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Based on record review and interviews, the hospital failed to ensure the rights of one of one patient (Patient #1) to receive care in a safe setting. Patient #1 was documented to be ambulatory, without recent falls, and without skin issues on admission. During her twelve day hospitalization, the patient experienced two falls which caused her to have bruises on both eyes and bleeding inside her head. Patient #1 required emergency hospitalization after both falls.

Cross refer to Tag 0144.

Based on record review and interviews, the hospital failed to ensure the rights of one of one patient (Patient #1) to receive care in a safe setting. Patient #1 was documented to be ambulatory, without recent falls, and without skin issues on admission. During her twelve day hospitalization, the patient experienced two falls which caused her to have bruises on both eyes and bleeding inside her head. Patient #1 required emergency hospitalization after both falls.

Findings included:

Patient #1's admission history and physical examination dated 01/07/15 at 20:00 reflected the patient was able to "move all [extremities]."

Nursing Admission Assessment dated 01/07/15 at 18:45, noted Patient #1 had no recent falls but was assessed to be a high risk for falls. The musculoskeletal assessment noted "no significant findings." The nursing skin assessment did not show any bruises or other skin impairments. The patient was noted without pain.

Daily Nursing Note dated 01/08/15 (day and night shift), 01/09/15 (night shift), 01/10/15 (day and night shift), and 01/11/15 (day shift) documented the patient to be "ambulatory."

Physician progress note dated 01/11/15 at 16:07, noted Patient #1 "requires almost 1:1 attention for safety."

Multidisciplinary progress notes dated 01/11/15 at 19:20, reflected Patient #1 "attempted to get up and fell. She hit her left brow and produced a hematoma...was sent to...[acute care hospital]."

Physician progress note dated 01/12/15 at 16:10, reflected Patient #1 "...fell last night and required emergency evaluation...has black eye." Physician orders dated 01/12/15 at 16:20, placed Patient #1 on a one-to-one observational status. The one-to-one observation was discontinued per physician order on 01/15/15 at 13:40.

Four days later, multidisciplinary notes dated 01/19/15 at 04:00, reflected Patient #1 fell while attempting to get out of bed. Nursing noted "new bump/swelling to the right side of her forehead...has an old bump and bruise to the left side of her face." The patient's heart rate was 94 beats per minute and her blood pressure was 161/78. There was no documentation of additional vital signs taken. Nursing staff assisted the patient back to bed. Three hours and ten minutes later, on 01/19/15 at 07:10, nursing documented a bruise above Patient #1's right eye and the patient was non-emergently transported per hospital van to the acute care Hospital B's Emergency Department (ED).

Physician Discharge orders dated 01/19/15 at 12:00, reflected Patient #1's condition on discharge was "worse."

Acute Care Hospital B admission information dated 01/19/15 at 11:25, noted Patient #1 was admitted with a diagnosis of Subdural Hematoma The discharge summary noted a discharge date of 01/25/15. Discharge diagnoses included Subdural Hematoma. The hospital course documentation noted the patient "...had a fall this morning from bed to concrete floor ...hit her head on the floor ...CT [computer tomography] ...showed small amount of subdural hemorrhage right temporoparietal region [relating to the temporal and the parietal bones or regions]...admitted with subdural hemorrhage [bleeding] from trauma..."

Hospital Employee #2 stated on 06/10/15 at 10:40, the patient was a non-emergent transported per hospital van to the acute care hospital B Emergency Department on 01/19/15.

Hospital Employee #4 stated on 06/10/15 at 11:00 that Patient #1 fell and was transported to the ED on 01/19/15 and "it was an emergency." Hospital Employee #4 was asked why the patient was transported by van instead of emergency services and responded,"That is a very valid question."

Based on record review and interviews the hospital failed to set priorities for its performance improvement activities that focus on high-risk and high volume area affecting patients' health. Although three out of four patient related incidents in January 2015 and February 2015, and close to every second incident in April of 2015 were fall related, the hospital's quality assurance committee meeting did not specify an action plan to address falls.

