HospitalInspections.org

Based on observation, interview, record review and policy review, showed that the facility failed to:
- Follow their fall risk policy at both locations, Liberty, and North Kansas City (NKC).
- Ensure that nursing staff consistently and accurately implemented interventions for patients that had been assessed as being at high risk for falls.
- Ensure patients identified as a fall risk had fall risk armbands in place for two current patients (#2 and #3) and one discharged patient (#10) of four patients reviewed for armbands.
- Ensure a total of 15 current patients (#2, #4, #5, #6, #7, #8, #9, #14, #15, #16, #17, #18, #19, #20 and #21) at the Liberty location, had fall magnets placed outside of their rooms to annotate fall risk, out of a total of 20 fall risk patients reviewed at both locations.
- Obtain a timely x-ray order and results for one discharged patient (#10), of one patient reviewed, who suffered an unwitnessed fall that resulted in a left pelvic (bones located in the area around and between the hip bones) fracture.
- Accurately document the appropriate observations for one discharged patient (#10) of five patients reviewed for rounding documentation.
These failures had the potential to increase the risk of injury to patients who are at risk, when at risk patients are not identified, appropriately monitored and/or protected. The facility census was 68.

The severity and cumulative effect of these failures resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation (COP): Nursing Services.

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure that nursing staff followed their fall risk policy at both locations, the North Kansas City (NKC) location, and the Liberty location.
- Ensure nursing staff consistently and accurately implemented interventions for patients identified as a fall risk.
- Ensure patients identified as a fall risk had fall risk armbands in place for two current patients (#2 and #3) and one discharged patient (#10) of four fall risk patients reviewed for appropriately placed fall risk armbands.
- Ensure a total of 15 current patients (#2, #4, #5, #6, #7, #8, #9, #14, #15, #16, #17, #18, #19, #20 and #21) at the Liberty location, had fall magnets placed outside of their rooms to annotate fall risk, out of a total of 20 fall risk patients reviewed at both locations.
- Obtain a timely x-ray order and results for one discharged patient (#10), of one patient reviewed, who suffered an unwitnessed fall that resulted in a left pelvic (bones located in the area around and between the hip bones) fracture.
- Accurately document the appropriate observations for one discharged patient (#10) of five patients reviewed for rounding documentation.
These failures had the potential to increase the risk of injury to patients who are at risk, when at risk patients are not identified, appropriately monitored and/or protected. The facility census was 68.

Findings included:

1. Review of facility's policy titled, "Fall Assessment and Precautions," revised 07/20/17, showed:
- The admitting nurse should assess the patient's fall risk status upon admission.
- The assigned nurse should re-assess the patient's fall risk status each shift.
- Patient's that are deemed a fall risk should have an orange armband applied, an orange magnet should be placed outside the patient's door, fall precautions "FP" should be placed on the Unit Shift Worksheet, and fall precautions should be marked on the patient's Clinical Status Report or 15-Minute Rounds Form.
- The mental health technician's (MHT) should update the Fall Precaution Interventions form daily for each fall risk patient.

An observation and concurrent interview with Staff B, MHT, at the Liberty location on 08/05/19 at 3:16 PM showed that:
- Staff B was at the bedside of Patient #2.
- He indicated that Patient #2 was a fall risk, and he had been assigned to monitor him as a one on one (1:1, continuous visual contact with close physical proximity) patient.
- He was unable to locate a fall risk bracelet (armband) on Patient #2, and stated that the patient should have had one in place.

During an interview on 08/05/19 at 3:27 PM, Staff C, Registered Nurse (RN), stated that:
- Fall risk for each patient would be assessed on admission and interventions initiated when needed.
- Fall risk patient's should have a fall bracelet on.
- She was Patient #2's assigned nurse and she did not know why he did not have a fall bracelet in place, but he should have had one on.

During concurrent observation and review of the facility's list of patients identified as fall risk at the Liberty location on 08/05/19 at 3:25 PM, showed that Patients #2, #4, #5, #6, #7, #8, #9, #14, #15, #16, #17, #18, #19, #20 and #21 should have had an orange magnet outside of their room, and they did not.

During an interview on 08/06/19 at 9:20 AM, Staff L, Risk and Process Improvement Director, stated that all fall risk patients should wear an orange wristband/bracelet, have a orange magnet placed outside their patient room, and that the process would be the same at both locations.

During concurrent observation and review of the facility's list of patients identified as fall risk patients at the NKC location on 08/06/19 at 9:30 AM, showed Patient #3 was identified as a fall risk patient, and she did not have a fall risk bracelet in place.

During an interview on 08/06/19 at 9:40 AM, Staff F, RN, stated that age, previous falls, history of seizures, and whether or not a patient was in the process of detoxing, would trigger the need to place a patient on fall precautions. Items that would identify a fall risk patient to the nursing staff would include an an orange magnet on the door frame of their room and a fall risk band.

During an interview on 08/06/19 at 2:11 PM, Staff M, RN, House Supervisor, stated that if a patient was identified as a fall risk, they would have a bracelet/wristband applied, but she never saw magnets placed outside the doors at the Liberty location.

During an interview on 08/06/19 at 11:09 AM, Staff J, RN, stated that patients were assessed for fall risk upon admission, and when the patients were identified as a fall risk, they would have a bracelet applied.

During an interview on 08/07/19 at 10:52 AM, Staff D, Chief Nursing Officer (CNO), stated that it should be the RN that re-assessed that fall interventions were in place.

