HospitalInspections.org

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. The facility failed to provide a safe patient care environment. The facility identified a problem of increased patient falls but did not investigate individual patients who experienced multiple falls while under the facility's care and did not implement actions to prevent reoccurrence of falls when identified as an issue in 5 of 5 medical records reviewed for patients with multiple falls (Patients #1, #7, #10, #12, and #13). The facility failed to ensure safe patient care was provided by nursing staff as evidence by the failure to initiate and re-evaluate patients' fall precuations. In addition, the facility failed to accurately assess and monitor safety processes put into place with regards to the use of one way speaking valves for tracheostomy patients (Patient #5) and with telemetry monitoring. These failures resulted in an unsafe patient environment and negative outcomes, including patient falls with injury and errors that contributed to the death of a patient and the changes in a patient's condition to go unrecognized

A-0168 The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. The facility failed to ensure an order was obtained from a physician or Licensed Independent Practitioner (LIP) prior to, or immediately after, the initiation of physical restraints in 2 of 8 medical records reviewed of patients with documented use of physical restraints (Patients #10 and #13). This failure created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

A-0213 [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient's death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. The facility failed to adhere to death reporting requirements for the Centers for Medicare and Medicaid Services (CMS). This failure resulted in CMS not being reported of the death of a patient who expired within 24 hours of restraint, by use of mitt restraints (Patient #5).

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.21 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM was out of compliance.

A-0286 The hospital must measure, analyze, and track adverse patient events. Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. The facility failed to ensure errors related to patient falls and safety were analyzed for cause. The facility failed to implement actions to reduce further reoccurrence of the falls, specifically in the management of patients who had multiple falls within the hospital stay in 5 of 5 medical records reviewed for patients with multiple falls (Patients #1, #7, #10, #12, and #13). Additionally, the facility failed to thoroughly investigate the factors contributing to the unexpected death of a patient and to implement and evaluate process changes to prevent similar patient safety incidents in the future. These failures resulted in negative patient outcomes related to patient falls, including falls with injury. In addition, these failures resulted in errors that contributed to the death of a patient and the changes in a patient's condition to go unrecognized.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0386 The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. The Clinical Chief Officer (CCO), who was responsible for nursing staff, failed to provide oversight of nursing services within the facility by not ensuring nursing staff consistently assessed fall risk, implemented fall precaution interventions to meet the needs of patients, and re-evaluated care plans to meet the patients needs and provide a safe environment. This failure resulted patients at risk for falls to receive less fall risk prevention and monitoring than needed to ensure patient safety.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Nursing staff failed to ensure equipment used for fall precautions, specifically bed alarms, were functioning in 2 of 3 observations conducted (Patient #13 and #14). The facility failed to ensure nursing staff implemented fall precautions according to the patients needs and who were considered at risk for falls (Patients #14, #15, and #16). Additionally, nursing staff failed to consistently evaluate patients who were at risk for falls. Further, the facility failed to provide safe nursing care for a tracheostomy patient with a one way speaking valve (Patient #5). This failure resulted in patient harm related to falls. Additionally, This failure resulted in errors that contributed to the death of a patient.

A-0396 The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. The nursing care plan may be part of an interdisciplinary care plan. The facility failed to ensure nursing staff re-evaluated patients' care needs, as well as the effectiveness of the care plan to maintain the patient's health and safety for patients in 5 of 5 medical records reviewed for patients with multiple falls (Patients #1, #7, #10, #12 and #13). This failure resulted in continued patient falls, including falls with injuries.

Based on observations, interviews and document reviews, the facility failed to provide a safe patient care environment. The facility identified a problem of increased patient falls but did not investigate individual patients who experienced multiple falls while under the facility's care and did not implement actions to prevent reoccurrence of falls when identified as an issue in 5 of 5 medical records reviewed for patients with multiple falls (Patients #1, #7, #10, #12, and #13). The facility failed to ensure safe patient care was provided by nursing staff as evidence by the failure to initiate and re-evaluate patients' fall precuations. In addition, the facility failed to accurately assess and monitor safety processes put into place with regards to the use of one way speaking valves for tracheostomy patients (Patient #5) and with telemetry monitoring.

These failures resulted in an unsafe patient environment and negative outcomes, including patient falls with injury and errors that contributed to the death of a patient and the changes in a patient's condition to go unrecognized.

Findings include:

Facility Policy:

According to the policy, Falls Prevention, the standard fall prevention interventions will be followed on all patients as follows: all patients and/or family members will be given the Fall Prevention Education Tool; the patient's bed is kept in the lowest position whenever unattended by hospital personnel; the patient will be oriented to the environment, location of bathroom, bathroom emergency call light cord, bed controls, and call bell; the call light will be kept within reach at all times whether the patient is in bed or up in a chair; all patients will be instructed to call for assistance, as appropriate; a light will be left on in the bathroom at night, as indicated; all patients will be instructed to wear non-skid slippers and to avoid wet floors; frequently used personal items will be within easy reach at all times; evaluate patient's perception of comfort as needed; evaluate whether use of side rails will increase potential for patients to climb over; and, frequent offering of toileting and staff monitoring patient while in bathroom.

A Score of > 10 = At Risk. Those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls. The At Risk interventions may include, but are not limited to: use of "risk for falls" sign/device to communicate risk to all caregivers (Falling Leaves, Falling Stars, bracelets, etc); use of a "remember to call for help" sign posted in patient's room to remind patient to call for assistance before getting out of bed; use of Bed Alarms/Chair alarms; turn (or position) bed with one side to the wall and place floor mat along entry/exit side of bed; avoid use of full-length side rails; move patient closer to the Nurses Station; rehab evaluation and treatment as appropriate for conditioning/strengthening options/use of assistive devices; pharmacy review of medications for fall risk potential; use of low bed; select suitable chairs that have armrests or another appropriate geriatric chair; and consider family staying, or changes needed in staffing.

In the event that a patient fall occurs, regardless of the score of the Initial Fall Risk screen, he/she will be automatically considered at risk for falls, additional interventions will be considered, and the Care Plan revised to reflect increased risk.

The Continuous Cardiac Monitoring (Telemetry) policy read, the use of continuous cardiac monitoring was expected for the duration of the patient stay in any critical care area. Alarms on the telemetry monitor were to be maintained in the "ON" position at all times. The nurse assigned to the patient was expected to respond immediately if they received notice of an alarm at the central monitoring station by a telemetry technician or other staff member and if there was any observed change in the patient's cardiac rhythm, loss of telemetry signal, unreadable signal due to artifact, or intermittent signal loss.

References:

According to the Posey KeepSafe Cadet 8323 manufacturer's instructions, the alarm unit's Green LED blinks to indicate the unit is "ON".

According to the POSEY Company sensor pad manufacturer's instructions, to reduce the risk of serious injury or death, ALWAYS follow these steps, make sure alarm is ON and in monitoring mode.

According to the Telemetry Escalation Algorithm, when the monitor showed leads off, a critical rate, a rhythm change or a telemetry interruption, the established process was to immediately notify the primary nurse. If the phone was answered, the process was to wait two minutes for restoration of the rhythm or a phone call from the nursing unit. If the phone was not answered, the process was to overhead page the primary nurse to assess the patient and call the nursing supervisor. If after two minutes, the telemetry had not been restored, a call was to be made to the nursing supervisor and the primary nurse was to reassess the patient. If the telemetry was not restored within another two minutes, the patient was to be reassessed and the need for a rapid response call determined.

1. The facility failed to ensure nursing staff implemented fall precautions according to the patients needs. In addition, the facility failed to ensure bed alarms and call lights used for patients, who were at risk for falls, were available and functioning.

a. Medical Records and event reports were reviewed for Patients #1, #7, #10, #12 and #13 who had multiple falls while admitted to the facility.

Review of Patient #7's medical record revealed six change of conditions for falls documented by nursing staff. Review of the patient's event reports and investigation worksheets for falls revealed three additional falls. Patient #7 had a total of nine falls during his six month admission. Patient #7 consistently scored greater than 10, including multiple documented fall scores greater than 20, on his fall risk assessments (with scores greater than 10 indicating a fall risk).

On 5/25/17, Nurse Supervisor (Supervisor #16) documented Patient #7 had a fall without injury. According to the event follow up report, the fall was referred to the appropriate Performance Improvement (PI) committee and the department manager. According to the event report narrative, the Director of Quality Management (DQM #10) reviewed the fall event. There was no evidence as to what follow up was done to prevent reoccurrence.

On 5/29/17 Supervisor #16 entered an event report for a fall which occurred three days prior on 5/26/17. According to the event reporting documentation, Patient #7 had another fall without injury from his bed. The event follow up was referred to the appropriate PI committee and department manager. There was no evidence as to what follow up was done to prevent reoccurrence.

On 6/28/17 at 11:00 a.m., RN #29 documented the patient was found sitting on the floor after a bed alarm was going off. The patient had a low bed with mats and was found on the mat with his restraints still in place. Documentation reported the patient did not have an injury. A fall investigation worksheet completed later the same afternoon by Supervisor #16 revealed a second fall occurred two hours later at 1:15 p.m.

One week later, on 7/6/17 at 7:45 p.m., RN #30 documented a change of condition which showed Patient #7 was found next to his bed with no injuries. According to the change of condition documentation, Physician #31 was notified of the fall and ordered a sitter. The facility was unable to provide any documented evidence a sitter was provided for Patient #7 throughout the patient's admission.

On 7/6/17, RN #30 entered an event report for Patient #7. She documented a fall without injury occurred at 7:45 p.m. Per the event report, filed 7/6/17 at 8:37 p.m., a rapid response was called after the patient slid out of bed onto the floor.

On 7/25/17 at 6:54 p.m., Nurse Supervisor (Supervisor) #7 documented Patient #7 fell out of an enclosed bed.

Two weeks later, on 8/9/17 at 9:35 p.m., RN #32 documented a change of condition for another fall. According to the documentation, Patient #7 walked into the hallway bleeding from his head following an unwitnessed fall. The documentation revealed the patient said he fell against the bed. The patient was transferred by ambulance to another facility for treatment of a head laceration and a head CT (computed tomography) scan. Nursing staff did not document if the patient's bed alarm was activated. At 3:25 a.m., the patient returned to the facility with staples for his laceration. On 8/10/17, RN #32 entered an event report for Patient #7's fall.

On 9/1/17 at 2:40 a.m., according to the change of condition documented by RN #32, the patient had another unwitnessed fall with injury. The documentation revealed both respiratory and nursing staff heard the patient yelling and the patient was found on the floor next to the bed. Patient #7 was confused and unsure how he got out of the bed. RN #32 documented the patient had a laceration on the right side of his nose and a small laceration above the left eye. The physician was notified and neurological checks were ordered.

On 9/1/17, RN #32 entered an event report for Patient #7's fall. A follow up investigation revealed that the netting had not been secured on the patient's enclosure bed, and the nurse manager would counsel staff on proper netting securement on enclosure beds. The event report identified inadequate patient supervision/monitoring and policy/other guidance not being followed as potential contributing factors.

On 09/15/17 at 9:02 a.m., Nurse Supervisor (Supervisor) #16 documented a change of condition for another fall. According to the documentation, Patient #7 was sitting next to the nurse's station when he tipped his wheelchair and fell back. The certified nursing assistant (CNA) was charting at the nurse's station at the time. On 9/15/17, Supervisor #16 entered an event for Patient #7's fall. According to the event report, Patient #7 was sitting in a wheelchair at the nursing station when at 8:08 a.m., he pushed himself backwards and fell to the floor. There were no signs of injury, and Physician #14 was notified.

On 9/21/17, Supervisor #16 entered an event report for Patient #7. She documented at 5:23 p.m., Patient #7 fell out of his chair while sitting at the nursing station. Patient #7 was wearing a helmet on his head, and did not sustain any injuries. This was the second time Patient #7 fell at the nursing station.

On 10/14/17, Supervisor #33 entered an event report for Patient #7. According to the event report, Patient #7 had an unwitnessed fall from his bed at 4:39 p.m. Patient #7 had no apparent injuries. Physician #18 was notified.

Review of Patient #7's care plan interventions for falls, dated 5/15/17 through 10/15/17, showed nursing staff documented the same interventions throughout the patient's stay. Interventions documented were: implement safety measures; obtain restraint order if necessary; place padded floor mats at each side of bed; maintain bed in low position; tubes hidden with bandages to prevent pulling of tubes; increased observation; and place fall precautions signage at the bedside. There was no evidence nursing staff adjusted Patient #7's care plan after each of the 9 falls the patient sustained while under their care; including how staff increased observation and monitoring which was one of the interventions on the care plan for five months.

The facility was unable to provided any documented evidence Patient #7 had a sitter for 1 on 1 observation after the physician ordered the change in monitoring on 7/6/17. Patient #7 had six additional falls after 7/6/17.

Similar findings were found in Patient's #1, #10, #12, and #13's medical record (Cross Reference Tag 396).

b. On 1/12/18 at 7:30 a.m., a tour of the Medical/Surgical (M/S) unit and the Medical Observation Unit (MOU) was conducted with the Nurse Manager (Manager #8).

At 7:40 a.m., Patient #13 was observed from the hallway, sliding down in bed with his legs over the right side of the bed. The patient's pulse oximetry alarm was alarming. Staff assistance was requested by the Nurse Manager. Upon entering the patient's room, the patient was found off his bed alarm pad. The bed alarm unit was not activated and the control box did not have the green light illuminated, according to manufacturer's instructions, to indicate power was on.

Review of Patient #13's event reports revealed the patient had five unwitnessed falls without injury from August 2017 through December 2017 (08/30, 09/01, 09/07, 11/16 and 12/22).

At 7:50 a.m., Patient #14's room was observed for fall precautions. Upon entering the patient's room with Nurse Manager #8, the patient was observed in bed with a bed alarm attached to the the headboard. The bed alarm was not on. The control box did not have the green light illuminated to indicate power was on. Nurse Manager #8 stated she assumed the light on the bed alarm would need to be on to indicate the alarm was functioning.

c. On 1/10/18 at 8:45 a.m., a tour of the nursing units was conducted with Manager #8. Two of seven patients who scored at risk for falls were found without the falling leaf sign, which indicated to other caregivers the patients were a fall risk, according to policy.

Inspection of Patient #16's room showed no evidence the patient was identified at risk for falls. However, review of Patient #16's last fall risk assessment, dated 1/10/18 at 2:20 a.m., showed the patient scored 13, which according to policy indicated the patient was at risk for falls. The patient's nurse documented the following risk factors for the patient: confusion/disorientation/sedation; unstable gait/balance or requires assistance to ambulate or transfer; user of orthopedic devices, forgets instructions or over estimates own limits and impaired vision or hearing.

Inspection of Patient #14's room was also conducted. There was no falling leaf sign on the patient's door. Review of Patient #14's last fall risk score, documented three days prior on 1/7/18, was 11, which indicated the patient was at risk for falls. According to the safety assessment documented by the patient's CNA on 1/10/18 at 6:47 a.m. (approximately 2 hours prior to observation), the patient had a fall prevention sign.

According to Manager #8, any patient who was at risk for a fall should have a leaf sign on the entry door. Manager #8 confirmed there was no sign on the door to Patient #14's room.

d. On 1/12/18 at 8:00 a.m., Patient #15 was observedin his room. According to the Nursing Supervisor's Bed Board document, dated 1/12/18, Patient #15 was a fall risk. There was no falling leaf signage on the patient's door indicating the patient was a fall risk. Review of the last fall score, documented by the patient's nurse on 1/11/18 at 11:55 a.m. (the day prior), showed the patient's total fall risk score was 10.

e. On 1/13/18 at 1:20 p.m., a tour of the nursing units was conducted with the House Supervisor (Supervisor #33), after an Immediate Jeopardy was called the day prior, on 1/12/18. Three patients who were listed at risk for falls, according to the Supervisor Bedboard document provided for the tour, did not have all fall precaution interventions in place as determined by nursing leadership and the facility policy.

