HospitalInspections.org

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Based on record review and interview, the hospital failed to ensure an accurate collection and analysis of quality assurance improvement (QI) program (data used to measure and improve processes) for pharmalogical services and the implementation and evaluation of fall prevention procedures. This failed practice created the potential for patients to be exposed to preventable medication errors (preventable event that may cause or lead to inappropriate medication use or patient harm) and placed patients at risk for injury from falls. Findings:

Pharmalogical

Review of the "Pharmacy and Therapeutics Meeting" minutes, dated 2/27/20; 3/21/20; 4/23/20;5/21/20; 6/18/20 reveled concerns with medication errors, diversion of narcotics, and shipments of medications being returned.

During the survey, 2 patient's called the State Survey team and stated the pharmacy's new automated prescription refill line was not working. On of the Patients (#13) stated the pharmacy refill line was not working and it took over a month to get her prescriptions filled.

During an interview on 7/2/20 at 10:10 am, the Medical Director stated mailed out packages of medications were not being accepted in remote areas from the pharmacy as the person authorized to receive them was concerned about getting COVID-19 (contagious virus causing a pandemic), from incoming mail. Returned packages were send back to the pharmacy and put back on the shelf. As a result, patients were without their medications for unknown periods of time as the facility did not track the returned medication or inform the prescribing provider of the medications patients had not received.

During an interview on 7/2/20 at 10:30 am, Provider #1 stated, just over 2 months ago, when a patient was intubated (had a breathing tube inserted in the wind pipe), the patient kept waking up during the procedure as the smart pump (electronic pump used for delivering medications through the vein) had not been updated. Further review on 7/3/20, revealed the medication library in the smart pump, had not been updated since 2014. Not having the medication library updated, with the current list of medications, doses, and rates used by the facility, placed patients at risk for being under medicated and over medicated.

Falls

Review of the Chief Nursing Officer report, presented to the Medical Staff/Executive Committee Meeting on 12/5/19, revealed "Falls Protocol Change: Keeping bed alarms on always, regardless if there is an escort for patient present."

Record review during the survey on 7/2/20 revealed Patient #1 had sustained a fracture to the hip after a fall out of the bed on 6/24/20. The patient did not have a bed alarm placed at the time.

Review of the "Annual Board of Director's Meeting Minutes", dated 3/9-13/20, revealed the quality report was presented via PowerPoint.

Review of the "Quality Improvement Overview", dated 3/10/20, revealed the data metrics "Inpatient falls with injury Rate...4 per 1000" for 2018-2019. Planned 2020 initiatives did not include patient falls with injury or medication errors.

Review of the "Quality Assurance and Performance Improvement Committee" meeting minutes, conducted 2/19/20 and 5/6/20, revealed no performance improvement projects that included medication errors or pharmacy errors.

During the survey, on 6/30-7/3/20, it was discovered the facility had 4 Directors of of Nursing Service (DNS) within several years, the current Interim DNS had started 2 weeks ago, was to resign, and the contracted Interim DNS started work on 7/5/20. The facility did not currently have a Chief Financial Officer or Chief Operations Officer, and the Medical Director had retired this week.

During an interview on 7/2/20 at 4:15 pm, the Quality Director's (QD) stated he/she had started working for the facility 10/2019. The facility did not have an acting QD when he/she started work. The QD stated the facility's improvement program description did not include safe and effective use of medications. When asked about the falls with injury, the QD stated QI was not looking at falls as the facility only had 3 documented falls with injury so far this year. When asked if the turn over in administrative staff could have been quality concern, due to loss of institutional knowledge and the ability involve improvements, the QD stated he/she would not add other QI project unless the chief of a department asked him/her for help. During the survey, the QD stated he/she did not have participate in any QA regarding staff turnover as that fell under Human Resources. The QD did not address how the lack of constant management staff would impact QI projects or data collection.

Review of the Quality Director Job Description, revealed "Essential Functions "Works with staff to monitor and measure healthcare service quality and established healthcare quality improvement programs related to medical service issues."

