls based on incident report review.


2. Review of the unusual occurrence summary for behavior related falls from 11/01/18 through 01/08/19 included three patients on the geriatric psychiatric unit and two patients on the adult psychiatric unit. Per Staff F these patients lowered themselves to the floor and it was recorded as a behavior related fall.


3. Review of the unusual occurrence summary report from 11/01/18 through 01/08/19 for unplanned emergencies related to falls included one minor and one moderate laceration. Both patients were treated at a local hospital for injuries related to a fall and returned to the facility.


4. Review of the unusual occurrence summary report from 11/01/18 through 01/08/19 noted the facility noted no falls required hospitalization. However review of the incident report for Patient #12 revealed the patient fell on 12/12/18 and was sent to the hospital and admitted with a subdural hemotoma.


5. Review of the Senior Leadership Meeting Minutes noted falls being identified as a facility priority due to the increased incidence within the facility. The meeting minutes revealed quality data was collected regarding falls from 11/01/18 through 01/08/19 and was being discussed during the meetings on 11/27/18, 12/05/18, 12/18/18, 12/25/18, 12/25/18, and 01/02/19, however, no improvement activities were identified and/or implemented to effectively reduce falls and to ensure patient safety.

Based on record review and interviews the facility failed to ensure the (QAPI) program was monitored by the governing body. This finding has the potential to affect all patient admitted into the inpatient psychiatric facility. The active census was 31.

Findings include:

Review of the Performance Improvement Plan Policy # PI.1 states the Governing Board is ultimately responsible for the quality of patient care provided. The Governing Board requires the medical staff, to implement and report on the quality assessment and performance improvement activities and mechanisms for process design and performance measurement, analysis and improvement; to monitor, assess and evaluate the quality of patient care, to identify and reduce the risk of sentinel events; to resolve problems and to identify opportunities to improve patient care and services.

Review of the Senior Leadership Meeting Minutes noted falls being identified as a facility priority due to the increased incidence within the facility. The meeting minutes revealed quality data was collected regarding falls from 11/01/18 through 01/08/19 and was being discussed during the meetings on 11/27/18, 12/05/18, 12/18/18, 12/25/18, 12/25/18, and 01/02/19, however, no improvement activities were identified and/or implemented to effectively reduce falls and to ensure patient safety.

An interview was conducted with Staff B on 01/08/19 at 4:30 PM who stated, "Falls were something the facility was looking at and discussing through leadership meetings however implementation "fell through the cracks." The facility hired a new Director of Nursing three weeks ago.

Based on record review, observation and staff interview it was determined the facility failed to ensure nursing staff completed an appropriate assessment before and after a fall, failed to ensure nursing staff implemented appropriate interventions that were individualized based on the assessment for patients identified as a high fall risk and failed to ensure 15 mnute observation checks were completed as ordered. (A 396) The cumulative effect of these systemic practices resulted in the facility's inability to ensure that the patients' nursing needs would be met. The facility active census was 31.

Based on record review, observation and staff interview it was determined the facility failed to ensure nursing staff completed an appropriate assessment before and after a fall and failed to ensure nursing staff implemented appropriate interventions that were individualized based on the assessment for patients identified as a high fall risk and failed to ensure 15 minute observation checks were completed as ordered. This affected thirteen (Patients #6, #8, #9, #10, #12, #14, #15, #16,#17, #18, #27, #28, #29) of thirty medical records reviewed. The active census was 31.

Findings include:

Review of the facility's policy titled "Fall Prevention Protocol" ( Revised 07/09/2017) states all patients admitted to Blueridge Vista Health and Wellness will be placed on fall prevention protocol. The policy lacked guidelines for nursing assessment and/or documentation following a patient fall and guidelines to develop a individualized care plan. Review of the medical records lacked individualized interventions of patients being identified as a high fall risk.