An inspection of Patient #16's room in the M/S unit, revealed no evidence of fall precaution interventions in place. The patient had only a falling leaf sign posted on the entry door. According to the bed board sheet provided by Supervisor #33, Patient #16 was a fall risk with a score of 11.

An inspection of Patient #15's room, also did not have evidence of falling sign precaution interventions in place. The fall sign was observed located on the entry door. However, there were no other additional interventions observed in the patient's room, such as bed alarms, or floor mats.

Furthermore, during the same tour, an inspection of a high fall risk patient located in room 2031, revealed the patient's call light was hanging over an IV (intravenous) pole, not within reach of the patient. This was in contrast to policy which stated that the call light would be kept within reach at all times. According to the Bed Board form, the patient's fall score was 22. Supervisor #33 immediately placed the patient's call light within reach of the patient who was in his bed.

2. The facility's quality department identified a problem of increased patient falls. However, the facility failed to investigate individual patients who experienced multiple falls and failed to implement systemic actions to prevent reoccurrence of falls when they had been identified as an issue.

a. Review of the Event Reports, from 7/1/17 through 1/9/18, revealed approximately 46 falls occurred in less than seven months, including three falls with injuries (Patients #7 and #12).

b. Review of Patient #7's fall event reports provided by the Director of Quality Management (DQM #10) showed a total of eight falls occurred over a six month period, from May 2017 - November 2017, not including one fall documented in the patient's change of conditions on 6/28/17 in which no event report was completed.

On 5/25/17, RN #16 documented Patient #7 had a fall without injury. According to the event follow up report, the fall was referred to the appropriate Performance Improvement (PI) committee and the department manager. According to the event report narrative, DQM #10 reviewed the fall event. There was no evidence as to what follow up was done by the facility to prevent reoccurrence.

On 5/29/17, RN #16 entered an event report for a fall which occurred 3 days prior on 05/26/17. According to the event reporting documentation, Patient #7 had another fall without injury from his bed. The event follow up was referred to the appropriate performance improvement (PI) committee and department manager. There was no evidence of follow up done by the facility.

On 7/6/17, RN #30 entered an event report for Patient #7. She documented the fall occurred at 7:45 p.m. Per the event report filed 7/6/17 at 8:37 p.m., a rapid response was called after the patient slid out of bed onto the floor. However, there was no documentation in the event report on what follow-up was done to ensure the patient experienced no further falls.

Subsequently, on 8/10/17, RN #32 entered an event report for Patient #7. She documented a fall with injury occurred on 8/9/17 at 9:35 p.m. According to the event report, Patient #7 had an unwitnessed fall from his bed. He sustained a head laceration and was taken to an acute care facility for a head CT and sutures. The severity level of the event was noted as "Major."

A root cause analysis (RCA) was completed on 8/11/17 in response to the 8/9/17 fall. The RCA determined the patient had an unwitnessed fall from a bariatric Low Boy Bed the evening after his enclosure bed had been discontinued. According to the RCA, fall mats were in place and the bed alarm was on. The RCA team developed an action plan, which suggested keeping the patient up in the chair longer to tire the patient out, and to engage the patient in more frequent toileting to decrease impulsivity. However, there was no evidence to show the facility evaluated whether the patient's bed alarm was turned on and functional. According to medical record documentation the patient was found walking in the hallway bleeding from the head after an unwitnessed fall.

On 9/1/17, RN #32 entered an event report for Patient #7. The event report revealed Patient #7 had an unwitnessed fall from an enclosure bed. Patient #7 sustained a laceration to the right side of his nose and above his eye. Physician #12 was notified and he ordered neuro checks as a result. A follow up investigation revealed that the netting had not been secured on the patient's enclosure bed, and the nurse manager would counsel staff on proper netting securement on enclosure beds. The event report identified inadequate patient supervision/monitoring and policy/other guidance not followed as potential contributing factors.

On 9/1/17, in response to the fall, a second RCA was conducted. The RCA determined the patient fell as a result of the enclosure bed netting not being properly secured. Patient #7 crawled out of bed and fell, and sustained a laceration to the right side of his nose and his eye. Physician #12 ordered serial neurological checks. The RCA developed an action plan, which stated the nurse manager would train staff to use the enclosure bed properly. Additionally, the RCA action plan suggested keeping the patient up in the chair longer throughout the day to tire the patient for night time and toilet the patient more often to decrease impulsivity. This was the same action plan documented on the first RCA, completed on 8/11/7, after Patient #7 sustained an injury due to a fall. There was no change in actions to protect the patient from falling again.

Subsequent to 9/1/17, Patient #7 experienced three additional falls.

Similar findings were found in Patients #1, #10, #12, and #13's event report details in which patient falls were not investigated fully.

c. Review of the fall committee meeting minutes, dated 8/9/17 through 1/3/18, showed the purpose of the fall task group was to review causes for the increase in fall events during the second quarter for 2017 (Q2), review the current fall prevention program and identify additional fall prevention components.

Six months of Fall Prevention meetings were held. Various leadership attended multiple meetings throughout the six months. The leadership included, the Chief Executive Officer (CEO), the Chief Clinical Officer (CCO #11), Director of Quality Management (DQM) #10, education coordinator, rehab coordinator, nurse manager and one of the nursing supervisors. Multiple fall prevention components were discussed at the meetings.

Although the fall committee implemented using helmets for at risk patients and completed fall education in November, none of the other interventions identified from the committee were implemented at the time the survey was conducted. Additionally, 10 more patient falls occurred over a 2 month period (November and December), which was 5 months after the Fall Committee had been created.

d. During an interview on 1/15/18 at 2:04 p.m., CCO #11 stated a task force was formed to investigate how fall prevention could be improved. She stated there were high incidences of falls amongst patients with traumatic brain injuries (TBIs). She reported the CEO, nurse manager, nurse educator, health information manager, and when available, a floor nurse, were part of the task force.

CCO #11 stated the facility was unable to use sitters as often they would like due to lack of available certified nursing assistants (CNAs). CCO #11 reported the facility had not hired any additional CNAs. She also stated the facility elected not to implement hourly rounding, as mentioned during their falls committee meetings. CCO #11 reported the committee determined the hourly rounding was not necessary.

CCO #11 stated the facility asked patients' families to stay if needed in order to monitor for falls. When asked about Patient #7, she stated the facility did not always have the opportunity to have sitters. She stated the facility tried to prevent further falls by having him by the nurse's station. Furthermore, according to CCO #11, Patient #7 did not often have a sitter, but his father and sister were often present in the room. CCO #11 was unable to provide documentation of this.

CCO #11 stated the facility requested a quote for video cameras to be used to monitor very high fall risk patients. Then she stated the cameras were too expensive so the facility opted not to purchase the monitoring equipment.

CCO #11 stated she would observe staff to ensure fall prevention interventions were in place, and would round and check rooms. However, she was unable to provide documentation to support this.

CCO #11 stated the patient transfer training discussed in the fall task force meeting since 8/9/17 had not occurred yet.

CCO #11 stated the facility had been unable to get beveled floor mats, which was discussed at the fall committee meetings as a potential intervention to reduce the risk of falls. She stated also the committee decided not to color code fall leaf signs as they felt fall assessments were too subjective and the color coding would be potentially confusing.

When asked what interventions were in place to reduce falls, CCO #11 stated the facility kept fall risk patients in low beds. She then stated "you can't prevent falls". She stated she did go out and observe staff to see what fall interventions were in place, but she was not sure if she documented it. When asked what the facility did after a patient fell, she stated it depended on what interventions were needed and if there was an injury to the patient. She stated she would go out onto the floor and make sure fall preventions were in place. They would review the fall if it might have happened due to a change in medications. She restated that it was "very hard to prevent falls''.

CCO #11 stated her responsibilities included clinical operation, conducting RCAs and ensured quality nursing care. She also stated she ensured nursing staff had the equipment, tools and education needed.

Upon exit of the survey, CCO #11 was unable to provide any evidence of fall precaution monitoring, consideration for sitters and/or changes in staffing (according to facility policy) for Patients #1, #7, #10, #12 and #13 or any additional evidence which showed process changes had been implemented to prevent reoccurrence of patients' falls.

e. On 1/16/18 at 1:30 p.m., an interview was conducted with Director of Quality Management (DQM) #10. She stated she was responsible for the quality improvement projects, had oversight of various committees, and had oversight and tracked the event reporting process. DQM #10 stated she was part of the fall prevention committee. She stated the committee was created because the facility noticed an increase in patient falls. DQM #10 stated the purpose of the task group was to see which patients were falling and why the patients were falling. She stated the fall prevention committee did some analysis and reviewed the fall prevention program; however, staff were not observed for compliance with fall precautions.

DQM #10 stated during the fall committee meetings, many interventions were discussed. These included getting patients up into chairs more frequently, more frequent rounding, and checking on patients at regular intervals (hourly). When asked if any interventions were implemented to reduce the patient falls, DQM #10 stated only the fall prevention education was completed, which was at the end of October 2017. According to DQM #10, the patient transfer training, discussed in the fall task force meeting on 8/9/17, had not been scheduled or completed. DQM #10 stated she had not determined the effectiveness of the education provided in October.

Review of Patient #7's fall events was conducted with DQM #10, including the two RCAs done on 8/11/17 and 9/1/17. DQM #10 stated nurses were front line and were the ones who hopefully made sure the bed alarms were in place, call lights were in reach and the bed was in low position. When asked how she was following up on nurses actions to prevent falls, she stated patients were discussed on a daily basis.

DQM #11 stated nursing staff would collaborate with rehabilitation to assist Patient #7 out of bed. When asked what changes were put in place for Patient #7, DQM #10 stated the facility got him a soft helmet, moved him closer to the nurse's station, and gave the patient things to do.

However, review of Patient #7's fall events showed the majority of the patient's falls occurred in the same room near the nurse's station. DQM #10 stated the team did brainstorm about how the patient could be kept safe. Then she stated a sitter, for closer observation, was discussed. Although discussed, the facility never implemented interventions for closer observation needed for Patient #7. DQM #10 could not provide any evidence the quality department addressed and identified possible causes of Patient #7's continued falls while under the care of the facility.

DQM #10 stated she tried to identify if there was anything the facility needed to do for the patients who continued to fall that they weren't already doing. She stated the tracking and trending of the individuals' falls would be located in the patient's record through the care plans and the interventions. When asked how she evaluated the success of the fall prevention program, she stated through a reduction in falls. A request for the data supporting the tracking and trending of falls was made. DQM #10 was unable to provide evidence to show if a reduction of falls had occurred. DQM #10 stated she could not provide evidence how the facility evaluated effectiveness of any fall interventions in place for patients with multiple falls prior to the survey. She stated the facility had been doing the best they could to manage particular patients and keep them safe.

DQM #10 stated she did not have any evidence sitters were provided for the patients who had multiple falls during their admission at the facility (Patients #1, #7, #10, #12 and #13) or any evidence the facility considered other interventions to closely monitor the patients and reduce the likelihood of continued falls.

Cross Reference Tag 0286, 0395 and 0396




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3. The facility failed to ensure the safe use of one-way speaking valves, in accordance with manufacturer's recommendations, for a patient who experienced an unrecognized change of condition and expired.

a. The One-Way Speaking Valve (Trach Communication Assistance) policy read, the one way speaking valve was designed to restore airflow through the upper airway allowing the patient to verbally communicate. An inflated tracheostomy tube cuff was listed as a contraindication for use of the one-way speaking valve.

According to Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valves (PMV) Instruction Booklet, Warning: tracheostomy tube cuff must have been completely deflated before placing the PMV. The patient will be unable to breathe if cuff is not fully deflated.

b. According to the admission history and physical, dated 10/5/17, Patient #5 was admitted to the facility on 10/5/17 with a primary diagnosis of traumatic brain injury (TBI) following an automobile accident on 9/20/17.

Patient #5's medical record revealed an Expiration Summary, dictated by Physician #13 on 10/31/17 at 3:24 p.m. Physician #13 documented she had responded to an emergency (code) for Patient #5 where she led the effort to resuscitate the patient from cardiac arrest. The record revealed the code was called on 10/31/17 at 11:40 a.m. Physician #13 documented Patient #5 was resuscitated for 10 minutes and remained pulseless; therefore, the resuscitation was stopped, and Physician #13 pronounced Patient #5 dead.

In the Expiration Summary, Physician #13 reported she was notified by the respiratory therapist (RT), after the code was completed, Patient #5 had a Passy-Muir Speaking Valve (PMV) in place at the beginning of the code with the tracheostomy cuff fully inflated. This was contraindicated in the Manufacturer's Instructions which warned a patient could not breathe with a PMV in place unless the cuff was fully deflated.

Review of Patient #5's medical record revealed the PMV had first been used with the patient the previous day, on 10/30/17. A note was entered on 10/30/17 at 12:24 p.m. by Speech Language Pathologist (SLP) #5 who reported Patient #5 tolerated the PMV well and accurately counted from 1 to 10 and stated the days of the week and the months of the year using the PMV. SLP #5 documented she left the PMV in place on the patient in agreement with the respiratory therapist (RT) and the RN.

On 1/15/18 at 5:19 p.m., an interview was conducted with Respiratory Therapist (RT) #6 who stated she had worked with SLP #5 to trial the PMV with Patient #5 on 10/30/17. She stated the patient did fine with his initial evaluation, but an hour later his airway became tight so she removed the PMV from the patient, placed the valve in the cupboard, and left the tracheostomy cuff deflated, as it remained until the following day. There was no documentation in the medical record on removal of the PMV by RT #6. Further

Based on interviews and document review, the facility failed to ensure an order was obtained from a physician or Licensed Independent Practitioner (LIP) prior to, or immediately after, the initiation of physical restraints in 2 of 8 medical records reviewed of patients with documented use of physical restraints (Patients #10 and #13).

This failure created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

Findings include:

Facility Policy:

According to the Physical Restraints (Violent and Non-Violent Behavior) and Seclusion policy:
"4 side rails up on a patient hospital bed are normally considered a restraint, unless the patient:
Is on a stretcher being transported;
Is sedated, or recovering from anesthesia;
Is experiencing involuntary movement or is on seizure precautions;
Is on a therapeutic bed that cannot be lowered, or rotates and turns (constantly moves)."

1. The facility did not ensure restraint orders for use of four side rails were obtained prior to or immediately after placing all four side rails up on the patients' beds.

a. A review of the medical record for Patient #10 revealed Registered Nurse (RN) #23 and RN #24 documented all four of Patient #10's bed rails as up on 9/26/17 between the hours of 1:25 p.m. and 10:00 p.m. and on 9/27/17 between the hours of 12:00 a.m. and 6:00 a.m. by RN #24.

A review of the nursing notes revealed that on 9/26/17 at 2:52 p.m., RN #23 documented "side rails up x 4" under safety assessment.

Further review of the medical record revealed RN #23 and RN #28 documented all four of Patient #10's bed rails as up on 10/2/17 between the hours of 12:00 a.m. and 10:00 p.m. and on 10/3/17 between the hours of 12:00 a.m. and 12:00 p.m. by RN #24 and RN #28.

Review of the restraint initiation/order signed at at 9/26/17 at 1:25 p.m. showed an order for bilateral mittens. An additional order was signed 9/27/17 at 7:45 a.m. for bilateral limb/soft restraints. No order was obtained for all four side rails to be up. None of the exceptions identified in the restraint and seclusion policy were listed for this patient.