Review of the policy provided by the facility, "Quality Improvement Policy", approved 4/20/18, revealed the QI Plan will reflect BBAHC process and activities that support the Joint Commission 5 Pillars of Quality...ii. identification of patient safety and adverse events and the implementation of related follow up actions as necessary...5. staffing: a. Support enhances efforts to recruit and retrain highly qualified clinicians."

(cross reference C-1016 and C-1018)
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Based on medical record review and staff interview, the facility failed to implement a facility-wide program which included monitoring and data collection for all departments, develop and implement action plans, and revise those plans when departments failed to reach specified goals. The failure to identify quality improvement (QI) projects independent of data collection, denied the facility the opportunity of process improvements in patient care and safety. Findings:

Falls

Review of medical records, on 7/2/20, revealed Patient #s 1 and 12 had fallen out of bed. Patient #1 had fallen out of bed and fractured his/her hip. Patient #12 had fell out of bed twice while unsupervised in the emergency department. The facility's investigation determined the Patient #s 1 and 12 had not had the required bed alarms placed under them.

Pharmacy

Review of "Pharmacy and Therapeutic" meeting minutes from 1/20-6/20 revealed there were medication errors due to:

Smart Pump

Medication library not being up to date in the smart pump (current list of medications, rates, and dosages used in the facility) used to administer intervenous medications.

Mailed Prescriptions

A medication delivered to a patient had the wrong medication in the bottle with the right medication on the label and packages of medications mailed out to remote areas were returned to the pharmacy due to concern about getting COVID (infectious virus) from the packages and patients not getting their medications.

Missing Narcotics

Record review on 7/2/20 of a "Medication Event Report RME", dated 3/18/20, revealed "Medications Involved Morphine [narcotic pain medication] 20 mg...2 syringes in Pyxis [secure medication cabinet] that did not contain any medication...we can't definitively say what happened with the two syringes as the pharmacist who prepared and loaded is no longer with us."

Record review on 7/2/20 of a RME, dated 4/20/20, "Pharmacy received one vial of opened diazepam [narcotic antianxiety] injectable from [village name] on 4/20/20. Injectable controlled substance log for that village on Share Point states that '2' vials were received into stock...all show a daily balance of '2'. Pharmacy however, only received ONE vial of diazepam returned, and the vial was opened. There is nothing documented in the controlled substance log...why the vial was opened...or (2) where the other 10 ml vial is."

Not ordered or in Wrong Bottle/ Slot

Record review of RME, dated 5/12/20, "...Order placed on 5/15/20 by [provider] as the patient had a history of preterm delivery, This medication was supposed to have been started at that time, however, came into Dillingham for an initial prenatal visit 5/22/20, which was when the error was found...called the pharmacy and spoke to...who saw the initial order but stated 'we don't do anything with those.' The order was never followed up or sent to the village for administration.

Emergency Room Pyxis

Levofloxacin [antibiotic]

Review of error dated 2/27/20, Levofloxacin (antibiotic) Pyxis in ER [emergency room] had the 750 mg loaded in the 500 mg slot...all incorrect meds removed. Pharmacy response is as follows "...It is hard to tell if Levofloxacin 500 mg and Levofloxacin 750 mg was indeed loaded in error as both slots were accessed..."

Review of error on 3/7/20, "...Amoxicillin-clavulanate [antibiotic] 875 mg-125 mg prepack...medication was stocked in wrong pharmacy bin located within the Pyxis. Med should have been in Bin #25 (empty) was stocked in Bin #26 ...ACTION TAKEN Medication relocated to correct Bin #25 by this RN (Registered Nurse)."

Further review of RME revealed the pharmacy response, "CC #043-20 this feedback is in response RME#043-20. I spoke with [Name of Pharmacist] while investigating this comment. The medication was loaded in an open drawer (both bin #25 and #26 do not have a lid). The inpatient pharmacist has assigned and relocated the Amoxicillin-Clavulanate to a closed cubie that pops open when assessed to prevent any issues in the future."