Cross refer to A0283.

Based on record review and interviews the hospital failed to set priorities for its performance improvement activities that focus on high-risk and high volume area affecting patients' health. Although three out of four patient related incidents in January 2015 and February 2015, and close to every second incident in April of 2015 were fall related, the hospital's quality assurance committee meeting did not specify an action plan to address falls.

Findings included:

Hospital faxed documentation dated 06/15/15 reflected that 25 out of 33 January 2015 incidents (or 75.7 percent) involved patient falls, 22 out of 29 total incidents (or 75.8 percent) dated February 2015 were fall incidents. April 2015 (latest available data) had 27 fall incidents out of 58 total incidents (or 46.5 percent).

Quality Assurance/Performance Improvement Committee Meeting dated 03/26/15 noted fall incidents were 75 percent. There was no action plan documented.

Quality Assurance/ Performance Improvement Committee Meeting minutes dated 05/28/15 did not report incident data for February 2015 through April 2015.

Hospital Personnel #5 stated on 06/09/15 at 15:35 that the hospital recently "realized we have a problem." Hospital Personnel was asked whether falls were addressed in quality meetings and responded "We touched on it in March. " Hospital Personnel #5 stated there was no action plan for the fall incidents at the hospital at the time of survey.

Hospital Personnel #4 agreed during an interview on 06/10/15 at 11:00 that falls were not addressed in the hospital quality program.

Based on record review and interviews, the hospital failed to provide nursing care to one of one patient (Patient #1) according to patient needs. Patient #1's health condition worsened during her hospitalization in that the patient, severely underweight and at risk for malnutrition, was left not eating at meal times on multiple occasions, experienced two falls at the hospital, which resulted in black eyes and required emergency care and treatment for a subdural hematoma (bleeding in her brain).

An immediate jeopardy situation was identified. Patient #1 suffered harm.

Cross refer to A0392 and A0395.

Based on record review and interviews, the hospital failed to provide nursing care to one of one patient (Patient #1) according to patient needs. Patient #1's health condition worsened during her hospitalization in that the patient, severely underweight and at risk for malnutrition, was left not eating at meal times on multiple occasions, experienced two falls at the hospital, which resulted in black eyes and required emergency care and treatment for a subdural hematoma (bleeding in her brain).

Findings included:

Nutrition Assessment dated 01/13/15 at 09:30 reflected Patient #1 was a "severe [nutritional] risk ...is underweight." The patient weighed 103 pounds and had a body mass index of 16.6. Nursing notes to document the patient's nutritional intake were left blank on 01/11/15 and 01/12/15. The patient was noted to eat none of her breakfast or lunch meals on 01/13/15 and 01/14/15 and none of her breakfast meals on 01/17/15 and 01/18/15.

Nursing Admission Assessment dated 01/07/15 at 18:45 noted Patient #1 had no recent falls but was assessed to be a high risk for falls. The musculoskeletal assessment noted "no significant findings." The nursing skin assessment did not show any bruises or other skin impairments.


Physician progress note dated 01/11/15 at 16:07 noted Patient #1 "requires almost 1:1 attention for safety."

Multidisciplinary progress notes dated 01/11/15 at 19:20 reflected Patient #1 "attempted to get up and fell. She hit her left brow and produced a hematoma...was sent to...[acute care hospital]."

Physician progress note dated 01/12/15 at 16:10 reflected Patient #1 "...fell last night and required emergency evaluation...has black eye." Physician orders dated 01/12/15 at 16:20 placed Patient #1 on a one-to-one observational status. The one-to-one observation was discontinued per physician order on 01/15/15 at 13:40.