Record review for Patient #10 revealed that RN #24 and Licensed Practical Nurse (LPN) #27 documented all four of Patient #10's bed rails as up on 10/3/17 between the hours of 12:00 a.m. and 12:00 p.m., and on 10/4/17 between the hours of 12:00 a.m. and 6:00 a.m. by RN #24.

Further, RN #23 and RN #25 documented all four of Patient #10's bed rails as up on 10/6/17 between 7:45 a.m. and 10:00 p.m. and on 10/9/17 between 7:30 a.m. and 10:00 p.m. by RN #23 and Licensed Practical Nurse (LPN) #26.

Review of the restraint initiation/order signed on 10/3/17 at 9:15 a.m. showed an order for bilateral limb/soft restraints only. No order was obtained for all four side rails to be raised. No exceptions to the restraint and seclusion policy were identified for this patient.

Review of Patient #10's medical record revealed that on 15 days out of his 31 day stay, all four of his bed rails were up. However, medical record review revealed no orders obtained for four side rails.

b. On 1/14/18 at 3:30 p.m., during a tour of the medical surgical unit with the nurse manager, Patient #13 was observed in bed with limb/soft restraints in place on bilateral upper extremities, and all four side rails up.

In an interview in 1/16/18 at 9:10 a.m., the Chief Clinical Officer (CCO #11) confirmed witnessing all four of Patient #13's side rails being up during the 1/14/18 tour.

Per the restraint initiation/order signed 1/7/2018 at 13:40 p.m., only limb/soft restraints were ordered for that day. No order was obtained for all four side rails to be up.

c. LPN #27 confirmed during an interview on 1/15/18 at 11:50 a.m. that a physician/LIP order was needed for all four bed rails to be up.

d. Nurse Supervisor (Supervisor #7) confirmed during an interview on 1/16/18 at 8:38 a.m. that all four side rail being up required an order. Additionally, she reviewed the restraint documentation for 10/10/17 and confirmed that per the documentation, all four sides rails of the bed were up and that an order should have been obtained.

The facility failed to adhere to death reporting requirements for the Centers for Medicare and Medicaid Services (CMS).

This failure resulted in CMS not being reported of the death of a patient who expired within 24 hours of restraint, by use of mitt restraints (Patient #5).

Findings include:

Facility Policy:

The Physical Restraints (Violent and Non-Violent Behavior) and Seclusion policy read, deaths must have been logged and called to CMS within one calendar day. The reporting requirements in this section applied whenever a patient death occurred while a patient is in restraints or within 24 hours after the patient was removed from restraint or seclusion. Reporting procedures for deaths included to document the death in the medical record, including the CMS office contacted, the phone number, name and title of any person reached with the notification and date/time of the notification.

1. The facility did not contact CMS to report the death of a patient while in mitt restraints.

a. On 1/11/20 at 1:00 p.m., the Director of Quality of Management (DQM) #10 provided a document titled Restraint Death Log for 2017. Patient #5 was the only entry on the log. The log was marked "Y", indicating yes, in the section Restraints removed 24 hours or less prior to death. DQM #10 stated Patient #5 had expired with restraints on, and the death had not been reported to CMS. DQM #10 stated she would have to check with Chief Clinical Officer (CCO) #11 whether the death should have been reported to CMS. DQM #10 stated it was her understanding reporting the death to the state was sufficient.

b. During a subsequent interview, on 1/16/18 at 1:30 p.m., DQM #10 confirmed Patient #5's death in restraints had not been reported to CMS as required.

Based on observations, interviews and document reviews, the facility failed to ensure errors related to patient falls and safety were analyzed for cause. The facility failed to implement actions to reduce further reoccurrence of the falls, specifically in the management of patients who had multiple falls within the hospital stay in 5 of 5 medical records reviewed for patients with multiple falls (Patients #1, #7, #10, #12, and #13). Additionally, the facility failed to thoroughly investigate the factors contributing to the unexpected death of a patient and to implement and evaluate process changes to prevent similar patient safety incidents in the future.

These failures resulted in negative patient outcomes related to patient falls, including falls with injury. In addition, these failures resulted in errors that contributed to the death of a patient and the changes in a patient's condition to go unrecognized.

Findings include:

Facility Policy:

The Event Reporting System policy read, this procedure established guidelines to improve patient care and safety and to understand how and why an event occurred and to prevent a similar event from happening in the future.

The One-Way Speaking Valve (Trach Communication Assistance) policy read, the one way speaking valve was designed to restore airflow through the upper airway allowing the patient to verbally communicate. An inflated tracheostomy tube cuff was listed as a contraindication for use of the one-way speaking valve.

The Continuous Cardiac Monitoring (Telemetry) policy read, the use of continuous cardiac monitoring was expected for the duration of the patient stay in any critical care area. Alarms on the telemetry monitor were to be maintained in the "ON" position at all times. The nurse assigned to the patient was expected to respond immediately if they received notice of an alarm at the central monitoring station by a telemetry technician or other staff member and if there was any observed change in the patient's cardiac rhythm, loss of telemetry signal, unreadable signal due to artifact, or intermittent signal loss.

References:

According to Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valves (PMV) Instruction Booklet, Warning: tracheostomy tube cuff must have been completely deflated before placing the PMV. Patient will be unable to breathe if cuff is not fully deflated.

According to the Telemetry Escalation Algorithm, when the monitor showed leads off, a critical rate, a rhythm change or a telemetry interruption, the established process was to immediately notify the primary nurse. If the phone was answered, the process was to wait two minutes for restoration of the rhythm or a phone call from the nursing unit. If the phone was not answered, the process was to overhead page the primary nurse to assess the patient and call the nursing supervisor. If after two minutes, the telemetry had not been restored, a call was to be made to the nursing supervisor and the primary nurse was to reassess the patient. If the telemetry was not restored within another 2 minutes, the patient was to be reassessed and the need for a rapid response call to be determined.

1. The facility failed to identify patterns in fall prevention, analyze them for cause to reduce further reoccurrence of the errors and implement necessary process changes or safety measures to protect patients from falls.

a. Review of the Event Reports, from 07/01/17 through 01/09/18, revealed approximately 46 falls occurred, including three of those falls with injuries (Patients #7 and #12). Patients #1, #7, #10, #12 and #13 records and event reports were reviewed for multiple falls.

b. Review of Patient #7's fall event reports provided by the Director of Quality Management (DQM #10) showed a total of eight falls occurred over a six month period, from May 2017 - November 2017, not including one fall documented in the patient's change of conditions on 6/28/17 in which no event report was completed.

On 05/25/17, Nurse Supervisor (Supervisor #16) documented Patient #7 had a fall without injury. According to to event follow up, the event was referred to the appropriate Performance Improvement (PI) committee and the department manager. According to the event report narrative, DQM #10 reviewed the fall event. There was no evidence as to what follow up was going to done to prevent reoccurrence.

On 05/29/17, Supervisor #16 entered an event report for a fall which occurred 3 days prior on 05/26/17. According to the event reporting documentation, Patient #7 had another fall without injury from his/her bed. The event follow up was referred to the appropriate PI committee and department manager. There was no evidence of follow up done.

On 7/6/17, RN #30 entered an event report for Patient #7. She documented the fall without injury occurred at 7:45 p.m. Per the event report filed 7/6/17 at 8:37 p.m., a rapid response was called after the patient slid out of bed onto the floor. However, there was no documentation in the event report on what follow-up was done to ensure the patient experienced no further falls.

On 8/10/17, RN #32 entered an event report for Patient #7. She documented a fall with injury occurred on 8/9/17 at 9:35 p.m. According to the event report, Patient #7 had an unwitnessed fall from his bed. He sustained a head laceration and was taken to an acute care facility for a head CT and sutures. The severity level of the event was noted as "Major".

On 9/1/17, RN #32 entered an event report for Patient #7. The event report revealed Patient #7 had an unwitnessed fall from an enclosure bed. Patient #7 sustained a laceration to the right side of his nose and above his eye. Physician #12 was notified and he ordered neuro checks as a result. A follow up investigation revealed that the netting had not been secured on the patient's enclosure bed, and the nurse manager would counsel staff on proper netting securement on enclosure beds. The event report identified inadequate patient supervision/monitoring and policy/other guidance not followed as potential contributing factors/causes.

On 9/15/17, Supervisor #16 entered an event for Patient #7. According to the event report, Patient #7 was sitting in a wheelchair at the nurse's station when at 8:08 a.m., he pushed himself backwards and fell to the floor. There were no signs of injury, and Physician #14 was notified.

On 9/21/17, Supervisor #16 entered an event report for Patient #7. She documented that at 5:23 p.m., Patient #7 fell out of his chair while sitting at the nurse's station. Patient #7 was wearing a helmet on his head, and did not sustain any injuries.

On 10/14/17, Supervisor #33 entered an event report for Patient #7. According to the event report, Patient #7 had an unwitnessed fall from his bed at 4:39 p.m. Patient #7 had no apparent injuries. Physician #18 was notified.

Two root cause analyses (RCAs) were completed after Patient #7's falls where he sustained injuries.

The first RCA was completed 8/11/17 in response to the 8/9/17 fall. The RCA determined the patient had an unwitnessed fall from a Bariatric Low Boy Bed the evening after his enclosure bed had been discontinued. According to the RCA, fall mats were in place and and the bed alarm was on. Patient #7 sustained an injury that required him to go to the emergency room for a CT (computerized tomography) scan and sutures. The RCA team developed an action plan, which suggested keeping the patient up in the chair longer to tire the patient out, and to engage the patient in more frequent toileting to decrease impulsivity.

The second RCA was completed 9/1/17 in response to the 9/1/17 fall. The RCA determined the patient fell as a result of the enclosure bed netting not being properly secured. Patient #7 crawled out of bed and fell, and sustained a laceration to the right side of his nose and his eye. Physician #12 ordered serial neuro checks. The RCA developed an action plan, which stated the nurse manager would train staff to use the enclosure bed properly. Additionally, the RCA action plan suggested keeping the patient up in the chair longer throughout the day to tire the patient for night time and toilet the patient more often to decrease impulsivity. This was the same action plan documented on the first RCA, completed on 8/11/17, after Patient #7 sustained an injury due to a fall. There was no change in actions to protect the patient from falling again.

Similar findings were found in Patients #1, #10, #12, and #13's event report details.

c. Review of the fall committee meeting minutes, dated 8/9/17 through 1/3/18, showed the purpose of the fall task group was to review causes for increase in fall events during the second quarter for 2017 (Q2), review the current fall prevention program and identify additional fall prevention components.

Six months of Fall Prevention meetings were held. Various leadership attended multiple meetings throughout the six months. The leadership included, the prior Chief Executive Officer (CEO), the current CEO (as of December 2017), the Chief Clinical Officer (CCO #11), DQM #10, education coordinator, rehab coordinator, nurse manager and one of the nursing supervisors. Multiple fall prevention components were discussed at the meetings. Although the fall committee implemented using helmets for at risk patients and completed fall education in November, none of the other interventions identified from the committee were implemented at the time the survey was conducted. Additionally, 10 more patient falls occurred over a 2 month period (November and December), which was 5 months after the Fall Committee had been created.

According to the 8/9/17 agenda items, the Chief Clinical Officer (CCO #11) presented the fall data for 2017 and the current fall prevention program was discussed. According to the analysis and discussion, there were 18 falls during Q2 compared to 10 falls in Q1. There were fewer falls in July as a result of more frequent rounding and staff aware of fall risks and implementing safety precautions. No additional fall prevention components were identified that were not already in place. Mobility training was discussed.

In the month of August, two additional meetings were held. Action plans documented included a quote to be obtained by CCO #11 for portable cameras to be placed in fall risk rooms, hourly rounding, low beds and patient mobility training for staff. At the 8/30/17 meeting, the cameras were on hold and hourly rounding form was to be reviewed by CCO #11.

In September, three meetings were held. A color coding process for fall leaves outside fall risk patients' rooms and inside on their white board was discussed, as well as mirrors to monitor patients, fall education and soft helmets for those patients at risk. On 9/27/17, the committee, including the CCO, decided not to use the hourly rounding form. The cameras discussed at the August meetings again were placed on hold.

In October, three meetings were held. According to the meeting minutes, dated 10/04/17, 10/18/17 and 10/25/17, the facility was still in the process of getting quotes for cameras, looking into purchasing larger fall mats and concave mirrors were ordered. Patient transfer training education had not been scheduled.

In November, four months after the fall prevention committee was formed, cameras were not in use, the mirrors ordered were documented as not useful, beveled floor mats were still in discussion and patient transfer training education had still not been scheduled. Fall prevention training was conducted.

According to the meeting minutes, dated 12/20/17, the committee determined the concave mirror was not useful and larger mirrors were ordered. The facility was still attempting to get beveled mats from another hospital .

The meeting minutes, dated 12/27/17, showed a larger mirror was ordered and six sets of beveled floor mats would be brought over to the facility from another hospital. There was no other fall prevention components identified or implemented. The patient transfer education was still not scheduled after being discussed for five months.

According to the meeting minutes dated 1/3/18, the larger mirror had still not been ordered. The facility did not have any beveled mats and patient transfer training education had yet to be scheduled for patient care staff.

d. During an interview on 1/15/18 at 2:04 p.m., CCO #11 stated a task force was formed to investigate how fall prevention could be improved. She stated there were high incidences of falls amongst patients with traumatic brain injuries (TBIs). She reported the CEO, nurse manager, nurse educator, health information manager, and when available, a floor nurse, were part of the task force.

CCO #11 stated the facility was unable to use sitters as often they would like due to lack of available certified nursing assistants (CNAs). CCO #11 reported the facility had not hired any additional CNAs. She also stated the facility elected to not implement hourly rounding, as mentioned during their falls committee meetings. CCO #11 reported the committee determined the hourly rounding was not necessary.

CCO #11 stated the facility asked patients' families to stay if needed to monitor for falls. When asked about Patient #7, she stated the facility did not always have the opportunity to have sitters. She stated the facility tried to prevent further falls by having him by the nurse's station. Furthermore, according to CCO #11, Patient #7 did not often have a sitter, but his father and sister were often present in the room. CCO #11 was unable to provide documentation of this.

CCO #11 stated the facility requested a quote for video cameras to be used to monitor very high fall risk patients. Then she stated the cameras were too expensive so the facility opted not to purchase the monitoring equipment.

CCO #11 stated she would observe staff to ensure fall prevention interventions were in place, and would round and check rooms. However, she was unable to provide documentation to support this.

CCO #11 stated the patient transfer training discussed in the fall task force meeting since 8/9/17 had not occurred yet.

CCO #11 stated the facility had been unable to get beveled floor mats, which was discussed at the fall committee meetings as a potential intervention to reduce the risk of falls. She stated also the committee decided not to color code fall leaf signs as they felt fall assessments were too subjective and the color coding would be potentially confusing.

When asked what interventions were in place to reduce falls, CCO #11 stated the facility kept fall risk patients in low beds. She then stated "you can't prevent falls". She stated she did go out and observe staff to see what fall interventions were in place, but she was not sure if she documented it. When asked what the facility did after a patient fell, she stated it depended on what interventions were needed and if there was an injury to the patient. She stated she would go out onto the floor and make sure fall preventions were in place. They would review the fall if it might have happened due to a change in medications. She restated that it was "very hard to prevent falls''.

CCO #11 stated her responsibilities included clinical operation, conducting RCAs and ensured quality nursing care. She also stated she ensured nursing staff had the equipment, tools and education needed.