Review of the facility's policy titled "Provision of Care, Treatment and Services, Policy Subject, Levels of Observation", Policy #: CS-72, effective date: 05/14/18 included it is the policy of the hospital to utilize levels of monitoring and observation matched to the patient's individualized needs based on assessed risks... documentation will occur on the 15 minute observation form.

During tour of the gero-psychiatric unit on 01/07/19 at 11:57 AM patients were observed in wheelchairs and utilizing walkers and staff using gait belts. No visual indicators identified patients as being a high fall risk on the unit. When staff were ask how they identify high fall risk patients it was reported fall risk patients are discussed during morning shift report. Those patient's identified as a fall risk were noted on the running board events daily log.

Review of the running board events daily log for the geriatric psychiatric unit for 01/07/18 included one patient identified as a high fall risk. Staff F confirmed six of the fifteen patients admitted to the geriatric psychiatric unit were identified as a high fall risk upon admission. A score of 90 or greater placed the patient as a high fall risk requiring interventions to be in place.

Review of the unusual occurrence summary report from 11/01/18 through 01/08/19 revealed the facility identified fifteen patient falls. Three of the fifteen patients were identified as repeat falls based on incident report review. Five patients were recorded as behavioral falls and per Staff F these patients lowered themselves to the floor. Two patients were unplanned emergencies related to falls that included one minor and one moderate laceration. Both patients were treated at a local hospital for injuries related to a fall and returned to the facility. One patient was identified as fall on 12/12/18 and was sent to the hospital and admitted with a subdural hemotoma.

Review of the Edmonson Psychiatric Fall Risk Assessment form completed by nursing staff identify patients as follows:

Low Fall Risk = a score of <90
High Fall Risk = a score of 90 or greater.

1. Review of the medical record for Patient #8 revealed the patient was admitted on 11/16/18 for diagnoses of bipolar disorder and psychosis with a fall risk score of 115 upon admission. Three incident report summaries noted the patient fell on 11/22/18, 11/26/18, and 12/08/18. The patient was identified as a high fall risk, however, lacked an individualized treatment plan with interventions prior to and/or after the three falls.

This finding was confirmed with Staff F on 01/08/19 at 3:32 PM.

2. Review of the medical record for Patient #9 revealed the patient was admitted on 11/09/18 with a fall risk score of 100. Review of the incident report summaries noted the patient fell twice on 11/24/18. The medical record identified the patient as a high fall risk, however, lacked an individualized treatment plan with interventions prior to the falls.

This finding was confirmed with Staff F on 01/08/19 at 3:43 PM.

3. Review of the medical record for Patient #10 revealed the patient was admitted on 12/03/18 and noted to be a low fall risk upon admission with a score of 88. The patient was noted to have a fall added to the treatment plan following a fall on 12/05/18, however, the plan lacked individualized interventions to prevent another fall. It was noted by incident report the patient fell again on 12/07/18.

Further review revealed the medical record lacked evidence of a nursing assessment after the fall on 12/07/18.

This finding was confirmed with Staff F on 01/08/18 at 3:52 PM.


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4. Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 12/11/18 with a diagnosis of combative behavior with a high fall risk score of 100. The medical record also revealed the patient had a fall at home prior to admission and developed lacerations to his/her forehead. The incident report revealed the patient fell on 12/12/18 and was sent to the hospital and admitted with a subdural hemotoma. The medical record lacked an individualized treatment plan with patient specific interventions prior to the fall. The patient did not return back to the hospital after this fall.

Further review of the medical record for Patient #12 revealed the patient had routine orders on admission for 15 minute checks. There was no documented evidence on the 12/11/18 observation form the 15 minute checks were completed at 6:30 PM and 6:45 PM. This finding was confirmed with Staff F on 10/10/19 prior to the exit conference.

This finding was confirmed with Staff F on 01/10/19 prior to the exit conference.

5. Review of the medical record for Patient #14 revealed the patient was admitted to the hospital on 12/22/18 with diagnoses of agitation and aggressive behavior and a high fall risk score of 100. The medical record lacked an individualized treatment plan with patient specific fall interventions for the patient.