Bubble Pack (a prepared medication pack to assist a person with safely administrating medications)

On 2/3/20 revealed, " ... Lisinopril [medication used to treat high blood pressure] ... Furosemide [medication used to take off fluid from the body[ ... Cholecalciferol [vitamin D]...Weekly bubble pack was prepared with a double dose, of three medications listed, in the Friday slot. The next daily slot, for Saturday, was missing the three tablets listed....Patient's daughter contacted pharmacy. Daughter stated she would remove the duplicate tablets and reserve them for the following day's dose. Asked daughter to bring the 4th card [4 bubble pack cards done on the same day, 2/3/20] back to the pharmacy for inspection."

During an interview,on 7/1/20 at 2:30 pm, the Pharmacy Director stated she/he did not know what the facility's medication error rate, and did not know who would track that information for quality data.

In addition, review of the monthly "Nurse Meeting" minutes and "Pharmacy and Therapeutic..." meeting minutes revealed the facility staff were not consistently filling out incident reports when unable to scan an ordered medications with a patient's wristband, smart pump failure, and medications returned to the pharmacy for failed delivery, and created a risk for flawed date collection.

Review of quality meeting minutes 2/10/20 identified antimicrobial stewardship (monitoring antibiotic use), data, and "New Data" med errors and declines in doc [documentation] Quality Director will follow up on each one."

During an interview with the Chief Compliance Officer (CCO) on 6/30/20 at 9:10 am, stated he/she did not know if the quality data was shared with the staff or physicians. The CCO stated the data was to be discussed with the quality team during the quality meetings.

Review of the "Quality Improvement Overview", presented to the board on 3/10/20 revealed the following goals: "Partnership for Patients", "2016-2018 Health Resources and Administration (HRSA) Results [clinical data for diabetics, heart disease and high blood pressure]", and GPRA [government performance and results act outcomes] quality measures". Other events included transitioning the department from the medical staff to the CEO [Chief Executive Officer]. Concerns identified during the Joint Commission survey [accrediting organization that performs patient-centered, data-driven, and focused on evaluating actual care processes, conducted every 3 years] was Quality leadership, using quality data to make changes, and Patient assessment of care addressing individual needs, safety, and quality...Antibiotic Stewardship."

During an interview on 7/1/20 at 1:00 pm, the Quality Director (QD) stated the facility did not have a quality person until he/she started October 2019. When asked how he/she got information from other departments, the QD stated he/she used the OPPE (ongoing professional practice evaluation) score card. The QD stated that he/she had just started the PCP (primary care provider) improvement program. The QD stated the facility had implemented compliance 360 (a compliance software program) into their QI policy. When asked how quality improvement projects outside data collection were chosen, the QD stated he/she only initiated quality projects if the chief of another departments asked for his/her help. During the same interview the QD stated he/she reports to the Board four times a year and the Medical Executive every quarter.

During an interview on 7/2/20 at 11:00 am, when asked what quality improvement projects the medical staff was working on, Physician #3 stated the patient safety data presented by quality was not accurate, The Physician stated patient safety initiatives were not being done. In addition, Physician #3 stated medical staff should attend the quality meetings but were not members of the quality team team.

Review of quality meeting minutes, dated 5/6/20, revealed quality improvement activities had been put on hold due to COVID (viral pandemic).

Review of the quality information, presented at the "Medical Staff/Executive Committee Meeting", dated 6/4/20, revealed "...reported there has been a waiver from CMS [Center for Medicare/Medicaid Services] to put all Quality activities on hold. 2. current activities include monitoring 2 dozen indications; 1 major emphasis focused on Diabetes...control and [high blood pressure]...still some research in the back ground but no new quality projects have been initiated.." The Recommendation [from the Medical Director] was "...Quality Dept. Continue to share information to the medical staff to help with the improvement of quality patient care."


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Based on interviews, and review of documents and records, it was determined that the governing body of the critical access hostpial (CAH) failed to ensure that the CAH and its staff were in compliance with all applicable Federal and State laws and regulations and rules that apply to the CAH and to its staff.