Upon exit of the survey, CCO #11 was unable to provide any evidence of fall precaution monitoring, consideration for sitters and/or changes in staffing (according to facility policy) for Patient #1, #7, #12, #10 and #13 or any additional evidence of which showed process changes implemented to prevent reoccurrence of patients' continued falls.

e. On 1/15/18 at 9:45 a.m., an interview was conducted with DQM #10 who stated the facility had seven performance improvement teams, including a fall work group.

On 1/16/18 at 1:30 p.m., a second interview was conducted with DQM #10. She stated she was responsible for the quality improvement projects and had oversight of various committees, had oversight and tracked the event reporting process.

DQM #10 stated she was part of of fall performance improvement committee. She stated the committee was created because the facility noticed an increase in falls. She stated the purpose of the task group was to see what patients were falling and why the patients were falling. She stated the fall prevention committee did some analysis and reviewed the fall prevention program; however, staff were not observed for compliance of fall precautions.

DQM #10 stated during the committee meetings, many interventions were discussed. These included getting patients up into chairs more frequently, more frequent rounding, and checking on patients on regular intervals (hourly). When asked if any interventions were implemented to reduce the patient falls, she stated only the fall prevention education was completed, which was done at the end of October 2017. The patient transfer training, discussed at the fall committee meeting on 8/9/17, had not been scheduled or completed. She stated the former CEO was going to set up the transfer training. She further stated she had not determined the effectiveness of the education provided in October.

Review of Patient #7's fall events was conducted with DQM #10, including the two RCAs done on 8/11/17 and 9/1/17. DQM #10 stated nurses were front line and were the ones who hopefully made sure the bed alarms were in place, call lights were in reach and the bed was in low position.

When asked how she was following up on nurses actions to prevent falls, she stated patients were discussed on a daily basis. Nursing staff would collaborate with rehabilitation staff to assist Patient #7 out of bed. When asked what changes were put in place for Patient #7, DQM #10 stated the facility got him a soft helmet, moved him closer to the nurse's station, and gave the patient things to do.

However, review of Patient #7 fall events showed the majority of the patient's falls occurred in the same room near the nurse's station. She stated the team did brainstorm about how the patient could be kept safe. Then she stated a sitter, for closer observation, was discussed. Although discussed, the facility never implemented interventions for closer observation needed for Patient #7. DQM #10 could not provide any evidence the quality department addressed and identified possible causes of Patient #7's continued falls while under the care of the facility.

Patient #13's fall event reports and non-functioning bed alarm observation (on 1/12/17) was reviewed with the DQM. Review of Patient #1 fall event reports were also reviewed.

DQM #10 stated she tried to identify if there was anything the facility needed to do for these patients but was not doing already. She stated the tracking and trending of the individuals' falls would be located in the patient's record through the care plans and the interventions. When asked how she evaluated the success of the fall prevention program, she stated through a reduction in falls. A request for the data supporting the tracking and trending of falls was made. She was unable to provide evidence to show if a reduction of falls had occurred.

DQM #10 stated she could not provide evidence how the facility evaluated effectiveness of any fall interventions in place for patients with multiple falls prior to the survey. She stated the facility had been doing the best they could to manage particular patients and keep them safe.

DQM #10 stated she did not have any additional evidence sitters were provided for the patients who had multiple falls during their admission at the facility (Patients #1, #7, #10, #12 and #13) or any evidence the facility considered other interventions to closely monitor the patients and reduce the likelihood of continued falls.


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2. The facility failed to complete a thorough investigation of the factors contributing to the death of a patient.

a. According to the admission history and physical, dated 10/5/17, Patient #5 was admitted to the facility on 10/5/17 with a primary diagnosis of traumatic brain injury (TBI) following an automobile accident on 9/20/17.

Patient #5's medical record revealed an Expiration Summary dictated by Physician #13 on 10/31/17 at 3:24 p.m. Physician #13 documented she had responded to an emergency (code) called for Patient #5 where she led the effort to resuscitate the patient from cardiac arrest. The record revealed the code was called on 10/31/17 at 11:40 a.m. Physician #13 documented Patient #5 was resuscitated for 10 minutes and remained pulseless; therefore, the resuscitation was stopped, and Physician #13 pronounced Patient #5 dead.

In the Expiration Summary, Physician #13 reported she was notified by the respiratory therapist (RT), after the code was completed, that Patient #5 had a Passy-Muir Speaking Valve (PMV) in place at the beginning of the code with the tracheostomy cuff fully inflated. This was in contrast to Manufacturer's Instructions which stated a patient would be unable to breathe with a PMV in place unless the tracheostomy tube cuff was fully deflated.

b. Review of the facility's Patient Event Report, last updated on 11/22/17, revealed the death of Patient #5 was classified as a Level 4 Sentinel Event. Necessary follow up actions identified included reviewing and/or revising policies and procedures, notifying the State, and referring the event to the Performance Improvement committee, Department Manager, medical leadership and the Chief Executive Officer (CEO). Potential contributing factors or causes were identified as communication issues between providers. Training opportunities identified included inadequate documentation monitoring and changes in condition. Policy and other guidance was identified as not followed. The likelihood of event recurrence within one year if no changes were made was identified was documented as very likely. The report stated the death was unexpected and that the coroner was notified.

c. Review of an email communication written on 11/1/17 from Case Manager (CM) #45 to CCO #11, DQM #10 and former Chief Executive Officer (CEO) #46 stated CM #45 had spoken to a point of contact for Patient #5's family who indicated he had "found out that he had experienced a PE arrest because of a blood clot" and the family was no longer requesting an autopsy.

d. Review of an occurrence report, provided by the facility on 1/9/17 was conducted. Question #3 asked, "Was the death the direct result of an occurrence in the facility?" The answer provided was "unknown."

Question 6 asked, "What was the conclusion of the facility?" The response provided was: "Following the internal investigation, the interviews of staff, and the review of medical records, the facility identified gaps in staff performance that may have affected the patient's outcome. An autopsy was not performed and therefore, cause of death is unknown."

Question 7 asked, "Were facility policies and procedures followed?" The response provided was: The Telemetry Escalation Algorithm was not followed. The Tele Tech did not notify the Primary Nurse after Telemetry did not re-engage after 2-4 minutes following telemetry interruption. The One-Way Speaking Valve policy was not followed. The RN placed the PMV and did not deflate the trach cuff."

Question 8 asked, "What interventions were put into place to prevent a recurrence?" The response was: "1. Re-education of all RNs, LPNs and MTs on Telemetry Escalation Algorithm. 2. The One-Way Speaking Valve policy: All RNs, RTs, and SLPs are being retrained on policy."

No additional interventions were identified as needed.

e. Review of the Mortality Review Form completed 11/17/17 by Physician #48 stated the cause of death was respiratory failure secondary to extensive thoracic trauma and pulmonary trauma. This document also stated the death was not unexpected, treatment was performed in a timely fashion and met standards of care.

f. Review of the Quality of Care Committee minutes from the meeting held 12/13/17, stated one mortality review was completed in November for the patient who died on 10/31/17. No referral to peer review was necessary and no further review was deemed necessary. There was no documentation of the rationale for how the review was considered complete or the results of any auditing or other interventions put into place to prevent a similar patient safety event from occurring again.

Review of the Quality of Care Committee minutes from the meeting held 11/8/17, stated there was one Sentinel Event in October. The minutes identified one code blue emergency event occurred in October, and the team responded immediately with physician at bedside. The minutes stated all protocols were followed, and there was an issue with the defibrillator and monitor, but this did not impede the resuscitation process. The opportunity and action plan identified was to continue to review code blue events as they occurred

No additional action items or investigation were documented in the meeting minutes.

g. On 1/16/18 at 1:35 p.m., an interview was conducted with DQM #10 who stated an investigation had been completed into the death of Patient #5. DQM #10 stated the purpose of the investigation was to find out what happened, what factors contributed to the event and to determine whether it was possible to identify the root cause of the event. The next step was to develop a plan to ensure the event did not reoccur.

DQM #10 stated the steps taken in the investigation included interviewing staff, looking at the details of the event itself, and adhering to reporting requirements.

DQM #10 stated the results of the investigation included that the Telemetry Escalation Algorithm and the One-Way Speaking Valve policies were not being followed. The action plan after the event was to re-educate staff on the correct use of PMVs and on telemetry expectations.

DQM #10 stated she did not have any concerns that RN #1, who placed the PMV on Patient #5 without deflating the cuff, was not the primary nurse for the patient. She stated RN #1 was trying to assist the patient to speak with his wife in his own language. DQM #10 stated that was the process, that everyone pitched in to help as needed. She stated this remained the process. DQM #10 stated the investigation had not focused on that and nothing specific had been identified during the investigation.

DQM #10 stated the steps that had been taken to ensure this event did not happen again were that RN #1 was educated and counseled on what she could and could not do with PMVs.

DQM #10 stated she was unaware whether nurses had keys to access the PMVs when they were locked in the cabinet in patient rooms.

DQM #10 stated MD #13 had done the mortality review and found the PMV was not a contributing cause to Patient #5's death. DQM #10 stated the fact that the cuff was not deflated was not found to be a contributing cause of the investigation. DQM #10 further stated she was unsure what had happened to the PMV after the Patient's death.

DQM #10 restated the focus on the investigation was the telemetry was not reading and what happened with the monitoring of the patient's condition. She stated the conclusion was the facility could not definitely identify a cause. DQM #10 stated the occurrence was the final report and it wasn't as comprehensive as it could have been.

DQM #10 stated MD #18 had also reviewed the case and stated a cause of death could not be determined.

DQM #10 stated the facility had performed a mortality review. DQM #10 completed a summary and then a physician not involved in the case did the mortality review. This review was then reviewed in the the Quality and Patient Safety committees; however, the death of Patient #5 on 10/31/17 had not yet been reviewed. She stated the Patient Safety committee would be meeting in February and the specific date had not been set yet.

DQM #10 stated an autopsy had not been completed on the Patient. DQM #10 stated the family initially wanted an autopsy but then the family changed their mind. DQM #10 stated this was not considered in the facility's investigation. DQM #10 stated the coroner had not been told Patient #5 had expired with a PMV in place with an inflated cuff. DQM #10 stated this fact was not addressed during the investigation.

3. The facility failed to identify the need to clearly define the process for the initiation and safe use of One-Way Speaking Valves.

a. A review of the One-Way Speaking Valve policy revealed the first step of the procedure for using a one-way speaking valve with a tracheostomy patient was to obtain a physician/provider order. The second step was for the SLP to complete an oral motor exam. The policy did not specify the roles and responsibilities of the RTs or the RNs regarding use of one-way speaking valves with non-ventilated patients or a clear process for initiating the use of one-way speaking valves.

b. An interview was conducted on 1/11/18 at 1:35 p.m. with RN #1 who stated the process for initiating Passy-Muir valves (PMV) was the speech therapist first tested the PMV with the patient, and then, once the patient passed the test, an order was written by the provider for ongoing use of the PMV. She stated the PMV was kept locked in a cabinet in the patient's room. If a patient needed to talk, the speech language pathologist (SLP), the respiratory therapist (RT) or the RN could apply the PMV to the patient's tracheostomy tube. She stated she knew it was okay to use the PMV because it was available in the room.

RN #1 stated she did not have a way to know whether there was a provider's order for ongoing use of the the PMV because the provider's order only appeared once on the RN's computer screen, and if she was not the RN to acknowledge the order, she had no way to know whether the provider had placed an order for a PMV.

c. On 1/15/18 at 5:19 p.m., an interview was conducted with Respiratory Therapist (RT) #6 who stated the PMV typically remained in a cupboard in the patient's room after the initial trial was conducted. Often, more than one trial was needed before the doctor wrote an order for ongoing use of the PMV. She stated the status of the trial was documented in the RT assessment, and a RN could have known whether a PMV located in a patient's cupboard was okay to use by speaking to the RT or looking in the documentation.

RT #6 stated the Respiratory Department was in charge of PMVs, and RTs preferred the RNs did not apply them to patients. However, RTs were unable to take away the RNs' ability to use the PMVs since it was a skill in RNs' scope of practice.

d. On 1/15/18 at 4:13 p.m., an interview was conducted with Speech Language Pathologist (SLP) #5 who stated she typically conducted the initial PMV trial in response to a physician's "treat and eval" order. This initial trial was typically completed in conjunction with an RT who managed the patient's cuff deflation and airway during the initial trial. She stated after that initial evaluation, the RT typically maintained possession of the PMV and took over the process of continuing the PMV trial with the patient. SLP #5 stated this process was not outlined in facility policy.

SLP # 5 stated she had recently been wondering whether this process was clear and had discussed with her manager whether there needed to be an additional physician order before she was able to proceed with using PMVs with patients. She stated this had not yet been determined.

e. On 1/16/18 at 10:35 a.m., an interview was conducted with the Respiratory and Radiology Director (Director) #9. Director #9 stated the process for RNs to use PMVs was not established in writing. He stated RNs were not in control of the PMV devices, but since use of a PMV was included in the RNs' scope of practice, they were able to use the device with patients if the RNs were comfortable. However, this practice was discouraged. Director #9 stated an RN would have known whether it was okay for them to use the PMV with a patient by looking at the physician orders for the day. However, Director #9 stated that, unfortunately, the order for the PMV no longer appeared on the RN's worklist once the order was acknowledged.

Director #9 stated he had made a decision the previous day with the Director of Rehabilitation to no longer keep the PMVs in the patients' rooms while the PMV was being trialed. He stated the PMVs were now kept in the SLP's office. Director #9 stated they had determined yesterday keeping the PMV in the patients' roo

Based on observations, interviews and document reviews, the Clinical Chief Officer (CCO) who was responsible for nursing staff, failed to provide oversight of nursing services within the facility by not ensuring nursing staff consistently assessed fall risk, implemented fall precaution interventions to meet the needs of patients, and re-evaluated care plans to meet the patients needs and provide a safe environment.

This failure resulted patients at risk for falls to receive less fall risk prevention and monitoring than needed to ensure patient safety.

Findings include:

Facility Policy:

According to the policy, Falls Prevention, the standard fall prevention interventions will be followed on all patients as follows: all Patients and/or family members will be given the Fall Prevention Education Tool; the patient's bed is kept in the lowest position whenever unattended by hospital personnel; the patient will be oriented to the environment, location of bathroom, bathroom emergency call light cord, bed controls, and call bell; the call light will be kept within reach at all times whether the patient is in bed or up in a chair; all patients will be instructed to call for assistance, as appropriate; a light will be left on in the bathroom at night, as indicated; all patients will be instructed to wear non-skid slippers and to avoid wet floors; frequently used personal items will be within easy reach at all times; evaluate patient's perception of comfort as needed; evaluate whether use of side rails will increase potential for patient to climb over; and, frequent offering of toileting and staff monitoring patient while in bathroom.

A Score of > 10 = At Risk. Those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls. The At Risk interventions may include, but are not limited to: use of "risk for falls" sign/device to communicate risk to all caregivers (Falling Leaves, Falling Stars, bracelets, etc); use of a "remember to call for help" sign posted in patient's room to remind patient to call for assistance before getting out of bed; use of Bed Alarms/Chair alarms; turn (or position) bed with one side to the wall and place floor mat along entry/exit side of bed; avoid use of full-length side rails; move patient closer to the Nurses Station; rehab evaluation and treatment as appropriate for conditioning/strengthening options/use of assistive devices; pharmacy review of medications for fall risk potential; use of low bed; select suitable chairs that have armrests or another appropriate geriatric chair; and consider family staying, or changes needed in staffing.

