HospitalInspections.org

Based on record review, policy review, document review, and interview, the hospital failed to ensure it met the requirements for Nursing Services Condition of Participation by failing to supervise and evaluate the nursing care for 7 of 13 (Patient 1, 2, 7, 9, 10, 12, and 13) sampled patients receiving care at this hospital.

Findings Include:

1. The hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for patients at risk for falls, pain evaluation and medication administration, and assessment of vitals as required per hospital policy. (Refer to A-0395)

2. The hospital failed to ensure an individualized plan of care was completed or updated as required for patients at risk for falls per hospital policy. (Refer to A-0396)

Based on policy review, record review, and interview, the Hospital failed to ensure nursing staff supervised and evaluated the nursing care for:
1. Falls for 5 of 13 sampled patients (Patient 1, 2, 9, 12, and 13)
2. Pain management for 1 of 13 sampled patients (Patient 1)
3. Vital signs for 1 of 13 sampled patients (Patient 10).
This deficient practice poses a risk for a change in a patient condition to go unrecognized or untreated and places any patient receiving services at this hospital at risk for harm.

Findings Include:

1. Falls
Nursing staff failed to follow required hospital policies and procedures for implementation of appropriate fall interventions, documentation of post fall nursing assessments, and the updating of patient care plans.

Review of a policy titled, "Fall Prevention," dated 07/18/25, showed that a fall is defined as any sudden, unintentional descent, with or without injury, by which a patient may come to rest on any object and/or person. The policy also stated that all patients are assessed for risk of falls upon admission, during shift assessment, or with any change in health status by utilizing the Morse Fall Scale. The Morse Fall Scale identifies fall risk based on a score as follows: Low risk: 0 - 24; Moderate risk: 25-44; High risk: 45-64; and extremely high fall risk: 65 or greater. The policy goes on to state that for a Morse Fall Scale score less than 45 (Moderate Risk), the hospital will provide patient education, write the fall risk score number on white board in the patient's room, ensure patient wears non-slip footwear, bed wheels are locked, rooms are free of clutter, and personal items are within patient reach. A Morse Fall Scale of 45 or greater (High Fall Risk) will have all the above interventions and include the following: yellow arm band, yellow light outside patient room, and fall prevention added to the care plan. A Morse Fall Scale of 65 or greater (Extremely High Fall Risk) will have all the above interventions and include the following: activated bed alarm and telesitter. The policy stated that all fall prevention interventions will be documented in the patient's electronic health record (EHR) in narrative form every shift that, "describe in detail why the interventions were initiated or maintained or were not appropriate for the patient or if patient refused ..."

Review of a policy titled, "Key Safety Packet," revised 12/11/24, showed that following any fall the patient will be assessed according to the "Post Fall Assessment," and that the provider and family must be notified. Staff are required to document the fall, the outcome, any initial and/or ongoing observations in the medical record and update the patient's care plan.

Patient 1

Review of Patient 1's active medical record showed a 53-year-old admitted on 06/18/25 at 12:44 PM with a diagnosis of anemia (low blood level). Patient 1 sustained a fall on 06/19/25.

Review of a document titled, "Fall Risk Scale Morse" dated 06/18/25 at 8:15 PM, showed that Patient 1 had a Morse Fall Score of 60 (indicating high fall risk) prior to fall.

Review of a progress note dated 06/19/25 at 3:50 AM showed that Patient 1 was found on the floor by a patient care technician at 3:50 AM. The note stated that the Registered Nurse (RN) had previously rounded on the patient at 2:30 AM and at that time the patient was noted to be asleep in a recliner chair. When the patient care technician entered the room to do morning vitals the patient was noted to be sitting on the floor directly in front of the recliner. The patient was disoriented and unable to report how he/she fell.

Review of Patient 1's medical record failed to show documented evidence of implemented fall interventions for the 7:00 PM to 7:00 AM shift on the date of Patient 1's fall (06/19/25 at 3:50 AM)

During an interview on 07/29/25 at 1:30 PM, Staff D, Registered Nurse (RN), stated that fall risk prevention interventions should have been in place, but were not at the time of Patient 1's fall.

Review of Patient 1's medical record failed to show documented evidence that a Post Fall Assessment was completed as required per hospital policy.

During an interview on 07/30/25 at 2:59 PM, Staff K, Advanced Practice Registered Nurse (APRN), stated that staff fail to follow current policies regarding falls.

Patient 2

Review of Patient 2's inpatient medical record showed a 73-year-old admitted on 04/12/25 at 8:12 AM with a diagnosis of abdominal pain. Patient 2 sustained a fall on 05/09/25 at 5:45 AM while in the Intensive Care Unit (ICU).

Review of a document titled, "Fall Risk Scale Morse" dated 05/08/25 at 8:12 PM, showed that Patient 2 had a Morse Fall Score of 60 (indicating high fall risk) prior to fall.

