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Based on observation, interview and record review, the facility failed to protect the rights of one (#3) of three confused patients reviewed requiring the Important Message for Medicare (IMM) notice and failed to provide care in a safe setting for one (#1) of one patients confused patients resulting in traumatic injury and potential loss of rights for all patients. Findings include:

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A0117 - The facility failed to protect the rights of one (patient #3) of three patients documented with confusion and a diagnosis of dementia resulting in failure to inform the patient's represenative of IMM information and the right to appeal discharge.

A0144 - The facility failed to provide care in a safe setting for one of one confused patients (patient #1) resulting in the patient sustaining a fall with traumatic injury.

Based on document review and interview the facility failed to protect the rights of one (#3) of three confused patients reviewed as requiring the Important Message for Medicare (IMM) notice resulting in the failure to inform the patient's representative of the right to appeal discharge and potential loss of rights for the patient. Findings include:

Review of patient medical records on 8/2/2021 at 1430 for the survey included review of consents for admission and procedures, the Important Message from Medicare (IMM), and review of petitions and certifications for Behavioral Health patients. Review of patient #3's consents revealed the patient was admitted on 3/21/2021 for altered mental status. Upon further review of the patient's admission information the patient was documented as having dementia. The patient's consent for admission was obtained via phone from the patient's daughter. The IMM provided the next day on 3/22/2021 stated, "verbal consent by patient." On 8/2/2021 at 1500, an interview occurred with staff F, the Chief Nursing Officer. Staff F was queried if a patient was admitted for altered mental status and a diagnosis of dementia who could not consent for admission to the hospital would it be feasible to present the IMM to the patient on the next day. Staff F stated that the IMM should have been reviewed with the family member who gave consent for admission or another family member.

Based on interview and document review the facility failed to provide care in a safe setting for one of one confused patients (patient #1) resulting in the patient sustaining a fall with injuries. Findings include:

On 8/2/2021 at 1400 a document review occurred of patient #1's medical record. According to the physician's documentation on the patient's discharge note the following described the patient's hospital course, "(an) 86 YO (year-old) male with dementia tested positive for Covid 12/30, presented to ED 1/4 with acute on chronic respiratory failure with hypoxia, requiring 6L oxygen from 3L. Placed on remdesivir, dexamethasone, and received plasma transfusion ... patient developed acute mental status change and treated with tpa (Tissue plasminogen activator - a clot busting medicine) for possible stroke. MRI (Magnetic Resonance Image - Scan of brain) negative. Patient had a fall on 1/13 leading to a left pneumothorax (collapsed lung) requiring chest tube placement through 1/19. Pulmonary consulted. Ultimately due to dementia with severe debility, poor intake, high aspiration risk, hospice care highly recommended. Family choosing to try skilled nursing for a couple days to see how he does and will likely transition to hospice care."

Further review of the patient's medical record included nursing documentation on 1/13/2021. Documentation revealed the patient sustained a "traumatic pneumothorax" requiring transfer to the intensive care unit where a chest tube was placed. Upon reviewing documentation, it was revealed the patient was rounded on by nursing staff on 1/13/2021 at 0113 and again at 0414 when the patient was found "on his hands and knees." The nursing assessment conducted on 01/12/2021 at 2100 stated the patient's demeanor as "confused and irritable."

The nurse caring for the patient on 01/13/2021 at the time of the fall was unavailable for interview at the time of survey. An interview with the Chief Nursing Officer, staff F, was conducted on 8/2/2021 at 1400. Staff F was queried regarding the expectation of rounding on patients during a shift. Staff F stated that during the daytime shift 0700 - 1900 that nursing staff were expected to round on patients every hour, and during the nighttime shift 1900 - 0700 nursing staff were expected to round on patients every two hours. Staff F was asked if the documentation supported that the patient was rounded on every two hours on the night the patient sustained his fall. Staff F stated, "no."

Document review of the patient's medical record for fall risk scores for the patient indicated that the patient upon admission was scored a 29 on 1/4/2021. Fall risks scores for the patient were documented as 14 throughout the patient's hospitalization including the fall assessment on 1/13/2021 at 0113. Staff I, a nurse specialist, was queried on 8/2/2021 at 1515 about the John Hopkins Fall Risk Scoring and the variation of the patient's scores. Staff I stated that once a patient has reached the score above 13 that the patient was considered a "high" fall risk and no further scoring is required. The patient was documented as having an AVASYS system (virtual monitoring system) through out his hospitalization until 1/12/2021, the day prior to planned discharge.

Further review of the patient's chart stated that the AVASYS virtual monitor was discontinued on 01/12/2021 by the attending stating that the patient was pending discharge on 01/13/2021. Review of the event information provided from the 01/13/2021 patient fall (pt. #1) stated the patient's bed alarm was not on at the time of the fall. Staff F, the Chief Nursing Officer stated that review of the incident stated the patient did have signage outside of the room, and the patient did have yellow non-skid socks on at the time of the fall.

A review of the adverse events log from 1/1/2021 to 8/2/2021 occurred on 8/2/2021 at 1530. The adverse event involving the patient of the complaint (pt.#1) was not included in the adverse event log. On 8/2/2021 at 1520 staff F was queried if there was any documentation regarding the patient's fall. At 1600 a document for internal reporting was provided for review. The document stated the patient's bed alarm was not on at the time of the fall. On 8/2/2021 at 1605 staff F was queried if further investigation or root cause analysis was conducted. Staff F stated further investigation, or a root cause analysis was not conducted related to the patient's fall or injury.

On 8/2/2021 at 1520 a document review of the policy titled, "Falls: Risk Assessment, Intervention, and Post-Fall Follow-Up - Adult Inpatient/Outpatient," policy number L6000-312, with an effective date of 7/16/2019 and last revision date of 7/22/2021. According to the policy When a patient rolls off a low bed onto a mat or is found on a surface where you would not expect to find a patient, this is considered a fall...Assessment If a patient who is attempting to stand or sit falls back onto a bed, chair, or commode, this is only counted as a fall if the patient is injured ... Adult Medical Surgical, Progressive Care, & Critical Care: A. The Johns Hopkins Fall Risk Assessment Tool (JHFRAT) is completed by a Registered Nurse (RN). B. Based on the JHFRAT scoring, patients are identified as low risk (0-5), moderate risk (6-13), or high risk (14 and greater). C. The JHFRAT is completed and scored on admission, on transfer from another patient care unit, with a change in condition, every 12 hours, and after a fall has occurred." Policy further stated the following, "Intervention: A. Every adult inpatient receives a JHFRAT scoring and fall prevention interventions are implemented based on their scoring as listed below ... High Fall Risk (14 and greater) (Add to Low and Moderate Fall Risk Measures) Consider Moving Patient Close to Nurses Station , Consider AVASYS, Team Rotation or Safety Attendant (Requires Manager/House Supervisor Approval)."

An interview with the attending physician, staff G, was conducted on 08/3/2021 at 0800. Staff G was queried why the AVASYS virtual monitor was discontinued with a documented confused, vascular dementia patient. Staff G stated that while working with discharge planners it was common knowledge that if a patient required a sitter or one on one care that placement to a long-term care facility was very difficult. Staff G stated that it was strongly encouraged to not have the requirement of sitter or a higher level of care the day before discharge.