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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on observations, interviews and document review, the facility failed to ensure nursing care was provided to meet the care needs of 17 out of 17 patients (#1, #3, #4, #5, #6, #7, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19).

Specifically, the facility failed to ensure nursing staff implemented preventive interventions for six patients (#1, #3, #4, #5, #6, and #7) at risk to fall. Further, the facility failed to ensure nursing staff provided oversight of activities of daily living (ADLs) ordered for 17 of 17 patients (#1, #3, #4, #5, #6, #7, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19).

Based on observations, interviews and document review, the facility failed to ensure nursing care was provided to meet the care needs of 17 out of 17 patients (#1, #3, #4, #5, #6, #7, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19)..

Specifically, the facility failed to ensure nursing staff implemented preventive interventions for six patients (#1, #3, #4, #5, #6 and #7) at risk to fall. Further, the facility failed to ensure nursing staff provided oversight for activities of daily living (ADLs) ordered for 17 of 17 patients (#1, #3, #4, #5, #6, #7, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19).

Findings include:

Facility policies:

The Clinical Alarms policy defined clinical alarms as a patient-generated or activated audible and or visual notification a patient's immediate physiological or health status could be life-threatening. The policy read, equipment with clinical alarms systems [for fall prevention] include bed or chair alarms. Fall prevention devices were considered life sustaining equipment or crisis level alarms. Staff were trained and oriented on department specific clinical alarms. The equipment education includes alarm purpose, operation, response and management of alarms. Clinical alarm performance improvement process included the review of occurrence reports for trends or patterns to identify patient safety improvement opportunities at the facility or regional level.

The Inpatient and Emergency Department Fall Prevention policy outlined the fall risk assessment, interventions, fall prevention strategies, documentation and instructions in the event a patient falls. Staff would utilize the fall assessment in the electronic health record (EHR) to determine the risk of falling for inpatient units. Universal high fall risk interventions included, but were not limited to, magnets or signage outside the patient room, yellow non-slip socks, yellow wrist bands, use of gait belts when ambulating, the use of bed or chair alarms, video monitoring or a staff member assigned as a safety monitor. The policy defined a fall as the sudden, unintentional descent, with or without injury to the patient which results in the patient coming to rest on the floor, on or against some other surface, on another person or an object. The policy defines a major injury to include a fracture, intracranial injury requiring neurological consultation, up to and including death as a result of the fall.

The PRO 1915 Skin Care Guidelines for Medical Surgical Units policy read, the policy provided guidelines for skin care, maintenance of skin integrity, decrease in the risk of skin bacteria transmission. Skin care included bathing at regular intervals based on patient needs, cleansing skin at the time of soiling, and to avoid excessive friction to the skin. Preoperative bathing included chlorhexidine (CHG) baths or showers, used to decrease the incidence of skin infection.

1. The facility nursing staff failed to ensure nursing care was provided to meet the care needs of six patients (#1, #3, #4, #5, #6, and #7) at risk or at high risk to fall. Specifically, despite knowledge of patient falls associated with staff's failure to implement safety interventions, observations revealed bed/chairs alarms for five of five patients were not activated.

A. Facility knowledge of patient falls associated with staff's failure to implement safety interventions (be/chair alarms).

a. Review of Patient #1's medical record revealed the patient was assessed to be a high fall risk and required the use of a bed alarm and a chair alarm when awake.

i. A nursing note in the medical record revealed on 6/11/21 at 3:39 a.m., Patient #1 was found lying on the floor by the certified nurse aide (CNA). The CNA alerted the registered nurse (RN) that the patient fell, unwitnessed, in their room.

ii. An incident report dated 6/11/21, had follow up documentation dated 6/14/21, which read the patient's bed alarm was not activated at the time of his fall.

iii. Staff interviews confirmed Patient #1's bed alarm was not activated at the time of his fall.

CNA #1 was interviewed on 8/19/21 at 8:16 a.m. She said she was caring for Patient #1 on the evening of his fall. CNA #1 stated she was called by the telemetry tech to notify her the patient's cardiac monitor was not on and his cardiac information was not transmitted. CNA #1 stated she went to Patient #1's room to check on the cardiac monitor and the room was dark upon entry. She said when she turned on the light, she found the Patient #1 lying on the floor; there were no alarm sounds to notify the staff the patient had gotten out of bed without assistance prior to his fall. She said Patient #1 was injured.
The injuries included a C5 spinal fracture, a break to bone in the neck and a right frontal hematoma, a build-up of blood on the surface of the brain. The injuries were confirmed in the incident follow up report and the medical record review.