In the event that a patient fall occurs, regardless of the score of the Initial Fall Risk screen, he/she will be automatically considered at risk for falls, additional interventions will be considered, and the Care Plan revised to reflect increased risk.

References:

According to the Posey KeepSafe Cadet 8323 manufacturer's instructions, the alarm unit's Green LED blinks to indicate the unit is "ON".

According to the POSEY Company sensor pad manufacturer's instructions, to reduce the risk of serious injury or death, ALWAYS, follow these steps, make sure alarm is ON and in monitoring mode.

According to Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valves (PMV) Instruction Booklet, Warning: tracheostomy tube cuff must have been completely deflated before placing the PMV. Patient will be unable to breathe if cuff is not fully deflated.

According to the Telemetry Escalation Algorithm, when the monitor showed leads off, a critical rate, a rhythm change or a telemetry interruption, the established process was to immediately notify the primary nurse. If the phone was answered, the process was to wait two minutes for restoration of the rhythm or a phone call from the nursing unit. If the phone was not answered, the process was to overhead page the primary nurse to assess the patient and call the nursing supervisor. If after two minutes, the telemetry had not been restored, a call was to be made to the nursing supervisor and the primary nurse was to reassess the patient. If the telemetry was not restored within another two minutes, the patient was to be reassessed and the need for a rapid response call determined.

1. The CCO failed to monitor nursing staff to ensure a standardized and effective fall prevention process was in place to meet the needs of patients who were at risk of falls.

a. On 1/12/18 at 7:30 a.m., a tour of the Medical/Surgical (M/S) unit and the Medical Observation Unit (MOU) was conducted with the Nurse Manager (Manager #8).

At 7:40 a.m., Patient #13 was observed from the hallway, sliding down in bed with legs over the right side. The patient's pulse oximetry alarm was alarming. Staff assistance was requested by the Nurse Manager. Upon entering the patient's room, the patient was found off his/her bed alarm pad. The bed alarm unit was not activated and the control box did not have the green light illuminated, according to manufacturer's instructions, to indicate power was on.

Review of Patient #13 event reports revealed the patient had five unwitnessed falls without injury from August 2017 through December 2017 (08/30, 09/01, 09/07, 11/16 and 12/22).

At 7:50 a.m., Patient #14's room was observed for fall precautions. Upon entering the patient's room with Nurse Manager #8, the patient was observed in bed with a bed alarm attached to the the headboard. The bed alarm was not on. The control box did not have the green light illuminated to indicate power was on. Nurse Manager #8 stated she assumed the light on the bed alarm would need to be on to indicate the alarm was functioning.

b. On 1/10/18 at 8:45 a.m., a tour of the nursing units was conducted with Manager #8. Two of 7 patients who scored at risk for falls were found without the falling leaf sign, which indicated to other caregivers the patients were a fall risk, according to policy.

Inspection of Patient #16's room showed no evidence the patient was identified at risk for falls. However, a review of Patient #16's last fall risk assessment, dated 1/10/18 at 2:20 a.m., showed the patient scored 13, which according to policy indicated the patient was at risk for falls. The patient's nurse documented the following risk factors for the patient: confusion/disorientation/sedation; unstable gait/balance or requires assistance to ambulate or transfer; user of orthopedic devices, forgets instructions or over estimates own limits and impaired vision or hearing.

Inspection of Patient #14's room was also conducted. There was no falling leaf sign on the patient's door. Review of Patient #14's last fall risk score, documented three days prior on 1/7/18, was 11. According to the safety assessment documented by the patient's CNA on 1/10/17 at 6:47 a.m. (approximately 2 hours prior to the observation), the patient had a fall prevention sign.

According to Manager #8, any patient who was at risk for a fall should have a falling leaf sign on the entry door. Manager #8 confirmed there was no sign on the door.

c. On 1/12/18 at 8:00 a.m., Patient #15 was observed in his room. According to the Nursing Supervisor's Bed Board document, dated 01/12/18 , Patient #15 was a fall risk. There was no falling leaf signage on the patient's door indicating the patient was a fall risk. Review of the last fall score documented by the patient's nurse on 1/11/18 at 11:55 a.m. (the day prior), showed the patient's total fall risk score was 10.

On 1/12/18 at 9:35 a.m., an interview was conducted with CNA #44 who stated the best way to prevent falls was to be proactive. CNA #44 then stated she was unsure if Patient #15 was a fall risk or not.

d. On 01/13/18 at 1:20 p.m., a tour of the nursing units was conducted with the House Supervisor (Supervisor #33), after an Immediate Jeopardy was called the day prior on 01/12/18. Three patients who were listed at risk for falls, according to the Supervisor Bedboard document provided for the tour, did not have all fall precaution interventions in place as determined by nursing leadership and the facility policy.

An inspection of Patient #16's room in the M/S unit, revealed no evidence of fall precaution interventions in place. The patient had only a falling leaf sign posted on the entry door. According to the bed board sheet provided by Supervisor #33, Patient #16 was a fall risk with a score of 11.

An inspection of Patient #15's room, also did not have evidence of fall precaution interventions in place. The fall sign was observed located on the entry door. However, there were no other additional interventions observed in the patient's room, such as bed alarms, or floor mats.

After observations of Patient #15 and #16's were discussed with Supervisor #33, he stated a low bed (a bed lower to the ground than a standard hospital bed) had been ordered and were located in the hall for both patients. Supervisor #33 stated the beds had been in the hallway since delivery around 6:00 a.m. (7 hours prior to the observations of Patient #15 and #16's rooms). During the tour, Patient #15's Licensed Practical Nurse (LPN #27) stated she was unaware a low bed was ordered for her patient. LPN #27 stated she needed to get the fall mats in Patient #15's room.

Furthermore, during the same tour, an inspection of a high fall risk patient located in room 2031, revealed the patient's call light hanging over an IV (intravenous) pole, not within reach of the patient. This was in contrast to policy which stated that the call light will be kept within reach at all times. According to the Bed Board form, the patient's fall score was 22. Supervisor #33 immediately placed the patient's call light within reach of the patient who was in his bed.

e. Review of two separate monitoring forms (Bed Alarms Check Audit and Facility Hospital Monitoring tool) implemented the evening of 1/12/18, showed both the Chief Clinical Officer (CCO #11) and Supervisor #33 documented on 1/13/18, 6 bed alarms were in patients rooms being used and functioning properly. However, observations conducted by the surveyor on the same day revealed only 4 of 6 fall risk patients actually had bed alarms in place.

At 3:30 p.m., CCO #11 stated she completed the Hospital Monitoring Tool on 1/12/18 and 1/13/18. When the surveyor reviewed the prior observation revealing the discrepancy for bed alarms in use, she stated she saw the alarms in the room. A second observation tour was conducted for all 6 fall risk rooms. Upon inspection of Patient #16's room, the CCO stated there was a bed alarm in the room earlier. However, Certified Nursing Assistant (CNA) #44 who was present, stated there was not a bed alarm in the room when she stared her shift earlier the same morning (on 1/13/18). Patient#15's room was inspected a second time. There was no bed alarm present.

After the interview, CCO #11 confirmed the monitoring tools, used to monitor compliance with fall precaution interventions, were inaccurate.

2. The CCO failed to ensure nursing staff adjusted care plans to meet the needs of patients who sustained multiple falls while under the care of the facility.

a. Review of the Event Reports from 07/01/17 through 01/09/18, revealed approximately 46 falls occurred, including three of those falls with injury (Patients #7 and #12). Patients #1, #7, #10, #12 and #13 records and event reports were reviewed for multiple falls.

b. Review of Patient #7's medical record revealed six change of conditions for falls documented by nursing staff. Review of the patient's event reports and investigation worksheets for falls revealed three additional falls. Patient #7 had a total of nine falls during his six month admission. Patient #7 consistently scored greater than 10, including multiple documented fall scores greater than 20, on his fall risk assessments; with scores greater than 10 indicating a fall risk.

On 5/25/17, Nurse Supervisor (Supervisor #16), documented Patient #7 had a fall without injury. According to to event follow up, the event was referred to the appropriate PI committee and the department manager. According to the event report narrative, the Director of Quality Management (DQM #10) reviewed the fall event. There was no evidence as to what follow up was done to prevent reoccurrence.

On 5/29/17, Supervisor #16 entered an event report for a fall which occurred three days prior on 5/26/17. According to the event reporting documentation, Patient #7 had another fall without injury from his bed. The event follow up was referred to the appropriate PI committee and department manager. There was was no evidence as to what follow up was done to prevent reoccurrence.

On 6/28/17 at 11:00 a.m., RN #29 documented the patient was found sitting on the floor after a bed alarm was going off. The patient had a low bed with mats and was found on the mat with restraints still in place. The patient did not have an injury. A fall investigation worksheet completed later the same afternoon by Supervisor #16 revealed a second fall two hours later at 1:15 p.m.

One week later, on 7/6/17 at 7:45 p.m., RN #30 documented a change of condition which showed Patient #7 was found next to his bed with no injuries. According to the change of condition, Physician #31 was notified of the fall and ordered a sitter.

The facility was unable to provide any documented evidence a sitter was provided for Patient #7 throughout the patient's admission.

On 7/6/17, RN #30 entered an event report for Patient #7. She documented the fall without injury occurred at 7:45 p.m. Per the event report filed 7/6/17 at 8:37 p.m., a rapid response was called after the patient slid out of bed onto the floor.

On 7/25/17 at 6:54 p.m., Nurse Supervisor (Supervisor) #7 documented Patient #7 fell out of an enclosed bed.

On 8/9/17, 2 weeks later, at 9:35 p.m., RN #32 documented a change of condition for another fall. According to the documentation, Patient #7 walked into the hallway bleeding from his head following an unwitnessed fall. The documentation revealed the patient said he fell against the bed. The patient was transferred by ambulance to another facility for treatment of a head laceration and a head CT (computed tomography) scan. Nursing staff did not document if the patient's bed alarm was activated. At 3:25 p.m., the patient returned to the facility with staples.
On 8/10/17, RN #32 entered an event report for Patient #7's fall.

On 9/1/17 at 2:40 a.m., according to the change of condition documented by RN #32, the patient had another unwitnessed fall with injury. This was three weeks after Patient #7's last fall which resulted in a head laceration. The documentation revealed both respiratory and nursing staff heard the patient yelling and the patient was found on the floor next to the bed. Patient #7 was confused and unsure how he got out of the bed. RN #32 documented the patient had a laceration on the right side of his nose and a small laceration above the left eye. The physician was notified and neurological checks were ordered.

On 9/1/17, RN #32 entered an event report for Patient #7's fall. A follow up investigation revealed that the netting had not been secured, and the nurse manager would counsel staff on proper netting securement on enclosure beds. The event report identified inadequate patient supervision/monitoring and policy/other guidance not followed as potential contributing factors/causes.

On 09/15/17 at 9:02 a.m., Nurse Supervisor (Supervisor) #16 documented a change of condition for another fall. According to the documentation, Patient #7 was sitting next to the nursing station when he tipped his wheelchair and fell back. The certified nursing assistant (CNA) was charting at the nurses' station at the time. On 9/15/17, Supervisor #16 entered an event for Patient #7. According to the event report, Patient #7 was sitting in a wheelchair at the nursing station when at 8:08 a.m., he pushed himself backwards and fell to the floor. There were no signs of injury, and Physician #14 was notified.

On 9/21/17, Supervisor #16 entered an event report for Patient #7. She documented at 5:23 p.m., Patient #7 fell out of his chair while sitting at the nursing station. Patient #7 was wearing a helmet on his head, and did not sustain any injuries. This was the second time Patient #7 fell at the nursing station.

On 10/14/17, Supervisor #33 entered an event report for Patient #7. According to the event report, Patient #7 had an unwitnessed fall from his bed at 4:39 p.m. Patient #7 had no apparent injuries. Physician #18 was notified.

Review of Patient #7's care plan interventions for falls, dated 5/15/17 through 10/15/17, showed nursing staff documented the same interventions throughout the patient's stay. Interventions documented were: implement safety measures; obtain restraint order if necessary; place padded floor mats at each side of bed; maintain bed in low position; tubes hidden with bandages to prevent pulling of tubes; increased observation; and place fall precautions signage at the bedside. There was no evidence nursing staff adjusted Patient #7's care plans after each of the 9 falls the patient sustained while under their care; including how staff increased observation monitoring which was one of the interventions on the care plan for six months.

The facility was unable to provided any documented evidence Patient #7 had a sitter for 1 on 1 observation after the physician ordered the change in monitoring on 7/6/17. Patient #7 had six additional falls after 7/6/17.

Similar findings were found in Patients #1, #10, #12, and #13's medical records and event report details.

Cross Reference Tag 396

c. During an interview on 1/15/18 at 2:04 p.m., CCO #11 stated a task force was formed to investigate how fall prevention could be improved. She stated there were high incidences of falls amongst patients with traumatic brain injuries (TBIs).

Review of the Fall Prevention Program Task Group meeting minutes, dated 8/9/17 through 1/3/18, showed CCO #11 was one of the responsible parties involved in decision making for fall prevention action plans discussed.

CCO #11 stated the facility was unable to use sitters as often they would like due to lack of available certified nursing assistants (CNAs). CCO #11 reported the facility had not hired any additional CNAs. She also stated the facility elected to not implement hourly rounding, as mentioned during their falls committee meetings. CCO #11 reported the committee determined the hourly rounding was not necessary.

CCO #11 stated the facility asked patient's families to stay if needed. When asked about Patient #7, she stated the facility did not always have the opportunity to have sitters. She stated the facility tried to prevent further falls by having him by the nurses' station. Furthermore, according to CCO #11, Patient #7 did not often have a sitter, but his father and sister were often present in the room. CCO #11 was unable to provide documentation of this.

CCO #11 stated the facility requested a quote for video cameras to be used to monitor very high fall risk patients. Then she stated the cameras were too expensive so the facility opted not to purchase the monitoring equipment.

CCO #11 stated she would observe staff to ensure fall prevention interventions were in place, and would round and check rooms. However, she was unable to provide documentation to support this.

When asked what interventions were in place to reduce falls, CCO #11 stated the facility kept fall risk patients in low beds. However, CCO #11 then stated "you can't prevent falls".

When asked what the facility did after a patient fell, she stated it depended on what interventions were needed and if there was an injury to the patient. She repeated she would go out onto the floor and make sure fall preventions were in place. CCO #11 restated it was "very hard to prevent falls''.

CCO #11 stated her responsibilities included clinical operation, conducting RCAs and ensured quality nursing care. She also stated she ensured nursing staff had the equipment, tools and education needed.

Upon exit of the survey, CCO #11 was unable to provide any evidence of fall precaution monitoring, consideration for sitters and/or changes in staffing (according to facility policy) for Patient #1, #7, #12, #10 and #13 or any additional evidence of which showed process changes implemented to prevent reoccurrence of patients' continued falls.

Cross Reference Tags 0395 and 0396

Based on observations, interviews and document reviews, nursing staff failed to ensure equipment used for fall precautions, specifically bed alarms, were functioning in 2 of 3 observations conducted (Patient #13 and #14). The facility failed to ensure nursing staff implemented fall precautions according to the patients needs and who were considered at risk for falls (Patients #14, #15, and #16). Additionally, nursing staff failed to consistently evaluate patients who were at risk for falls. Further, the facility failed to provide safe nursing care for a tracheostomy patient with a one way speaking valve (Patient #5).

This failure resulted in patient harm related to falls. Additionally, This failure resulted in errors that contributed to the death of a patient.