Findings include:

CFR 485.627, Condition of Participation: Organizational Structure.

2. Refer to the Condition-level deficiency at Tag C-1004 §485.635 Condition of Participation: Provision of Services.
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Based on interview, policy and record review, the facility failed ensure a succession plan for departing medical staff. This failed practice placed patents at risk for not having necessary provider services. Findings:


Provider Staffing

During an interview with the medical staff and the interim Medical Director on 7/2/20 at 10:10 am, 6 of the 9 physicians present, including the interim Medical Director stated they would be leaving within the next few months. Of the 3 remaining physicians 2 stated they planned to reduce their hours to part-time. Physician #2 sated he/she would be the only full time physician at the hospital after December 2020.

During the interview, the physicians expressed concern over the loss of medical staff and a hospital being almost fully staffed by locum (temporary physicians). The physicians stated the use of temporary doctors to staff the hospital undervalues continuity plays in the hospital setting and can lower the quality of care delivered to the community.

Review of the "Joint Conference Committee Meeting Minutes", dated 5/18/20, agenda revealed "Medical Staff Report...Medical staff is budgeted for 13.2 full-time positions and is currently staffed with 10.74 ...Recruitment...unfortunately there are no candidates currently under review."

Further review revealed 3 of the remaining physicians would be leaving and 2 will have reduced their hours to part time.

During an interview, the Provider Coordinator (PC) stated by the time he/she gets approval for an applicant, the provider had often accepted a position some place else. In addition, he/she can often cannot get the provider up to visit the hospital, due to travel delays from Human Resources.

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Based on interview and record review the facility failed to ensure there was a provision for notifying the State agency of a change in medical director (clinical director). Findings:

During the entrance interview on 6/29/20 at 8:30 am, Physician #3 stated he/she was retiring as the Medical Director within the next 2 days, after which Physician #4 would be interim.

During an interview on 7/2/20 at 11:00 am, the Interim Medical Director (Physician #4) stated it was unclear would cover for his/her 1 month absence next month and after he/she resigns.

Review of the Medical Staff Bylaws, signed 3/12/20, revealed there was no provision for notifying the State agency of a change in the clinical director.

Review of the State agency facility binder on 7/2/20, revealed the State agency had not received notification of the change in the medical director (clinical director).

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The facility failed to ensure the condition of participation for was met as evidenced by:

Refer to C-1016: The facility failed to ensure smart pumps, used to deliver intravenous and high-alert medications (drugs that that have a high risk of causing significant patient harm if used in error) were accurately programmed with the facility's drug formulary. The failure to maintain the proper programing of the smart pumps, used for the implementation of safeguards to reduce medication errors before it reached patients, placed patients at immediate risk for harm or death from medication errors.

Refer to C-1018: Failed to ensure medication incidents were accurate and had systemic corrective actions.

Refer to C-1046: Failed to ensure nursing interventions met the needs of the patients.

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Based on interview, record review, and observation the facility failed to ensure intravenous (through a vein) medications were administered per acceptable standards of practice, for two patients (Pt. #s 10 and 11), reviewed for intravenous medication administration. Specifically, the facility failed to ensure the Alaris© smart pumps, used to deliver intravenous and high-alert medications (drugs that that have a high risk of causing significant patient harm if used in error) were accurately programmed with the facility's pharmacy drug formulary for medications, concentrations, dosing units and dose limits. The facility had been aware of the concern with the smart pump drug library since 2/2020, and continued to utilize the pumps without a process to remove the risk to patients. The facility failure to maintain the proper programing of the smart pumps, used for the implementation of safeguards to reduce medication errors before it reached patients, and placed patients at immediate risk for harm or death from medication errors.

The Immediate Jeopardy to the life and safety of patients receiving high-risk medications intravenously was brought to the attention of facility administration on 7/2/20 at 5:45 pm.