This finding was confirmed with Staff F on 01/10/19 prior to the exit conference.

6. Review of the medical record for Patient #16 revealed the patient was admitted to the hospital on 01/02/19 for psychiatric inpatient stabilization with a high fall risk score of 118. The patient has a history of visual hallucinations and major depressive disorder. The medical record lacked an individualized treatment plan with patient specific fall interventions for the patient.

This finding was confirmed with Staff F on 01/10/19 prior to the exit conference.

7. Review of the medical record for Patient #18 revealed the patient was admitted to the hospital on 01/01/19 for aggressive behavior and is bipolar. The patient also has a history of dementia. The fall risk assessment was not completed according to the patient's history and physical on admission and noted a total score of 86, low risk.

The psychiatric fall risk assessment under mental status identified the patient as intermittently confused but failed to include the patient has agitation/anxiety which would have made the mental status score on the fall risk assessment 25 instead of 13; elimination was rated with a score of eight for independent with control of bowel and bladder, however, there was documented evidence on admission the patient was incontinent which would have made the elimination score a 12, and under ambulation/balance the score was a seven revealing the patient was independent with a steady gait but the admission assessment identified the patient as unsteady gait and a score of eight. Based on documented evidence in the history and physical Patient #18 should have been identified as high risk, 103.

This finding was confirmed with Staff F on 01/10/19 prior to the exit conference.

8. Review of the medical record for Patient #28 revealed the patient was admitted to the hospital on 10/16/18 for agitation and depression with a high fall risk score of 94. Review of a daily nursing note dated 10/21/18 for 7:00 AM revealed the patient was a fall risk and a fall risk band is in place. The medical record lacked an individualized treatment plan with patient specific fall interventions for the patient.

This finding was confirmed with Staff F on 01/10/19 prior to the exit conference.

9. Review of the medical record for Patient #29 revealed the patient was admitted to the hospital on 12/02/18 for depression with a high fall risk score of 116. The medical record lacked an individualized treatment plan with patient specific fall interventions for the patient.

Further review of the medical record for Patient #29 revealed the patient had routine orders on admission for 15 minute checks. There was no documented evidence on the observation form for 12/07/18 at 7:15 AM and 7:30 AM the 15 minute checks were completed.

This finding was confirmed with Staff F on 01/10/19 prior to the exit conference.


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10. Patient #6 was admitted on 12/28/18 with a chief complaint of confusion and aggression. The patient received a fall risk score of 104 upon admission making the patient a high risk for falls. The patient's medical record lacked an individualized treatment plan with appropriate interventions in place to prevent falls.

11. Patient #15 was admitted on 12/27/18 with a chief complaint of agitation and aggressive behavior. The patient received a fall risk score of 106 upon admission making the patient a high risk for falls. The patient had a falls treatment plan problem sheet but lacked interventions in place to prevent falls.

12. Review of the medical record for Patient #17 was completed on 01/10/19. Patient #17 was admitted on 12/28/18 with aggression. The patient received a fall score of 80, which put the patient at low risk for falls, however, the patient had a fall on 01/03/19. A falls treatment plan problem sheet was completed but lacked interventions in place to prevent another fall.

13. Review of the medical record for Patient #27 was admitted on 11/27/18 with suicidal ideation, auditory hallucination to kill him/herself and psychosis. The patient had routine orders on admission for 15 minute checks. There was no documented evidence on the observation forms for 12/06/18 at 6:45 AM and 7:00 AM and for 12/11/18 at 7:15 AM and 7:30 AM that the observation forms for the 15 minute checks were completed.

Based on observation, interview, and record review, the facility failed to ensure building construction types, failed to ensure emergency light inspections, failed to ensure kitchen hood cleaning, failed to ensure fire/smoke damper inspections, failed to ensure fire safety plan and staff training, failed to ensure quarterly fire drills and alarm forces notification, failed to ensure annual fire door inspections, failed to ensure annual testing of electrical outlets. (A-710) The cumulative effect of these systemic practices resulted in the facility's inability to ensure a safe environment for all 31 patients.