Findings include:

Facility Policy:

According to the policy, Falls Prevention, the standard fall prevention interventions will be followed on all patients as follows: all patients and/or family members will be given the Fall Prevention Education Tool; the patient's bed is kept in the lowest position whenever unattended by hospital personnel; the patient will be oriented to the environment, location of bathroom, bathroom emergency call light cord, bed controls, and call bell; the call light will be kept within reach at all times whether the patient is in bed or up in a chair; all patients will be instructed to call for assistance, as appropriate; a light will be left on in the bathroom at night, as indicated; all patients will be instructed to wear non-skid slippers and to avoid wet floors; frequently used personal items will be within easy reach at all times; evaluate patient's perception of comfort as needed; evaluate whether use of side rails will increase potential for patients to climb over; and, frequent offering of toileting and staff monitoring patient while in bathroom.

A Score of > 10 = At Risk. Those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls. The At Risk interventions may include, but are not limited to: use of "risk for falls" sign/device to communicate risk to all caregivers (Falling Leaves, Falling Stars, bracelets, etc); use of a "remember to call for help" sign posted in patient's room to remind patient to call for assistance before getting out of bed; use of Bed Alarms/Chair alarms; turn (or position) bed with one side to the wall and place floor mat along entry/exit side of bed; avoid use of full-length side rails; move patient closer to the Nurse's Station; rehab evaluation and treatment as appropriate for conditioning/strengthening options/use of assistive devices; pharmacy review of medications for fall risk potential; use of low bed; select suitable chairs that have armrests or another appropriate geriatric chair; and consider family staying, or changes needed in staffing.

In the event that a patient fall occurs, regardless of the score of the Initial Fall Risk screen, he/she will be automatically considered at risk for falls, additional interventions will be considered, and the Care Plan revised to reflect increased risk.

The One-Way Speaking Valve (Trach Communication Assistance) policy read, the one way speaking valve was designed to restore airflow through the upper airway allowing the patient to verbally communicate. An inflated tracheostomy tube cuff was listed as a contraindication for use of the one-way speaking valve.

The Continuous Cardiac Monitoring (Telemetry) policy read, the use of continuous cardiac monitoring was expected for the duration of the patient stay in any critical care area. Alarms on the telemetry monitor were to be maintained in the "ON" position at all times. The nurse assigned to the patient was expected to respond immediately if they received notice of an alarm at the central monitoring station by a telemetry technician or other staff member and if there was any observed change in the patient's cardiac rhythm, loss of telemetry signal, unreadable signal due to artifact, or intermittent signal loss.

References:

According to the Posey KeepSafe Cadet 8323 manufacturer's instructions, the alarm unit's Green LED blinks to indicate the unit is "ON".

According to the POSEY Company sensor pad manufacturer's instructions, to reduce the risk of serious injury or death, ALWAYS follow these steps, make sure alarm is ON and in monitoring mode.

According to the Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valves (PMV) Instruction Booklet, Warning: tracheostomy tube cuff must have been completely deflated before placing the PMV. Patient will be unable to breathe if cuff is not fully deflated.

According to the Telemetry Escalation Algorithm, when the monitor showed leads off, a critical rate, a rhythm change or a telemetry interruption, the established process was to immediately notify the primary nurse. If the phone was answered, the process was to wait two minutes for restoration of the rhythm or a phone call from the nursing unit. If the phone was not answered, the process was to overhead page the primary nurse to assess the patient and call the nursing supervisor. If after two minutes, the telemetry had not been restored, a call was to be made to the nursing supervisor and the primary nurse was to reassess the patient. If the telemetry was not restored within another two minutes, the patient was to be reassessed and the need for a rapid response call determined.

1. Nursing staff failed to ensure bed alarms and call lights used for patients, who were at risk for falls, were available and functional.

a. On 1/12/18 at 7:30 a.m., a tour of the Medical/Surgical (M/S) unit and the Medical Observation Unit (MOU) was conducted with the Nurse Manager (Manager #8).

At 7:40 a.m., Patient #13 was observed from the hallway, sliding down in bed with legs over the right side. The patient's pulse oximetry alarm was alarming. Staff assistance was requested by the Nurse Manager. Upon entering the patient's room, the patient was found off his bed alarm pad. The bed alarm unit was not activated and the control box did not have the green light illuminated, according to manufacturer's instructions, to indicate power was on.

Review of Patient #13's event reports revealed the patient had 5 unwitnessed falls without injury from August 2017 through December 2017 (08/30, 09/01, 09/07, 11/16 and 12/22).

At 7:50 a.m., Patient #14's room was observed for fall precautions. Upon entering the patient's room with Nurse Manager #8, the patient was observed in bed with a bed alarm attached to the the headboard. The bed alarm was not on. The control box did not have the green light illuminated to indicate power was on. Nurse Manager #8 stated she assumed the light on the bed alarm would need to be on to indicate the alarm was functioning.

b. On 01/13/18 at 1:20 p.m., a tour of the nursing units was conducted with the House Supervisor (Supervisor #33). During the tour, an inspection of a high fall risk patient located in room 2031, revealed the patient's call light was hanging over an IV (intravenous) pole, not within reach of the patient. This was in contrast to policy which stated that the call light would be kept within reach at all times. According to the Bed Board form, the patient's fall score was 22. Supervisor #33 immediately placed the patient's call light within reach of the patient who was in his bed.

c. On 01/12/18 at 9:35 a.m., an interview was conducted with Certified Nursing Assistant (CNA) #44 who stated the best way to prevent falls was to be proactive. CNA #44 stated she started her shift at 6:00 a.m., and her normal process was to check if bed alarms were present, but she did not always check if the alarm worked.

CNA #44 stated Patient #13 was a fall risk and the patient's bed alarm was not working properly during the observation done earlier the same morning. CNA #44 confirmed the patient was not on the bed alarm mat. CNA #44 stated she did not know how long Patient #13's bed alarm did not work.

CNA #44 stated Patient #14 had a bed alarm, but she did not check if the bed alarm worked when she started her shift. CNA #44 stated she did not check to see if the green light was on. She stated the light should always be on. CNA #44 further stated bed alarms were important so staff could respond to a patient falling. Then she reported the purpose of the bed alarm was to know the patient had fallen.

d. On 1/12/18 at 10:09 a.m., an interview was conducted with Registered Nurse (RN) #2. He stated he did a fall screen on the first day he would work with a patient, and at the start of his shifts for the week. RN #2 said if the patient was a fall risk, he would place a falling leaf sign on the entryway of the room. He also stated he would make sure the patient's bed was in a low position, ensure the side rails were raised, and place a bed alarm if needed.

RN #2 reported he used bed alarms for patients who were more confused than others. RN #2 stated he would test to see if the bed alarm was functioning by disconnecting the cord from the box, but stated he did not know if there was a light or not, to indicate the bed alarm was on. RN #2 stated he would test the alarm every two hours when he repositioned a patient. However, after review of the observation conducted earlier in Patient #13's room, RN #2 stated the patient's bed alarm was not working and he did not know how long the bed alarm was off. RN #2 stated he did not check it in the morning, which contradicted his earlier statement.

RN #2 reported the nurse who completed the fall risk assessment was responsible for placing the falling leaf sign on the wall outside the entry way door. RN #2 stated if fall interventions were not in place or worked, the patient could be hurt. He further stated interventions were implemented to keep patients safe.

2. Nursing staff failed to ensure fall precaution interventions were in place for patients who were at risk for falls.

a. On 1/10/18 at 8:45 a.m., a tour of the nursing units was conducted with Manager #8. Two of 7 patients who scored at risk for falls were found without the falling leaf sign, which indicated to other caregivers the patients were a fall risk, according to policy.

Inspection of Patient #16's room showed no evidence the patient was identified at risk for falls. However, review of Patient #16's last fall risk assessment, dated 1/10/18 at 2:20 a.m., showed the patient scored 13, which according to policy indicated the patient was at risk for falls. The patient's nurse documented the following risk factors for the patient: confusion/disorientation/sedation; unstable gait/balance or requires assistance to ambulate or transfer; user of orthopedic devices, forgets instructions or over estimates own limits and impaired vision or hearing.

Inspection of Patient #14's room was also conducted. There was no falling leaf sign on the patient's door.
Review of Patient #14's last fall risk score, documented three days prior on 1/7/18, was 11, which indicated the patient was at risk for falls. According to the safety assessment documented by the patient's CNA on 1/10/18 at 6:47 a.m. (approximately 2 hours prior to observation), the patient had a fall prevention sign.

According to Manager #8, any patient who was at risk for a fall should have a falling leaf sign on the entry door. Manager #8 confirmed there was no sign on the door to Patient #14's room.

b. On 1/12/18 at 8:00 a.m., Patient #15 was observed in his room. According to the Nursing Supervisor's Bed Board document, dated 1/12/18 , Patient #15 was a fall risk. There was no falling leaf signage on the patient's door indicating the patient was a fall risk. Review of the last fall score documented by the patient's nurse on 1/11/18 at 11:55 a.m. (the day prior), showed the patient's total fall risk score was 10.

On 1/12/18 at 9:35 a.m., an interview was conducted with CNA #44 who stated the best way to prevent falls was to be proactive. CNA #44 then stated she was unsure if Patient #15 was a fall risk or not.

c. On 01/13/18 at 1:20 p.m., a tour of the nursing units was conducted with the House Supervisor (Supervisor #33), after an Immediate Jeopardy was called the day prior on 1/12/18. Three patients who were listed at risk for falls, according to the Supervisor Bedboard document provided for the tour, did not have all fall precaution interventions in place as determined by nursing leadership and the facility policy.

An inspection of Patient #16's room in the M/S unit, revealed no evidence of fall precaution interventions in place. The patient had only a falling leaf sign posted on the entry door. According to the bed board sheet provided by Supervisor #33, Patient #16 was a fall risk with a score of 11.

An inspection of Patient #15's room, also did not have evidence of fall precaution interventions in place. The fall sign was observed located on the entry door. However, there were no other additional interventions observed in the patient's room, such as bed alarms, or floor mats.

After observations of Patient #15 and #16's were discussed with Supervisor #33, he stated a low bed (a bed lower to the ground than a standard hospital bed) had been ordered and were located in the hall for both patients. Supervisor #33 stated the beds had been in the hallway since delivery around 6:00 a.m., the same morning (7 hours prior to the observations of Patient #15 and #16's rooms). During the tour, Patient #15's Licensed Practical Nurse (LPN #27) stated she was unaware a low bed was ordered for her patient. LPN #27 stated she needed to get the fall mats in Patient #15's room.

Furthermore, during the same tour, an inspection of a high fall risk patient located in room 2031, revealed the patient's call light hanging over an IV (intravenous) pole, not within reach of the patient. This was in contrast to policy which stated that the call light will be kept within reach at all times. Supervisor #33 immediately placed the patient's call light within reach of the patient who was in his bed. According to the Bed Board form, the patient's fall score was 22.

d. Review of two separate monitoring forms (Bed Alarms Check Audit and Facility Hospital Monitoring tool) implemented the evening of 1/12/18, showed both the Chief Clinical Officer (CCO #11) and Supervisor #33 documented on 1/13/18, 6 bed alarms were in patients rooms being used and functioning properly. However, observations conducted by the surveyor on the same day revealed only 4 of 6 fall risk patients actually had bed alarms in place.

On 1/13/18 at 3:30 p.m., CCO #11 stated she completed the Hospital Monitoring Tool on 1/12/18 and 1/13/18. When the surveyor reviewed the prior observation revealing the discrepancy for bed alarms in use, CCO #11 stated she saw the alarms in the room. A second observation tour was conducted for all 6 fall risk rooms. Upon inspection of Patient #16's room, the CCO stated there was a bed alarm in the room earlier. CNA #44, who was present, stated there was not a bed alarm in the room when she started her shift earlier the same morning (on 1/13/18). Patient #15's room was inspected a second time. There was no bed alarm present.

At 4:05 p.m., Supervisor #33 was interviewed. He confirmed the bed alarms were not in the room at the time he documented on the Bed Alarm Check Audit form earlier the same day on 1/13/18. He stated the goal was to have the bed alarm units in the patients' rooms, plugged in and working. He stated the intent of the audit was to confirm the bed alarm unit was on, in the patients' room. He stated he had not gotten the nurses to place the bed alarms in the room. He stated the alarms were on the counter at the nurse's station at the time he filled out the audit sheet.

After the interviews, both CCO #11 and Supervisor #33 confirmed the monitoring tools, used to monitor compliance with fall precaution interventions, were inaccurate.




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3. The facility failed to ensure nursing staff provided treatment in accordance with manufacturer's instructions for patients utilizing one-way speaking valves, potentially resulting in a negative patient outcome.

a. The One-Way Speaking Valve (Trach Communication Assistance) policy read, the one way speaking valve was designed to restore airflow through the upper airway allowing the patient to verbally communicate. An inflated tracheostomy tube cuff was listed as a contraindication for use of the one-way speaking valve.

According to Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valves (PMV) Instruction Booklet, Warning: tracheostomy tube cuff must have been completely deflated before placing the PMV. The patient will be unable to breathe if cuff is not fully deflated.

b. According to the admission history and physical, dated 10/5/17, Patient #5 was admitted to the facility on 10/5/17 with a primary diagnosis of traumatic brain injury (TBI) following an automobile accident on 9/20/17.

Patient #5's medical record revealed an Expiration Summary, dictated by Physician #13 on 10/31/17 at 3:24 p.m. Physician #13 documented she had responded to an emergency (code) for Patient #5 where she led the effort to resuscitate the patient from cardiac arrest. The record revealed the code was called on 10/31/17 at 11:40 a.m. Physician #13 documented Patient #5 was resuscitated for 10 minutes and remained pulseless; therefore, the resuscitation was stopped, and Physician #13 pronounced Patient #5 dead.

In the Expiration Summary, Physician #13 reported she was notified by the respiratory therapist (RT), after the code was completed, Patient #5 had a Passy-Muir Speaking Valve (PMV) in place at the beginning of the code with the tracheostomy cuff fully inflated. This was contraindicated in the Manufacturer's Instructions which warned a patient could not breathe with a PMV in place unless the cuff was fully deflated.

Review of Patient #5's medical record revealed the PMV had first been used with the patient the previous day, on 10/30/17. A note was entered on 10/30/17 at 12:24 p.m. by Speech Language Pathologist (SLP) #5 who reported Patient #5 tolerated the PMV well and accurately counted from 1 to 10 and stated the days of the week and the months of the year using the PMV. SLP #5 documented she left the PMV in place on the patient in agreement with the respiratory therapist (RT) and the RN.

On 1/15/18 at 5:19 p.m., an interview was conducted with Respiratory Therapist (RT) #6 who stated she had worked with SLP #5 to trial the PMV with Patient #5 on 10/30/17. She stated the patient did fine with his initial evaluation, but an hour later his airway became tight so she removed the PMV from the patient, placed the valve in the cupboard, and left the tracheostomy cuff deflated, as it remained until the following day. There was no documentation in the medical record on removal of the PMV by RT #6. Further there was no documentation as to when the cuff was reinflated and by whom.

c. On 1/12/18 at 7:28 a.m., a tour was conducted with Respiratory and Radiology Director (Director) #9. At 8:03 a.m., Director #9 entered the room of Patient #2 who was wearing a TT02 speaking valve. Director #9 stated the TT02 valve functioned similarly to a PMV. He stated both valves required the tracheostomy cuff to be deflated. Director #9 stated he would know if the cuff was inflated when the valve was placed because the patient would have lost her voice and would have been panicking because she could not breathe.

d. On 1/11/18 at 1:35 p.m., an interview was conducted with RN #1. RN #1 stated she was called to Patient #5's room on 10/31/17 in the a.m. to translate for the wound care team. RN #1 stated she had been present the previous day (10/30/17) and had observed Patient #5 speaking using the PMV. RN #1 stated the patient's wife wanted the patient to be able to speak directly with the wound care team regarding his worsening pain, and the wife pointed to the PMV which was located in the cabinet in Patient #5's room.