The facility implemented a removal plan that ensured: 1) all intravenous medications would checked by a pharmacist and a nurse: 2) the pharmacy would sign off they verified the medication dose, drip rate, and parameters: and 3) the smart pumps were to be updated by August 11, 2020. The Interim Chief Nursing Officer would audit the reports daily for compliance. The State survey agency reviewed the plan with the facility's administrative team and accepted the IJ removal plan on 7/3/20 at 3:00 pm.

Findings:

During an interview on 7/2/20 at 10:10 am, Physician #1 and Physician #2 stated approximately 2 months ago Pt #10 presented to the emergency department following a head trauma and was sedated (put to sleep with medication) so he/she could be intubated (a breathing tube inserted into the windpipe attached to life support) and placed on ventilator support. During the intubation, the Pt woke up and struggled against the procedure. The Physicians discovered the smart pump, used to deliver the sedating medication (Versed-narcotic used for sedation and Fentanyl-narcotic pain medication used for sedation) to the Pt, had delivered only one tenth of the dose needed for the Pt's sedation. Physician #1 stated the smart pumps used to deliver the medication, had not been updated with a current drug library.

Record review on 7/2/20 of the "ED-Provider Note", dated 4/20/20, revealed the 12-year-old Pt was admitted to the emergency department (ED) by medivac following a head injury. "Decision to intubate was made due to poor oxygenation and need for emergent head CT [CAT scan]. Once intubated [Pt.] was started on a fentanyl (50 mcg/hr drip and (100 mcg/min drip, also titrated up...began to move around and clench down on the ET tube, thus an additional fentanyl bolus was given 50 mcg IV push and a bite block was placed ...Interventions: In reviewing [his/her] medication doses, it appears the midazolam [versed] pump was set to about 10% of the intended dose..."

Pt. #11

During an interview on 7/2/20 at 1:00 pm, Licensed Nurse (LN) #2 stated about 2-3 weeks ago he/she had a Pt with a STEMI (ST-Elevation Myocardial Infarction/ heart attack). The LN stated because the smart pump library was not updated, he/she was unable to enter the correct dose of Heparin (blood thinner used to stop clotting/ can bruising and/or hemorrhaging-based on weight and amount given) into the pump for administration. The LN stated he/she did the math and entered the dose (by overriding the parameters) in the smart pump. The LN
stated he/she liked having the smart pump as second check for safety. The LN stated when he/she notified the supervisor about the pump being defective, the supervisor stated the facility was working on a fix. The LN stated it was the Heparin drip rate that had to be calculated for Pt #11.

Record review on 7/2/20, revealed Pt. #11 was admitted to the ED on 6/7/20 for chest pain. The medications administered by LN #2 included the titrate dose of "Heparin 20,000 unit(s) + Dextrose 5% in water intravenous solution 500 ml, Dose: 500 ml, IV ...titrate ..." "Continuous infusion 40 units/ml Start at 12 units/kg/hr titrate".

Observation in the inpatient and emergency departments of the hospital revealed the facility used the Alaris© (CareFusion) infusion smart pumps for intravenous infusion therapy.

Review of "Pharmacy and Therapeutics" meeting minutes, dated 2/27/20, 4 months ago, revealed "Alaris [smart] Pumps are pumps used to pump IVs throughout the hospital. This is an open issue regarding who oversees the pumps. Both Nursing and Pharmacy do not have access...Recommendation Pharmacy to update the Alaris pump library to fix concentration and add new medication."

Review of the Pharmacy and Therapeutics pharmacy report, dated 6/4/20, almost 4 months after the concern was identified, revealed, "Pharmacy is working on Alaris pump library update."

According to the 2019, "Unintended Patient Safety Risks Due to Wireless Smart Infusion Pump Library Delays" published in the "Journal of Patient Safety". Reviewed 7/3/20, " ...potential serious harm can happen when IV infusions are administered with outdated drug limit settings due to delays in drug library updates on the pump."

Further review revealed the facility's smart pumps drug library had not been updated since 2014.