Review of a physician's progress note dated 05/09/2025 at 6:19 AM, showed, "RN paged that patient fell out of bed, occurred within the past hour. Unwitnessed, may have rolled out [of bed], was lying on her back ..."

Review of an incident report dated 05/09/25 at 5:45 AM, showed that Patient 2 had an unwitnessed fall in which the patient was found lying on his/her back, on the floor beside the bed. Further review showed that Patient 2 had been on a ventilator which became dislodged upon the fall and was not able to be reconnected immediately. The inability to reconnect the ventilator required Patient 2 to be manually "bagged" (manual ventilation using a bag-valve mask device to help them breathe.) The incident report went on to state that Patient 2 was a high risk for injury due to extended immobility and that nursing had reported the patient had been swinging his/her legs out of the bed on the previous shift without implementation of increased fall preventions.

During an interview on 07/31/25 at 8:53 AM Staff O, Registered Nurse (RN), stated that the nurse caring for Patient 2 was witnessed sleeping at the time of the fall.

Patient 9

Review of Patient 9's active medical record showed a 74-year-old admitted on 07/29/25 at 7:13 PM with a diagnosis of abdominal pain and shortness of breath.

Review of document titled, "Fall Risk Scale Morse" dated, 07/30/25 at 1:53 AM, showed that Patient 9 had a Morse Fall Score of 85 (extremely high risk) indicating the need for a bed alarm and telesitter as required per hospital policy. Further review of the medical record failed to show documented evidence that nursing staff implemented the use of a bed alarm and telesitter as required.

During an interview on 07/30/25 at 11:03 AM, Staff P, RN, stated that the use of a bed or chair alarm was a nursing judgement decision and utilization of an alarm was at the discretion of the nurse.

Patient 12

Review of Patient 12's discharged medical record showed a 65-year-old admitted on 07/18/25 at 12:07 PM, with a diagnosis of septic shock; hypotension (low blood pressure); and acute colitis (inflammation of the colon). Patient 12 sustained an unwitnessed fall on 07/22/25 during his/her hospitalization.

Review of a document titled, "Fall Risk Scale Morse" dated 07/22/25 at 7:40 AM, showed that Patient 12 had a fall risk score of 70 (indicating extremely high fall risk) on the morning of the fall. Per hospital policy a score of 70 would require the use of an activated bed alarm and a sitter.

Review of a nursing narrative note dated 07/22/25 at 2:45 PM, showed that Patient 12 sustained an unwitnessed fall between 11:30 AM - 11: 45 AM. The nurse noted bruising to each knee at the time of the fall and the patient claimed he/she hit head and twisted an ankle. Documentation also indicated that Patient 12 required standby assistance to the commode and with transfers, would refuse to wear "non-slip" socks and that a bed alarm was not utilized due to "Pt [patient] moved around so much ...that a bed alarm could not be placed ..." The note went on to state that a "patient observer" was not utilized to reduce fall risk until after Patient 12 sustained the fall.

Review of Patient 12's medical record failed to show documented evidence that a post fall nursing assessment was performed or that the patient's family/representative was notified that a fall had occurred as required per hospital policy.

Review of Patient 12's plan of care showed that "Falls" was implemented on 07/20/25 at 12:24 PM and discontinued on 07/26/25. Review of the plan of care showed an entry on 07/26/25 at 7:02 AM that stated, "Pt [patient] has not fallen during the hospital stay to date ..." The plan of care failed to show documented evidence of a fall or an update/revision to the plan of care after Patient 12's fall on 07/22/25 as required per hospital policy.

During an interview on 07/30/25 at 2:59 PM, Staff K, Advanced Practice Registered Nurse (APRN), stated that any fall should have follow up of vitals every 4 hours at a minimum, and an order set that would prompt for neuro checks if indicated. Staff K went on to state that staff fail to follow current policies regarding falls.

Patient 13

Review of Patient 13's active medical record showed a 73-year-old admitted on 07/24/25 at 7:35 PM with a diagnosis of sepsis and penile abscess. Patient 13's medical record indicated the patient sustained a fall on 07/28/25.

Review of Patient 13's medical record indicated that a provider was notified on 07/28/25 at 5:52 PM that Patient 13 had sustained a fall. Further review of the medical record failed to show documented evidence that a fall had occurred as required per hospital policy.

Review of a document titled "Fall Risk Scale Morse" dated 07/24/25 at 8:31 PM, showed that Patient 13 had a Morse Fall Score of 70 (indicating extremely high fall risk). Further review of the medical record failed to show documented evidence that nursing staff implemented the use of a telesitter as required for a fall risk score of 65 or higher as required per hospital policy.