Based on observation, record review and staff interview the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This finding had the potential to affect all 31 residents in the facility.

Findings include:

K-161 - the facility failed to ensure failed to ensure building construction types
K-291 - failed to ensure emergency light inspections
K-324 - failed to ensure kitchen hood cleaning
K-521 - failed to ensure fire/smoke damper inspections
K-711 - failed to ensure fire safety plan and staff training
K-712 - failed to ensure quarterly fire drills and alarm forces notification
K-761 - failed to ensure annual fire door inspections
K-914 - failed to ensure annual testing of electrical outlets

Please see the life safety report for more details.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) contained individualized active treatment interventions with a specific focus or purpose based on the presenting psychiatric problems and treatment goals of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). Instead, the MTPs included routine physician and nursing functions and/or global statements written as treatment interventions rather than active treatment interventions to assist each patient's recovery. These deficiencies resulted in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent and ineffective treatment.

Findings include:

I. Record Review:

A. Interventions for the problem of "Aggressive/assaultive behavior"

1. Patient A1: (MTP dated12/28/18)

"Physician/LIP [Licensed Independent Practitioner] to assess: mood, presence of internal stimuli, presence of HI [homicidal ideation], effectiveness of medication."

"Nursing to assess: mood, behavioral status, presence of internal stimuli, interaction on unit, presence of HI, patient perception of medication of effectiveness."

2. Patient A3: (MTP dated12/27/18)

"Physician/LIP to assess: mood, mental status, presence of internal stimuli, presence of HI, effectiveness of medication."

"Nursing to assess: mood, behavioral status, presence of internal stimuli, orientation, sleep pattern, interaction on unit, presence of HI, patient perception of medication effectiveness."

3. Patient A4: (MTP dated12/27/18)

"Physician/LIP to assess: mood, mental status, effectiveness of medication."

"Nursing to assess: mood, behavioral status, sleep pattern, interaction on unit, patient perception of medication effectiveness."

4. Patient B4: (MTP dated1/3/19)

"Physician/LIP to assess: mood, mental status, effectiveness of medication."

"Nursing to assess: mood, behavioral status, hygiene status, presence of internal stimuli, sleep pattern, interaction on unit, patient perception of medication effectiveness."


B. Interventions for the problem of "psychotic behaviors/out of contact with reality"

1. Patient A2 (MTP dated1/2/19)

"Physician/LIP to assess: mood, presence of SI [suicidal ideation], effectiveness of medication."

"Nursing to assess: mood, behavioral status, hygiene status, orientation, appetite, sleep pattern, interaction on unit, presence of SI, patient perception of medication effectiveness."

2. Patient B3: (1/1/19)

"Physician/LIP to assess: mood, mental status, presence of SI."

"Nursing to assess: mood, hygiene status, internal stimuli, orientation, appetite, sleep pattern."

C. Interventions for the problem of "self-harm & [and] suicide"

1. Patient B1: (1/1/19)

"Physician/LIP to assess: mood, presence of SI, effectiveness of medication."

"Nursing to assess: mood, behavioral status, hygiene status, orientation, appetite, interaction on the unit, presence of SI, patient perception of medication effectiveness."

2. Patient B2: (MTP dated12/30/18)

"Physician/LIP to assess: mood, mental status, presence of SI, effectiveness of medication."

"Nursing to assess: mood, behavioral status, hygiene status, orientation, appetite, sleep pattern, interaction on unit, presence of SI, patient perception of medication."


II. Interviews

1. On 1/8/19 at 9:00a.m., the Clinical Director was interviewed. The issue of generic interventions on the treatment plans by psychiatry staff was discussed. He agreed that the interventions were generic discipline functions and not patient specific.

2. In an interview on 1/8/19 at 11:17a.m., the lack of individualized active treatment interventions with a specific focus of purpose based on patient's specific problems and needs was discussed with the Director of Nursing. He did not dispute the findings.