During an interview on 7/2/20 at 4:20 pm, when asked about the smart pump under administering the sedating medications 4/20/20 during the emergency procedure with Pt #10, the Pharmacy Manager (PM) stated that was when the facility determined the drug libraries in the smart pumps needed to be updated. The PM stated the technology was a challenge and the facility was to have access to the pump library the week of 7/6/20. The PM stated the vendor (maker of the smart pump) had to work with the facility information technology department to get the pumps updated. The PM stated this coming Tuesday (7/7/20) staff were to receive training to manipulate the library on the pump. The PM stated the smart pump libraries should ideally be updated yearly.

According to Institute of Safe Medication Practices accessed at www.ismp.org, on 7/3/20, "Smart pumps with dose-error reduction software (DERS) allow organizations to create a tailored library of medications with dosing guidelines by establishing standard concentrations, dosing limits, and alerts...They can also provide a great deal of data that is useful in improving safe practices."

According to BD, the manufactures of the Alaris© smart pump system, accessed on 7/2/20, at www.BD.com "System data is created by each facility/hospital and contains the drug and fluid libraries. The Guardrail Suit limits device configurations....When your facility releases and new data set, it needs to be activated into he BD Alaris© system."
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Based on record reviews and interview the facility failed to ensure medication errors were accurately reflected and documented. This failed practice failed to ensure systemic corrective actions for the reduction or prevention of reoccurrences for all patients receiving services from the hospital. Findings:

Mailed Prescriptions

During an interview on 7/2/20 at 10:10 am, the Medical Director [MD} stated some mailed out packages of medications were not being accepted in remote areas as the person authorized to receive them was concerned about getting COVID-19 (contagious virus causing a pandemic), from incoming mail. Returned packages were send back to the pharmacy and put back on the shelf. As a result, patients were without their medications for unknown periods of time as the facility did not track the returned medication.

Review on 7/2/20, of the "Pharmacy and Therapeutics Teleconference Meeting", dated 5/21/20, revealed "The medication errors for refusal of medication packages began in March per [Pharmacy Director]. The Medical Staff strongly suggested that the errors should have been reported immediately when they began in March of 2020. "

Review on 7/2/20 of the "Pharmacy and Therapeutics Teleconference Meeting", dated 6/18/20, revealed "Pharmacy has identified challenges with [Village Name] accepting med packages-due to fear of COVID-19 contaminated packages." "Recommendation [MD] suggest an RME [incident report] be completed for any returned packages regardless of why packages were refused."

Duplicate Fills

During an interview on 7/2/20 at 10:45 am, Physician #3 stated that the the pharmacy and providers were responsible for checking the Alaska Prescription Drug Monitoring Program (APDMP) prior to prescribing any narcotics. The Physician stated patients obtained double fills of opiods (narcotic pain medications).

Review of the facility incident reports list on 7/2/20, revealed no reports of patients obtaining duplicate refills.

Smart Pump

During an interview on 7/2/20 at 1:00 pm, Licensed Nurse (LN) #2 stated about 2-3 weeks ago he/she had a Pt with a STEMI (ST-Elevation Myocardial Infarction/ heart attack). The LN stated because the smart pump library was not updated, he/she was unable to enter the correct dose of Heparin (blood thinner used to stop clotting/ can bruising and/or hemorrhaging-based on weight and amount given) into the pump for administration. The LN stated he/she could do the math, but felt safer having the smart pump as a second check for safety. The LN stated when he/she notified the supervisor about the pump being defective, the supervisor stated the facility was working on a fix. The LN confirmed it was Pt. #11.

Record review on 7/2/20, revealed Pt. #11 was admitted to the ED on 6/7/20 for chest pain. The medications administered by LN #2 included the titrate dose of "Heparin 20,000 unit(s) + Dextrose 5% in water intravenous solution 500 ml, Dose: 500 ml, IV ...titrate ..." "Continuous infusion 40 units/ml Start at 12 units/kg/hr titrate".

Review of the facility's incident report list, on 7/2/20, revealed the error with the smart pump was not reported.