RN #3 was interviewed on 8/18/21 at 9:38 a.m. She said she was caring for Patient #1 on the evening of his fall. RN #3 stated Patient #1 was found lying on the floor with a bump on the right side of his head. RN #3 stated the alarm was not activated, likely due to human error.

b. Review of nine patient fall events, dated from 8/20/20 to 7/12/21, revealed:

i. Seven patients had unwitnessed falls. The event follow ups documented the patients' bed or chair alarms were not activated at the time of the falls.

ii. Six of the seven patients had notations in their medical records of unbalanced, unsteady or weak gait when ambulated, placing them at risk for falls.

iii. A facility risk review of an adverse safety event on 7/12/21 revealed increased trends of patient falls associated with a lack of safety interventions being implemented.

B. Observations revealed nursing staff's failure to implement safety interventions for patients identified as fall risk and/or high fall risk, and who, had bed and/or chair alarms.

a. On 8/18/21 between 3:53 p.m. and 4:45 p.m., observations were made on the Medical and Cardiac inpatient units.

i. Observations revealed the unit census listed five patients (Patients #4, #5, #6, #7, #8) admitted to the unit who were fall risk patients and who were found without their bed alarms activated.

ii. Four of five patients (Patients #4, #5, #6, #7) identified as fall risk patients on the unit census were further classified as high fall risk patients.

According to the Inpatient and Emergency Department Fall Prevention policy, staff would utilize the fall assessment in the electronic health record (EHR) to determine the risk of falling for inpatient units and interventions to address risk included the use of bed or chair alarms.

According to Clinical Alarms Policy, fall prevention devices, such as bed or chair alarms, were considered life sustaining equipment.

C. Interviews confirmed the importance and expectation that bed and/or chair alarms be activated and monitored by all nursing staff for patients at risk for falls.

a. On 8/19/21 at 8:16 a.m., an interview was conducted with CNA #1. CNA #1 stated the bed alarms were activated at all times so the alarm would sound and staff would be alerted to a patient getting up without assistance and at risk of a fall. CNA #1 stated it was the responsibility of all staff to monitor activation of bed/chair alarms for high fall risk patients. CNA #1 stated it was important to monitor bed/chair alarms for the safety of the patient, as patients were in often unfamiliar surroundings, many were on new medications, or post anesthesia, all of which put the patients at a higher risk of falls.

b. On 8/19/21 at 7:52 a.m., an interview was conducted with CNA #2. CNA #2 stated staff members must stay with the high fall risk patients while out of their bed or chair. CNA #2 stated high fall risk patients were placed on a bed/chair alarm for their safety when staff was not in the room to monitor them. CNA #2 stated patients were at increased risk of falls, injuries, and head injuries if alarms were not activated.

c. On 8/18/21 at 9:38 a.m., an interview was conducted with RN #3. RN #3 stated patients assessed to be high fall risks had multiple interventions to keep them safe. The interventions included bed/chair alarms, keeping higher risk patients close to the nurses' station, keeping belongings close, frequent purposeful rounding and call lights were expected to be answered within 10 minutes. RN #3 stated all staff who entered the patient's room for care were responsible for bed/chair alarm activation. RN #3 stated it was important to activate bed/chair alarms to prevent falls; the more frequent a patient was assessed the safer they could keep them. RN #3 stated the risk to patients included but was not limited to bruises, skin tears, reopened surgical incisions and fractures. The biggest risk was injury.

d. On 8/19/20 at 10:09 a.m., an interview was conducted with RN #4. RN #4 stated it was important for staff to verify the interventions were in place for high fall risk patients. RN #4 stated many of her patients were on blood thinners. The risk to the patients was falls, trauma, fracture, internal injury and up to death.