2. Review of the facility's service agreement for radiology services, which began on 02/01/18 showed:
- Turnaround times are measured from the time an order is received by the radiology service, to the time a facility receives a preliminary report.
- Exam priority "STAT" is defined as an order that a duly licensed physician or non-physician practitioner has requested as emergent.
- Turn around benchmark for a STAT exam is four hours.

Review of Patient #10's medical records showed the following:
- On July 6th, 2019 at 3:45 PM, the patient was noted to have had an unwitnessed fall.
- On July 6th, 2019 at 4:00 PM, the patient complained of pain to her leg and groin area and Tylenol 650 milligrams (mg, unit of measure) was given by mouth. The patient's pain was rated a seven out of 10 on the numeric pain scale (a tool used to help assess a person's pain level with 0 representing no pain to 10 representing the other pain extreme).
- On July 6th, 2019 at 8:00 PM, the patient complained of increased pain to her groin area, rating the pain as an eight out of 10 on the pain scale. An order was received for Norco (medication used to alleviate significant pain) 5/325 mg, as needed for pain.
- On July 6th, 2019 at 8:30 PM, the patient received Norco 5/325 mg.
- On July 6th, 2019 at 10:00 PM, an order was received for a STAT x-ray of the pelvic region.
- On July 7th, 2019 at 2:00 AM, the contracted radiology service arrived to obtain the pelvic x-ray.
- On July 7th, 2019 at 7:30 AM, the facility received results of the pelvic x-ray, which showed a left pelvic fracture.
- On July 7th, 2019 at 8:09 AM, an order was received to send Patient #10 to local acute care hospital Emergency Department for evaluation and treatment, which resulted in admission.

During an interview on 08/06/19 at 2:10 PM, Staff M, RN, stated that:
- They had previous issues with the contracted radiology service having long wait times when x-rays were ordered.
- The currently contracted radiology service was their only option for x-rays unless they sent patients out to the emergency department.
- Meetings were had by upper management with the contracted radiology service because of poor service and long wait times.
- Nurses should follow up by phone with the contracted radiology service when STAT orders were not resulted timely.

During an interview on 08/06/19 at 2:50 PM, Staff Q, RN Nurse Supervisor, stated that:
- He was notified of Patient #10's fall. and assisted the RN with her post fall care.
- He contacted the NP provider on call, and informed her of Patient #10's complaints of pain after the fall.
- He received verbal direction from the NP to continue to monitor the patient and if there was no improvement, to order an x-ray.
- From his experience, a provider had never left the decision up to the nurse's discretion, whether or not to obtain an x-ray.
- He did not request clarification or further direction from the NP.
- He did not order the x-ray for Patient #10.
- He was notified on the next morning that Patient #10 had continued to complain of pain and had received an order for a STAT x-ray at 10:00 PM on 07/06/19.

During an interview on 08/06/19 at 3:10 PM, Staff P, Nurse Practitioner (NP), stated that:
- The NKC location appeared more organized than the Liberty location.
- Orders for x-rays should always be based on assessment findings and not left to nursing judgement.
- She respected and valued nurse assessments but understood that it was not in the scope of practice for a nurse to decide if and or when an x ray should be obtained.
- The order for an x-ray should come from the provider.

During an interview on 08/06/19 at 3:30 PM, Staff E, Chief Executive Officer (CEO), stated that:
- She was made aware of the issues that they had with the contracted radiology services.
- She held meetings with them prior to Patient #10's fall, to discuss their long wait times with x-ray orders.
- Their physician services were contracted.
- She was unaware that a NP gave verbal direction to an RN to obtain an x-ray if Patient #10 did not improve.
- She agreed that the timetable of events after Patient #10's fall was unacceptable.

During an interview on 08/07/19 at 3:30 PM, Staff D, CNO, stated that:
- The Liberty location did not have fall magnets outside the doors to identify those at risk for falls.
- She expected fall bracelets to be in place when a patient was identified as a fall risk.
- The fall risk bracelets should be checked daily on rounds to ensure that they were still in place.
- She was aware of the issues with the contracted radiology services.
- She was aware of the inconsistent documentation with her staff.
- She did not agree with the NP's verbal direction given to the RN regarding obtaining an x-ray.
- She agreed that Patient #10 waited too long after the fall to get an X-ray and have it resulted.

3. Review of the facility's policy titled, "Precautionary Levels at Signature Psychiatric Hospital," revised 07/30/19, stated that every patient is placed at a minimum on every 15 minute rounds. Staff are to document on the Observation Record to reflect where the patient was located, what behavior was observed, and the time of the observation.

Review of Patient #10's Individual Observation Records showed the following inconsistent documentation:
- There was a corresponding Observation Record for each day the patient was observed.
- On 07/07/19, there were two Observation Records for the patient, and both forms were signed by Staff S, MHT.
- The rounding times on these form were completely different.
- One of the forms did not include the patient's observation level or precautions marked.
- Both forms included the patient's photo, but one form did not include the patient's name or room number.

Review of Patient #10's Fall Precaution Intervention sheet dated 07/07/19, showed that the night shift MHT documented fall interventions several hours after Patient #10 was discharged. Patient #10 had been discharged on 07/07/19 at 11:58 AM, the night shift did not start until 7:00 PM.

During an interview on 08/07/19 at 9:37 AM, Staff S, MHT, stated that:
- He would have been responsible for documenting her 15 minute checks during the times in question.
- He would have documented the patient's observation level, precautions, and written in the patient's name and room number on the form at the beginning of his shift.
- He could not explain why there were two Individual Observation Record forms that were both dated the same, and signed by him.


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