Review of the facility's policy "Risk Management Event Identification and Investigation", dated 1/24/20, revealed "Incidents involving patient care will be trended and significant patterns identified will be presented to the Quality Committee and the Patient Safety Committee as part of BBAHC's [Bristol Bay Area Health Corporation] overall quality assurance program. s. Incidents involving BBAHC's environment of care will be trended and significant patterns presented to the Environment of Care committee as part of BBAHC's overall quality assurance program.
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Based on record review and interviews the facility failed to ensure provided nursing services met the needs of the patients. The facilities nursing staff failed to implement fall prevention interventions for 2 patients (Pt. #s 1 and 12), identified as high risk for falls. This failed practice caused Pt. #1 a fracture from a fall and placed Pt. #12 at risk for injury. Findings:

Pt. #1

Record review on 7/2/20 revealed Pt. #1 was admitted to "Swing Bed" status (longer skilled stay) in the facility on 6/14/20. The Pt. had history of a left hip replacement (the ball and socket of the hip replaced).

Review of the fall score assessment, completed on 6/14/20, revealed the Pt. had scored a "45" and was considered high risk for falls. Interventions included "scan room for environmental hazards" and wear "non-skid socks".

Review of a nurse's note, dated 6/24/20 at 4:30 am, revealed "Got up to got to bathroom without assistance or using cane located at bedside/ pt. found flat on back c/o right hip/side pain ...pt. assisted from floor to wheelchair and from wheelchair to bedside toilet as pt. still needed to void. MD ...notified ...order AM x-ray. Pt. assisted from bedside toilet to bed and provided comfort measures ...Pt. instructed not to get up without using call light or cane/ pt given instruction on how to effectively use call light and why [he/she] should not get up alone ...bed alarm placed, non-skid socks in place, personal items within reach, and bed rails were raised ..."

Review of the right hip x-ray, performed 6/24/20 revealed Pt. #1 had obtained a fracture to the right hip. The Patient had to be flown to Anchorage for further treatment.

During an interview on 7/2/20 at 10:30 am, Provider #2 stated he/she had been on call when Pt. #1 had fractured his/her right hip. The Provider stated the Pt. had to be transferred to a hospital in Anchorage that day. Provider #2 stated the Pt.'s fall could have been prevented.

Review of the facility investigation, completed by the interim Director of Nursing on 6/30/20, revealed nursing staff should have placed a "bed alarm [alarm that sounds when the pt. gets out of bed] " and ensured the room was well lit.

During an interview with the Risk Manager (RM) on 7/2/20 at 2:00 pm, when asked if the Pt. was wearing the correct footwear at the time of the fall, as the CP interventions, had not been identified in the investigation. The RM stated Pt. #1 was wearing regular socks at the time. The RM stated the Pt. had not liked the way the textured socks felt on his/her feet. The RM stated the Pt. did not have a bed alarm placed until after the fall.

Pt. #12

Record review on 7/2/20 revealed on 6/26/20 Pt. #12 was being evaluated in the Emergency Department [ED]. Review of the nurses notes, dated 6/26/20 at 9:15 pm revealed the Pt. was "found on the floor" [in the ED]. Ten minutes later, facility staff caught the Pt. attempting to climb over the side rails.

Review of the event report revealed "No portable fall prevention alarms available. Not enough staff to be able to allocate a dedicated sitter. The event could have been prevented with the adequate staffing and the right equipment available."

Review of Chief Nursing Officer report, presented to the Medical Staff/Executive Committee Meeting on 12/5/19, revealed "Falls Procedural Change: Keeping bed alarms on always regardless if there is an escort for patient present."

There was no information in the quality or nursing minutes about the the lack of portable alarms and staffing and selecting appropriate fall risk interventions for high risk patients.

During an interview 6/29/20 at 10:30 am, the Interm Director of Nursing Services (DNS) stated he/she had only started the position 2 weeks ago and would be leaving in a week. The DNS stated she was filling in until then, the consultant DNS would be starting Monday 7/6/20. The Interm DNS stated the facility had 4 DNS's in the last few years.

Review of the Patient Bill of Rights, dated 12/7/18, "You have the right to considerate, respectful care in a safe and secure environment..."
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