Multidisciplinary notes dated 01/19/15 at 04:00 reflected Patient #1 fell while attempting to get out of bed. Nursing noted "new bump/swelling to the right side of her forehead...has an old bump and bruise to the left side of her face." The patient's heart rate was 94 beats per minute and her blood pressure was 161/78. There was no documentation of additional vital signs taken. Nursing staff assisted the patient back to bed. Three hours and ten minutes later, on 01/19/15 at 07:10 nursing documented a bruise above Patient #1's right eye and the patient was non-emergently transported per hospital van to the acute care Hospital B's Emergency Department (ED).

Physician Discharge orders dated 01/19/15 at 12:00 reflected Patient #1's condition on discharge was "worse."

Acute Care Hospital B admission information dated 01/19/15 at 11:25 noted Patient #1 was admitted with a diagnosis of Subdural Hematoma The discharge summary noted a discharge date of 01/25/15. Discharge diagnoses included Subdural Hematoma. The hospital course documentation noted the patient "...had a fall this morning from bed to concrete floor...hit her head on the floor...CT [computer tomography] ...showed small amount of subdural hemorrhage right temporoparietal region [relating to the temporal and the parietal bones or regions]...admitted with subdural hemorrhage [bleeding] from trauma..."

Hospital Employee #2 stated on 06/10/15 at 10:40 the patient was a non-emergent transported per hospital van to the acute care hospital B Emergency Department on 01/19/15.

Hospital Employee #4 stated on 06/10/15 at 11:00 that Patient #1 fell and was transported to the ED on 01/19/15 and "it was an emergency." Hospital Employee #4 was asked why the patient was transported by van instead of emergency services and responded,"That is a very valid question."

Based on record review and interview, the hospital's registered nursing staff failed to supervise and evaluate the nursing care for one of one patient (Patient #1) according to the patient's needs. Nursing failed to

1) monitor Patient #1's severely underweight condition placing the patient at risk for further malnutrition and

2) to recheck Patient #1's elevated vital signs after the patient fell, and ensure timely and adequate emergency transport to the acute care hospital after Patient #1 suffered from bleeding inside her brain.

Findings included:

1) Patient #1's Nutrition Assessment dated 01/13/15 at 09:30 reflected Patient #1 was a "severe [nutritional] risk ...is underweight." The patient weighed 103 pounds and had a body mass index of 16.6.

Nursing notes to document the patient's nutritional intake were left blank on 01/11/15 and 01/12/15. The patient was noted to eat none of her breakfast or lunch meals on 01/13/15 and 01/14/15 and none of her breakfast meals on 01/17/15 and 01/18/15. There was no evidence of nursing evaluation of the patient's nutritional risk.

2) The admission nursing assessment dated 01/07/15 at 18:45 noted Patient #1 did not have recent falls. The nursing skin assessment did not show any bruises or other skin impairments. The patient did not have any pain.

Multidisciplinary notes dated 01/19/15 at 04:00 reflected Patient #1 fell while attempting to get out of bed. Nursing noted "new bump/swelling to the right side of her forehead...has an old bump and bruise to the left side of her face." The patient's heart rate was 94 beats per minute and her blood pressure was 161/78. There was no documentation of additional vital signs taken. Nursing staff assisted the patient back to bed. Three hours and ten minutes later, on 01/19/15 at 07:10 nursing documented a bruise above Patient #1's right eye and the patient was non-emergently transported per hospital van to the acute care Hospital B's Emergency Department (ED).

Physician Discharge orders dated 01/19/15 at 12:00 reflected Patient #1's condition on discharge was "worse."

Acute Care Hospital B admission information dated 01/19/15 at 11:25 noted Patient #1 was admitted with subdural hemorrhage [bleeding] from trauma..."

Hospital Employee #4 stated on 06/10/15 at 11:00 that Patient #1 fell and was transported to the ED on 01/19/15 and "it was an emergency." Hospital Employee #4 was asked why the patient was transported by van instead of emergency services and responded,"That is a very valid question."