e. On 8/19/21 at 12:17 p.m., an interview was conducted with Patient Safety Specialist (Specialist) #5. Specialist #5 was a member of the Falls Committee, which analyzed patient falls to find areas for improvement. Specialist #5 stated she was not surprised five patients were found on the Medical and Cardiac inpatient units without their bed alarms on. Specialist #5 stated the falls were sorted into 3 categories; interventions in place/not able to reach patients prior to fall, impulsive/altered patients, and policy failure/human error. Specialist #5 stated audits occurred every 4 hours to check for bed/chair alarm activation. Specialist #5 stated the audit could occur at 8:00 a.m., and then staff could enter the patient room at 9:00 a.m. and deactivate the alarm to perform patient care. The alarm could be deactivated until the next audit at 12:00 p.m., which could put the patient at risk for falls due to human error.

2. The facility failed to ensure nursing staff provided oversight of patient ADLs ordered by their providers. Specifically nursing staff failed to ensure bath and/or showers were performed for 17 patients whose records were reviewed.

A. Document review of patient medical records and ADLs performed.

a. Patient #1's medical record revealed the patient was admitted to the facility on 6/6/21. Patient #1 was discharged from the facility on 6/15/21, nine days later.

i. Patient #1 had a written order from the provider to receive a CHG bath or shower every 24 hours for five consecutive days starting on 6/7/21.

ii. Review of Patient #1's medical record revealed the patient did not receive a CHG bath or shower on the following days: 6/7/21, 6/10/21 and 6/11/21. There was no evidence in the medical record Patient #1 refused or declined to bathe while admitted at the facility.

b. Patient #3's medical record revealed the patient was admitted to the facility 2/16/21. Patient #3 was discharged from the facility on 2/19/21, three days later.

i. Patient #3 had a written order from the provider to receive a CHG bath every 24 hours for the entire inpatient stay.

ii. The patient did not receive a CHG bath or shower on 2/19/21. There was no evidence in the medical record Patient #3 refused or declined to bathe while admitted at the facility.

c. Document review of unit census reports for the medical and cardiac inpatient units on 8/18/21 revealed nursing staff failed to provide 15 patients baths or showers since at least 8/14/21. All had orders to receive a CHG bath every 24 hours.

i. Six patients (#4, #10, #12, #14, #15, and #16) had not bathed since 8/12/21, two patients (#6 and #13) were last bathed on 8/11/21, one patient (#18) had not bathed since 8/9/21 and two patients (#7 and #9) had last bathed on 8/6/21

The PRO 1915 Skin Care Guidelines for Medical Surgical Units policy read, bathing, including chlorhexidine (CHG) baths or showers, is used to decrease the incidence of skin infection.

B. Interviews revealed bath and or showers were needed to maintain skin integrity, prevent infection and to promote patient hygiene.

a. On 8/19/21 at 7:52 a.m., an interview was conducted with CNA #1. CNA #1 stated showers and baths were primarily handled by the CNAs. CNA #1 stated a person in the hospital should be bathed/showered at least every other day. CNA #1 stated it was important to bathe patients for both hygiene and to promote self-care activities.

b. On 8/19/21 at 8:16 a.m., an interview was conducted with CNA #2. CNA #2 stated it was a group effort to bathe patients, all CNAs, nurses on both day and night shift, were responsible to bathe patients. CNA#1 stated patients should be offered a bath and/or a shower at least every 24 to 48 hours. CNA #2 stated patients can refuse baths and/or showers and the refusal could be recorded in the patient record. CNA #2 stated the purpose of baths and showers was for patient hygiene, to prevent infections and encourage patient wellness. CNA #2 stated a bath and/or shower could be beneficial and even therapeutic for the patients.

c. On 8/19/21 at 12:43 p.m., an interview was conducted with the Cardiac Unit Manager (Manager) #6. Manager #6 stated open heart patients should be bathed every day, other patients should be bathed at least every other day. Manager #6 stated staff should document refusals of baths and/or showers. Manager #6 stated the risk for patients not given bath/showers include risk for infection, and skin breakdown.

d. On 8/19/21 at 1:12 p.m., an interview was conducted with the Medical Unit Manager (Manager) #7. Manager #7 stated patients should be offered a bath every day. Manager #7 stated baths and showers were basic nursing, as it maintains skin integrity, and promotes cleanliness and decreases infections.