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Based on hospital policy reviews, medical record reviews, observations during tours, physician and staff interviews, the hospital's nursing staff failed to implement high risk fall prevention measures for 1 of 6 Progressive Care Unit patients (#6) identified as at risk for falls; and failed to notify the physician of a patient's change in condition for 1 of 1 patients (#9) that expired while hospitalized.

1. Review of current hospital policy "Falls Reduction Program" revised October 2009, revealed ...III. Procedure ...Identification of Patients at risk for Falls All patients that meet the criteria for fall risk will have a yellow armband placed on their wrist to identify them as 'at risk for falling' throughout the continuum of care. ...Risk Reduction Strategies ...High Risk Prevention Measures -A yellow band will be placed on the patient's wrist...."

Review of a current "Adult Inpatient/Transitional Care Unit/Rehabilitation Unit Fall Reduction Protocol" form dated October 2009 revealed "Assessment of Patients ...*Patients that score 51 or above will be identified as at risk for falling ..."

Observation during tour of the Progressive Care Unit (3 West) on 09/04/2013 at 1336 revealed:

During tour, a request was made to the Charge Nurse to identify the patients currently assessed as at risk for falls on the unit. The Charge Nurse provided a "Nursing Worklist" dated 09/04/2013 at 1344 listing current patients and room numbers. The Charge Nurse identified the patients in rooms 337, 340, 343, 346, 363 and 368 as at risk for falls.

Observation at 1358 revealed Patient #6 was located in room 368. Observation upon entry to room 368 revealed the patient was sitting in a bedside chair with family/visitors in the room. Observation revealed the patient did not have a yellow falls armband placed on her wrists, identifying the patient as at risk for falls. Interview during tour with the Charge Nurse (with Nursing Management Staff present) revealed the patient was assessed as at risk for falls. Interview revealed the patient should have had a yellow falls armband placed on her wrists. Interview revealed the yellow falls armband is used by staff to identify the patient as at risk for falls. Interview confirmed the patient did not have on a yellow falls armband. Observation and interview confirmed the nursing staff failed to follow hospital policy.

Open medical record review on 09/04/2013 for Patient #6 revealed an 82 year old female admitted on 08/30/2013 for Altered Mental Status and Seizures. Record review revealed a past medical history of advanced dementia. Record review revealed upon admission a falls assessment was performed by a nurse. Review revealed the patient's fall score was assessed as 115 (score 51 or greater, patient is at risk for falls). Review revealed a second falls assessment was performed the same day with a fall score assessed as 85. Further record review revealed no available documentation of a falls reassessment being performed on 08/31, 09/01, 09/02, 09/03, and 09/04 (as of the time of observation). Interview with Nursing Management staff during record review confirmed Patient #6 was assessed as at risk for falls on 08/30/2013.

2. Review of current hospital policy "Universal Nursing Services" effective August 01, 2006 revealed "RAPID RESPONSE TEAM (RRT) Purpose To bring a trained clinical team to an adult patient at the first signs of deterioration to provide quick accurate assessments and interventions to prevent more serious consequences. Policy ...Criteria for call RRT: ...*Acute Mental Status Changes ...*General Concern or Worry. ..."