RN #1 stated she then removed the PMV from the cabinet and placed it on Patient #5's tracheostomy tube. She stated the patient said hello in his native language to the team but was unable to answer questions as he had the previous day. RN #1 stated Patient #5 was then turned onto his side by the wound care team, and RN #1 confirmed with the team it was okay for her to leave. RN #1 stated she thought she had not deflated the tracheostomy cuff before she left the room; however, she recalled the patient's oxygen levels were okay. RN #1 stated she did not have any concerns about the patient prior to leaving the room. RN #1 stated she did not document placing the PMV on the patient because she had resumed giving medications to her patients after leaving the patient's room.

RN #1 acknowledged she was not Patient #5's primary nurse on 10/31/17 and she did not inform the primary nurse she had placed the PMV or chart it in the medical record. RN #1 stated she did not know if there was an order for the PMV. She stated if the PMV was in the room "you know you can use it."

A subsequent interview was conducted with RN #1 on 1/12/18 at 3:43 p.m. RN #1 stated she always tried to be helpful, but realized it was important to draw a clearer line between her patients and other nurse's patients. She stated she needed to always ask the patient's primary nurse before assisting their patient.

e. An interview was conducted on 1/11/18 at 3:58 p.m. with Wound Care Registered Nurse (RN) #42. RN #42 stated he entered Patient #5's room on 10/31/17 with Physician Assistant (PA) #41 to provide wound care. RN #42 stated the patient was sleeping when they entered the room, and they woke the patient up to tell him what they were going to do. RN #42 stated they wanted to speak with the patient so they asked RN #1 to come into the room to translate. RN #42 stated RN #1 was speaking to the patient, but the patient was not responding. He stated the patient was rolled onto his right side and the dressing change completed. RN #42 stated he typically wrote the time the dressing was applied on the dressing, and he recalled writing 11:20 a.m. on Patient #5's dressing that day. He stated the patient was calmer than usual, opened his eyes, but did not engage as he usually had.

f. On 10/31/17 at 8:37 a.m., RN #2 documented his morning assessment for Patient #5. RN #2 charted the patient was unable to express his pain score due to having a tracheostomy but did not specifically address the status of the tracheostomy tube or the use of a PMV with the patient.

An interview was conducted on 1/10/18 at 2:35 p.m. with RN #2 who was Patient #5's primary nurse on 10/31/17. RN #2 stated he completed his morning assessment with Patient #5 and later entered the patient's room to apply the patient's Fentanyl patch. RN#2 stated when he placed the Fentanyl patch he noticed something did not look right with the patient, and he "hollered" for the nursing supervisor (Supervisor #7). Supervisor #7 entered the room and called the emergency (code) response team.

On 1/16/18 at 9:22 a.m., an interview was conducted with Supervisor #7 who stated while she was on rounds on 10/31/17, RN #2 asked for her assistance charting the Fentanyl patch he had placed on Patient #5. Supervisor #7 stated she entered Patient #5's room, assisted the RN with charting, and then left the room when her phone rang. She stated she only went out for a second when RN #2 asked her to re-enter the room to look at the patient, and she came right back in. Supervisor #7 stated she then noticed Patient #5's lips were pale and he "was not right," so she pushed the emergency (code) button.

The Medication Administration Record (MAR) revealed a topical fentanyl citrate patch was documented as placed on Patient #5's left shoulder by RN #2 on 10/31/17 at 11:37 a.m.

Review of Patient #5's Code Blue Flowsheet, dated 10/31/17, showed the emergency code was called at 11:40 a.m., approximately 20 minutes after the completion of the wound care and after the passy-muir valve was placed without the tracheostomy cuff being deflated. The flowsheet noted Patient #5 was unresponsive and pulseless.

Based on interviews and document reviews, the facility failed to ensure nursing staff re-evaluated patients' care needs, as well as the effectiveness of the care plan to maintain the patient's health and safety for patients in 5 of 5 medical records reviewed for patients with multiple falls (Patients #1, #7, #10, #12 and #13).

This failure resulted in continued patient falls, including falls with injuries.

Findings include:

Facility Policy:

According to the policy, Falls Prevention, the standard fall prevention interventions will be followed on all patients as follows: all patients and/or family members will be given the Fall Prevention Education Tool; the patient's bed is kept in the lowest position whenever unattended by hospital personnel; the patient will be oriented to the environment, location of bathroom, bathroom emergency call light cord, bed controls, and call bell; the call light will be kept within reach at all times whether the patient is in bed or up in a chair; all patients will be instructed to call for assistance, as appropriate; a light will be left on in the bathroom at night, as indicated; all patients will be instructed to wear non-skid slippers and to avoid wet floors; frequently used personal items will be within easy reach at all times; evaluate patient's perception of comfort as needed; evaluate whether use of side rails will increase potential for patients to climb over; and, frequent offering of toileting and staff monitoring patient while in bathroom.

A Score of > 10 = At Risk. Those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls. The At Risk interventions may include, but are not limited to: use of "risk for falls" sign/device to communicate risk to all caregivers (Falling Leaves, Falling Stars, bracelets, etc); use of a "remember to call for help" sign posted in patient's room to remind patient to call for assistance before getting out of bed; use of Bed Alarms/Chair alarms; turn (or position) bed with one side to the wall and place floor mat along entry/exit side of bed; avoid use of full-length side rails; move patient closer to the Nurse's Station; rehab evaluation and treatment as appropriate for conditioning/strengthening options/use of assistive devices; pharmacy review of medications for fall risk potential; use of low bed; select suitable chairs that have armrests or another appropriate geriatric chair; and consider family staying, or changes needed in staffing.

In the event that a patient fall occurs, regardless of the score of the Initial Fall Risk screen, he/she will be automatically considered at risk for falls, additional interventions will be considered, and the Care Plan revised to reflect increased risk.

1. Nursing staff failed to re-evaluate and adjust care plans after patients sustained a fall.

a. Review of the Event Reports, from 7/1/17 through 1/9/18, revealed approximately 46 patient falls occurred, including three of those falls with injury (Patients #7 and #12). Patients #1, #7, #10, #12 and #13 records were reviewed for multiple falls.

i. Review of Patient #7's medical record revealed six change of conditions for falls documented by nursing staff. Review of the patient's event reports and investigation worksheets for falls revealed three additional falls. Patient #7 had a total of nine falls during his six month admission. Patient #7 consistently scored greater than 10, including multiple documented fall scores greater than 20, on his fall risk assessments; with scores greater than 10 indicating a fall risk.

On 5/25/17, Nurse Supervisor (Supervisor #16), documented Patient #7 had a fall without injury. According to to event follow up, the event was referred to the appropriate PI committee and the department manager. According to the event report narrative, the Director of Quality Management (DQM #10) reviewed the fall event. There was no evidence as to what follow up was done to prevent reoccurrence.

On 5/29/17, Supervisor #16 entered an event report for a fall which occurred three days prior on 5/26/17. According to the event reporting documentation, Patient #7 had another fall without injury from his bed. The event follow up was referred to the appropriate PI committee and department manager. There was no evidence as to what follow up was done to prevent reoccurrence.

On 6/28/17 at 11:00 a.m., RN #29 documented the patient was found sitting on the floor after a bed alarm was going off. The patient had a low bed with mats and was found on the mat with restraints still in place. The patient did not have an injury. A fall investigation worksheet completed later the same afternoon by Supervisor #16 revealed a second fall two hours later at 1:15 p.m.

One week later, on 7/6/17 at 7:45 p.m., RN #30 documented a change of condition which showed Patient #7 was found next to his bed with no injuries. According to the change of condition, Physician #31 was notified of the fall and ordered a sitter.

The facility was unable to provide any documented evidence a sitter was provided for Patient #7 throughout the patient's admission.

On 7/6/17, RN #30 entered an event report for Patient #7. She documented the fall without injury occurred at 7:45 p.m. Per the event report filed 7/6/17 at 8:37 p.m., a rapid response was called after the patient slid out of bed onto the floor.

On 7/25/17 at 6:54 p.m., Nurse Supervisor (Supervisor) #7 documented Patient #7 fell out of an enclosed bed.

On 8/9/17, 2 weeks later, at 9:35 p.m., RN #32 documented a change of condition for another fall. According to the documentation, Patient #7 walked into the hallway bleeding from his head following an unwitnessed fall. The documentation revealed the patient said he fell against the bed. The patient was transferred by ambulance to another facility for treatment of a head laceration and a head CT (computed tomography) scan. Nursing staff did not document if the patient's bed alarm was activated. At 3:25 p.m., the patient returned to the facility with staples.
On 8/10/17, RN #32 entered an event report for Patient #7's fall.

On 9/1/17 at 2:40 a.m., according to the change of condition documented by RN #32, the patient had another unwitnessed fall with injury. This was three weeks after Patient #7's last fall which resulted in a head laceration. The documentation revealed both respiratory and nursing staff heard the patient yelling and the patient was found on the floor next to the bed. Patient #7 was confused and unsure how he got out of the bed. RN #32 documented the patient had a laceration on the right side of his nose and a small laceration above the left eye. The physician was notified and neurological checks were ordered.

On 9/1/17, RN #32 entered an event report for Patient #7's fall. A follow up investigation revealed that the netting had not been secured, and the nurse manager would counsel staff on proper netting securement on enclosure beds. The event report identified inadequate patient supervision/monitoring and policy/other guidance not followed as potential contributing factors/causes.

Two root cause analyses (RCAs) were completed after Patient #7's falls where he sustained injuries.

The first RCA was completed 8/11/17 in response to the 8/9/17 fall. The RCA determined the patient had an unwitnessed fall from a bariatric low boy bed the evening after his enclosure bed had been discontinued. According to the RCA, fall mats were in place and the bed alarm was on. Patient #7 sustained an injury that required him to go to the emergency room for a CT scan and sutures. The RCA team developed an action plan, which suggested keeping the patient up in the chair longer to tire the patient out, and to engage the patient in more frequent toileting to decrease impulsivity.

The second RCA was completed 9/1/17 in response to the 9/1/17 fall. The RCA determined the patient fell as a result of the enclosure bed netting not being properly secured. The RCA developed an action plan, which stated the nurse manager would train staff to use the enclosure bed properly. Additionally, the RCA action plan suggested keeping the patient up in the chair longer throughout the day to tire the patient for night time and toilet the patient more often to decrease impulsivity. This was the same action plan documented on the first RCA completed after Patient #7 sustained an injury due to a fall. There was no change in actions to protect the patient from falling again.

Patient #7 had 3 additional falls after the two RCAs were conducted on 8/11/17 and 9/1/17.

On 09/15/17 at 9:02 a.m., Nurse Supervisor (Supervisor) #16 documented a change of condition for another fall. According to the documentation, Patient #7 was sitting next to the nurse's station when he tipped his wheelchair and fell back. The certified nursing assistant (CNA) was charting at the nurse's station at the time. On 9/15/17, Supervisor #16 entered an event for Patient #7. According to the event report, Patient #7 was sitting in a wheelchair at the nurse's station when at 8:08 a.m., he pushed himself backwards and fell to the floor. There were no signs of injury, and Physician #14 was notified.

On 9/21/17, Supervisor #16 entered an event report for Patient #7. She documented at 5:23 p.m., Patient #7 fell out of his chair while sitting at the nurse's station. Patient #7 was wearing a helmet on his head, and did not sustain any injuries. This was the second time Patient #7 fell at the nurse's station.

On 10/14/17, Nurse Supervisor (Supervisor #33) entered an event report for Patient #7. According to the event report, Patient #7 had an unwitnessed fall from his bed at 4:39 p.m. Patient #7 had no apparent injuries. Physician #18 was notified.

Review of Patient #7's care plan interventions for falls, dated 5/15/17 through 10/15/17, showed nursing staff documented the same interventions throughout the patient's stay. Interventions documented were: implement safety measures; obtain restraint order if necessary; place padded floor mats at each side of bed; maintain bed in low position; tubes hidden with bandages to prevent pulling of tubes; increased observation; and place fall precautions signage at the bedside. There was no evidence nursing staff adjusted Patient #7's care plans after each of the 9 falls the patient sustained while under their care; including how staff increased observation monitoring which was one of the interventions on the care plan for six months.

The facility was unable to provided any documented evidence Patient #7 had a sitter for 1 on 1 observation after the physician ordered the change in monitoring on 7/6/17. Patient #7 had six additional falls after 7/6/17.

According to the policy, at risk for fall interventions may include, but were not limited to "Consider family staying, or changes needed in staffing". Review of all event reports for Patient #7's falls, showed no evidence either nursing staff or leadership considered this change to Patient #7's care plan.

ii. According the the admitting physician history and physical dated 9/8/17, Patient #12 was involved in an unhelmeted motorcycle accident on 8/19/17. He sustained extensive intracranial injuries. Patient #12 was transferred to this facility on 9/8/17 for ventilator weaning, wound care and rehabilitation services. On admission, Physician #18 described Patient #12 as having decreased mentation, and was probably encephalopathic (a term for any brain disease that alters brain function or structure).

RN #15 assessed Patient #12 for fall risk on 9/9/17 at 9:48 a.m. and scored him 12, indicating Patient #12 qualified as a fall risk according to facility policy. No interventions were charted this shift. At 10:21 p.m., RN #25 charted Patient #12's fall risk interventions. Interventions included: implement safety measures; keep call light readily available and educate on use; perform fall risk assessment; orient to the environment; frequent assessment of the need for invasive devices, tubes, IV (intravenous) lines.

On 9/10/17, RN #34 entered a fall event report for Patient #12. Per the event report, Patient #12 sustained an unwitnessed fall at 10:20 p.m. No injuries were apparent. The event report stated all fall precautions were in place, but a review of the fall investigation worksheet reveals the bed/chair alarm was not in use.

Review of Patient #12's change of condition revealed staff were alerted to the patient's room by the telemetry technician, who noticed the patient was off telemetry. Staff entered the room, and found the patient prone on his fall mats. Physician #35 was notified, and Patient #12 was placed in soft limb restraints.

On 9/12/17 at 8:17 p.m., RN #38 scored Patient #12, 21 on the fall risk scale, which indicated a change from previous scores. Risks identified were: confusion/disorientation/sedation; high risk drugs in the past 72 hours; unstable gait/balance or required assistance to ambulate or transfer; forgets instructions or overestimates own limits and previous falls. The interventions charted included: implement safety measures; maintain bed in a low position; keep call light readily available and educate on use; perform fall risk assessment; orient to the environment; frequent assessment of the need for invasive devices, tubes, IV lines.

On 9/25/17, Supervisor #33 entered an event report for Patient #12. According to the event report, Patient #12 was sitting in a chair with a lap belt. At 11:00 a.m., he was found on the ground by an Licensed Practical Nurse (LPN). He had a new, small abrasion on his right cheek. Physician #13 was notified and no new orders were given. A review of documentation and the fall investigation worksheet was unable to show the bed/chair alarm was in use, as no alarm was mentioned, and the question was left blank on the worksheet.

RN #36 reassessed Patient #12 for fall risk at 5:23 p.m. that day. Patient #12 scored 21 on the fall risk scale, indicating a fall risk. Interventions charted by RN #36 at 6:43 p.m. did not reflect any changes from the previous interventions documented despite the patient had fallen.