Review of Patient 13's plan of care showed an entry on 07/30/25 at 3:25 PM that stated, " ...Pt [patient] has not yet experienced a fall of any kind during this hospitalization ..." Further review of the plan of care failed to show any documentation of a fall or an update to include falls after Patient 13's fall on 07/28/25 as required per hospital policy.

An observation on 07/31/25 showed that Patient 13 was in bed without an activated bed alarm, no fall risk score posted on white board, and no sitter or 1:1 observation for a patient with a fall risk score >65.

During an interview on 07/31/25 at 10:42 AM, Staff U, RN, stated that Patient 13's Morse Fall Score was 85 and verified that nursing staff failed to initiate fall interventions as required for a patient at extremely high risk for falls.

2. Pain Management

Nursing staff failed to address and identify patient's pain and failed to administer pain medication as ordered.

Review of a policy titled, "Admission Assessment and Reassessment Documentation," dated 04/2025, showed that a complete assessment will include pain management and stated that the consideration of acute or chronic pain needs would be assessed, and any uncontrolled pain would be reported to the provider.

Review of a policy titled, "Pain Management," dated 10/2024, showed, " ...The patient has the right to appropriate assessment of condition and management of pain. The patient also has the right to expect a quick response to reports of pain ..." The policy further showed that pain scales would be utilized to assess the patient's pain. Pain shall be assessed after every pain management intervention. Documentation in the patient's medical record shall include pain assessments, reassessments, and non-pharmacologic interventions.

Patient 1

Review of Patient 1's active medical record showed a 53-year-old admitted on 06/18/25 at 12:44 PM with a diagnosis of anemia (low blood level). Past medical history included degenerative disc disease (a form of arthritis that affects the spine joints), and chronic back pain with a failed back surgery.

Review of a physician order dated 06/18/25 at 5:27 PM, showed an order for morphine (pain medication) 15 milligrams (mg) by mouth 5 times a day as needed for pain.

Review of the medical record failed to show that a follow-up pain assessment for effectiveness was completed after the administration of morphine on 06/18/25 at 7:37 PM and 11:46 PM and on 06/19/25 at 10:21 AM.

Review of a physician order dated 06/18/25 at 4:00 PM, showed an order for hydromorphone (pain medication) 0.5 mg intravenous every four hours as needed for pain.

Review of the medical record failed to show that a follow-up pain assessment for effectiveness was completed after the administration of hydromorphone on 06/18/25 at 3:45 PM.

From 06/18/25 at 12:50 PM through 06/19/25 at 10:21 AM, Patient 1 reported pain of 6 or above, indicating severe to worst pain ever. Patient 1 failed to receive pain medication as ordered therefore resulting in increased and uncontrolled pain throughout the hospital stay.

During an interview on 07/29/25 at 1:30 PM, Staff D, Registered Nurse (RN), stated that during bedside report, it was stated that the patient was having severe abdominal pain. Staff D stated that after report Patient 1 received what medication could be given based on the medication administration record (MAR). Staff D went on to state that the patient's pain was never controlled and the patient continued to ask for more pain medication. Staff D stated that the patient was NPO (nothing by mouth) after midnight, so advised the patient to wait on pain medication until just before midnight. Staff D stated that during patient checks Patient 1 would be sleeping and would not be disturbed to ask about pain.

During an interview on 07/30/25 at 2:59 PM, Staff K, Advanced Practice Registered Nurse (APRN), stated that the provider should have been notified that the patient was having uncontrolled pain. Staff K went on to state that Patient 1 had a history of chronic pain and should have been receiving pain medication as ordered.

During an interview on 07/31/25 at 11:18 AM, Staff W, RN, verified that Patient 1 did not have any follow-ups for pain medication administration documented in the medical record, nor received pain medication as ordered, despite having a diagnosis of chronic pain. Staff W went on to state that the physician was not notified of Patient 1's uncontrolled pain as required by hospital policy.

3. Vital signs

Nursing staff failed to reassess and/or notify a provider of vital signs outside of parameters as required per hospital policy.

Review of a policy titled, "Admission Assessment and Reassessment Documentation," dated 04/2025, showed, " ...Reassess and report the following, including but not limited to: Reassess and report the following, including but not limited to: 1. Heart rate less than 50 or greater than 120. 2. Systolic Blood Pressure less than 90 or greater than 150. 3. Temperature over 100.5 F or less than 96.8 F. 4. Respiratory rate less than 12 or greater than 24. 5. Respiratory distress/SpO2 less than 89%, or as ordered ..."

Patient 10

Review of Patient 10's active medical record showed a 77-year-old admitted on 07/28/25 at 1:48 PM with a diagnosis of hypoxia (low oxygen saturation). Past medical history included Metastatic Melanoma (cancer that has spread from origination source); Pulmonary Fibrosis (lung disease), Seizures, and Atrial Fibrillation (irregular heart rate). Patient 10 failed to have vitals assessed as required.