Closed medical record review on 09/05/2013 for Patient #9 revealed an 83 year old female admitted to the hospital on 12/18/2012 with a diagnosis of chronic obstructive pulmonary disease (COPD) and uncompensated congestive heart failure (CHF). While hospitalized the patient sustained a fall on 12/21/2012 between 0100 and 0122 resulting in a right lower leg fracture. Review of nursing physical assessment documentation on 12/21/2012 at 1600 by RN #1 revealed "Neurological Parameters" assessed as "Within Normal Limits" and "Level of Consciousness" assessed as "Awake." Review of nursing physical assessment documentation on 12/21/2012 at 2000 (4 hours later) by RN #2 revealed "Neurological Parameters" assessed as "Not Within Normal Limits"; "Oriented To" assessed as "Unable to Respond"; "Arousable To" assessed as "Unable to Respond"; and "Level of Consciousness" assessed as "Drowsy." Review of nursing note documentation on 12/21/2012 by RN #2 revealed "ON INITIAL ASSESSMENT PT (patient) IS UNRESPONSIVE AND HAVING LABORED RESPIRATIONS. ...". Review of nursing note documentation on 12/21/2012 at 2240 revealed "Dr. (Physician A) on the floor to assess pt. Orders given see chart." Review of a physicians progress note dictated at 2347 by Physician A revealed "12/21/2012: Subjective: The patient is unresponsive. Her sister as well as nursing staff say that she has been like this since the afternoon. However, this morning she was much better and talkative. ..." Review of physician's orders dated 12/21/2012 at 2240 written by Physician A revealed orders for a "Stat (immediately)" electrocardiogram (EKG), Arterial Blood Gas (ABG), portable CXR (chest x-ray), Brain CT (computed tomography), and Blood work (D-Dimer, Troponin I, Cardiac enzymes). Record review revealed documentation of the patient's advanced directive for a natural death dated 08/06/2012. Review revealed a physician's Do Not Resuscitate (DNR) order written by Physician B on 12/22/2012 at 0110 (after change in condition). Review revealed the patient expired on 12/22/2012 at 0500 with a final diagnosis of COPD, uncompensated CHF, Obstructive pulmonary embolism, and left (right) leg fracture. Record review failed to reveal any available documentation Physician A was notified by the nursing staff of the patient's change in condition from being awake to becoming unresponsive prior to Physician A's arrival on the unit at 22:40 (2 hours and 40 minutes after RN #2 assessed the patient as unresponsive).

Interview on 09/05/2013 at 1500 with RN #2 revealed she remembers the patient "because they (hospital staff) called me already." Interview revealed she received in report that the patient was unresponsive and her condition was deteriorating. Interview revealed she does not recall who gave her the report. Interview confirmed she was the nurse that conducted the patient's physical assessment at 2000 on 12/21/2012. Interview revealed the patient was assessed as unresponsive. Interview revealed the physician was not called because she was told in report the patient was unresponsive. Interview revealed she does not recall any "specifics" between 2000 and 2240 before Physician A arrived on the unit. Interview revealed she can't remember exactly what happened. Interview revealed the hospital does have a rapid response team (RTT). Interview revealed staff can call for a rapid response when there are changes in the patient's condition (i.e. unresponsive, decreased heart rate, decreased responsiveness). Interview revealed she did not call for a rapid response for Patient #9 after her 2000 assessment. Interview with Nursing Management Staff present during the interview revealed calling a rapid response is an option for the nursing staff. The policy does not require the nursing staff to call a RRT.

Telephone interview on 09/05/2013 at 1653 with RN #1 revealed she does not recall the patient, and would have to look at the chart. Interview revealed "I would have documented if the patient is unresponsive at shift change." Interview revealed "I would have done a rapid response call for the patient." Interview revealed she does not recall who she gave report to on 12/21/2012 at shift change.

Telephone interview on 09/05/2013 at 1607 with Physician A revealed he was the attending physician for Patient #9 during her hospitalization. Interview revealed on 12/21/2012 he was conducting regular rounds and was notified upon arrival to the unit of the patient's status. Interview revealed he does not recall the nursing staff on-duty. Interview revealed he examined the patient earlier in the morning and she was "fine." Interview revealed the patient was "mentally aware and responsive." Interview revealed he "could appreciate the difference" in the patient's status when he examined her (at 2240). Interview revealed he does not remember being notified of the patient's condition change. Interview revealed he would expect to have been notified by the RN of a change in condition. Further interview revealed a DNR means that heroic measures such as CPR (cardiopulmonary resuscitation) will not be performed, it does not preclude the administration of treatments for symptoms or conditions.

Interview on 09/05/2013 at 1806 with Administrative Management Staff revealed the hospital does not have a policy with a "quantified measurement" as to when nursing staff are to notify a physician of a change in condition.

NC00090865