A RCA was conducted as a result of the fall with injury on 9/25/17. The RCA team, which consisted of Nurse Manager #37, Supervisor #33, and Director of Quality Management (DQM) #10, determined the cause of the fall was Patient #12 was able to reach and release his Velcro lap belt on his chair. The prevention strategies determined were: use of a low bed and a room close to the nurse's station. The action plan the team agreed on was to use a bed/chair alarm, effective immediately.

Patient #12 sustained two more falls after the RCA was completed.

On 10/3/17, RN #21 entered an event report for Patient #12. According to the event report, Patient #12 slid out of his bed at 6:50 p.m. while attempting to remove his adult diaper. A rapid response was called to his room. No new injuries were reported. The event report stated all fall precautions were in place. However, review of the fall investigation worksheet did not indicate the bed/chair alarm was in use, as the question was left blank. The bed/chair alarm was part of the action plan for the RCA completed eight days prior.

RN #39 documented a new fall risk assessment at 9:09 p.m. Patient #12 scored 21, indicating a fall risk. Interventions were charted at 10/4/17 at 3:24 a.m. and did not show any changes in interventions from the previous documentation, despite the patient falling nine hours prior.

On 10/5/17, RN #7 entered an event report for Patient #12. According to the event report, Patient #12 sustained an unwitnessed fall in his room at 2:45 p.m. The physician was notified, and no new orders were received. Review of the change of condition revealed the patient was found lying on the floor by staff and was assisted back to bed.

Review of IDT (Interdisciplinary Team) meeting notes for Patient #12 revealed neither falls nor fall prevention was discussed at IDT team meetings held 9/12/17, 9/19/17, 9/26/17 and 10/3/17. The team set a goal for increased participation in activities of daily living (ADLs) on 9/26/17, but no safety goals were set otherwise.

iii. According to a history and physical, Patient #1 was transferred to the facility on 8/31/17 for tracheostomy and airway management. An admitting physician history and physical note dated 8/31/17 revealed Patient #1 had a recent history of alcohol abuse and withdrawal.

Patient #1 sustained five falls during his care at the facility. There was no evidence in the medical record which showed nursing staff re-evaluated the patient's care plan and implemented process changes to prevent continued falls.

On 9/2/17 at 7:45 a.m., RN #15 documented Patient #1's first fall risk assessment. Patient #1 scored 14 on the fall risk assessment, with scores greater than 10 indicating a fall risk. Risks for falls identified on the assessment included: confusion/disorientation/sedation; unstable gait/balance or requires assistance to ambulate to transfer, user of orthopedic devices; sensory status, forgets instructions or overestimates own limits; language barrier; and no previous fall history. Interventions documented were: implemented safety measures; assisted with activities of daily living (ADLs); assisted with ambulation; maintained bed in low position; keep call light readily available and educated on use and orient patient to environment.

On 11/12/17 at 11:02 p.m., a fall risk assessment was documented for Patient #1. He scored 21 on the fall risk scale.

An event report filed by Supervisor #16 on 11/13/2017 revealed at 10:10 a.m., Patient #1 fell out of his wheelchair in his room. The physician was notified and no injuries were reported. A fall investigation worksheet completed 11/13/17 at 10:10 a.m. stated at the time of the fall, the call light was functioning and was within reach, the bed was in a low position, fall risk signage was in use, and the patient had a history of falls. The question of whether a bed or chair alarm was in use was left blank.

Post fall interventions charted by RN #2 on 11/13/17 at 10:55 a.m. included: implement safety measures; assist with ADLs, assist with ambulation, maintain bed in low position, keep call light readily available and educate on use, orient to environment. The interventions documented by RN #2 were the same interventions documented for Patient #1's first fall risk assessment; prior to the patient's fall. Patient #1 was not reassessed for fall risks until 11/13/17 8:03 p.m., at which time he was scored 21.

On 11/19/17 at 9:00 p.m., RN #20 documented a new fall risk assessment. This assessment showed a fall risk score of 9, which indicated Patient #1 was not at risk for falls. In this assessment, RN #20 documented that patient #1 had not had a previous fall which was inaccurate according to earlier documentation in the patient's medical record. No fall interventions were charted for the shift.

An event report filed on 11/20/17 by RN #17 revealed at 11:35 a.m., Patient #1 was found on the floor/ground of his room after an unwitnessed fall from his wheelchair. According to a change of condition filed 11/20/17 at 5:33 p.m., by RN #17, a rapid response was called to the room, Physician #18 was notified, and the bed alarm was in place. According to the event report, Patient #1 did not sustain any injuries and patient's confusion was identified as a contributing factor in the fall. Fall interventions documented prior to the fall on 11/20/17 at 10:00 a.m. were the same interventions documented prior to the patient's first fall on 11/13/17: assist with ADLs; assist with ambulation; maintain bed in low position; keep call light available and educate on use and orient to environment.

On 11/20/17 at 1:32 p.m., a new fall risk assessment was documented, in which the patient scored 19. No new interventions were charted despite the patient falling.

On 11/30/17 at 9:50 a.m., Supervisor #16 witnessed Patient #1 fall forward out of his wheelchair while in his room, according to an event report filed by Supervisor #16. Staff observed a reddened area on Patient #1's torso after the fall, Physician #18 ordered a thoracic spine x-ray. The x-ray revealed no injuries. The event report stated all fall precautions were in place at the time. A fall investigation worksheet completed 11/30/17 at 9:50 a.m. stated at the time of the fall, the bed/chair alarm was in use, the call light was functioning and was within reach, bed was in low position, and fall signage was in place. Patient #1's mental status was also identified as "Confused at times."

The change of condition filed 11/30/17 at 10:26 a.m. stated that Patient #1 fell out of the wheelchair despite a seat belt being used to secure the patient. The patient was placed back into wheelchair by staff after the fall, at 9:50 a.m.

Another event report filed by Supervisor #16 on 11/30/17 revealed at 10:05 a.m., Patient #1 sustained a second fall that day. Patient #1 was sitting in a wheelchair in his room. Staff responded to the chair alarm sounding in the room, and upon entering, they found the patient on the floor. A fall investigation worksheet completed 11/30/17 stated the call light was functioning and was within reach, the bed was in low position, fall risk signage was in use and the bed/chair alarm was in use.

According to the narrative section of the event report, "Review team decided to implement a new process to avoid patient being in chair unattended. Rehab will get him up daily to ambulate. Scheduled toileting program will be put into place. Patient will have HOB [head of bed] raised periodically during the day."

Staff completed a root cause analysis (RCA) on 11/30/17 in response to the multiple falls, including two falls within 15 minutes of each other. The stated goal of the RCA was to determine causes and prevent future falls. The RCA concluded confusion was a contributing factor. The RCA outlined an action plan which suggested the patient should be placed back into bed after therapy sessions, therapy would trial sitting the patient up in bed, and nursing would initiate bowel and bladder training.

Prior to this fall, Patient #1's fall risk score was 21 according to nursing notes filed 11/29/17 at 10:26 p.m. Interventions filed with the assessment were: assist with ADLs; assist with ambulation; maintain bed in a low position; keep call light readily available and educate on use; and orient to environment. On 12/1/17 at 12:47 a.m., Patient #1's post-fall fall score was documented as 23. Fall risk interventions documented at the same time do not reflect any changes from previous documentation.

Patient #1 sustained another fall 12/4/17 (three days later) at 12:36 p.m., according to an event report filed by RN #21 on 12/4/17. A change of condition filed 12/4/17 at 1:36 p.m., revealed Patient #1 had been sitting in a wheelchair in his room, when RN #36 left the room to obtain a new pulse oximetry probe. Patient #1 was found on the floor upon the RN's return to the room. There were no apparent injuries. Patient #1 was then placed back into bed, with floor pads and bed alarm active. The fall investigation worksheet stated the call light was functioning and within reach, fall risk signage was in use, bed alarm was in use, and stated the patient's mental status was confused.

Fall interventions documented prior to the fall on 12/4/17 at 7:37 a.m. were: assist with ADLs; assist with ambulation; maintain bed in a low position, keep call light readily available and educate on use; orient to environment. Fall risk interventions charted after the fall on 12/4/17 at 11:15 p.m. did not reflect any changes to these interventions.

An event report filed 1/9/18 by RN #22 at 3:34 a.m., revealed Patient #1 sustained an unwitnessed fall from bed at 3:00 a.m. Per the fall investigation worksheet completed 1/9/18, the call light was functioning and within reach, the bed was in a low position, and fall risk signage was in use. The question pertaining to whether or not the bed alarm was in use was left blank. According to the event report, this incident was forwarded to DQM #10.

Interventions charted 1/8/18 (prior to the fall) at 10:58 p.m. were: implement safety measures; assist with ADLs; assist with ambulation; maintain bed in a low position, keep call light readily available and educate on use, orient to the environment. Interventions charted after the fall on 1/9/18 at 10:00 did not reflect any changes.

iv. According to the admitting physician history and physical dated 9/27/17, Patient #10 suffered a traumatic brain injury on 9/12/17. He had a past medical history of Parkinson's disease, though was living independently prior to the injury. Patient #10 transferred to this facility on 9/26/17. Physician #14 stated in his notes Patient #10 had marked periods of agitation, which required multiple staff to control him.

On 9/26/17, RN #23 completed a fall risk assessment for Patient #10. She scored him 22, with scores greater than 10 indicating a fall risk. Fall risks identified included: age 65 or older; high risk drugs in the past 72 hours; confusion/disorientation/sedation; unstable gait/balance or requires assistance to ambulate or transfer; forgets instructions or overestimates own limits; previous history of falls. Under safety assessment, RN #23 documented side rails up x4; bed position low; call light within reach; ID (identification) band; fall prevention signage; and low bed with extender mats ordered.

On 9/27/17 at 8:33 a.m., RN #29 charted the following fall risk interventions: implement safety measures; maintain bed in a low position; perform fall risk assessment; increased observation. At 12:05 p.m., RN #29 scored Patient #10 a 24 on a fall risk assessment.

A change of condition filed by RN #29 revealed on 9/27/17 (one day after admission) at 14:34, Patient #10 was found with legs on the floor, soft wrist restraints still tied, and with a pool of blood beneath his peripherally inserted central venous catheter (PICC). RN #29 called a rapid response, and a chest x-ray was ordered to confirm the PICC placement. There were no other apparent injuries. A fall investigation worksheet stated that the bed alarm was in use at the time.

That evening, RN #25 documented the following fall interventions of Patient #10: implement safety measures; maintain bed in a low position; perform fall risk assessment; increased observation. These interventions do not reflect any changes in the patient's care plan prior to the patient's fall.

On 9/30/17, RN #20 at 9:00 p.m. scored Patient #10 a seven on a fall risk assessment, indicating the patient was not a fall risk. In the assessment, Patient #10 was given a zero for previous falls, despite falling three days prior to this assessment. RN #20 documented fall interventions, which did not reflect any changes from the previous assessment.

RN #24 completed a fall assessment the next night, on 10/1/17 at 10:17 p.m. Patient #10 scored 22 on this assessment, again indicating fall risk.

On 10/2/17 at 2:15 p.m., the IDT round discussed the high fall risk medications on Patient #10's medication profile. No interventions were mentioned.

On 10/6/17, RN #32 entered an event report on Patient #10. According to the event report, on 10/5/17 at 11:50 p.m., Patient #10 was found on mats next to his bed. His soft wrist restraints were still tied. A rapid response was called. Physician #18 was called and gave an order for Seroquel (an antipsychotic medication with sedative properties). No injuries were apparent. On the completed fall investigation worksheet, the question of whether a bed/chair alarm was in use at the time of the fall was left blank.

RN #25 documented a change of condition regarding this fall, on 10/6/17 at 1:19 a.m. RN #25 documented the patient had stretched his arms enough to get out of bed while remaining tied in restraints. He also stated that the patient required five nurses to re-restrain the patient once he was back in bed.

Fall intervention charted by RN #25 on 10/5/17 at 9:53 p.m., included: implement safety measures; maintain bed in low position; perform fall risk assessment; increased observation. Interventions charted after the fall, on 10/6/17 at 10:14 a.m. did not reflect any changes or adjustment to interventions.

On 10/16/17, RN #34 completed an event report on Patient #10. According to the report, on 10/15/17 at 8:45 p.m., Patient #10 had an unwitnessed fall in his room. There were no apparent injuries. Physician #35 was notified and no new orders were given. On the completed fall investigation worksheet, the question of whether a bed/chair alarm was in use at the time of the fall was left blank.

On 10/15/17 at 9:54 a.m., RN #23 documented the following interventions: implement safety measures; maintain bed in a low position; perform fall risk assessment; increased observation. Fall risk interventions documented by RN #34 on 10/15/17 at 9:32 p.m. (after the fall) did not reflect any changes or other adaptations to these interventions.

During an interview with DQM #10 conducted on 1/16/18 at 1:30 p.m., she stated the facility discussed the effectiveness of fall interventions and care plans during IDT rounds. Review of the notes taken during the 10/3/17 and 10/10/17 rounds, revealed no discussion of Patient #10's fall. Notes taken during the 10/19/17 IDT meeting revealed that physical therapy added a goal on 10/19/17. The stated goal was for Patient #10 to walk 50 feet with minimal assist with a two wheeled walker. However, documentation revealed that falls and falls prevention were not discussed at this meeting.

v. According to the admitting physician history and physical dated 8/2/17, Patient #13 presented to the emergency room of an acute care facility complaining of a "thunderclap headache" and inability to walk. A CT scan was done, which revealed a subarachnoid hemorrhage. Patient #13 was transferred to a different acute facility for management. Patient #13 had a complicated hospital stay, in which he required multiple surgical and radiological interventions, and developed a cerebellar infarct. Patient #13 had a tracheostomy and percutaneous enteral gastrostomy (PEG) tube placed, and was transferred to a long term care facility within the acute care hospital. On 8/2/17, Patient #13 was admitted to the facility for continuing care, and tracheostomy and PEG management.

Review of Patient #13 event reports revealed the patient had 5 unwitnessed falls without injury from August 2017 through December 2017 (08/30, 09/01, 09/07, 11/16 and 12/22).

On 8/30/17, RN #7 entered an event report for Patient #13. According to the event report, Patient #13 was found sitting on the floor next to his bed at 3:00 p.m. A rapid response was called. No injuries were reported and no new orders were received. Review of the fall investigation worksheet revealed under the room/patient check after fall section the reporter wrote "Place bed alarm now".

On 9/1/17, RN #32 entered an event report for Patient #13. Per the event report, Patient #13 was found sitting on the mat next to his bed at 1:00 a.m. A rapid response was called. No injuries were reported and all fall precautions were in place. The fall investigation worksheet stated the bed alarm was in place at the time of the fall.

On 9/7/17, RN #32 entered an event report for Patient #13. According to the event report, at 12:20 a.m., Patient #13 had an unwitnessed fall within his room. No new orders were received, and all fall precautions were in place. According to the fall investigation worksheet, the bed alarm was on.

On 11/16/17, RN #7 entered an event report for Patient #13. According to the event report, Patient #13 sustained an unwitnessed fall and was found on the floor next to his wheelchair at 5:00 p.m. The physician was notified, assessed the patient and determined there were no injuries. The event report states all fall precautions were in place. On the fall investigation worksheet, the question regarding the bed alarm status was left blank.

On 12/22/17, RN #22 entered an event report for Patient #13. Per the event report, a CNA entered Patient #13's room and found him on the floor. He had no apparent injuries and the physician was notified. According to the fall investigation worksheet, all fall precautions were in place and the bed alarm was in use. This was the patient's third fall with no changes in fall prevention intervention.

b. On 1/12/18 at 7:30 a.m., a tour of the Medical/Surgical (M/S) unit and the Medical Observation Unit (MOU) was con