Review of a document titled, "Vital Signs" showed that from 07/28/25 at 1:55 PM through 7/30/2025 at 11:03 AM, the following vital signs were out of range without provider notification:
58 times Patient 10's Respiratory Rate was either less than 12 or greater than 24.
10 times Patient 10's Heart Rate was either less than 50 or greater than 120.
15 times Patient 10's SpO2 was less than 89%.
3 times Patient 10's Systolic Blood Pressure was either less than 90 or greater than 150.

Based on policy review and record review, the hospital failed to ensure nursing staff updated and/or initiated an individualized plan of care for a patient either at a high risk for a fall or after a fall event occurred for 4 of 13 sampled patients (Patient 1, 2, 7, and 12). This deficient practice has the potential to delay patient care and services or cause patient harm.

Findings Include:

Review of a policy titled, "Admission Assessment and Reassessment Documentation," dated 04/2025, showed that an individualized Plan of Care shall be developed for each patient and completed at least once every 24 hours by a Registered Nurse (RN). The admission assessment date is utilized to develop the Plan of Care.

Review of a policy titled, "Key Safety Packet," revised 12/11/24, showed that following any fall the patient will be assessed according to the "Post Fall Assessment," and that the provider and family must be notified. Staff are required to document the fall, the outcome, any initial and/or ongoing observations in the medical record and update the patient's care plan.

Patient 1

Review of Patient 1's active medical record showed a 53-year-old admitted on 06/18/25 at 12:44 PM with a diagnosis of anemia (low blood level). Patient 1 sustained a fall on 06/19/25.

Review of a document titled, "Fall Risk Scale Morse" dated 06/18/25 at 8:15 PM, showed that Patient 1 had a Morse Fall Score of 60 (indicating high fall risk) prior to fall.

Review of a progress note dated 06/19/25 at 3:50 AM showed, that Patient 1 was found on the floor by a patient care technician at 3:50 AM. The note stated that the Registered Nurse (RN) had previously rounded on the patient at 2:30 AM and at that time the patient was noted to be asleep in a recliner chair. When the patient care technician entered the room to do morning vitals the patient was noted to be sitting on the floor directly in front of the recliner. The patient was disoriented and unable to report how he/she fell.

Review of Patient 1's plan of care failed to show documented evidence that fall prevention was implemented as part of the plan of care and/or updated to include falls after Patient 1 fell on 06/19/25 as required per hospital policy

Patient 2

Review of Patient 2's discharged medical record showed a 73-year-old admitted on 04/12/25 at 8:12 AM with a diagnosis of abdominal pain. No significant past medical history. Patient 2 sustained a fall while in the hospital on 05/09/25.

Review of Patient 2's "Fall Risk Scale Morse" dated 05/08/25 at 8:12 PM, showed that Patient 2 had a Morse Fall Score of 35 (indicating moderate fall risk) prior to the fall.

Review of the medical record showed that Patient 2 sustained a fall on 05/09/25 at 5:45 AM. Further review failed to show documented evidence that risk for falls was added to Patient 2's plan of care following the fall as required per hospital policy.

Patient 7

Review of Patient 7's active medical record showed a 75-year-old admitted on 07/23/25 at 11:13 AM with a diagnosis of chest pain. The medical record showed Patient 7 was at risk for falls.

Review of a document titled, "Fall Risk Scale Morse" dated 07/23/25 at 5:02 PM showed that Patient 7 had a Morse Fall Score of 45, indicating Patient 7 should have a fall risk interdisciplinary plan of care.

Review of a document titled, "Plans of Care" showed that Falls Interdisciplinary Plan of Care (IPOC) was not initiated until 07/24/25 at 10:08 PM, approximately 29 hours after the initial fall risk score.

Patient 12

Review of Patient 12's discharged medical record showed a 65-year-old admitted on 07/18/25 at 12:07 PM, with a diagnosis of septic shock; hypotension (low blood pressure); and acute colitis (inflammation of the colon). Patient 12 sustained an unwitnessed fall on 07/22/25 during his/her hospitalization.

Review of a document titled, "Fall Risk Scale Morse" dated 07/18/25 at 3:54 PM, showed that Patient 12 had a documented Morse Fall Risk score of 60, indicating Patient 12 should have a fall risk interdisciplinary plan of care.

Review of Patient 12's plan of care showed that "Falls" was not implemented until 07/20/25 at 12:24 PM (approximately 44 hours after patient was identified as a fall risk) and discontinued on 07/26/25. Review of the plan of care showed an entry on 07/26/25 at 7:02 AM that stated, "Pt [patient] has not fallen during the hospital stay to date ..." The plan of care failed to show documented evidence of a fall or an update/revision to the plan of care after Patient 12's fall on 07/22/25 as required per hospital policy.